eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

De Quervain Tenosynovitis: Treatment

Author: Roy A Meals, MD, Clinical Professor, Department of Orthopedic Surgery, University of California at Los Angeles
Contributor Information and Disclosures

Updated: Feb 17, 2009

Treatment

Medical Therapy

Splinting of the thumb and wrist relieves symptoms, but most patients find the loss of the thumb for functional activities too restrictive and do not consistently wear the splints.

Injection of corticosteroid into the sheath of the first dorsal compartment reduces tendon thickening and inflammation.8,9 A dose of 0.5 mL of 1% plain Xylocaine and 0.5 mL of a long-acting corticosteroid preparation can be injected either sequentially or simultaneously. One injection permanently relieves symptoms in roughly 50% of patients. A second injection given at least a month later permanently relieves symptoms in another 40-45% of patients.10,11

Caution should be exercised to ensure that the injection is placed in the sheath rather than subcutaneously, where corticosteroids can lead to fat and dermal atrophy. Atrophy causes a hollowing-out of the skin and a loss of normal pigmentation. Although these atrophic changes generally resolve over 6 months, their presence is disturbing to most patients.

Surgical Therapy

If injection therapy fails, surgical release of the first dorsal compartment relieves the entrapment.12

Preoperative Details

Surgical release of de Quervain tenosynovitis is an outpatient procedure. The operation can be performed under local or regional anesthesia, depending on surgeon preference. Use of a tourniquet precludes intraoperative bleeding and facilitates the identification of structures.

Intraoperative Details

A 3-cm incision is placed over the prominent thickening of the first dorsal compartment. A transverse skin incision is preferred because it provides better appearance of the scar in this highly visible area. Once the skin is incised, only longitudinal, blunt dissection is used until the first dorsal compartment is exposed. This minimizes the risk of sharp injury to the superficial radial nerve, which runs superficial to the first dorsal compartment. Along its dorsal margin, the first dorsal compartment is sharply opened longitudinally for approximately 2 cm.

The tendon(s) are inspected to ensure that the abductor pollicis longus and the extensor pollicis brevis are released. If present, a septum separating the 2 motor units can be deceiving.13 Gently moving the patient's thumb distinguishes one tendon from the other. If a tendon glides with metacarpophalangeal (MCP) joint motion, it belongs to the extensor pollicis brevis. If a septum between the abductor pollicis longus and the extensor pollicis brevis is identified, it also is released.

Surgeons have personal preferences regarding the management of the sheath. Some excise a portion, and others make a step-cut and then suture a strip of sheath back loosely over the exposed tendons.14,15 The author obtains good results without sheath excision or reconstruction by releasing just the thickened portion of the first dorsal compartment and leaving in place the transparent fascia overlying the tendons proximal and distal to the first dorsal compartment.

The skin is sutured. Patients generally appreciate the diminished disfigurement from the placement of a subcuticular skin closure. A soft, dry, circumferential wrist dressing is placed for a week.

Postoperative Details

Early use of the hand for self-care and light activities is encouraged. The suture is removed approximately 10 days after surgery. Thereafter, patients may rapidly resume full activities. Some surgical-site tenderness is expected for several months.

Complications

Although de Quervain tenosynovitis features a simple tendon entrapment and the treatment is quick and straightforward, complications can be profound and permanent.16 Careful attention to surgical technique at the initial release is paramount to avoiding complications.

Superficial radial nerve injury is the most irksome complication. Sharp injury, traction injury, or adhesions in the scar can cause neuritis in this high-contact area, greatly limiting hand and wrist function. This complication is best avoided through careful blunt dissection of the subcutaneous tissue and gentle traction.

Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longus are mistaken for the tendons of the abductor pollicis longus and the extensor pollicis brevis. In such a case, the extensor pollicis brevis tendon may remain entrapped within the septated first dorsal compartment. Should repeat cortisone injections fail to relieve symptoms, careful surgical re-exploration may allow a previously overlooked tendon to be released.

Subluxation of released tendons is possible.17 With wrist flexion and extension, the tendons of a widely released first dorsal compartment snap over the radial styloid. This complication is best avoided by carefully limiting the release to the thickest mid – 2 cm of the first dorsal compartment or by reconstructing a loose roof to the released sheath. Reconstruction of the sheath with a slip of local tissue may relieve symptoms.

