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De Quervain Tenosynovitis

Basics

  • First described in 1895 by Fritz De Quervain.
  • Painful condition due to stenosis of tendon sheath in 1st dorsal compartment (radial wrist).
  • Tendons involved: Extensor Pollicis Brevis (EPB) and Abductor Pollicis Longus (APL).
  • Caused by repetitive thumb and wrist motion leading to metaplastic changes and sheath thickening.

Epidemiology

  • Predominant age: 30 to 50 years.
  • Women affected more commonly than men.
  • Incidence: 0.9 per 1,000 person-years; higher in >40 years and women.
  • Prevalence: 1.3% in females, 0.5% in males.
  • Anatomic variations (subcompartmentalization) common and may influence incidence.

Etiology & Pathophysiology

  • Microtrauma from repetitive motion and forceful grasping causes tendon sheath thickening.
  • EPB and APL tendons glide over radial styloid; resistance causes pain.
  • Histopathology: myxoid degeneration, dense fibrous tissue, mucopolysaccharide accumulation.
  • Anatomic septum within 1st dorsal compartment present in 34-44% of individuals; subcompartmentalization in 86-94% with disease.

Risk Factors

  • Female sex, aged 30-50.
  • Pregnancy (3rd trimester and postpartum).
  • Black race.
  • Systemic diseases like rheumatoid arthritis.
  • Activities requiring repetitive thumb/wrist motion and forceful grasping (sports, gaming, manual labor).

Prevention

  • Avoid overuse/repetitive motions with forceful grasping and wrist deviation.

Diagnosis

History

  • Repetitive motion or overuse of wrist/thumb.
  • Gradually worsening radial wrist/thumb pain, especially with ulnar deviation.
  • Pregnancy, occupational and leisure activity history.

Physical Exam

  • Tenderness/swelling over radial styloid.
  • Pain worsened with thumb movement or fist making.
  • Crepitus on thumb movement.
  • Decreased thumb range of motion.
  • Positive Finkelstein test: pain with ulnar deviation while thumb is grasped.
  • Eichhoff test: grasped flexed thumb with ulnar deviation.
  • Finkelstein test more sensitive for EPB and APL tenosynovitis.

Differential Diagnosis

  • Scaphoid fracture
  • Scapholunate ligament tear
  • Dorsal wrist ganglion
  • 1st CMC joint osteoarthritis
  • Flexor carpi radialis tendonitis
  • Infectious tenosynovitis
  • Wrist extensor tendonitis
  • Intersection syndrome
  • Trigger thumb

Diagnostic Tests

  • Primarily clinical diagnosis.
  • Wrist radiographs to exclude fractures or arthritis if needed.
  • MRI to rule out soft tissue injury or wrist pathology.
  • Ultrasound for detecting anatomic variations and guiding injections; sensitivity ~100%.

Treatment

General Measures

  • Rest, NSAIDs, ice (15-20 min, 5-6 times/day).
  • Thumb spica splint immobilization.
  • Occupational therapy and acupuncture.

Medication

  • First line: splinting, rest, NSAIDs.
  • Second line: corticosteroid injection into tendon sheath (preferably ultrasound-guided).
  • Corticosteroid plus immobilization more effective than immobilization alone.
  • Newer techniques: ultrasound-guided tenotomy, retinacular release, platelet-rich plasma.

Surgery

  • Indicated if no improvement after 3-6 months of conservative treatment.
  • Endoscopic release preferred over open release for fewer complications and better patient satisfaction.
  • Surgery is highly effective with low complication rates.

Referral

  • Refer to hand surgeon if conservative treatment fails.

Ongoing Care

  • Additional corticosteroid injections may be done after 4-6 weeks if symptoms persist; avoid excessive injections.
  • Avoid repetitive painful activities.

Patient Education

  • Avoid repetitive wrist/thumb movements and forceful grasping.
  • Prognosis excellent with conservative care; full recovery can take up to 1 year.
  • About one-third may have persistent symptoms.

Complications

  • NSAID-related GI, renal, hepatic injury.
  • Surgical nerve damage.
  • Corticosteroid injection risks: hypopigmentation, fat atrophy, bleeding, infection, tendon rupture (reduced with ultrasound guidance).
  • Untreated disease may cause thumb stiffness from fibrosis.

ICD10: - M65.4 Radial styloid tenosynovitis [de Quervain]

Clinical Pearls: - Most common causes are repetitive wrist/thumb movements and forceful grasping. - Anatomic variations in 1st dorsal compartment common. - Corticosteroid injections safer and more effective when ultrasound guided. - Combined splinting and corticosteroid injection better than either alone. - Surgery reserved for refractory cases; endoscopic release shows benefits.