De Quervain’s Syndrome (De Quervain’s Tenosynovitis)

Definition

De Quervain’s syndrome is a stenosing tenosynovitis involving the first dorsal compartment of the wrist.

The condition affects the tendons of:

• Abductor Pollicis Longus (APL)
• Extensor Pollicis Brevis (EPB)

It commonly affects the dominant hand and is frequently seen in women, particularly during the postpartum period.

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Anatomy

First Dorsal Compartment

The first dorsal compartment contains:

• Abductor Pollicis Longus (APL)
  • Often has multiple tendon slips
• Extensor Pollicis Brevis (EPB)
  • May lie within a separate sub-compartment

Anatomically:

• EPB lies more dorsally than APL

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Related Extensor Compartments

Second Dorsal Compartment

Contains:

• Extensor Carpi Radialis Longus (ECRL)
• Extensor Carpi Radialis Brevis (ECRB)

Third Dorsal Compartment

Contains:

• Extensor Pollicis Longus (EPL)

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Clinical Correlation

• First dorsal compartment pathology causes De Quervain’s syndrome
• Pathology at the intersection of the first and second compartments produces Intersection syndrome

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Pathophysiology

Inflammation within the tendon sheath leads to:

• Thickening of the sheath
• Stenosis of the compartment
• Restricted tendon gliding

This results in:

• Pain
• Swelling
• Functional limitation

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Clinical Features

Symptoms

Patients commonly complain of:

• Pain along the radial side of the wrist
• Pain at the base of the thumb

Pain is worsened by:

• Thumb movement
• Wrist movement
• Gripping activities

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Signs

Examination may reveal:

• Swelling over the radial styloid
• Localized tenderness over the first dorsal compartment

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Risk Factors and Causes

Common contributing factors include repetitive wrist and thumb activities such as:

• Wringing clothes
• Hammering
• Racquet sports
• Playing musical instruments
• Lifting heavy objects

Other associations include:

• Postpartum state
• Trauma

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Differential Diagnosis

First Carpometacarpal (CMC) Joint Arthritis

Features

• Pain localized at the thumb base

Diagnostic Test

• Positive grind test

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Intersection Syndrome

Features

• Pain approximately 4 cm proximal to the wrist joint

Pathology

Occurs where:

• APL and EPB cross over ECRL and ECRB

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Wartenberg’s Syndrome

Cause

Compression of the superficial radial nerve

Clinical Features

• Pain over dorsum of the hand
• Paresthesia
• Positive Tinel’s sign

Pain is typically located approximately 8 cm proximal to the radial styloid.

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Clinical Tests

Finkelstein Test

Technique

• Patient places thumb inside a clenched fist
• Examiner ulnar deviates the wrist

Positive Test

• Sharp pain over the radial styloid

Important point:

• The maneuver can be very painful and patients should be warned beforehand.

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Grind Test

Used to evaluate for thumb CMC arthritis.

Technique

• Axial compression combined with rotation of the thumb metacarpal

Positive Test

• Pain
• Crepitus at the CMC joint

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Investigations

X-ray

Routine radiographs are usually not necessary.

However, X-rays may help exclude:

• First CMC joint arthritis

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Management

Conservative Treatment

Initial treatment includes:

• Rest
• NSAIDs
• Thumb spica splint
• Activity modification

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Steroid Injection

Indications

Used when conservative management fails.

Technique

• Injection into the first dorsal compartment

Outcome

• High success rate in symptom relief

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Surgical Treatment

Indications

Surgery is considered when symptoms persist despite prolonged non-operative treatment, typically after approximately 6 months.

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Procedure

First Dorsal Compartment Release

Key surgical steps include:

• Dorsal incision over the wrist
• Protection of the superficial radial nerve
• Identification and release of:
  • APL tendon slips
  • EPB tendon
  • Any separate EPB sub-compartments

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Complications

Potential complications include:

• Recurrence
• Incomplete release
• Tendon subluxation
• Neuroma involving the superficial radial nerve
• Painful scar formation