De Quervains disease
De Quervain’s tenosynovitis is the inflammation or stenosis of the sheath of the first extensor compartment, which surrounds the abductor pollicis longus and extensor pollicis brevis tendons at the wrist.
This causes pain, swelling, and even blockage of the tendons within the first compartment when the patient moves the thumb.
De Quervains symptoms
De Quervain’s disease affects middle-aged women and appears from repeated use of the thumb. Patients report pain on the lateral aspect of the wrist, which worsens when moving the thumb or making a fist. Crackling noises may also appear when moving the thumb.
De Quervains physical examination
De Quervain’s examination reveals inflammation and tenderness of the tendons of the first compartment in the lateral region of the distal radius. A crepitus can be palpated when the patient flexes and extends the thumb.
The Filkenstein maneuver, which consists of placing the thumb in the palm and ulnar deviation of the wrist, is positive. This maneuver causes pain and is suggestive but not diagnostic of De Quervain.
It is important to look for selective maneuvers for selective involvement of the extensor pollicis brevis tendon. In addition, the thickening of the compartment and the presence of liquid in the sheath can be perceived.
These last two can be well evaluated with ultrasound performed in the same consultation.
De Quervain’s diagnostic tests
The clinic in the evaluation of De Quervain’s disease, is of great help for the diagnosis of this type of injury.
It is important to perform imaging studies with wrist radiographs to rule out bone abnormalities and calcifications associated with this pathology. MRI is less requested, and ultrasound is crucial for the clinical assessment of patients with this pathology.
Ultrasound allows to perform the diagnosis in the same office without the need for more tests (other tests are more expensive and require a new consultation for evaluation).
Ultrasound is very useful in case of doubt as it allows to identify the thickening of the first extensor compartment, the presence of fluid inside the compartment and around the tendons and see the numerous anatomical variants that contribute to this frequent pathology.
The anatomical variations that contribute to the development and prognosis of De Quervain’s disease are: presence of septum, presence or absence of extensor pollicis brevis, number of accessory abductor tendons…
One of the most frequent causes of treatment failure in De Quervain’s disease, is the presence of selective involvement of the extensor pollicis brevis compartment. We can see easily in our doing an ultrasound study and objectifying the presence of liquid only around that tendon.
De Quervain’s differential diagnosis
- Osteoarthritis of the base of the thumb
- Scaphoid fracture
- Intersection syndrome.
- Superficial radial neuritis, sometimes associated with De Quervains disease. (Wartenberg syndrome)
- Wrist osteoarthritis.
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Treatment of De Quervains disease
Conservative treatment of De Quervains disease
Treatment should include the use of oral and topical NSAIDs. Thumb inclusion splints can be used in very painful situations.
If conservative treatment fails, ultrasound-guided infiltrations can be used. Infiltrations are very effective in patients with De Quervain.
Ultrasound-guided infiltration allows the fluid to be introduced in the right place, reducing complications, and improving results.
Another option is to infiltrate growth factors, which can also be effective in this type of injury.
Why do we infiltrate De Quervains disease ultrasound guided?
We do it for the following reasons:
- They help us for diagnosis
- Identify the selective involvement of the extensor pollicis brevis tendon and provide reliability to the infiltration. They allow to visualize the areas that present more inflammation to carry out a more effective treatment.
Physiotherapy can also help to resolve the condition, especially in those cases in which there is inflammation of the tendon sheath of the first compartment.
When conservative treatment fails, therefore, surgery is indicated.
Surgical treatment of De Quervain
De Quervains surgery consists of opening the first extensor compartment and releasing the tendons, paying special attention to the septa that may be separating the tendons and protecting the superficial radial nerve.
The results are satisfactory in the treatment of this condition. The surgery is performed through a mini incisión (less 1 cm).
Mobilization after De Quervain surgery is immediate, allowing the patient to carry out activities of daily living, and allowing return to work in 2-3 weeks.
Frequently Asked Questions about De Quervain disease
De Quervain’s disease, always needs surgery?
No. Initially, physiotherapy treatment can help, with the use of a splint for the first finger.
Does infiltration work on de Quervain?
If the infiltration is ultrasound-guided and the variables and characteristics of each patient are considered, it works, allowing the results of conservative treatment to be improved.
If conservative treatment fails, is De Quervains surgery aggressive?
No. It is a very small approach and allows an early recovery.
“The first extensor compartment has big anatomical variabilities”
“Anatomical variabilities in De Quervain makes ultrasound essential”
“Ultrasound-guided infiltration, is a precise technique that improves the results of conservative treatment”