De Quervain tenosynovitis

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Background

  • Tenosynovitis of abductor pollicis longus (APL), extensor pollicis brevis (EPB)
    • Groove of radial styloid
    • First extensor compartment
  • Middle-aged, more common in women
  • Associated with rheumatoid arthritis, SLE
  • Overuse of the thumb[1]
    • Classically mothers that frequently lift infants
    • Or secretarial, nursing occupations
    • Recently, over-texting on phones has increasingly been the culprit
extensor compartments of wrist

Clinical Features[2]

  • Pain along radial aspect of wrist (may radiate to thumb or extend into the forearm)
  • Painful abduction of thumb
  • Decreased grip strength
  • Swelling at tendon sheath along radial styloid
  • Positive Finkelstein, pathognomonic
    • Patient grasps thumb in palm of the hand and ulnar deviates the thumb and hand
    • Stretches the tendons over the radial styloid producing sharp pain
  • Negative Phalen and Tinel test

Differential Diagnosis

Hand and finger injuries

Workup

  • ESR usually normal[3]
  • Consider arthrocentesis for joint effusion to evaluate for crystals, gram stain, culture

Imaging[4]

  • Plain films usually nondiagnostic
    • May see soft tissue swelling or radial styloid sclerosis or erosion
    • Important to rule out fracture, gas formation, late osteomyelitis
  • US diagnostic
    • Thickened extensor retinaculum overlying radial styloid
    • Thickened APL and EPB under extensor retinaculum, as contrasted with unaffected wrist
    • Edema surrounding tendons within first dorsal wrist compartment
    • Surrounding hyperemia on Doppler within peritendinous subcutaneous area
    • Intertendinous septum (hypoechoic area between EPB and APL) increases need for operative management[5]
Presence of intertendinous septum
APL and EPB not separated by septum

Management

  • Splint thumb and wrist
    • Instruct patient to remove splint briefly each day to perform range-of-motion exercises
  • NSAIDs for 10-14 days
  • Persistent cases may require steroid injection or surgical decompression
  • First steroid injection provides permanent relief in ~50%
    • Second steroid injection > 1 mo later curative in another 40%[6]
    • 0.5-1 cc of 1% lidocaine
    • Plus 0.5-1 cc of long acting steroid (methylprednisolone acetate, triamcinolone)[7]
  • Intertendinous septum presence increases likelihood of needing surgery[8]

Disposition

  • Rheumatology referral for joint injections and conservative treatment
  • Hand surgery outpatient referral for failed conservative management

See Also

References

  • Diop AN, Ba-Diop S, Sane JC et-al. [Role of US in the management of de Quervain's tenosynovitis: review of 22 cases] J Radiol. 2008;89 (9 Patient 1): 1081-4.
  • Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. 2007;31 (2): 265-8.
  1. Ashurst JV et al. Tenosynovitis Caused by Texting: An Emerging Disease. The Journal of the American Osteopathic Association, May 2010, Vol. 110, 294-296.
  2. Keon-Cohen B. De Quervain disease. J Bone Joint Surg Br. 1951;33-B(1):96-99 http://www.jbjs.org.uk/cgi/reprint/33-B/1/96.
  3. Ferri FF. Ferri's CLinical Advisor 2013. Elsevier Health Sciences, Jun 1, 2012.
  4. Kamel M, Moghazy K, Eid H, Mansour R. Ultrasonographic diagnosis of de Quervain tenosynovitis. Ann Rheum Dis. 2002;61(11):1034-1035. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1753934/pdf/v061p01034.pdf.
  5. Kwon BC et al. Sonographic Identification of the Intracompartmental Septum in de Quervain’s Disease. Clin Orthop Relat Res. 2010 Aug; 468(8): 2129–2134.
  6. Pagonis T, Ditsios K, Toli P, Givissis P, Christodoulou A. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. Am J Sports Med. 2011 Feb. 39(2):398-403.
  7. Stephens MB. Musculoskeletal Injections: A Review of the Evidence. Am Fam Physician. 2008 Oct 15;78(8):971-976.
  8. Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. (2004) ISBN:0721629202.