You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY De Quervain TenosynovitisArticle Last Updated: Nov 16, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Roy A Meals, MD, Clinical Professor, Department of Orthopedic Surgery, University of California at Los Angeles Roy A Meals is a member of the following medical societies: American Society for Surgery of the Hand Editors: Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: first dorsal compartment stenosing tendinitis, de Quervain tendinitis, de Quervain's tendinitis, de Quervain's tenosynovitis, de Quervain disease, de Quervain's disease, abductor pollicis longus, extensor pollicis brevis, entrapment tendinitis, Finkelstein test, tendovaginitis INTRODUCTIONSection 2 of 10
  History of the ProcedureIn 1895, a Swiss surgeon, Fritz de Quervain, published 5 case reports of patients with a tender, thickened first dorsal compartment at the wrist.1, 2 The condition has subsequently borne his name. ProblemDe Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist; it causes pain during thumb motion. (See also the eMedicine articles De Quervain Tenosynovitis [in the Physical Medicine and Rehabilitation section] and Tenosynovitis.) FrequencyThe most common entrapment tendinitis of the hand and wrist is trigger digit, followed by de Quervain tenosynovitis, although the latter occurs approximately one twentieth as often as does trigger digit. EtiologyThe tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath. Efforts at thumb motion, especially when combined with radial or ulnar deviation of the wrist, cause pain and perpetuate the inflammation and swelling. ClinicalPatients note pain resulting from thumb and wrist motion, along with tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. Patients frequently are mothers of infants aged 6-12 months, and symptoms are often noted in both wrists. Repetitive lifting of the baby as it grows heavier is responsible for friction tendinitis. Day care workers and other persons who repetitively lift infants are frequently affected as well. De Quervain tenosynovitis can also develop in individuals who have sustained a direct blow to the area of the first dorsal compartment. Examination The first dorsal compartment over the radial styloid becomes thickened and feels bone hard; the area becomes tender. Usually, the compartment's thickening so distorts the sparsely padded skin in this area that a visible fusiform mass is created (see Image 1). The Finkelstein test (consisting of flexion of the thumb across the palm and then ulnar deviation of the wrist) causes sharp pain at the first dorsal compartment (see Image 2).3 Tenderness is absent over the muscle bellies proximal to the first dorsal compartment. Tenderness and pain on axial loading are absent at the carpometacarpal (CMC) joint unless the patient has arthritis in that joint. For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Tendinitis. RELEVANT ANATOMYSection 3 of 10
The tendons of the abductor pollicis longus and the extensor pollicis brevis pass through the first dorsal compartment. The abductor pollicis longus tendon is usually multistranded. The extensor pollicis brevis tendon is typically much smaller than even a single slip of the abductor pollicis longus tendon, and it may be congenitally absent. A septum separating the first dorsal compartment into distinct subcompartments for the abductor pollicis longus tendons and the extensor pollicis brevis tendon is often noted at surgery.4 WORKUPSection 4 of 10
Imaging Studies
TREATMENTSection 5 of 10
Medical therapySplinting of the thumb and wrist relieves symptoms, but most patients find the loss of the thumb for functional activities too restrictive and do not consistently wear the splints. Injection of corticosteroid into the sheath of the first dorsal compartment reduces tendon thickening and inflammation.5 A dose of 0.5 mL of 1% plain Xylocaine and 0.5 mL of a long-acting corticosteroid preparation can be injected either sequentially or simultaneously. One injection permanently relieves symptoms in roughly 50% of patients. A second injection given at least a month later permanently relieves symptoms in another 40-45% of patients. (See also the article Corticosteroid Injection for Treatment of de Quervain's Tenosynovitis: A Pooled Quantitative Literature Evaluation, on Medscape.) Caution should be exercised to ensure that the injection is placed in the sheath rather than subcutaneously, where corticosteroids can lead to fat and dermal atrophy. Atrophy causes a hollowing-out of the skin and a loss of normal pigmentation. Although these atrophic changes generally resolve over 6 months, their presence