What is the treatment for de Quervain tenosynovitis?

Treatment of De Quervain Tenosynovitis

Begin with thumb spica splinting combined with NSAIDs, followed by corticosteroid injection if symptoms persist, and reserve surgery only for patients who fail 3-6 months of conservative therapy. 1

First-Line Conservative Management

• Thumb spica splinting is the cornerstone of initial treatment, immobilizing the first dorsal compartment to rest the affected abductor pollicis longus and extensor pollicis brevis tendons 1, 2
• NSAIDs provide short-term pain relief and should be initiated alongside splinting 1
• Topical NSAIDs are preferred when treating localized disease as they provide equivalent pain relief with fewer gastrointestinal side effects compared to oral formulations 1
• Local heat application may provide additional symptomatic relief 1
• Continue splinting and activity modification for at least 4-6 weeks before escalating treatment 1

Second-Line: Corticosteroid Injection

• If splinting and NSAIDs fail after 4-6 weeks, proceed to corticosteroid injection into the first dorsal compartment 1, 2
• Use ultrasound guidance to improve injection accuracy, particularly to identify subcompartmentalization within the first dorsal compartment that occurs in some patients 1
• Ultrasound can detect anatomical variations like accessory tendons or septum within the compartment that may affect treatment success 1
• Limit to a maximum of 2-3 corticosteroid injections, as repeated injections do not alter long-term outcomes and may inhibit tendon healing 1
• For pregnant patients in the third trimester or those breastfeeding, corticosteroid injection is safe and provides optimal symptomatic relief without impacting the baby 3

Adjunctive Physical Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis 1
• Low-level laser therapy has demonstrated effectiveness in reducing pain and improving function in De Quervain tenosynovitis 4
• Extracorporeal shock wave therapy (ESWT) is a safe noninvasive option for chronic cases, though it is expensive 5, 4
• Neural therapy with local anesthetics can reduce pain and improve hand function when added to splinting, with effects lasting up to 12 months 6

Surgical Management

• Surgery is indicated only after 3-6 months of failed conservative management including splinting, NSAIDs, and at least 2 corticosteroid injections 1, 2
• Open surgical release through a longitudinal incision is preferred as it allows better visualization of anatomy, resulting in fewer injuries to the superficial branch of the radial nerve and lower incidence of hypertrophic scarring compared to transverse incisions 3
• Endoscopic first dorsal compartment release can provide quicker symptom improvement, superior scar cosmesis, and lower incidence of radial sensory nerve injury for surgeons experienced in endoscopic techniques 3
• The procedure can be safely performed using the WALANT (wide-awake local anesthesia no tourniquet) technique with potential cost savings 3
• Critical surgical consideration: Identify all accessory compartments and subcompartments during release, as incomplete release due to anatomical variations is a common cause of surgical failure 2, 3

Common Pitfalls to Avoid

• Do not confuse De Quervain tenosynovitis with intersection syndrome, first carpometacarpal joint osteoarthritis, or scaphoid fracture 1
• If diffuse wrist swelling extends beyond the first dorsal compartment with joint effusions or systemic inflammatory signs, consider inflammatory arthritis rather than isolated De Quervain tenosynovitis 1
• Protect the superficial branch of the radial nerve during surgical release, as nerve injury is the most common complication 7, 3
• Approximately 80% of patients recover fully within 3-6 months with appropriate conservative treatment 5