Updated: 4/2/2020

De Quervain Tenosynovitis

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Overview
 

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)
  • 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
  • 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
  • Prognosis
    • 90% will resolve within 1 year
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
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
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.OR.17.4798) A 25-year-old mother presents to her primary care physician for wrist pain. The patient recently gave birth to a healthy newborn at 40 weeks gestation. Beginning one week ago, she started having pain over her wrist that has steadily worsened. The patient notes that she also recently fell while walking and broke the fall with her outstretched arm. The patient is an accountant who works from home and spends roughly eight hours a day typing or preparing financial statements. Recreationally, the patient is a competitive cyclist who began a rigorous training routine since the birth of her child. The patient's past medical history is notable for hypothyroidism that is treated with levothyroxine. On physical exam, inspection of the wrist reveals no visible or palpable abnormalities. Pain is reproduced when the thumb is held in flexion, and the wrist is deviated toward the ulna. The rest of the patient's physical exam is within normal limits. Which of the following is the best next step in management? Review Topic | Tested Concept

QID: 109250
1

Radiography of the wrist

29%

(8/28)

2

Thumb spica cast

11%

(3/28)

3

Wrist guard to be worn during work and at night

21%

(6/28)

4

Repositioning of the wrist while cycling

4%

(1/28)

5

Rest and ibuprofen

36%

(10/28)

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