is disturbing to most patients. Surgical therapyIf injection therapy fails, surgical release of the first dorsal compartment relieves the entrapment. Preoperative detailsSurgical release of de Quervain tenosynovitis is an outpatient procedure. The operation can be performed under local or regional anesthesia, depending on surgeon preference. Use of a tourniquet precludes intraoperative bleeding and facilitates the identification of structures. Intraoperative detailsA 3-cm incision is placed over the prominent thickening of the first dorsal compartment. A transverse skin incision is preferred because it provides better appearance of the scar in this highly visible area. Once the skin is incised, only longitudinal, blunt dissection is used until the first dorsal compartment is exposed. This minimizes the risk of sharp injury to the superficial radial nerve, which runs superficial to the first dorsal compartment. Along its dorsal margin, the first dorsal compartment is sharply opened longitudinally for approximately 2 cm. The tendon(s) are inspected to ensure that the abductor pollicis longus and the extensor pollicis brevis are released. If present, a septum separating the 2 motor units can be deceiving.6 Gently moving the patient's thumb distinguishes one tendon from the other. If a tendon glides with metacarpophalangeal (MCP) joint motion, it belongs to the extensor pollicis brevis. If a septum between the abductor pollicis longus and the extensor pollicis brevis is identified, it also is released. Surgeons have personal preferences regarding the management of the sheath. Some excise a portion, and others make a step-cut and then suture a strip of sheath back loosely over the exposed tendons. The author obtains good results without sheath excision or reconstruction by releasing just the thickened portion of the first dorsal compartment and leaving in place the transparent fascia overlying the tendons proximal and distal to the first dorsal compartment. The skin is sutured. Patients generally appreciate the diminished disfigurement from the placement of a subcuticular skin closure. A soft, dry, circumferential wrist dressing is placed for a week. Postoperative detailsEarly use of the hand for self-care and light activities is encouraged. The suture is removed approximately 10 days after surgery. Thereafter, patients may rapidly resume full activities. Some surgical-site tenderness is expected for several months. COMPLICATIONSSection 6 of 10
Although de Quervain tenosynovitis features a simple tendon entrapment and the treatment is quick and straightforward, complications can be profound and permanent.7 Careful attention to surgical technique at the initial release is paramount to avoiding complications. Superficial radial nerve injury is the most irksome complication. Sharp injury, traction injury, or adhesions in the scar can cause neuritis in this high-contact area, greatly limiting hand and wrist function. This complication is best avoided through careful blunt dissection of the subcutaneous tissue and gentle traction. Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longus are mistaken for the tendons of the abductor pollicis longus and the extensor pollicis brevis. In such a case, the extensor pollicis brevis tendon may remain entrapped within the septated first dorsal compartment. Should repeat cortisone injections fail to relieve symptoms, careful surgical re-exploration may allow a previously overlooked tendon to be released. Subluxation of released tendons is possible.8 With wrist flexion and extension, the tendons of a widely released first dorsal compartment snap over the radial styloid. This complication is best avoided by carefully limiting the release to the thickest mid–2 cm of the first dorsal compartment or by reconstructing a loose roof to the released sheath. Reconstruction of the sheath with a slip of local tissue may relieve symptoms. OUTCOME AND PROGNOSISSection 7 of 10
Relief is permanent following successful surgery. Some patients who have been successfully treated with injections may have recurrent symptoms when they return to lifting infants aged 6-12 months. This author would suggest the following: relief is usually permanent. FUTURE AND CONTROVERSIESSection 8 of 10
Surgeons have had more than 100 years of experience with de Quervain tenosynovitis. The described treatment is widely accepted, and no significant controversies exist. No significant changes in diagnosis and treatment are anticipated for this lowly, yet irksome, condition. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
De Quervain Tenosynovitis excerpt Article Last Updated: Nov 16, 2007 | ||||||||||||||
