De Quervain’s Tenosynovitis
S. Brent Brotzman, MD, Steven J. Meyers, MD, and Kyle Phillips, PA
Background
This disorder is the most common overuse injury involving the wrist and often occurs in individuals who regularly use a forceful grasp coupled with ulnar deviation of the wrist (such as in a tennis serve).
Injury occurs because of inflammation around the tendon sheath of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) in the first dorsal compartment (Fig. 1–71A). Pain and tenderness localized over the radial aspect of the wrist (over the first dorsal compartment) are the typical presenting symptoms.
Finklestein test is diagnostic for de Quervain’s tenosynovitis (Fig. 1–71B). This test places stress on the APL and EPB by placing the thumb into the palm of a “fist,” then ulnarly deviating the wrist. Mild de Quervain’s may present with pain only on resisted thumb MCP joint extension.
The other possible causes of pain in the “radial dorsal pain” category include:
CMC arthritis of the thumb—pain and crepitance are present with the thumb “crank and grind test.” This test is done by applying axial pressure to the thumb while palpating the first CMC joint. (The crank and grind test is positive only with CMC arthritis of the thumb. Both de Quervain’s and CMC arthritis may have a “positive” Finklesteins test and pain on thumb motion; however, the crank and grind test will be positive only in arthritis of the basal joint [CMC] of the thumb.)
Scaphoid fracture—tender in the anatomic snuff box.
Chauffeur’s fracture—radial styloid fracture.
Intersection syndrome—more proximal pain and tenderness (see later in this chapter).
Conservative Management
A thumb spica splint is used to immobilize the first dorsal compartment tendons with a commercially available splint or, depending on the patient’s comfort, a custom-molded Orthoplast device. The splint maintains the wrist in 15 to 20 degrees of extension and the thumb in 30 degrees of radial and palmar abduction. The IP joint is left free, and motion at this joint is encouraged. The patient wears the splint during the day for the first 2 weeks and at night until the next office visit, generally at 6 to 8 weeks. Splinting may continue longer, depending on the response to treatment. The splint can be discontinued during the day if symptoms permit and if daily activities are gradually resumed. Workplace activities are advanced accordingly. Other considerations include:
A corticosteroid sheath injection can be offered to patients with moderate to marked pain or with symptoms lasting more than 3 weeks. The injection should individually distend the APL and EPB sheaths. Discomfort after injection is variable, and a 2- to 3-day supply of mild analgesic is recommended.
A systemic NSAID is commonly prescribed for the initial 6 to 8 weeks of treatment.
Thumb use is restricted so that the first dorsal compartment tendons are at relative rest. Activities that require prolonged thumb IP joint flexion, pinch, or repetitive motions are avoided.
Distal-to-proximal thumb Coban wrapping, retrograde lotion, or ice massage over the radial styloid.
Phonophoresis with 10% hydrocortisone can be used for edema control.
Gentle active and passive thumb and wrist motion are encouraged 5 minutes every hour to prevent joint contracture and tendon adhesions.
Operative Management
Symptoms are often temporarily relieved and the patient elects to repeat the management outlined previously. Unsatisfactory symptom reduction or symptom persistence requires surgical decompression.
Multiple separate compartments for the APL (which typically has two to four slips) and the EPB require decompression. Extreme caution in the approach will spare sensory branches of the lateral antebrachial cutaneous nerve and dorsal sensory branches of the radial nerve. Before decompression, the encasing circular retinacular fibers that are across the radial styloid should be exposed. The floor of this compartment is the tendinous insertion of the brachioradialis tendon, which sends limbs to the volar and dorsal margins of the compartment. The APL and EPB tendons may be difficult to differentiate, especially in the absence of septation. When this Y tendinous floor is identified, it can serve as a landmark to indicate decompression of the first dorsal compartment. |
