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De Quervain Tenosynovitis

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Topic updated on 11/13/17 11:48am

Snapshot
  • A 32-year-old secretary presents with pain over the radial side of her right wrist. She denies any history of wrist trauma. Her pain is aggravated by carrying her 3-month-old son. She is swollen and tender over the radial styloid. Finkelstein test is positive. Radiographs are normal without signs of osseous abnormalities.
Introduction
  • Clinical definition
    • stenosing tenosynovial inflammation of the first dorsal compartment tendons
      • abductor pollicis longus (APL)
      • extensor pollicis brevis (EPB)
  • Epidemiology
    • incidence
      • common cause of radial-sided wrist pain
    • demographics
      • women more likely than men
      • adults more likely than children
    • risk factors
      • repetitive wrist motion
        • new mothers and day care workers
          • caused by frequent lifting of babies
        • assembly line workers
        • secretaries
        • golfers and racquet sports players
      • traumatic wrist injury
  • Etiology
    • posttraumatic
    • overuse injury
  • Pathoanatomy
    • normal anatomy
      • wrist has 6 dorsal compartments ordered from radial to ulnar
        • 1 - abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
        • 2 - extensor carpi radialis longus (ECRL) and brevis (ECRB)
        • 3 - extensor pollicis longus (EPL)
        • 4 - extensor digitorum communis (EDC) and extensor indices (EI)
        • 5 - extensor digiti minimi (EDM)
        • 6 - extensor carpi ulnaris (ECU)
      • extensor retinaculum overlies the dorsal compartments
    • pathophysiology
      • extensor retinaculum thickens and swells leading to friction with tendon movement
  • Prognosis
    • 90% will resolve within 1 year
Presentation
  • Symptoms
    • radial-sided wrist pain
      • aggravated by thumb and wrist motion
  • Physical exam
    • Finkelstein test
      • ulnar deviation of the hand with the thumb flexed elicits pain
    • tenderness at radial styoid along APL and EPB tendons
    • no tenderness proximally along APL and EPB muscle bellies
Imaging
  • Radiography
    • indications
      • needed to rule out bony conditions that could be causing radial sided wrist pain
    • findings
      • normal in De Quervain tenosynovitis as condition is limited to soft tissues (e.g., tendons and fascia)
Differential
  • Osteoarthritis of the 1st carpometacarpal joint (base of the thumb) 
    • distinguishing factors
      • will demonstrate osteoarthritic changes at the base of the thumb on radiography
      • typically presents over months to years
  • Intersection syndrome (tenosynovitis where the 1st and 2nd dorsal compartments cross)
    • distinguishing factors
      • pain is less radial and more proximal than De Quervain tenosynovitis (2 inches proximal to the wrist)
Treatment
  • Nonoperative
    • rest, NSAIDs, splinting, and steroid injection 
      • indication
        • first-line treatment
      • technique
        • thumb spica splint 
        • steroid injections into first dorsal compartment  
  • Operative
    • surgical release of 1st dorsal compartment 
      • indications
        • severe disease that does not improve with non-operative management
Complications
  • Superficial radial nerve injury
    • surgical complication due to nerve passing directly over first dorsal compartment
    • supplies sensory function along radial thumb
  • Neuroma


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