What is De Quervain's tenosynovitis (De Quervain's disease)?

From the Guidelines

De Quervain's tenosynovitis should be diagnosed using MRI or US as the initial examination, as these modalities are highly effective in depicting fluid-filled and synovial-lined structures, including tendon sheaths, and can help identify infectious and noninfectious tenosynovitis 1. De Quervain's tenosynovitis is a painful condition affecting the tendons on the thumb side of the wrist. Treatment typically begins with conservative measures including rest, ice, and anti-inflammatory medications like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks. Wearing a thumb spica splint that immobilizes the thumb and wrist for 2-6 weeks, especially during activities that aggravate symptoms, is highly effective. Corticosteroid injections into the tendon sheath can provide significant relief when other methods fail. Physical therapy focusing on gentle stretching and strengthening exercises helps in recovery and prevention of recurrence. For severe or persistent cases not responding to conservative treatment for 4-6 months, surgical release of the tendon sheath may be necessary. This condition occurs when the tendons that move the thumb become inflamed due to repetitive movements or overuse, causing the protective sheath around them to swell and restrict movement. Pregnant women, new mothers, and people who perform repetitive hand movements are particularly susceptible. Modifying activities that worsen symptoms is crucial for recovery. Some key anatomic variations in the first extensor compartment, including subcompartmentalization, can be identified using US 1. However, the most recent and highest quality study recommends MRI as the initial examination for diagnosing De Quervain's tenosynovitis 1. Key points to consider in the diagnosis and treatment of De Quervain's tenosynovitis include:

• The use of MRI or US as the initial examination
• The importance of conservative measures, such as rest, ice, and anti-inflammatory medications
• The effectiveness of corticosteroid injections and physical therapy in recovery and prevention of recurrence
• The need for surgical release of the tendon sheath in severe or persistent cases.

From the Research

Definition and Treatment of De Quervain's Tenosynovitis

• De Quervain's tenosynovitis is an overuse disease that involves a thickening of the extensor retinaculum, which covers the first dorsal compartment 2.
• The mainstay of treatment is corticosteroid injection (CSI), which has been shown to provide optimal symptomatic relief 3.
• A pooled quantitative literature evaluation found that injection alone had an 83% cure rate, which was higher than any other therapeutic modality 4.

Treatment Options and Effectiveness

• A systematic review and network meta-analysis found that interventions that included ultrasonography-guided CSI ranked at the top for pain, and CSI with thumb spica immobilization had the highest probability of being the most effective intervention for short- and mid-term function 5.
• A review of conservative management options found that a multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation 6.
• Ultrasound-guided injections have been shown to be more accurate and confer better outcomes than non-guided injections 6.

Surgical Treatment

• Surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief when nonoperative treatment is unsuccessful 3.
• Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision 3.
• Endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury 3.

Special Considerations

• For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby 3.
• Several prior and concurrent medical conditions may affect conservative treatment outcome, and a Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease 6.