De Quervain's Tenosynovitis

Introduction

A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes
- abductor pollicis longus (APL)
- extensor pollicis brevis (EBP)
Epidemiology
- common in
  - woman 30-50 years
  - racquet sports
Pathophysiology
- causes include
  - idiopathic
  - overuse
    - golfers and racquet sports
  - post-traumatic
  - postpartum

Anatomy

Extensor tendon compartments

Presentation

Symptoms
- radial sided wrist pain
Physical exam
- Finkelstein provocative maneuver
  - ulnar deviated wrist with thumb clenched in fist
  - tenderness over 1st dorsal compartment at level of radial styloid
    - location of tenderness differentiates from intersection syndrome (tenderness 5cm proximal to wrist joint)

Imaging

Radiographs
- recommended views
  - radiographs not indicated

Treatment

Nonoperative
- rest, NSAIDS, thumb spica splint, steroid injection
  - indications
    - first line of treatment
  - technique
    - steroid injections into first dorsal compartment
Operative
- surgical release of 1st dorsal compartment
  - indications
    - severe symptoms and nonoperative management has failed

Surgical Techniques

Surgical release of 1st dorsal compartment
- approach
  - transverse incision with release on dorsal side of 1st compartment to prevent volar subluxation of the tendon
    - has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-osseous compartment
    - a distinct EPB sheath is often encountered dorsally

Complications

Sensory branch of radial nerve injury
Neuroma formation
Failure to decompress with recurrence
- may be caused by failure to recognize and decompress EPB or APL lying in separate subsheath/compartment
Complex regional pain syndrome

TAG

(OBQ08.9) A 31-year-old mother of a 2-month-old infant complains of radial sided wrist pain. Corticosteroid injections should be directed into what anatomic area? Topic

Review Topic

1. First carpometacarpal joint
2. Carpal tunnel
3. First dorsal compartment near the radial styloid
4. A1 pulley of thumb
5. At the crossing of the first and second dorsal compartments

PREFERRED RESPONSE ▶

DISCUSSION: There is an association between the postpartum state and de Quervain’s tenosynovitis. De Quervain’s is a pathologic process of the 1st dorsal (extensor) compartment which contains the extensor pollicis brevis and abductor pollicis longus tendons. The best choice is #3 because of the very common and known association of postpartum state and de Quervain’s as well as the potential for resolution with appropriately placed steroid injection. Answer #1 refers to basal joint arthritis which is typically seen in older patients. Answer #2 refers to carpal tunnel syndrome, which would present with paresthesias in the median nerve distribution. Answer #4 refers to a trigger thumb. Answer #5 alludes to intersection syndrome which is generally more proximal to the wrist and results from inflammation at crossing point of 1st dorsal compartment (APL and EPB) and 2nd dorsal compartment (ECRL, ECRB). To review, the wrist extensor compartments (from radial to ulnar) are: 1) APL & EPB; 2) ECRL & ECRB (common radial wrist extensors); 3) EPL; 4) EIP & EDC; 5) EDM; 6) ECU.

REFERENCES:

1. Wolfe SW:Tenosynovitis, In Green DP, Hotchkiss RN,Pedereson WC, et al (eds): Green's Operative Hand Surgery, Edition 5, Philadephia, PA Elsevier, 2005, PP 2137-2158

2. Schned ES. DeQuervain tenosynovitis in pregnant and postpartum women. ObstetGynecol. 1986 Sep;68(3):411-4. PMID:3488531 (Link to Abstract)

Question Authors:

Doug Nowak MD, Derek Moore, Guillem Lomas MD,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Wolfe SW:Tenosynovitis, In Green DP, Hotchkiss RN,Pedereson WC, et al (eds): Green's Operative Hand Surgery, Edition 5, Philadephia, PA Elsevier, 2005, PP 2137-2158
Schned ES. DeQuervain tenosynovitis in pregnant and postpartum women. ObstetGynecol. 1986 Sep;68(3):411-4. PMID:3488531 (Link to Abstract)

	Dequervain's Tendonitis Injection Hand - Treatment Consult - De Quervain's Tenosynovitis Demonstrates 1st extensor compartment anatomy and injection technique	2/22/2013 393 views 5
	Dequervain's tenosynovits release Hand - Surgical Techniques - De Quervain's Tenosynovitis Shows Dequervain's 1st extensor compartment release	7/4/2012 772 views 3

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