Review Question - QID 219569

The patient has de Quervain tenosynovitis, which involves the extensor tendons of the first dorsal wrist compartment (abductor pollicis longus and extensor pollicis brevis) that are innervated by the posterior interosseous nerve.

Stenosing tenosynovitis involving the first dorsal compartment tendons is a common cause of radial-sided wrist pain. It occurs more commonly in women aged 30-50, is more frequently seen in the dominant wrist, and can be caused by overuse in golfers and racquet sport enthusiasts. The pathoanatomy involves thickening and swelling of the extensor retinaculum surrounding the first dorsal compartment tendons (as shown in the ultrasound in Figure 2), which may be related to an aberrant deposition of mucopolysaccharides. Notably, the deposition is not the result of an inflammatory process. The presentation involves the gradual onset of radial-sided wrist pain exacerbated by gripping and lifting objects, with tenderness on exam seen over the first compartment at the level of the radial styloid (Figure 1). The Finklestein maneuver involves grasping the patient's affected thumb and quickly abducting the hand ulnar, reproducing the patient's symptoms over the styloid, which is commonly confused with the Eichoff maneuver that involves having the patient grasp their thumb in their palm with brisk ulnar deviation of the wrist causing them pain, followed by a relief of the pain with extension of the thumb from the grasped position. Treatment typically starts conservatively with rest, bracing, and anti-inflammatories, followed by steroid injection if there is no relief, with surgical first dorsal compartment release reserved as a treatment for recalcitrant symptoms.

Ilyas et al. reviewed de Quervain tenosynovitis of the wrist. The authors note that it represents a common wrist pathology, with pain resulting from resisted gliding of the abductor pollicis longus and the extensor pollicis brevis tendons in the fibro-osseus canal. Nonsurgical management, consisting of corticosteroid injections and supportive thumb spica splinting, is usually successful. They conclude that in resistant cases, surgical release of the first dorsal compartment may be necessary, taking care to protect the radial sensory nerve and to identify all accessory compartments.

Kutsumi et al. published a biomechanical analysis of Finklestein's test for de Quervain’s disease. The authors performed their analysis on fifteen fresh-frozen cadavers, measuring gliding resistance and excursion in 4 different wrist positions, including the wrist position of Finkelstein’s test (30° ulnar deviation), and calculated the bulk and tethering effect based on the mean gliding resistance over the tendon proximal/distal excursion cycle and the gliding resistance at the terminal distal excursion. They found that EPB tendon excursion was significantly more distal in 30° ulnar deviation than in 60° extension. In contrast, the APL tendon exhibited no significant difference in either the tendon excursion or the bulk and tethering resistance between 30° ulnar deviation and 60° extension. They concluded that in the position of Finkelstein’s test, the EPB tendon is significantly more distal and has a considerably greater bulk and tethering effect compared with the other EPB positions, suggesting that an abnormal Finkelstein’s test reflects differences of the EPB more than it does the APL.

Figure A is a photographic image of a hand depicting the location of pain over the first dorsal compartment at the level of the radial styloid of the wrist. Figure B is an ultrasound image depicting the thickening of the tendon sheaths around the first dorsal compartment tendons.

Incorrect Answers:
Answers 1-3 and 5: The PIN, not the radial nerve proper, median, or ulnar nerves, is responsible for innervating the muscles of the first dorsal wrist compartment tendons.