Continuing Education Activity
De Quervain tenosynovitis is named after the Swiss surgeon, Fritz de Quervain, who first described it in 1895. It is a condition which involves tendon entrapment affecting the first dorsal compartment of the wrist. With this condition thickening of the tendon sheaths around the abductor pollicis longus and extensor pollicis brevis develops where the tendons pass in through the fibro-osseous tunnel located along the radial styloid at the distal wrist. Pain is exacerbated by thumb movement and radial and ulnar deviation of the wrist. This activity reviews the etiology, presentation, evaluation, and management of De Quervain tenosynovitis and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.
- Describe the etiologies and pathophysiology of De Quervain tenosynovitis.
- Review the examination procedures necessary to perform on a patient presenting with suspected De Quervain tenosynovitis.
- Summarize the treatment and management of De Quervain tenosynovitis.
- Outline possible interprofessional team strategies for improving care coordination and communication to advance the evaluation and treatment of De Quervain tenosynovitis and improve outcomes.
De Quervain tenosynovitis is named after the Swiss surgeon, Fritz de Quervain, who first described it in 1895. It is a condition which involves tendon entrapment affecting the first dorsal compartment of the wrist. With this condition thickening of the tendon sheaths around the abductor pollicis longus and extensor pollicis brevis develops where the tendons pass in through the fibro-osseous tunnel located along the radial styloid at the distal wrist. Pain is exacerbated by thumb movement and radial and ulnar deviation of the wrist.
While the exact cause of de Quervain tenosynovitis is unclear, it has been attributed to myxoid degeneration with fibrous tissue deposits and increased vascularity rather than acute inflammation of the synovial lining. This deposition results in thickening of the tendon sheath, painfully entrapping the abductor pollicis longus and extensor pollicis brevis tendons. It is associated with repetitive wrist motion, specifically motion requiring thumb radial abduction and simultaneous extension and radial wrist deviation. The classic patient population is mothers of newborns who are repeatedly lifting a newborn with thumbs radially abducted and wrists going from ulnar to radial deviation.
The estimated prevalence of de Quervain tenosynovitis is about 0.5% in men and 1.3% in women with peak prevalence among those in their forties and fifties. It may be seen more commonly in individuals with a history of medial or lateral epicondylitis. Bilateral involvement is often reported in new mothers or child care providers in whom spontaneous resolution typically occurs once lifting of the child is less frequent.
The first dorsal compartment of the wrist contains the abductor pollicis longus and extensor pollicis brevis tendons lined by a synovial sheath which separates it from the five other dorsal wrist compartments. As these tendons pass through an approximately 2 cm long fibrous tunnel passing over the radial styloid and under the transverse fibers of the extensor retinaculum, they are at risk for entrapment, particularly in the setting of acute trauma or repetitive motion.
History and Physical
Patients present with radial-sided wrist pain which is typically worsened by thumb and wrist motion. The condition may be associated with pain or difficulty with tasks such as opening a jar lid. Tenderness overlying the radial styloid is usually present, and fusiform swelling in this region may also be appreciated. The provocative Finkelstein test, in which the thumb is flexed and held inside a fist, and patient actively clearly deviates the wrist, causes sharp pain along the radial wrist at the first dorsal compartment.
The diagnosis of de Quervain tenosynovitis is a clinical one. While not helpful in confirming the diagnosis, plain radiographs may be helpful in differentiating other causes of radial wrist pain such as thumb carpometacarpal joint osteoarthritis.
Treatment / Management
De Quervain tendinopathy can be self-limited and may resolve without intervention. For those individuals with persistent symptoms, splinting, systemic anti-inflammatories and corticosteroid injection are the most frequently utilized non-surgical treatment options. Splinting with a thumb spica brace may offer patients temporary relief, but failure and recurrence are often high and compliance low.
Corticosteroid injection has been reported to provide near complete relief with one or two injections. Injection is performed into the tendon sheath about 1 cm proximal to the radial styloid where the tendons are palpable. An attempt should be made to palpably infiltrate both the abductor pollicis longus and extensor pollicis brevis sheaths as deep as possible in the fibro-osseus tunnel to minimize the risk of subcutaneous atrophy and hypopigmentation. The use of ultrasound guidance during injection has been reported to allow visualization and adequate injection of the multiple septae and subsheaths which may be present in the first dorsal extensor compartment. Symptomatic relief is reported by about 50% of patients with a single injection. A second injection may provide relief in another 40% to 45% of patients. Potential complications of steroid injection include fat and dermal atrophy and hypopigmentation, typically associated with subcutaneous injection rather than in the tendon sheath. These may improve or resolve over time.
If symptoms fail to improve or recur after two corticosteroid injections, operative management is an option. Surgery is usually performed in the outpatient setting. It can entail local, regional or general anesthesia and typically involves a tourniquet to limit intraoperative bleeding and allow for ease of identification of important anatomic structures. This is performed through an approximately 2 cm transverse skin incision over the first dorsal compartment. Using caution to avoid injury to the branches of the superficial radial sensory nerve, the ligament covering the first dorsal compartment is exposed through blunt dissection. The dorsal margin of the sheath is then sharply incised. Subsheaths, if present, are identified and incised. Once all subcompartments are released, the skin is closed, and a bulky, soft dressing is applied and early mobilization performed. Multiple variations of surgical techniques have been reported in the literature, including endoscopic approaches and partial excision of the extensor retinaculum. Regardless of the technique, high rates of symptomatic relief are reported with low rates of complications.
Post-operative care is usually limited. A simple dressing or wrap is frequently utilized with no need for complex wound care. Patients are advised to begin early use for activities of daily living and other light activities. Once sutures are removed, usually by two weeks, patients are typically released to resume normal activities. Patients may continue to experience mild swelling and tenderness at the surgical site for a few months.
Surgical complications are infrequent but do occur. Local soft tissue infection and wound dehiscence are the most frequent but are typically managed with non-operative interventions including oral antibiotics and local wound care, respectively. The superficial radial nerve overlying the first dorsal compartment can be injured due to sharp transection, traction injury or compression related to scarring. This can result in extreme sensitivity, pain and/or paresthesias. While sometimes self-limited, this can rarely require surgical intervention for neurolysis or treatment of a neuroma.
Following release, patients may also experience subluxation of the first dorsal compartment tendons with wrist flexion and extension. This may be bothersome when the tendons rub or subluxes over the radial styloid. This may be associated with excessive release of the tendon sheath at the time of surgery.
Enhancing Healthcare Team Outcomes
De Quervain tenosynovitis is a relatively common disorder. The patient may present to a number of specialists including a hand surgeon, orthopedic surgeon, primary care provider or an emergency room physician. Nurses may come across this disorder at workers compensation clinic and at rehabilitation centers. Finally, some patients may present to a pharmacist and ask for a pain reliever. The key is to make the diagnosis promptly and avoid the morbidity of the condition.
For patients who seek treatment, the outcomes are excellent. For patients who don't get treatment, the resulting pain often results in disability. Surgery has the best outcomes however it is also associated with the potential of complications. Cortisone injections do work but recurrences are known to occur. In addition, with cortisone injections, the recovery may take 3-9 months. All patients should avoid repetitive actions to prevent recurrence of symptoms. Some patients may need a change in the job and others may need to enroll in long-term hand rehabilitation exercises.