De Quervain Tendinopathy

Background

De Quervain's causes radial-sided wrist pain.

Aetiology

The aetiology is not well understood. There are aetiologic hypotheses, but these are all based on mostly observational data. The condition affects both the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) at the first dorsal compartment, a fibro-osseous tunnel. The APL and EPB allow thumb radial abduction. Histologically the disease is noninflammatory, with thickening of the tendons and the tunnel.

It is most common in the 6-12 month postpartum period in young women. It also commonly affects early childcare workers.

It is usually atraumatic but may result after a direct blow.

Symptoms are often bilateral.

Pain caused by movement of the thumb or wrist.

Diagnosis

Based on characteristic history of atraumatic radial sided wrist pain with tenderness and enlargement of the first dorsal compartment over the radial styloid, and pain at the radial styloid with active or passive stretch of the tendons over the radial styloid in thumb flexion.

Differential Diagnoses

Acute Wrist Pain

Distal radius fracture (often intra-articular in the athlete)
Scaphoid Fracture
Wrist ligament sprain/tear (intercarpal, scapholunate, lunotriquetral)
Fracture of hook of hamate
Triangular fibrocartilage complex tear
Distal radioulnar joint instability
Scapholunate dissociation
Carpal dislocation
Anterior dislocation of lunate
Perilunar dislocation
Traumatic ulnar artery aneurysm or thrombosis (karate)
Dorsal wrist pain - Scaphoid fracture, Scaphoid impaction syndrome, Fracture dislocation of carpus, Lunate fracture, Distal radius fracture, Scapholunate ligament tear, Kienbock's disease (acute onset), Lunotriquetralligament tear, Distal radioulnar joint injury, Carpometacarpal dislocation
Volar wrist pain - Carpal instability, Hook of hamate fracture

Subacute Dorsal Wrist Pain

Ganglion
Intersection syndrome
Kienbock's disease
Dorsal pole of lunate and distal radius impingement (gymnasts)
Posterior interosseous nerve entrapment
Inflammatory arthropathy
Degenerative joint disease
Extensor carpi ulnaris tendinopathy
Extensor carpi ulnaris subluxation
Injuries to distal radial epiphysis (children)
Extensor pollicis longus impingement on Lister's tubercle (occasional rupture)

Subacute Volar Wrist Pain

Scaphoid aseptic necrosis
Stenosing tendinopathies
Flexor carpi ulnaris tendinopathy
Carpal tunnel syndrome
Ulnar tunnel syndrome
Pisotriquetral degenerative joint disease
Avascular necrosis of the capitate (weightlifters)
Extensor pollicis longus impingement/rupture (gymnasts)

Subacute Ulnar Wrist Pain

Triangular fibrocartilage complex tears
Ulnar Impaction syndrome
Distal radioulnar joint instability
Carpal instability
Scapholunate dissociation
Ulnar nerve compression (cyclists, golfers)
Flexor carpi ulnaris tendinopathy
Extensor carpi uinaris tendinopathy
Extensor carpi ulnaris subluxation
Distal radioulnar joint impaction syndromes (golfers)
Scaphoid impaction syndrome

Subacute Radial Wrist Pain

Scaphoid Fracture (missed)
Non-union of scaphoid fracture
De Quervain Tendinopathy
Scaphoid impaction syndrome
Intersection Syndrome
Flexor carpi radialis tendinopathy
Dorsal pole of lunate impingement on distal radius (gymnasts)
Scapholunate dissociation
First Carpometacarpal Joint Osteoarthritis
Scaphotrapeziotrapezoid (STT) Joint Osteoarthritis
Osteoarthritis of the radiocarpal joint
Ganglia
Radial sensory nerve entrapment in the forearm
Crystal-induced arthritis
C6 radicular syndrome

Carpal Tunnel Syndrome

Cervical radicular pain (C6 or C7): Neck pain, positive Spurlings test
First Carpometacarpal Joint Osteoarthritis : Painful thumb motion, positive grind test, radiographic findings
De Quervain Tendinopathy: Tenderness distal radial styloid
Polyneuropathy: History of diabetes mellitus, bilateral, lower extremity involvement.
Thoracic Outlet Syndrome: ulnar sided symptoms, positive EAST and ULTT.
Pronator teres syndrome (median nerve compression at the elbow): Forearm pain; sensory loss over the thenar eminence; weakness with thumb flexion, wrist extension, and forearm pronation
Ulnar neuropathy: Paresthesias of the ring and little fingers, positive Tinel sign and compression tests at the elbow or wrist (Guyon canal)
Radial neuropathy
Raynaud syndrome:Symptoms related to cold exposure, typical color changes
Vibration white finger:Use of vibratory hand power tools, symptoms of Raynaud phenomenon
Wrist osteoarthritis: painful wrist motion, radiographic findings
Inflammatory arthropathy
Peripheral nerve tumour
Multiple sclerosis
Amyotrophic lateral sclerosis
Acute compression syndromes (eg, Saturday night palsy)

Imaging

Ultrasound may show a thickened extensor retinaculum with hypervascularity. There may be thickening of the APL and APB tendons, however the EPB may be thinned due to stenosis from a thickened extensor retinaculum.
Xray may help evaluate other causes such as OA of the 1st CMC joint.

Management

The condition is normally self-limited. It generally resolves after a year, and doesn't usually recur.

Activity Modification

Splinting

Forearm-based thumb spica splint with the interphalangeal joint free

Steroid Injection

Surgery

There are no placebo-controlled trials. It involves releasing the the first dorsal compartment. Complications included an erythematous, raised, and tender incision area for 6 to 12 months, injury of the superficial radial sensory nerve, failure to improve symptoms, and inability to use the wrist for a few weeks postoperatively.