More on De Quervain Tenosynovitis

Overview: De Quervain Tenosynovitis
Workup: De Quervain Tenosynovitis
Treatment: De Quervain Tenosynovitis
Follow-up: De Quervain Tenosynovitis
Multimedia: De Quervain Tenosynovitis
References
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References

  1. DeQuervain F. Ueber eine Form von chronischer Tendovaginitis. Corresp Blatt Schweizer Arzte. 1895;25:389-94.

  2. de Quervain F. On a form of chronic tendovaginitis by Dr. Fritz de Quervain in la Chaux-de-Fonds. 1895. Am J Orthop. Sep 1997;26(9):641-4. [Medline].

  3. de Quervain F. On the nature and treatment of stenosing tendovaginitis on the styloid process of the radius. (Translated article: Muenchener Medizinische Wochenschrift 1912, 59, 5-6). J Hand Surg [Br]. Aug 2005;30(4):392-4. [Medline].

  4. de Quervain F. On a form of chronic tendovaginitis. (Translated article: Cor-Bl.f.schweiz. Aerzrte 1895:25:389-94). J Hand Surg [Br]. Aug 2005;30(4):388-91. [Medline].

  5. Guerini H, Pessis E, Theumann N, Le Quintrec JS, Campagna R, Chevrot A, et al. Sonographic appearance of trigger fingers. J Ultrasound Med. Oct 2008;27(10):1407-13. [Medline].

  6. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. Journal of Bone and Joint Surgery. 1930;12:509-40.

  7. Kulthanan T, Chareonwat B. Variations in abductor pollicis longus and extensor pollicis brevis tendons in the Quervain syndrome: a surgical and anatomical study. Scand J Plast Reconstr Surg Hand Surg. 2007;41(1):36-8. [Medline].

  8. Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. J Hand Surg [Am]. Jul 1994;19(4):595-8. [Medline].

  9. Stephens MB, Beutler AI, O'Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician. Oct 15 2008;78(8):971-6. [Medline].

  10. Diop AN, Ba-Diop S, Sane JC, Tomolet Alfidja A, Sy MH, Boyer L, et al. [Role of US in the management of de Quervain's tenosynovitis: review of 22 cases]. J Radiol. Sep 2008;89(9 Pt 1):1081-4. [Medline].

  11. Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. Apr 2007;31(2):265-8. [Medline].

  12. Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop. Oct 28 2008;[Medline].

  13. Jackson WT, Viegas SF, Coon TM. Anatomical variations in the first extensor compartment of the wrist. A clinical and anatomical study. J Bone Joint Surg [Am]. Jul 1986;68(6):923-6. [Medline].

  14. Dierks U, Hoffmann R, Meek MF. Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial. Tech Hand Up Extrem Surg. Sep 2008;12(3):183-7. [Medline].

  15. Louis DS. Incomplete release of the first dorsal compartment--a diagnostic test. J Hand Surg [Am]. Jan 1987;12(1):87-8. [Medline].

  16. Arons MS. de Quervain's release in working women: a report of failures, complications, and associated diagnoses. J Hand Surg [Am]. Jul 1987;12(4):540-4. [Medline].

  17. McMahon M, Craig SM, Posner MA. Tendon subluxation after de Quervain's release: treatment by brachioradialis tendon flap. J Hand Surg [Am]. Jan 1991;16(1):30-2. [Medline].

  18. Cannon DE, Dillingham TR, Miao H, et al. Musculoskeletal disorders in referrals for suspected cervical radiculopathy. Arch Phys Med Rehabil. Oct 2007;88(10):1256-9. [Medline].

  19. Linscheid RL. Injuries to radial nerve at wrist. Arch Surg. Dec 1965;91(6):942-6. [Medline].

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Further Reading

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Keywords

De Quervain tenosynovitis, DeQuervain tenosynovitis, first dorsal compartment stenosing tendinitis, de Quervain tendinitis, de Quervain's tendinitis, de Quervain's tenosynovitis, de Quervain disease, de Quervain's disease, abductor pollicis longus, extensor pollicis brevis, entrapment tendinitis, Finkelstein test, tendovaginitis

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Contributor Information and Disclosures

Author

Roy A Meals, MD, Clinical Professor, Department of Orthopedic Surgery, University of California at Los Angeles
Roy A Meals, MD is a member of the following medical societies: American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Medical Editor

Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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