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Updated: May 18 2023

De Quervain's Tenosynovitis

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https://upload.orthobullets.com/topic/6026/images/extensor compartments_moved.jpg
  • summary
    • De Quervain's Tenosynovitis is a stenosing tenosynovial inflammation of the 1st dorsal compartment.
    • Diagnosis is made clinically with radial sided wrist pain made worse with the Finkelstein maneuver.
    • Treatment is generally conservative with thumb spica braces, injections and in refractory cases, 1st dorsal compartment surgical release.
  • Epidemiology
    • Incidence
      • very common
        • ~1 per 1000 annually
    • Demographics
      • woman > men
      • 30 - 50 years old
    • Anatomic location
      • most commonly in the dominant wrist
    • Risk factors
      • overuse
        • golfers and racquet sports
      • post-traumatic
      • postpartum
  • Etiology
    • Pathophysiology
      • pathoanatomy
        • thickening and swelling of extensor retinaculum causes increased tendon friction
        • NOT considered an inflammatory process
          • may be related to accumulation of mucopolysaccharides
  • Anatomy
    • Extensor tendon compartments
      • Compartment 1 (De Quervain's Tenosynovitis)
        • APL
        • EPB
      • Compartment 2 (Intersection syndrome )
        • ECRL
        • ECRB
      • Compartment 3
        • EPL
      • Compartment 4
        • EIP
        • EDC
      • Compartment 5 (Vaughan-Jackson Syndrome )
        • EDM
      • Compartment 6 (Snapping ECU )
        • ECU
  • Presentation
    • Symptoms
      • gradual onset
      • radial sided wrist pain
      • pain exacerbated by gripping and raising objects with wrist in neutral
    • Physical exam
      • inspection
        • tenderness over 1st dorsal compartment at level of radial styloid
      • motion
        • usually normal wrist motion
        • pain with resisted radial deviation
      • neurovascular exam
        • normal
      • provocative tests
        • Finkelstein maneuver
          • On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is painful
          • more indicative of EPB > APL tendon pathology
        • Eichhoff maneuver
          • ulnar deviated wrist while patient clenches thumb in fist, followed by relief of pain once the thumb is extended even if the wrist remains ulnar deviated
  • Imaging
    • Radiographs
      • recommended views
        • AP, lateral views of wrist
      • indications
        • radiographs usually not indicated
      • findings
        • may be used to rule out
          • basilar arthritis of the thumb
          • carpal arthritis
  • Differential
    • Thumb CMC arthritis
    • Intersection syndrome
    • FCR tendinitis 
  • Diagnosis
    • Clinical
      • diagnosis is made with careful history and physical examination
  • Treatment
    • Nonoperative
      • rest, NSAIDS, thumb spica splint, steroid injection
        • indications
          • first line of treatment
        • technique
          • NSAIDS, rest and immobilisation usually first step
          • steroid injections into first dorsal compartment usually second step
        • outcomes
          • overall corticosteriods found to be superior to splinting
          • concomitant splinting and/or NSAIDs after steriods injection does not improve outcomes
    • Operative
      • surgical release of 1st dorsal compartment
        • indications
          • severe symptoms
          • usually consider after 6 months of failed nonoperative management
        • technique
          • radial based incision proximal to the wrist
          • protect the superficial radial sensory nerve
  • 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
          • EPB is more dorsal than APL 
          • 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
  • Prognosis
    • Most cases resolve with non-operative management
    • High recurrence rate
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