De Quervain Tenosynovitis Treatment & Management

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.

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.

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.

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.