De Quervain Tenosynovitis
De Quervain Tenosynovitis is a stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the 1st dorsal compartment of the wrist. It was first described by Fritz de Quervain in 1895.
- Women are affected more frequently than men.
- Mostly in middle-aged group.
A similar description had been reported in the 1893 edition of Gray’s Anatomy and named “washer woman’s sprain”.
See Also: Extensor compartments of the wrist
De Quervain Tenosynovitis Causes
The most common cause of De Quervain Tenosynovitis is related to overuse in the home or at work.
Other causes or risk factors include:
- Rheumatoid arthritis.
- Golf players.
- Racquet-sport athletes.
- Wrist Trauma.
- Post partum or new mothers
- The process is attributed to activities requiring frequent abduction of the thumb and simultaneous ulnar deviation at the wrist.
- Tension on the tendons of the first dorsal compartment, if sustained and repeated, is said to produce friction at the rigid retinacular sheath, with subsequent swelling or narrowing of the fibro-osseous canal.
- Acute angulation of the tendons at the retinaculum occurs with wrist extension, and increased anatomic angulation of the tendons in women was suggested by Bunnell to help explain their markedly increased prevalence of the disease.
- Aberrant tendons and variations in anatomy of the tendons and their sheaths have been thought by several authors to contribute to the process and help explain the poor response to conservative treatment in certain individuals.
De Quervain Symptoms & Signs
Symptoms of De Quervain disease include:
- Pain and tenderness at the radial styloid that is aggravated by movement of the thumb.
- Sometimes a thickening of the fibrous sheath is palpable at the radial styloid.
Clinical Examination includes:
- Finkelstein test.
- Eichoff maneuver: local tenderness and swelling 1 to 2 cm proximal to the radial styloid and knife-like pain when the thumb is clasped in the palm and the wrist forced into ulnar deviation.
These two tests place first extensor compartment tendons under maximum tension and exacerbates symptoms.
De Quervain Tenosynovitis disease must be differentiated from other conditions that include:
- Intersection Syndrome: pain, swelling, and in severe cases, crepitus are found over the second dorsal compartment tendons more proximally.
- Trigger finger of the thumb: this may be related to the presence of a separate fibro-osseous tunnel and “pseudo-triggering” of the extensor pollicis brevis (EPB) tendon.
- Arthritis of the thumb carpometacarpal (CMC) or scaphotrapezial-trapezoid joints (or both): although these lesions may coexist because of their similar demographics. Radiographic study also excludes scaphoid fracture and arthrosis involving the radiocarpal or intercarpal joints.
De Quervain Tenosynovitis Treatment
The treatment of De Quervain Tenosynovitis starts with conservative treatment, then injection treatment and lastly a surgical treatment.
It’s the first line of treatment of De Quervain, it includes the following:
- Activity modification.
- Thumb spica splinting/bracing.
- Nonsteroidal antiinflammatory drugs (NSAIDs).
- Corticosteroid injections into the first dorsal extensor compartment.
Corticosteroid injections successful in more than 80% of patients, but it is less effective in patients with diabetes.
In de Quervain disease of pregnancy and lactation, nonoperative treatment is highly effective, and the condition tends to resolve after cessation of lactation.
Surgical Treatment of De Quervain Tenosynovitis is indicated if non-surgical methods failed to relieve the pain.
- The surgical treatment include surgical release of the first extensor compartment of the wrist with local infiltration of anesthesia.
- Use a transverse incision to protect the numerous superficial sensory nerves.
- It is recommended to incise the sheath on its most dorsal margin and leave a flap of palmar sheath to prevent subluxation of the tendons postoperatively.
- Identify both tendons, and inspect for the EPB subsheath; and excise the septa.
- Ask the patient to voluntarily move the thumb to confirm a complete release.
Complications of Surgical treatment
- Iatrogenic injury to the superficial sensory radial nerve.
- Tendon subluxation.
- Complex regional pain syndrome.
- Recurrence from incomplete release.
- Anatomical variations are common in the first dorsal compartment, and separate compartments have been noted
in 21% of anatomical specimens.
- Reports of separate compartments found at surgery vary from 20% to 58%. More than half of patients may have “aberrant” or duplicated tendons (usually the abductor pollicis longus).
- These tendons sometimes insert more proximally and medially than usual, into the trapezium, the abductor pollicis brevis muscle, the opponens pollicis muscle, or the muscle fascia.
- The extensor pollicis brevis is considered a “late” tendon phylogenetically and is absent in about 5% of wrists.
- The presence of these variations and failure to deal with them at the time of surgery may account for any persistence of pain.