Updated: 12/28/2021

De Quervain Tenosynovitis

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  • 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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(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?

QID: 109250

Radiography of the wrist

24%

(9/37)

Thumb spica cast

16%

(6/37)

Wrist guard to be worn during work and at night

16%

(6/37)

Repositioning of the wrist while cycling

3%

(1/37)

Rest and ibuprofen

38%

(14/37)

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