History
Patients with de Quervain tenosynovitis typically report localized pain at the dorsolateral aspect of the wrist.
Occasionally, a patient's history may indicate isolated, acute trauma to the involved site.
More commonly, the history includes chronic, repetitive activities using the involved hand or thumb.
Inquire about specific repetitive activities that may have contributed to the onset of symptoms. Examples include work activities (eg, computer use, materials handling) or recreational activities (eg, knitting, golf, racket sports).
A thorough understanding of the ergonomics of precipitating activities contributes to making an accurate diagnosis and forms the basis for necessary ergonomic interventions.
Ask how the patient's symptoms limit the patient's ability to perform vocational or avocational activities.
Physical
The most classic finding in de Quervain tenosynovitis is a positive Finkelstein test.
Perform the Finkelstein test by having the patient make a fist with the thumb inside the fingers. The clinician then applies passive ulnar deviation of the wrist to reproduce the chief complaint of dorsolateral wrist pain.
Perform the Finkelstein test bilaterally to compare the involved side with the uninvolved one. [20]
Carefully access the first carpometacarpal (CMC) joint, since pathology at this site can cause a false-positive Finkelstein test.
Look for swelling at the first dorsal compartment of the wrist.
Sensory examination specifically includes careful evaluation in distributions of the median and radial nerves, since either of these could cause pain/dysesthesias radiating into the thumb.
Because cervical radiculopathy also can cause thumb pain/dysesthesias, evaluation includes assessment for upper limb strength, muscle stretch reflexes, sensation, and provocative neck maneuvers (eg, the Spurling test to assess for cervical root impingement).
Because some cases of dorsolateral forearm pain are caused by lateral epicondylitis, evaluate for point tenderness in the region of the lateral epicondyle, at the elbow.
In some cases, de Quervain tenosynovitis may be associated with rheumatoid arthritis; therefore, assess the hands for rheumatologic deformities and malalignment.
A prospective study by Goubau et al indicated that the wrist hyperflexion and abduction of the thumb (WHAT) test is more sensitive and specific than the Finkelstein test for diagnosing de Quervain tenosynovitis. The WHAT test was devised to focus only on the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, without causing pain or stress at the thumb and wrist joints. During the test, the patient positions his or her wrist in hyperflexion, with the thumb in full extension (at the interphalangeal and metacarpophalangeal joints). The thumb is then actively abducted against the physician’s index finger, which provides resistance. [21]
The study involved 100 patients with de Quervain tendinopathy, with the results of the Finkelstein and WHAT tests compared with ultrasonographic findings. According to Goubau and colleagues, the WHAT test showed greater sensitivity (0.99) and specificity (0.29) than did the Finkelstein test, as well as increased positive and negative predictive values (0.95 and 0.67, respectively). [21]
A study by Lutsky et al found that among patients with De Quervain tenosynovitis, carpal tunnel syndrome, osteoarthritis, or trigger finger, the disorder occurred in the dominant and nondominant hands with roughly equal prevalence (although lateral epicondylitis was found to occur more commonly on the dominant side). [22]
Causes
Minor cumulative (ie, repetitive) trauma commonly contributes to the development of de Quervain tenosynovitis. Activities that may cause repetitive trauma to the wrist include factory work, secretarial duties, golfing, or racket sport playing.
Isolated acute trauma also may contribute to the development of de Quervain tenosynovitis. In addition, the disorder may occur in association with rheumatoid arthritis.
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The first dorsal compartment of the wrist includes the tendon sheath that encloses the abductor pollicis longus and the extensor pollicis brevis tendons at the lateral border of the anatomic snuffbox.
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The Finkelstein test is performed by having the patient make a fist with the thumb inside the fingers. The clinician then applies ulnar deviation of the wrist to reproduce the presenting symptoms of dorsolateral wrist pain.
