What is the best initial management for DeQuervain's (De Quervain's) tenosynovitis?

Management of De Quervain's Tenosynovitis

Begin with thumb spica splinting combined with NSAIDs and ice therapy for 2-4 weeks; if symptoms persist, proceed directly to corticosteroid injection into the first dorsal compartment, which is significantly more effective than immobilization alone and should be considered first-line definitive treatment. 1, 2

Initial Conservative Management (First 2-4 Weeks)

Immobilization and Activity Modification

• Apply a thumb spica splint to immobilize the wrist and thumb, reducing tension on the abductor pollicis longus and extensor pollicis brevis tendons. 1
• Maintain relative rest while avoiding complete immobilization, as complete immobilization leads to muscle atrophy and deconditioning. 3, 1
• Allow patients to continue activities that do not worsen pain, but avoid repetitive thumb and wrist movements that aggravate symptoms. 3

Adjunctive Therapies

• Apply ice through a wet towel for 10-minute periods to provide effective short-term pain relief and reduce inflammation. 3, 1
• Prescribe NSAIDs for pain relief, with topical formulations preferred over oral to eliminate gastrointestinal hemorrhage risk. 3, 1
• Note that NSAIDs provide symptomatic relief but do not alter long-term outcomes. 3

Corticosteroid Injection (Primary Definitive Treatment)

Evidence for Efficacy

• Corticosteroid injection demonstrates significantly greater treatment success than immobilization alone (relative risk: 1.61,95% CI: 1.21-2.15), with 65% of patients symptom-free at 2 weeks after first injection. 2, 4
• Combined treatment (injection plus immobilization) shows even greater efficacy than either modality alone (relative risk: 2.15,95% CI: 1.77-2.62). 2
• By 12 weeks, 98.75% of patients achieve symptom resolution with one to three injections. 4

Injection Technique

• Inject a mixture of 1 ml (40mg) methylprednisolone acetate with 1 ml of 2% lidocaine into the first dorsal compartment sheath, NOT into the tendon substance itself. 1, 4
• Injecting directly into the tendon substance weakens the tendon and predisposes to spontaneous rupture. 3, 1
• Consider ultrasound guidance to improve injection accuracy and identify anatomical variations such as a septum within the compartment. 1, 5

Follow-up Protocol

• Reassess at 2 weeks; if symptoms persist, administer a second injection. 4
• Up to 35% of patients require a second injection, and occasionally a third injection may be needed. 4
• Expect adverse reactions (likely subcutaneous atrophy or depigmentation) in approximately 25% of patients, which typically resolve within 20 weeks. 4

Surgical Intervention (Reserved for Treatment Failures)

Indications

• Reserve surgical release of the first dorsal compartment for patients who fail 3-6 months of conservative therapy including corticosteroid injections. 1, 5
• Approximately 80% of patients recover fully with conservative management, making surgery necessary in only a minority. 1

Surgical Considerations

• Preoperative ultrasound to identify a septum or subcompartmentalization within the first dorsal compartment can improve surgical outcomes. 1
• Open longitudinal incision provides better visualization and lower rates of nerve injury and hypertrophic scarring compared to transverse incision. 5
• Endoscopic release offers quicker symptom improvement and superior cosmesis for surgeons experienced with the technique. 5

Common Pitfalls to Avoid

• Do not misdiagnose as first carpometacarpal joint osteoarthritis or intersection syndrome—De Quervain's has localized tenderness over the first dorsal compartment with positive Finkelstein's test. 1
• Do not delay corticosteroid injection for months of failed conservative therapy—injection is more effective than prolonged immobilization and should be offered early. 2
• Do not allow premature return to aggravating activities before adequate healing, as this leads to recurrence. 1
• Do not delay surgical referral beyond 6 months if conservative measures have failed, as this prolongs recovery unnecessarily. 1