De Quervain’s Tenosynovitis

Introduction

De Quervain’s tenosynovitis is inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.

It is most common in women between the ages of 30-50, especially in those with occupations or hobbies involving repetitive movements of the wrist.

In this article, we shall look at the pathophysiology, clinical features and management of De Quervain’s tenosynovitis.

The Extensor Compartment of the Wrist

There are 6 extensor compartments on the dorsal aspect of the wrist, each containing separate tendon groups (from lateral to medial):

(1) Extensor pollicis brevis and abductor pollicis longus (2) Extensor carpi radialis longus and brevis (3) Extensor pollicis longus (4) Extensor indicis and extensor digitorum (5) Extensor digiti minimi (6) Extensor carpi ulnaris

De Quervain’s tenosynovitis involves the tendons of the extensor pollicis brevis and abductor pollicis longus.

Figure 1 – Cross section of the muscles of the distal forearm, highlighting those of the posterior compartment


Risk Factors

The main risk factors for developing De Quervain’s tenosynovitis include:

  • Age – most common between 30 and 50 years
  • Female gender
  • Pregnancy

Certain occupations or hobbies, especially those that involve repetitive movements of the hand and wrist, also increase the risk of developing the condition.


Clinical Features

Patients with De Quervain’s tenosynovitis will often complain of pain near the base of the thumb with an associated swelling (secondary to thickening of the tendon sheath). Movements involving grasping or pinching are particularly painful and difficult

On examination, there will be swelling and palpable thickening over the tendon group fibrous sheath. Finkelstein’s test is often positive.

Finkelstein’s Test

The patient makes fist over their thumb, placing the thumb inside a closed fist and ulnar deviates their wrist. In a positive test, pain felt in the radial styloid region.

This test can be painful even in the absence of De Quervain’s tenosynovitis, so check bilaterally for any markedly increased pain on a specific side.


Differential Diagnosis

  • Arthritis of Carpometacarpal (CMC) joint – more gradual in onset, usually with a negative Finkelstein’s Test and positive Grind test.
    • The Grind test involves forcefully pushing thumb against CMC joint whilst also rotating it slightly, with a positive result producing pain felt on the volar side of the wrist.
  • Intersection syndrome – tendons of the first compartment cross over with those of the second compartment, resulting in pain felt over the second compartment.
  • Wartenberg’s syndrome – neuritis of the superficial radial nerve, often seen in those wearing tight jewellery.

Figure 2 – A normal wrist X-ray, as seen in cases of De Quervain’s tenosynovitis

Investigations

De Quervain’s tenosynovitis is a clinical diagnosis, with no investigations required. However, a plain hand radiograph (Fig. 2) may be used to exclude other diagnoses (such as CMC joint arthritis)


Management

Conservative management of De Quervain’s tenosynovitis involves lifestyle advice (avoiding repetitive actions) and a wrist splint. Steroid injections will reduce swelling and relieve pain in most cases, and can be repeated several times if a good response is observed.

For those options failing to respond to conservative management, surgical decompression of the extensor compartment can be performed under local or general anaesthetic. This involves a transverse or longitudinal incision made and the tendon sheath split in the central aspect in a longitudinal direction, thus allowing the tunnel roof to form again as it heals but wider and with more space for the tendons to move.

Complications from surgical decompression include failure to resolve, reduce range of movements in wrist or hand, neuroma formation, and nerve impingement.

Key Points

  • De Quervain’s tenosynovitis is inflammation of the tendons within the first extensor compartment of the wrist
  • Patients present with pain and swelling, often positive for Finkelstein’s Test
  • Most cases can be managed conservatively with wrist splints and steroid injections, yet surgical decompression is available for resistant cases

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