Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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de Quervain Tenosynovitis (Thumb Extensor)

Basics
Description
  • Thumb extensor or de Quervain tendinitis is stenosing tenosynovitis of the 1st dorsal compartment of the wrist, which contains the abductor pollicis longus and the extensor pollicis brevis.
  • Patients present with pain and discomfort on the radial aspect of the wrist.
  • It often occurs in middle-aged females, although males and females of all ages can be affected.
Epidemiology
Incidence
This condition is common-up to 6 times more common in females than in males.
 
Risk Factors
Frequently seen in new mothers, in part secondary to repetitive lifting and setting down of the baby.
 
Etiology
  • Repetitive motions of thumb or wrist
  • Associated with:
    • Racquet sports
    • Fly fishing
    • Golf (often affecting the nondominant hand in golfers)
    • Infant care
  • Can be associated with rheumatoid arthritis
Associated Conditions
Rheumatoid arthritis

Diagnosis
Signs and Symptoms
  • Pain and tenderness on the radial aspect of the wrist, often isolated to directly over the 1st dorsal compartment
  • Pain and discomfort exacerbated by extension or abduction of the thumb with simultaneous ulnar deviation of the wrist
  • Repetitive activities particularly painful
Physical Exam
  • Note pain, tenderness, swelling, bogginess, and crepitus over the 1st dorsal compartment of the wrist and the radial aspect of the radial styloid.
  • A positive Finkelstein test helps confirm the diagnosis: Exacerbation of the symptoms (pain) with the thumb clenched in the palm and ulnar deviation of the wrist.
  • Examine the 1st CMC joint, use the grind test, and assess ROM to rule out degenerative joint disease; degenerative joint disease and de Quervain syndrome can coexist:
    • Intersection syndrome is rarer than de Quervain and often is associated with more severe symptoms.
    • On physical examination, the pain localizes 4 cm proximal to the wrist, rather than over the radial styloid, as in de Quervain syndrome.
Tests
Lab
No serum laboratory tests are needed.
 
Imaging
AP and lateral views of the wrist and 1st CMC views are helpful in ruling out other disorders and in differentiating between degenerative joint disease of the 1st CMC and de Quervain syndrome.
 
Pathological Findings
  • The dorsum of the wrist is divided anatomically into 6 separate extensor tendon compartments.
    • The 1st compartment contains the abductor pollicis longus and extensor pollicis brevis, which can become inflamed and irritated as they enter and pass through the rigid fibro-osseous tunnel of the 1st compartment.
    • Intersection syndrome is thought to be an inflammatory condition that exists at the point where the 1st and 2nd dorsal compartment (the ECRL and ECRB) cross; this site of intersection is ~4 cm proximal to the wrist.
Differential Diagnosis
  • Degenerative joint disease of the 1st (thumb) CMC joint
  • Intersection syndrome (much rarer)
  • Radiocarpal arthritis

Treatment
General Measures
As with most types of tendinitis, rest and avoidance of aggravating conditions are the mainstays of treatment.
 
Special Therapy
Physical Therapy
  • Splinting often is helpful to put the tendon at rest.
  • Iontophoresis (ultrasound through a corticosteroid cream) can help decrease the inflammation.
  • Stretching the wrist also may be helpful.
Medication
First Line
  • The 1st line of therapy is nonoperative care, which includes:
    • Immobilization of thumb and wrist, usually in a thumb spica splint.
    • NSAIDs.
    • Steroid injection into the 1st dorsal compartment; success rates for steroid injection range from 50-80%.
  • Recalcitrant or recurrent symptoms often require surgical release of the 1st dorsal compartment.
  • Decrease activity until symptoms resolve.
Second Line
Patients who have persistent pain despite nonoperative measures are candidates for surgical release of the 1st dorsal compartment.
 
Surgery
  • Positive response to injection should precede decision for surgery.
  • Make a radial incision over the 1st dorsal compartment with release of the fibro-osseous tunnel and all its septa, as well as the release of the fascial sheaths of each tendon and the compartment.
  • Incise the sheath on dorsal margin to prevent tendon subluxation.
  • Multiple anatomic variations are present.
Follow-up
Prognosis
The prognosis is good.
 
Complications
  • The most serious complication of surgical intervention is transection of the dorsal sensory radial nerve, which lies in proximity to the 1st dorsal compartment.
  • This complication can leave the patient with a small area of numbness/absence of sensation or, more seriously, with a painful neuroma, which often requires surgical resection.
Patient Monitoring
Patients are followed at 3-month intervals until their symptoms resolve.
 
Miscellaneous
Codes
ICD9-CM
727.04 de Quervain tendinitis
 
Patient Teaching
  • Patients are counseled to avoid repetitive activities that worsen the pain.
  • Attention to workplace ergonomics also is important.
FAQ
Q: What is the 1st line of treatment for de Quervain syndrome?
A: Thumb spica splint immobilization, anti-inflammatory medication, and therapy with modalities.
 
Q: Are any risks associated with corticosteroid injection?
A: Some localized hypopigmentation may occur after injection.
 
Q: What other diagnoses can cause radial-side wrist pain?
A: The differential diagnosis for de Quervain syndrome includes thumb CMC arthritis and radiocarpal arthritis. Thumb CMC arthritis is distinguished by pain over the thumb CMC joint, a positive grind test, and a negative Finkelstein test. Radiocarpal arthritis may be distinguished by pain over the radiocarpal joint and pain with radial deviation of the wrist, as compared with pain with ulnar deviation with de Quervain syndrome.

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