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DE QUERVAIN'S DISEASE (TENOSYNOVITIS)

Introduction

de Quervain’s disease – also known as “washer woman’s sprain” and more recently as “Blackberry thumb” – is a stenosing tenovaginitis of the first extensor compartment of the wrist. Histologically, the disease is characterized by thickening of the sheaths surrounding the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles. The pathophysiology more likely involves degenerative rather than inflammatory mechanisms. de Quervain’s disease is one of the most common diagnoses among patients presenting with wrist pain.

Related Anatomy

  • First dorsal compartment of the wrist
  • APL and EPB tendon sheaths
  • EPB often in separate sheath inside the first extensor compartment
  • APL frequently has more than one tendon slip. (2-7 tendon slips are common)

Incidence and Related Conditions

  • 6 times more prevalent in women than men
  • Common in pregnancy; more common among women with infants

Differential Diagnosis

  • Intersection syndrome
  • Osteoarthritis of the carpometacarpal joint (CMC) of the thumb
  • Osteoarthritis of a radiocarpal or intercarpal joint
  • Scaphoid fracture
  • Superficial radial nerve neuroma
  • Wartenburger’s syndrome
Clinical Presentation Photos and Related Diagrams
  • Palpating for first extensor compartment (Hover over right edge to see more images)
    Palpating for first extensor compartment (Hover over right edge to see more images)
  • Traditional Finkelstein's Sign
    Traditional Finkelstein's Sign - Thumb is placed in palm, fingers flexed over the thumb, and then the wrist is ulnarly deviated. This passively pulls the AbPL and the EPB through the tight first extensor compartment and reproduces the patient's pain.
  • Alternative Finkelstein maneuver - The wrist is in neutral position while the thumb MP joint is maximally flexed. This pulls the EPB through the first extensor compartment and reproduces the patient's pain.
    Alternative Finkelstein maneuver - The wrist is in neutral position while the thumb MP joint is maximally flexed. This pulls the EPB through the first extensor compartment and reproduces the patient's pain.
Symptoms
Pain on the radial aspect of the wrist
Pain exacerbated by thumb movements
Swelling, tissue thickening, or lump on radial styloid area of the wrist
Rarely, wrist clicking with thumb motion
Typical History

The patient with DeQuervain's Tenosynovitis is typically a female with pain at the base of the thumb or radial aspect of the wrist which has been present for several weeks.  It is common for the patient to be a new mother with a young infant.  It is rare for the wrist to click but this does occur in chronic cases.  Increased repetitive use of the hand may have iniated the symptoms.  Increased thumb use and power pinch often aggravates the pain.

Positive Tests, Exams or Signs
Finkelstein Sign
First Extensor Compartment Tenderness
Extensor Tendon Exam
Work-up Options
Magnetic resonance imaging - MRI without contrast
Sonographic studies - Ultrasound
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • The patient with DeQuervain's tenosynovitis will have tenderness (red dot) but the wrist X-ray will be normal.
    The patient with DeQuervain's tenosynovitis will have tenderness (red dot) but the wrist X-ray will be normal.
Treatment Options
Conservative: 
  • Non-steroidal anti-inflammatory drugs (NSAIDS)
  • Wrist-thumb splinting
  • Corticosteroid injections
Operative: 
  • Complete release of first extensor dorsal compartment to decompression of APL/EPB tendons
  • Avoid injury to the radial sensory nerve
  • Frequently, EPB has a secondary compartment within the first extensor compartment and requires an additional release
Treatment Photos and Diagrams
  • Transverse incision in Langer's lines just distal to the tip of the radial styloid (Hover over right edge to see more images)
    Transverse incision in Langer's lines just distal to the tip of the radial styloid (Hover over right edge to see more images)
  • Transverse incision in Langer's lines just distal to the tip of the radial styloid incision made. Note dorsal radial sensory nerve in subcutaneous tissue superficial to first extensor fascia.
    Transverse incision in Langer's lines just distal to the tip of the radial styloid incision made. Note dorsal radial sensory nerve in subcutaneous tissue superficial to first extensor fascia.
  • First extensor compartment fascia exposed.
    First extensor compartment fascia exposed.
  • Fascia exposed. Nerve retracted. Longitudinal incision being made in dorsal ilanr third of first extensor fascia.
    Fascia exposed. Nerve retracted. Longitudinal incision being made in dorsal ulnar third of first extensor fascial compartment.
  • First extensor fascia released. Note multiple tendons because AbPL has from 2-7 slips and EPB has one slip.
    First extensor fascia released. Note multiple tendons because AbPL has from 2-7 slips and EPB has one slip.
  • EPB frequently in separate compartment with first extensor compartment. EPB release verified by pulling on the tendon and observing thumb MP extension.
    EPB frequently in separate compartment with first extensor compartment. EPB release verified by pulling on the tendon and observing thumb MP extension.
  • Incision closed with subcuticular proline suture
    Incision closed with subcuticular proline suture
Complications
  • Conservative: corticosteroid injections can cause depigmentation, fat necrosis and subcutaneous atrophy (rare)
  • Operative: inadequate decompression, volar subluxation of APL/EPB, radial sensory nerve injury (neurapraxia or neuroma-in-continuity), reflex sympathetic dystrophy, infection and scar adherence to the radial styloid
Outcomes
  • Splinting has a 70% failure rate, and shows no additional benefit over corticosteroid injection
  • Single corticosteroid injections alleviate symptoms in ~62% of patients; 2 injections are successful in ~80% of patients
  • Operative findings: ~90% of patients can be expected to have a satisfactory outcome
Video
Normal ultrasound of first extensor compartment. Radial cortex (R); Extensor tendons - extensor pollicis brevis and abductor pollicis longus.
Key Educational Points
  • A common septum is found between the APL and EPB in 80% of patients requiring surgical release. EPB release should be confirmed by traction on the tendon, demonstrating MCP joint extension and a visible muscle belly.
  • Intersection syndrome is caused by inflammation at the intersection of the first and second dorsal extensor compartments.
Practice and CME
References

New articles

  1. Mardani-Kivi M, Karimi Mobarakeh M, Bahrami F, et al. Corticosteroid injection with or without thumb spica cast for de Quervain tenosynovitis. J Hand Surg Am 2014;39(1):37-41.
  2. Huisstede BM, Coert JH, Fridén J, Hoogvliet P; European HANDGUIDE Group. Consensus on a multidisciplinary treatment guideline for de quervain disease: results from the European HANDGUIDE study. Phys Ther 2014;94(8):1095-110.

Reviews

  1. Stahl S, Vida D, Meisner C, et al. Systematic review and meta-analysis on the work-related cause of de Quervain tenosynovitis: a critical appraisal of its recognition as an occupational disease. Plast Reconstr Surg 2013;132(6):1479-91.
  2. Ilyas AM, Ast M, Schaffer AA, Thoder J. De quervain tenosynovitis of the wrist. J Am Acad Orthop Surg 2007;15(12):757-64.

Classics

  1. Harvey FJ, Harvey PM, Horsley, MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg Am 1990;15;83-7.
  2. Watkins JT, Pitkin HC. Stenosing tendovaginitis of de Quervain: report of case. Cal West Med 1930;32(2):101-2.