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Updated: Dec 28 2021

De Quervain Tenosynovitis

  • Snapshot
    • A 32-year-old secretary presents with pain over the radial side of her right wrist. She denies any history of wrist trauma. Her pain is aggravated by carrying her 3-month-old son. She is swollen and tender over the radial styloid. Finkelstein test is positive. Radiographs are normal without signs of osseous abnormalities.
  • Introduction
    • Clinical definition
      • stenosing tenosynovial inflammation of the first dorsal compartment tendons
        • abductor pollicis longus (APL)
        • extensor pollicis brevis (EPB)
  • Etiology
    • Posttraumatic
    • Overuse injury
    • Pathoanatomy
      • normal anatomy
        • wrist has 6 dorsal compartments ordered from radial to ulnar
          • 1 - abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
          • 2 - extensor carpi radialis longus (ECRL) and brevis (ECRB)
          • 3 - extensor pollicis longus (EPL)
          • 4 - extensor digitorum communis (EDC) and extensor indices (EI)
          • 5 - extensor digiti minimi (EDM)
          • 6 - extensor carpi ulnaris (ECU)
        • extensor retinaculum overlies the dorsal compartments
      • pathophysiology
        • extensor retinaculum thickens and swells leading to friction with tendon movement
  • Epidemiology
    • Incidence
      • common cause of radial-sided wrist pain
    • Demographics
      • women more likely than men
      • adults more likely than children
    • Risk factors
      • repetitive wrist motion
        • new mothers and day care workers
          • caused by frequent lifting of babies
        • assembly line workers
        • secretaries
        • golfers and racquet sports players
      • traumatic wrist injury
  • Presentation
    • Symptoms
      • radial-sided wrist pain
        • aggravated by thumb and wrist motion
    • Physical exam
      • Finkelstein test
        • ulnar deviation of the hand with the thumb flexed elicits pain
      • tenderness at radial styoid along APL and EPB tendons
      • no tenderness proximally along APL and EPB muscle bellies
  • Imaging
    • Radiography
      • indications
        • needed to rule out bony conditions that could be causing radial sided wrist pain
      • findings
        • normal in De Quervain tenosynovitis as condition is limited to soft tissues (e.g., tendons and fascia)
  • Differential
    • Osteoarthritis of the 1st carpometacarpal joint (base of the thumb)
      • distinguishing factors
        • will demonstrate osteoarthritic changes at the base of the thumb on radiography
        • typically presents over months to years
    • Intersection syndrome (tenosynovitis where the 1st and 2nd dorsal compartments cross)
      • distinguishing factors
        • pain is less radial and more proximal than De Quervain tenosynovitis (2 inches proximal to the wrist)
    • Gamekeeper or Skier thumb (metacarpophlanageal ulnar ligament injury)
      • distinguishing factors
        • caused by radial deviation of the thumb (such as a skier getting their thumb stuck)
        • pain over medial aspect of thumb
          • laxity when lateral force is applied to the thumb
        • thumb spica placement or operative repair
    • Flexor tenosynovitis - a surgical emergency with infection of the flexor sheaths and deep spaces of the hand
      • distinguishing factors
        • pain, tenderness, and swelling over the flexor tendons with erythema and pain with passive rance of motion
      • management
        • broad spectrum antibiotics
        • emergency surgery
  • Treatment
    • Nonoperative
      • rest, NSAIDs, splinting, and steroid injection
        • indication
          • first-line treatment
        • technique
          • thumb spica splint
          • steroid injections into first dorsal compartment
    • Operative
      • surgical release of 1st dorsal compartment
        • indications
          • severe disease that does not improve with non-operative management
  • Complications
    • Superficial radial nerve injury
      • surgical complication due to nerve passing directly over first dorsal compartment
      • supplies sensory function along radial thumb
    • Neuroma
  • Prognosis
    • 90% will resolve within 1 year
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