De Quervain Tenosynovitis 

Updated: Aug 27, 2018
Author: Roy A Meals, MD; Chief Editor: Harris Gellman, MD 

Overview

Background

In 1895, a Swiss surgeon, Fritz de Quervain, published five case reports of patients with a tender, thickened first dorsal compartment at the wrist.[1, 2, 3, 4] The condition has subsequently borne his name, de Quervain tenosynovitis. De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist; it causes pain during thumb motion.[5]

Surgeons have had more than 100 years of experience with de Quervain tenosynovitis. The described treatment options are widely accepted, and no significant controversies exist. No significant changes in diagnosis and treatment are anticipated for this lowly, yet irksome, condition.[6]

For patient education resources, see Tendinitis.

Anatomy

The tendons of the abductor pollicis longus and the extensor pollicis brevis pass through the first dorsal compartment. The abductor pollicis longus tendon is usually multistranded. The extensor pollicis brevis tendon is typically much smaller than even a single slip of the abductor pollicis longus tendon, and it may be congenitally absent. A septum separating the first dorsal compartment into distinct subcompartments for the abductor pollicis longus tendons and the extensor pollicis brevis tendon is often noted at surgery.[7]

Etiology

The tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath. Efforts at thumb motion, especially when combined with radial or ulnar deviation of the wrist, cause pain and perpetuate the inflammation and swelling.

Epidemiology

The most common entrapment tendinitis of the hand and wrist is trigger digit,[8] followed by de Quervain tenosynovitis, though the latter occurs only about one twentieth as often as does trigger digit.

Prognosis

Relief is permanent following successful surgery. Some patients who have been successfully treated with injections may have recurrent symptoms when they return to lifting infants aged 6-12 months. This author would suggest the following: Relief is usually permanent.

 

Presentation

History

Patients with de Quervain tenosynovitis note pain resulting from thumb and wrist motion, along with tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. Patients frequently are mothers of infants aged 6-12 months, and symptoms are often noted in both wrists. Repetitive lifting of the baby as it grows heavier is responsible for friction tendinitis. Day care workers and other persons who repetitively lift infants are frequently affected as well. De Quervain tenosynovitis can also develop in individuals who have sustained a direct blow to the area of the first dorsal compartment.

Physical Examination

The first dorsal compartment over the radial styloid becomes thickened and feels bone-hard; the area becomes tender. Usually, the compartment's thickening so distorts the sparsely padded skin in this area that a visible fusiform mass is created (see the image below).

In de Quervain tenosynovitis, the first dorsal com In de Quervain tenosynovitis, the first dorsal compartment is thickened, raising the skin and creating a prominence at the radial styloid.

The Finkelstein test (consisting of flexion of the thumb across the palm and then ulnar deviation of the wrist) causes sharp pain at the first dorsal compartment (see the image below).[9]

The Finkelstein test draws the tendons of the firs The Finkelstein test draws the tendons of the first dorsal compartment distally and causes sharp, local pain when tendon entrapment has occurred and inflammation is present.

Tenderness is absent over the muscle bellies proximal to the first dorsal compartment. Tenderness and pain on axial loading are absent at the carpometacarpal (CMC) joint unless the patient has arthritis in that joint.

 

Workup

Radiography

Although the thickened first dorsal compartment can be bony hard, the thickening is made up of fascia and tendon. Radiographs are negative and are not necessary for routine diagnosis. However, it should be emphasized that radiographs should be obtained to rule out other conditions that may be responsible for the patient's pain.

Radiographs may be helpful in differentiating the patient who has de Quervain tenosynovitis from one who has osteoarthritis at the thumb carpometacarpal (CMC) joint or who is suffering from both conditions.

 

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.[10, 11] A dose of 0.5 mL of 1% plain lidocaine 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.[12, 13]  The addition of hyaluronic acid to the injectate may contribute to reduction of recurrence rates.[14]

Injections at four separate sites in the first dorsal compartment showed a higher response rate in high-resistance training male athletes than injections at two sites.[15] The four injections would be additionally painful when the corticosteroid and local anesthetic were mixed in the same syringe.

Whether the landmarks for accurate placement of the corticosteroid would still be visible if the local anesthetic was injected first is not known. It is also unknown if the four-site injection technique is more effective than the conventional technique in the typical patients with de Quervain disease—new mothers.

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.[16]

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.

Operative 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 two motor units can be deceiving.[17] 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.[18, 19] 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 Care

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 of surgical treatment can be profound and permanent.[20]  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.[21]  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 middle 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.

 

Questions & Answers