De Quervains Tenosynovitis

Other Names

Washerwoman's Sprain or Strain
Stenosing Tenosynovitis
De Quervain's Tenosynovitis (DQTS)

Background

This page refers to stenosing tenosynovitis of the first dorsal (extensor) compartment of the wrist

History

Named after Swiss surgeon Fritz De Quervain

Epidemiology

Second most common entrapment tendinopathy of hand behind Trigger Finger (need citation)

Pathophysiology

General
Generally associated with overuse, although direct trauma can also be a source

Etiology

The extensor retinaculum creates a fibroosseus tunnel, securing the APL and EPB tendons
Thickening of the retinaculum from repetitive microtrauma restricts normal gliding
Subsequently, there is swelling, thickening, remodeling and ultimately stenosing of the sheath
- Note this is not generally considered to be an inflammatory process

Pathoanatomy

1st Dorsal Compartment^[1]
- Contains: Abductor Pollicis Longus (APL), Extensor Pollicis Brevis (EPB)

Risk Factors

Demographic
- Female > Male
- Middle Age
Occupational risk factors
- Mothers and childcare workers
- Secretarial occupations
- Nursing

Differential Diagnosis

DDx Finger and Hand Pain

Fractures
- Phalanx Fractures (Hand)
- Metacarpal Fractures
Dislocations
Tendinopathies
Ligament Injuries
- Gamekeepers Thumb (UCL)
- Radial Collateral Ligament of the Thumb Injury (RCL)
Neuropathies
Arthropathies
Nail Bed Injuries
Pediatric Considerations
- Proximal Phalanx Avulsion Fracture (Thumb)
- Middle and Distal Phalanx Avulsion Fracture
Other
- Dupuytrens Contracture
- Intrinsic Plus

DDx Wrist Pain

Fractures
Dislocations
- Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
- Carpometacarpal Joint Dislocation
- Distal Radioulnar Joint Dislocation
- Lunate Dislocation
- Perilunate Dislocation
Instability & Degenerative
Tendinopathies & Ligaments
Neuropathies
Pediatric Considerations
- Distal Radial Epiphysitis (Gymnast's Wrist)
- Torus Fracture
Arthropathies
Cartilage
- Osteochondral Defect
Vascular
- Hypothenar Hammer Syndrome
Other

Clinical Features

History
- Patients typically report gradual onset of pain in thumb and wrist
- Worse with movement
- They report pain specifically over the radial styloid
- Symptoms can be bilateral
Examination: Physical Examination Wrist
- They will be tender at some point along the tendon distribution, most commonly at radial styloid
- Triggering or crepitus may be appreciated
- Range of motion, neurovascular exam typically normal
Special Tests
- Finkelsteins Test: is positive (pain with passive ulnar deviation)
- Eichhoffs Test: Also typically positive
- WHAT Test: Wrist Hyperflexion and Abduction of the Thumb

Evaluation

Short axis view of De Quervain's. Thickening of tendon, hypoechoic fluid surrounds the EPB tendon. Note the difference compared to APL.^[2]

Radiographs

Standard Radiographs Wrist, Standard Radiographs Hand
- Standard for screening, may identify other etiology of symptoms
- Typically normal
- Can show soft tissue swelling, periosteal reaction

Ultrasound

Often diagnostic if clinical uncertainty exists
Findings
- Will show edema or thickening of tendons
- Increased fluid within the first extensor compartment
- Thickening of retinaculum
- "Hypoechoic Halo Sign": peritendous subcutaneus edema

MRI

Sensitive and specific for De Quervain's
- Helpful to evaluate for intertendinous septum, which increases likelihood of surgical intervention
Findings
- Increased fluid within tendon sheath
- Debris within sheath
- Thickened retinaculum
- Peritendinous subcutaneus edema and contrast enhancement

Management

Nonoperative

Indications
- Vast majority of cases
- Conservative treatment is very effective in treating this condition
Medications including NSAIDS
Corticosteroid Injection
- Sawaizumi et al studied 36 patients with DQTS, 50% of patients experience resolution of symptoms with 1 while another 40% experienced resolution after a second injectioninjection^[3]
- Harvey et al found an 80% success rate among 71 cases^[4]
- Use of ultrasound is recommended if possible, although not required
Thumb Spica Splint
Physical Therapy

Operative

Indications
- Refractory cases
Technique
- Surgery entails release of 1st dorsal compartment
- Intertendinous septum between APL And EPB increases likelihood of intervention

Rehab and Return to Play

Rehabilitation

Needs to be updated

Return to Play/ Work

Needs to be updated

Complications and Prognosis

Prognosis

Complications

Chronic pain syndrome
Superficial radial nerve injury
Subluxation
Neuroma
Complex Regional Pain Syndrome

References

↑ Anderson M, Tichenor CJ. A patient with de Quervain’s tenosynovitis: a case report using an Australian approach to manual therapy. Phys Ther. 1994;74(4):314–26.
↑ Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 51160
↑ Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. 2007;31 (2): 265-8. doi:10.1007/s00264-006-0165-0
↑ Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg. 1990;15A:83–7.

Created by:

John Kiel on 11 June 2019 01:53:32

Authors:

John Kiel

Last edited:

16 October 2022 00:19:30

Categories:

[1] Anderson M, Tichenor CJ. A patient with de Quervain’s tenosynovitis: a case report using an Australian approach to manual therapy. Phys Ther. 1994;74(4):314–26.

[2] Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 51160

[3] Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. 2007;31 (2): 265-8. doi:10.1007/s00264-006-0165-0

[4] Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg. 1990;15A:83–7.

[1]

[2]

[3]

[4]