De Quervain's tenosynovitis is the most common entrapment tendonitis of hand and wrist after trigger finger. It is most commonly seen in women between 30 and 50 years of age. It refers to entrapment tendonitis/tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius. It is most often a cumulative movement disorder due to chronic overuse of the wrist and hand. Bilateral or unilateral tenosynovitis may also accompany pregnancy, direct trauma, and systemic diseases such as rheumatoid arthritis and calcium apatite deposition disease.
De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist, resulting in pain during thumb motion. In most cases pain may be self-limiting but in some cases injection treatment and surgery may need to be considered if conservative management fails.
de Quervain’s tenosynovitis affects two thumb tendons: the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). These tendons are responsible for extending the thumb backwards and for moving the thumb away from the palm of the hand. These tendons connect their respective muscles in the forearm to the thumb. On their way to the thumb, the APL and EPB traverse side-by-side through a thick fibrous sheath that forms a tunnel at the radial styloid process. Normally, the APL and EPB glide easily back and forth within this tunnel.
Repetitive or unaccustomed use of the thumb that involves pinching with the thumb while moving the wrist in radial and ulnar directions (eg, gripping and grasping) leads to thickening of the fibrous tendon sheath. Thickening results in inflammation and stenosis as the tendon sheath passes over the distal radius. Left untreated, this friction-induced tenosynovitis can progress to fibrosis and loss of flexibility of the thumb in flexion (stenosing tenosynovitis).
Direct trauma to the first extensor (dorsal) compartment in the region of the radial styloid can also lead to inflammation in this region, subsequently leading to de Quervain’s tenosynovitis. In addition, systemic diseases like rheumatoid arthritis or calcium apatite deposition disease may lead to synovitis of the wrist, which may sometimes lead to de Quervain’s tenosynovitis.
Patients with de Quervain’s tenosynovitis typically note pain at the radial side of the wrist during pinch grasping or during thumb and wrist movement. Pain may radiate to the thumb or up to the volar aspect of the wrist. The patient may complain of difficulty gripping and often rubs over the radial styloid when describing the condition. The patient may present with painful swelling or enlargement of the first extensor (dorsal) compartment. Patients often have tenderness and thickening at the radial styloid. Crepitation as seen in carpal-metacarpal (CMC) joint osteoarthritis is absent.
Mothers caring for infants may be affected, and symptoms are often noted in both wrists. Daycare workers and other persons who repetitively lift infants are frequently affected as well.
In the absence of trauma to the distal radius, radial styloid tenderness coupled with pain aggravated by resisting thumb extension is highly suggestive of active tenosynovitis. A positive Finkelstein test provides further confirmation of the diagnosis, although the test also can be positive in patients with carpometacarpal (CMC) osteoarthritis of the thumb.
X-rays of the wrist and thumb are not usually necessary in most patients. Plain films of these areas are normal in patients with de Quervain’s tenosynovitis; calcification of the affected tendons does not occur. However, x-rays may be helpful in identifying CMC osteoarthritis as a potential cause of local pain, although the two conditions can often coexist. In patients suspected of a distal radial bone tumor or of an occult scaphoid fracture, a radiograph may also be of benefit.
The goals of treatment of de Quervain’s tenosynovitis are to reduce inflammation in the tenosynovial sac, to prevent the formation of adhesions, and to prevent recurrent tendinitis (with exercises and altering lifting and grasping).
Injection of local anaesthetic and steroid into the sheath of the first extensor (dorsal) compartment is indicated if pain or swelling is persistent for two to six weeks despite conservative treatment. The injection may be repeated at four to six weeks if needed. It is important to inject the medication into the sheath of the first extensor (dorsal) compartment and not subcutaneously. Adverse effects of subcutaneous injection of steroid in this region include fat and dermal atrophy, which may take up to six months to resolve.
Surgical consultation is indicated if symptoms are recurrent or persist inspite of steroid injections. Surgery involves decompression of the first extensor (dorsal) compartment with or without tenosynovectomy.
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