De Quervain's Tenosynovitis

Patients describe radial-sided wrist pain aggravated by thumb extension and abduction (lifting a kettle, opening jars, holding a baby) and by ulnar deviation. Pain may radiate proximally up the forearm and distally into the thumb. Symptoms typically build over weeks, though acute post-partum presentations can be rapid.

Examination:

• •Tenderness over the first dorsal compartment at the radial styloid
• •Visible or palpable swelling and crepitus over the compartment
• •Finkelstein's test (Eichhoff manoeuvre): thumb is tucked into the palm and the wrist is ulnar-deviated; reproduction of radial-sided pain is positive. The original Finkelstein's test is grasping the thumb and ulnar-deviating the wrist with the examiner's force - both forms are widely used in UK practice

Additional tests: WHAT (wrist hyperflexion and abduction of the thumb) test is more specific for de Quervain's than Finkelstein's, especially when there is co-existing thumb CMC OA. Differentials include thumb CMC osteoarthritis (positive grind test, tenderness at the CMC joint), scaphoid pathology (anatomical snuffbox tenderness), intersection syndrome (proximal location), and superficial radial nerve neuritis (Wartenberg's syndrome, sensory rather than mechanical symptoms).

De Quervain's is a clinical diagnosis. No imaging is required for typical presentations.

Ultrasound is useful in selected cases:

• •Atypical or unilateral presentations where the diagnosis is uncertain
• •To detect a septated compartment before steroid injection (predicts failure of single-injection therapy)
• •To guide injection placement in failed conservative attempts
• •Differentiating from intersection syndrome and other peritendinous pathology

Ultrasound shows thickening of the extensor retinaculum, peritendinous hypoechoic fluid, and tendon swelling, with potential visualisation of an intracompartmental septum. MRI is rarely indicated and is reserved for occult pathology or persistent symptoms despite escalated treatment. Plain radiographs are unhelpful for the tendinopathy itself but may identify co-existing thumb CMC osteoarthritis or scaphoid pathology. Consider inflammatory bloods (CRP, ESR, RhF, anti-CCP) if a systemic rheumatic process is suspected.

Management follows a stepwise NICE / BSSH pathway based on severity and response to conservative measures.

First-line (mild symptoms, duration under 6 weeks):

• •Activity modification - reduce repetitive thumb-loaded gripping; advise on safe ways of carrying an infant
• •Thumb spica splinting (forearm-based, including thumb IP joint or stopping at the IP joint) for 4-6 weeks
• •Simple analgesia and short course topical or oral NSAIDs
• •Ice for symptomatic relief in the acute phase

Second-line (persistent symptoms or moderate severity): corticosteroid injection (typically methylprednisolone 20-40 mg with 1% lidocaine) into the first dorsal compartment. Cure rate ~80% at 6-12 months with a single injection in a non-septated compartment; failure rate higher in septated anatomy. Ultrasound guidance improves accuracy, particularly in septated compartments. Counsel about transient skin and fat atrophy and depigmentation. NICE supports up to two injections before surgical referral.

Third-line (failed two injections, persistent severe symptoms): surgical release of the first dorsal compartment. Open release is the standard procedure, with attention to identifying and releasing any septum and protecting the superficial branch of the radial nerve (the major surgical complication). Day-case under regional anaesthetic. Success rate >90% in carefully selected patients.

Post-partum and pregnancy: prefer splinting and activity modification first. Injection is reasonable if conservative measures fail; counsel about systemic effects but local corticosteroid is generally considered safe in pregnancy and breastfeeding.

Conservative pathway: thumb spica splinting for 4-6 weeks combined with progressive thumb and wrist range-of-movement exercises once acute symptoms settle. Hand therapy referral is helpful for splinting fit and for graduated loading. Activity modification advice is critical, particularly in post-partum women - alternative baby-carrying techniques (palm down, supporting under the bottom rather than scooping with the thumb extended) reduce recurrence.

Progressive loading:

• •Weeks 0-2: isometric thumb abduction and extension within pain limits
• •Weeks 2-6: progressive resisted thumb extension, abduction, and grip exercises
• •Weeks 6-12: sport-specific or task-specific loading (racquet sport return, manual trades)

Post-injection: avoid heavy gripping or thumb-loaded activity for 1-2 weeks to optimise local response; resume splinting at night if symptoms persist.

Post-operative (first compartment release):

• •Week 0-2: bulky dressing then light dressing, active thumb and wrist range of motion encouraged. Suture removal 10-14 days
• •Week 2-6: scar massage, progressive strengthening, return to office work usually within 2 weeks
• •Week 6-12: full return to manual work and sport

Persistent symptoms beyond 3 months warrant reassessment for missed septum, superficial radial nerve injury, or alternative pathology.

• •NICE CKS Tendinopathy - Supports stepwise pathway with splinting and steroid injection before surgical referral; recommends up to two injections before considering surgery.
• •BSSH De Quervain's Disease Patient Information - UK hand-surgery framework: open release is the surgical standard with >90% success when a septated compartment is recognised and released.
• •Peters-Veluthamaningal Cochrane Review (2009) - Corticosteroid injection significantly outperformed placebo for de Quervain's; effect size larger when the compartment is non-septated.
• •Choi et al. (2011) - Demonstrated higher injection failure in ultrasonographically septated compartments; supports pre-injection ultrasound in recurrent disease.
• •Goel & Abzug (2015) - Systematic review confirmed superiority of corticosteroid injection over splinting alone for symptom resolution and time to recovery.

• •Finkelstein's test (or Eichhoff variant) reproduces radial-sided wrist pain. The WHAT test (wrist hyperflexion and thumb abduction) is more specific where co-existing thumb CMC OA blurs the picture.
• •A septated first dorsal compartment is present in up to 60% of patients and is the leading reason for injection failure. Pre-injection ultrasound is justified in recurrent disease.
• •Up to two steroid injections are supported before surgical referral. Mean cure rate ~80% in non-septated compartments and lower in septated.
• •Intersection syndrome is the major proximal differential - tenderness 4-6 cm proximal to the radial styloid where the first and second compartments cross. Distinguish it from de Quervain's by location.
• •Post-partum de Quervain's (mother's thumb) is common and responds well to splinting plus activity modification (alternative baby-carrying technique). Local corticosteroid is generally considered safe in pregnancy and breastfeeding when conservative measures fail.
• •The major surgical complication is injury to the superficial branch of the radial nerve - patients will describe burning numbness over the dorsoradial hand. Counsel before surgery.