What is the procedure to treat De Quervain's (De Quervain's tenosynovitis)?

Treatment of De Quervain's Tenosynovitis

Start with thumb spica splinting combined with NSAIDs and relative rest as first-line treatment, followed by corticosteroid injection into the tendon sheath (not the tendon itself) if conservative measures fail after 3-6 weeks, and reserve surgical release for cases that fail 3-6 months of conservative therapy. 1

First-Line Conservative Management

Thumb Spica Splinting

• Apply a thumb spica splint to immobilize the abductor pollicis longus and extensor pollicis brevis tendons and prevent ongoing damage 1
• Use relative rest rather than complete immobilization, as complete immobilization leads to muscular atrophy and deconditioning 1
• Continue splinting for approximately 3 weeks while allowing some controlled movement 2

Pain Management

• Prescribe NSAIDs for short-term pain relief and potential anti-inflammatory benefit 3, 1
• Topical NSAIDs are preferable to oral NSAIDs when possible, as they eliminate the risk of gastrointestinal bleeding associated with systemic NSAIDs 4
• Apply cryotherapy through a wet towel for 10-minute periods to provide effective short-term pain relief 4, 1

Activity Modification

• Avoid activities that worsen pain, particularly repetitive wrist ulnar deviation with thumb abduction and extension 1, 2
• Maintain some activity level to prevent muscular atrophy while reducing repetitive loading of the damaged tendon 3

Second-Line Treatment: Corticosteroid Injection

Injection Technique (Critical)

• Inject corticosteroid into the tendon sheath, NOT into the tendon substance itself, as injection into the tendon can cause deleterious effects and predispose to tendon rupture 4, 1
• Consider ultrasound guidance to improve injection accuracy and identify separate subcompartments within the first dorsal compartment 5
• Ultrasound can diagnose abnormalities of tendons and tendon sheaths and identify septa or subcompartmentalization that may affect treatment 4

Injection Alone vs. Injection with Immobilization

• Recent high-quality evidence shows that corticosteroid injection alone is as effective as injection with immobilization, with 88% symptom resolution at 6 months 2
• Immobilization following injection increases costs, may hinder activities of daily living, and does not improve patient outcomes 2
• Patients receiving injection alone had superior resolution of radial-sided wrist pain (100% vs 64%) compared to those with post-injection immobilization 2

Special Populations

• For patients in the third trimester of pregnancy or breastfeeding, corticosteroid injection is not contraindicated and provides optimal symptomatic relief without impacting the baby 5

Adjunctive Physical Modalities

Evidence-Based Options

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak 3, 4
• Low-level laser therapy has shown effectiveness for De Quervain tenosynovitis in multiple studies 6
• Extracorporeal shock wave therapy appears safe, noninvasive, and effective but expensive for chronic tendinopathies 3

Limited Evidence Modalities

• Corticosteroid iontophoresis and phonophoresis have uncertain benefit 3

Surgical Management

Indications

• Reserve surgery for carefully selected patients who have failed 3-6 months of conservative therapy 3
• Surgery is effective in resistant cases when nonsurgical management has been unsuccessful 7

Surgical Technique Considerations

• Open release through a longitudinal incision allows better visualization of underlying anatomy, resulting in fewer injuries to structures and lower incidence of hypertrophic scarring compared to transverse incision 5
• Identify all accessory compartments and septa during surgery, as preoperative ultrasound identification of subcompartmentalization can affect surgical management 4
• Protect the superficial branch of the radial nerve during release 8, 7
• Endoscopic first dorsal compartment release can result in quicker symptom improvement, superior scar cosmesis, and lower incidence of radial sensory nerve injury for surgeons comfortable with the technique 5
• WALANT (wide-awake local anesthesia no tourniquet) technique can be safely and effectively used with potential cost savings 5

Treatment Algorithm Timeline

• Weeks 0-3: Thumb spica splinting + NSAIDs + activity modification + cryotherapy 1
• Weeks 3-6: If no improvement, proceed to corticosteroid injection into tendon sheath (without additional immobilization) 2
• Months 3-6: If injection fails, consider repeat injection or begin discussing surgical options 3, 5
• After 6 months: Surgical release for persistent symptoms despite adequate conservative management 3