De Quervain’s Tenosynovitis

DEFINITION

Irritation of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons on the radiodorsal aspect of the wrist.

SYNONYMS

• Stenosing tenosynovitis of the first dorsal compartment.

• Radial styloid tenosynovitis.

De-Quervain's-Tenosynovitis

ETIOLOGY

• Pathologically, de Quervain’s tenosynovitis refers to chronic irritation of the EPB and APL tendons as they pass deep to the extensor retinaculum in the first dorsal compartment.

• The pathology occurs secondary to overuse or misuse, often the result of a change in customary use patternsfor the wrist and thumb, and leads to inflammation.The condition may be precipitated by discrete trauma,such as a blow to the wrist,but onset is usually gradual.

• Initially, physical irritation results in acute inflammation of the tendon sheath. Over time, chronic degenerative changes develop as a result of this inflammation, leading to tendinosis.

EPIDEMIOLOGY AND 

DEMOGRAPHICS

This relatively common problem is equally frequent in people of all races but is somewhat more common in women than men.

MECHANISM OF INJURY

Repeated wrist radial deviation and/or thumb palmar or radial abduction, especially under load.

De-Quervain's-Tenosynovitis

COMMON SIGNS AND 

SYMPTOMS

Pain in the radial aspect of the wrist,especially over the involved tendons, refers into the thumb and up the radial side of the forearm.

AGGRAVATING ACTIVITIES

Activities involving wide grip and resistance to ulnar deviation such as pouring from a bottle of milk, using a hammer, or lifting an infant.

EASING ACTIVITIES

• Rest

• Ice

• Splinting (thumb spica)

• Possibly heat, if chronic

• Avoiding aggravating  activities

24-HOUR SYMPTOM PATTERN

Symptoms are generally worse with activity and may seem worse at night when distractions are absent.

PAST HISTORY FOR THE REGION

• Recurrent episodes are  common.

• Work requiring aggravating activities is often cited.

• Onset in women after the birth of a child is probably caused by altered hand use in lifting the infant and positioning for breast feeding.

PHYSICAL EXAMINATION

• Tenderness over the  involved tendons may be severe.

• Resisted use of the involved tendons will be painful.

• There may be visible or  palpable edema in the radial side of the wrist.

IMPORTANT OBJECTIVE TESTS

Finkelstein’s test, which involves active flexion of the thumb into the palm, closing a fist over it, and then ulnarly deviating the wrist, is the gold standard for testing de Quervain’s tenosynovitis.

DIFFERENTIAL 

DIAGNOSIS

• Scaphoid fracture

• Scapholunate dissociation

• Thumb CMP joint arthritis

• Intersection syndrome

• Local radial sensory nerve     irritation.

• Radial nerve impingement in the arm.

• C6 radiculopathy

CONTRIBUTING FACTORS

Wearing constrictive watches or bracelets may increase irritation on the tendons.

De-Quervain's-Tenosynovitis

TREATMENT

SURGICAL OPTIONS

• The usual surgery is a release of the first dorsal compartment.

• Surgery is often successful but technically challenging.

• Problems include failure to release all slips of the tendon,injury to the superficial radial nerve, and tendon adhesions in the scar bed.

• Surgery should be considered if 6 to 8 conservative treatments do not relieve symptoms at least 75%.

REHABILITATION

• Without surgery, the most important single aspect of treatment is protecting the tendons from stress through activity modification and splinting (thumb spica splint). Modalities, including heat, ice, ultrasound, and iontophoresiswith dexamethasone, play a secondary role in recovery.

• After surgery, the patient may need a splint to protect the area while healing. Activity modification remains important to prevent recurrence. Scar mobilization and joint mobilization may assist in restoration of motion, as may therapeutic exercises. Gentle strengthening of EPB and APL will minimize scarring around the tendons.

• Initially, exercise may worsen the condition until the inflammation has been controlled.

• Later in recovery or when tendinosis suspected,careful progression of eccentric palmar abduction exercises for the thumb may be helpful.

PROGNOSIS

• DeQuervain’stenosynovitis may resolve if treated promptly and if biomechanical aggravating factors are well controlled.

• Recurrences are common, probably a result of the patient returning to prior provocative activities.

SIGNS AND SYMPTOMS 

INDICATING REFERRAL 

TO PHYSICIAN

The patient should be referred to a physician if the symptoms started after a fall (scaphoid injury should be ruled out) or if conservative treatment is not producing marked improvement in a few weeks.

SUGGESTED READINGS

- Foye PM, Stitik TP. DeQuervain tenosynovitis. Retrieved April 21, 2008 http://www.emedicine.com/pmr/TOPIC36.HTM; 2006.