What is De Quervain Tenosynovitis
De Quervain tenosynovitis is a stenosing tenosynovitis affecting the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons within the first dorsal compartment of the wrist, characterized by radial-sided wrist pain, localized tenderness, and a positive Finkelstein test. 1
Pathophysiology
The condition involves non-inflammatory thickening of the tendinous sheath that leads to entrapment and increased friction of the APL and EPB tendons as they pass through the first dorsal compartment. 2
Despite being termed "tenosynovitis," the exact etiology remains debated between inflammatory-mediated pathways versus degenerative changes, though substantial evidence exists for both mechanisms. 3
The pathology specifically involves stenosing tenosynovitis where the synovial sheath becomes thickened and hypoechoic, restricting normal tendon gliding. 4
Clinical Presentation
Patients present with pain localized to the radial (thumb) side of the wrist, impairment of thumb function, and tenderness over the first dorsal compartment. 5
The Finkelstein test is the classic diagnostic maneuver: pain is elicited when the patient makes a fist with the thumb tucked inside the fingers, and the wrist is deviated ulnarly. 6, 7
The condition is more common in women, particularly those aged 30-50 years and those 4-6 weeks postpartum. 2
It can be associated with repetitive wrist ulnar deviation combined with thumb abduction and extension, though many cases have unknown etiology. 6, 2
Critical Anatomical Considerations
Anatomical variations are common and clinically significant: the presence of a septum or subcompartmentalization within the first dorsal compartment occurs frequently and affects surgical outcomes if not identified preoperatively. 1
Ultrasound can identify these septal variations and accessory tendons, which is essential information for complete surgical release if conservative treatment fails. 4
Diagnostic Approach
Diagnosis is primarily clinical, based on the triad of radial-sided wrist pain, first dorsal compartment tenderness, and positive Finkelstein test. 4, 6
Imaging is not required for straightforward cases but should be obtained when confirmation is needed or before surgical intervention. 4
When imaging is indicated, ultrasound is the first-line modality because it can demonstrate the thickened, hypoechoic tenosinovial sheath around the APL and EPB tendons and identify anatomical variations. 1, 4
MRI without IV contrast is appropriate when comprehensive evaluation of extra-articular pathology is needed or when symptoms are atypical. 1, 4
Radiographs serve primarily to exclude other pathology such as scaphoid fractures, carpometacarpal arthritis, or other bony abnormalities. 4
Differential Diagnosis Pitfalls
- If edema extends beyond the first dorsal compartment, joint effusions are present, or systemic inflammatory signs exist, consider alternative diagnoses including:
- Intersection syndrome (more proximal on the forearm)
- First carpometacarpal joint osteoarthritis
- Scaphoid fracture
- Carpal tunnel syndrome
- Inflammatory arthritis (rheumatoid arthritis or other systemic conditions) 4
Treatment Principles
Most cases are self-limiting but often require treatment for symptom relief. 2
Conservative management includes NSAIDs, wrist splints, and activity modification as initial therapy. 6, 7
Corticosteroid injection into the first dorsal compartment is highly effective: 65% of patients are symptom-free at 2 weeks after a single injection, and 98.75% are symptom-free by 12 weeks with up to three injections. 7
Immobilization after corticosteroid injection does not improve outcomes and may actually be inferior for resolution of radial-sided wrist pain (64% vs 100% resolution without immobilization), while increasing costs and hindering activities of daily living. 6
Surgical release of the first dorsal compartment is reserved for cases refractory to conservative treatment, with preoperative ultrasound identification of septal variations being essential for complete release. 1, 4, 2