DeQuervain Tenosynovitis

By admin Last updated Nov 29, 2023

Ovid: 5-Minute Sports Medicine Consult, The

William W. Briner Jr

Basics

Description

de Quervain tenosynovitis is a stenosing tendinosis of the 1st dorsal compartment of the wrist.
The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons course through this compartment.
It is the most frequently encountered tendinosis on the dorsal side of the wrist.
de Quervain tenosynovitis is typically an overuse injury, but may result from direct trauma.
Synonym(s): Extensor tendonitis; Stenosing tenosynovitis; Stenosing tendinitis; Peritendinitis; Styloid tenovaginitis; Stenosing tendovaginitis

Epidemiology

Usually seen in adults aged 30–50 yrs
More common in females than males

Risk Factors

Activities requiring forceful grasp with excessive ulnar wrist deviation or repetitive use of the thumb (eg, golfing, bowling, wrestling, fly fishing, racquet sports [squash, badminton, tennis], javelin or discus throwing)
Direct trauma with associated scarring
Also can be seen as systemic component of rheumatologic disorders such as rheumatoid arthritis

Etiology

Repetitive or sustained tension on tendons of the 1st dorsal compartment cause an inflammatory, then fibroblastic response.
There is thickening and swelling of the extensor tendons and retinaculum.
Pain is produced from resisted gliding of the APL and EPB tendons in the narrowed fibroosseous canal.
Histopathology is consistent with collagen disorientation and mucoid changes (tendinosis), not inflammation.

Diagnosis

History

Gradual onset of pain along the radial styloid of the wrist for several weeks to months
Acute onset of pain over the radial styloid after trauma
Pain is aggravated by moving the wrist or thumb.
Pain may radiate to the thumb, up the dorsoradial aspect of the forearm, or occasionally into the shoulder.

Physical Exam

Swelling, tenderness, and/or crepitus to palpation of the APL and EPB tendons near the radial styloid process
Positive Finkelstein test is pathognomonic and confirms the diagnosis.
To perform the Finkelstein test, the examining physician grasps the thumb of the patient and the hand is ulnar-deviated sharply. A positive test produces sharp pain along the distal radius.
A similar test was previously described by Eichoff, in which the thumb is placed in the palm of the hand and held with the fingers; the hand is then ulnar-deviated, causing intense pain over the radial styloid. (This test is often confused with the Finkelstein test.)
Uncommon presentations include extensor triggering or locking of the thumb and dorsal ganglion cyst formation.

Diagnostic Tests & Interpretation

Imaging

Usually none needed
If patient has history of trauma or other bone pathology is suspected, obtain wrist x-rays.
US and US-guided injection may help confirm the diagnosis, identify anatomical variants, and ensure proper placement of medication, which may increase efficacy and decrease complications and possibly recurrences.

Differential Diagnosis

Trigger thumb
Thumb carpometacarpal joint arthritis
Intersection syndrome
Flexor carpi radialis tendonitis
Radial styloid fracture
Scaphoid fracture
Avascular necrosis of the scaphoid
Radial neuritis
Wartenburg's syndrome

P.115

Treatment

Rest from offending activity.
Ice massage is beneficial when used early.
Corticosteroid injection is effective treatment:
- Place a rolled-up towel under the wrist to position it in slight ulnar deviation.
- Use a 2-mL mixture of 1/3 each: lidocaine, bupivacaine, and dexamethasone phosphate.
- Inject into the 1st dorsal compartment at the radial styloid through a 27-gauge needle at a 45-degree angle to the skin.
- Inject along the axis of the sheath.
- Infiltrate the sheath from distal to proximal.
- Fusiform swelling occurs in the 1st dorsal compartment if properly placed.
Pain relief is often immediate.
Patient must be cautioned against overuse following an injection.
If no improvement is seen in 2 wks, patient may have an anatomical variant with 2 tendon sheaths or a septation in the 1st dorsal compartment. In addition, there can be multiple slips of the APL or EPB tendon. Anatomic variants may be seen in as many as 40–60% of patients who fail injections.
Can inject again in the same manner, but redirect needle to enter both tendon sheaths, or under US guidance to assess for anatomic variants
Consider surgical referral if 2nd injection fails.
Water-soluble corticosteroid decreases local complications, including SC atrophy and hypopigmentation.

Medication

NSAIDs may benefit some patients.

Additional Treatment

Using a thumb spica splint may relieve pain, but there is some suggestion that immobilization could increase recovery time.
There is little research supporting other therapeutic modalities, including stretching, strengthening, iontophoresis, and US.

Surgery/Other Procedures

If conservative therapy is ineffective, surgical release of the fibrous 1st dorsal compartment may be considered. Repair of the extensor retinaculum is rarely required.

Ongoing Care

Complications

Complications of injection:
- SC fat atrophy
- Hypopigmentation
- Pain
- Neuritis
- Fat necrosis
- Postinjection flare
- Local infection
Complications of surgery:
- Radial sensory nerve injury
- Incomplete decompression
- Volar subluxation of the APL and EPB tendons

Additional Reading

Ilyas A, Ast M, Schaffer AA, et al. De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 2007;15:757–764.

Ilyas AM. Nonsurgical treatment for de Quervain's tenosynovitis. J Hand Surg [Am]. 2009;34:928–929.

Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone and bupivacaine in the management of de Quervain's disease. Skeletal Radiol. 2009.

Peters-Veluthamaningal C, van der Windt DA, Winters JC, et al. Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database Syst Rev. 2009:CD005616.

Richie CA, Briner WW. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. 2003;16:102–106.

Codes

ICD9

727.04 Radial styloid tenosynovitis