de Quervain (Thumb Extensor) Tenosynovitis

By admin Last updated Mar 19, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > de Quervain (Thumb Extensor) Tenosynovitis

de Quervain (Thumb Extensor) Tenosynovitis

Dawn M. LaPorte MD

Peter R. Jay MD

Basics

Description

Thumb extensor or de Quervain tendinitis
is stenosing tenosynovitis of the 1st dorsal compartment of the wrist,
which contains the abductor pollicis longus and the extensor pollicis
brevis.
Patients present with pain and discomfort on the radial aspect of the wrist.
It often occurs in middle-aged females, although males and females of all ages can be affected.

Epidemiology

Incidence

This condition is common—up to 6 times more common in females than in males (1,2).

Risk Factors

Frequently seen in new mothers, in part secondary to repetitive lifting and setting down of the baby.

Etiology

Repetitive motions of thumb or wrist
Associated with:
- Racquet sports
- Fly fishing
- Golf (often affecting the nondominant hand in golfers)
- Infant care
Can be associated with rheumatoid arthritis

Associated Conditions

Rheumatoid arthritis

Diagnosis

Signs and Symptoms

Pain and tenderness on the radial aspect of the wrist, often isolated to directly over the 1st dorsal compartment
Pain and discomfort exacerbated by extension or abduction of the thumb with simultaneous ulnar deviation of the wrist
Repetitive activities particularly painful

Physical Exam

Note pain, tenderness, swelling,
bogginess, and crepitus over the 1st dorsal compartment of the
wrist—the radial aspect of the radial styloid.
A positive Finkelstein test (Fig. 1)
helps confirm the diagnosis: Exacerbation of the symptoms (pain) with
the thumb clenched in the palm and ulnar deviation of the wrist (2,3).

Fig.
1. Finkelstein test. Test is considered positive if it produces sharp
pain when the thumb is clasped in the palm and the wrist is forced into
ulnar deviation.
Examine the 1st CMC joint, use the grind
test, and assess ROM to rule out degenerative joint disease;
degenerative joint disease and de Quervain syndrome can coexist:
- Intersection syndrome is rarer than de Quervain and often is associated with more severe symptoms.
- On physical examination, the pain
  localizes 4 cm proximal to the wrist, rather than over the radial
  styloid, as in de Quervain syndrome.

Tests

Lab

No serum laboratory tests are needed.

Imaging

AP and lateral views of the wrist and 1st CMC views are
helpful in ruling out other disorders and in differentiating between
degenerative joint disease of the 1st CMC and de Quervain syndrome.

Pathological Findings

The dorsum of the wrist is divided anatomically into 6 separate extensor tendon compartments.
- The 1st compartment contains the abductor
  pollicis longus and extensor pollicis brevis, which can become inflamed
  and irritated as they enter and pass through the rigid fibro-osseous
  tunnel of the 1st compartment.
- Intersection syndrome is thought to be an
  inflammatory condition that exists at the point where the 1st and 2nd
  dorsal compartment (the ECRL and ECRB) cross; this site of
  “intersection” is ~4 cm proximal to the wrist.

Differential Diagnosis

Degenerative joint disease of the 1st (thumb) CMC joint
Intersection syndrome (much rarer)
Radiocarpal arthritis

P.93

Treatment

General Measures

As with most types of tendinitis, rest and avoidance of aggravating conditions are the mainstays of treatment.

Special Therapy

Physical Therapy

Splinting often is helpful to put the tendon at rest.
Iontophoresis (ultrasound through a corticosteroid cream) can help decrease the inflammation.
Stretching the wrist also may be helpful.

Medication

First Line

The 1st line of therapy is nonoperative care, which includes:
- Immobilization of thumb and wrist, usually in a thumb spica splint.
- NSAIDs
- Steroid injection into the 1st dorsal compartment; success rates for steroid injection range from 50–80% (4,5).

Recalcitrant or recurrent symptoms often require surgical release of the 1st dorsal compartment.
Decrease activity until symptoms resolve.

Second Line

Patients who have persistent pain despite nonoperative
measures are candidates for surgical release of the 1st dorsal
compartment.

Surgery

Positive response to injection should precede decision for surgery.
Make a radial incision over the 1st
dorsal compartment with release of the fibro-osseous tunnel and all its
septa, as well as the release of the fascial sheaths of each tendon and
the compartment.
Incise the sheath on dorsal margin to prevent tendon subluxation.
Multiple anatomic variations are present.

Follow-up

Prognosis

The prognosis is good.

Complications

The most serious complication of surgical
intervention is transection of the dorsal sensory radial nerve, which
lies in proximity to the 1st dorsal compartment.
This complication can leave the patient
with a small area of numbness/absence of sensation or, more seriously,
with a painful neuroma, which often requires surgical resection.

Patient Monitoring

Patients are followed at 3-month intervals until their symptoms resolve.

References

1. Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg 1990;15A:83–87.

2. Piver JD, Raney RB. De Quervain’s tendovaginitis. Am J Surg 1952;83:691–694.

3. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 1930;12A:509–540.

4. Phalen
GS. Stenosing tenosynovitis: trigger fingers, trigger thumb, and de
Quervain’s disease. Acute calcification in wrist and hand. In: Jupiter
JB, ed. Flynn’s Hand Surgery, 4th ed. Baltimore: Williams & Wilkins, 1991:439–447.

5. Weiss APC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg 1994;19A:595–598.

Additional Reading

Wolfe SW. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005:2137–2159.

Miscellaneous

Codes

ICD9-CM

727.04 de Quervain tendinitis

Patient Teaching

Patients are counseled to avoid repetitive activities that worsen the pain.
Attention to workplace ergonomics also is important.

FAQ

Q: What is the 1st line of treatment for de Quervain syndrome?

A: Thumb spica splint immobilization, anti-inflammatory medication, and therapy with modalities.

Q: Are any risks associated with corticosteroid injection?

A: Some localized hypopigmentation may occur after injection.

Q: What other diagnoses can cause radial-side wrist pain?

A:
The differential diagnosis for de Quervain syndrome includes thumb CMC
arthritis and radiocarpal arthritis. Thumb CMC arthritis is
distinguished by pain over the thumb CMC joint, a positive grind test,
and a negative Finkelstein test. Radiocarpal arthritis may be
distinguished by pain over the radiocarpal joint and pain with radial
deviation of the wrist, as compared with pain with ulnar deviation with
de Quervain syndrome.