De Quervains disease is a tenosynovitis of the 1st dorsal compartment of the wrist. This is an osteofacial compartment, which contains the tendons of EPB (Extensor Pollicis Brevis) and APL (Abductor Pollicis Longus). Differential diagnosis should exclude Thumb CMCJ osteoarthritis, scaphoid fracture, radioscaphoid arthritis and intersection syndrome. This is a step-by-step guide to surgically release and decompress the 1st dorsal compartment in De Quervain’s tenosynovitis.
INDICATIONS : I plan surgical intervention in patients who have recurrence of symptoms following a steroid injection or those that are refractory to conservative methods.
SYMPTOMS & EXAMINATION: Patients present with symptoms of dorsoradial wrist pain which are often aggravated with thumb movements. The patients have pain on opening bottles and jars (Note that is similar to the symptoms with osteoarthritis of thumb CMCJ). Typically patients find it difficult to supinate the hand with a clenched fist – such as opening a door handle. A history of rheumatoid disease and diabetes is important due to their association with this condition. Diagnosis is mainly clinical with tenderness over the 1st dorsal compartment and a positive provocative test – namely Finklestein’s test, Eichhoff test or WHAT test. Examination of the thumb CMCJ and the scaphoid is essential. Eichhoff test – Active provocative test – Patient clenches his fingers on the opposed thumb and the examiner employs an ulnar deviation force to the wrist. Finklestein test – Passive provocative test – Examiner applies longitudinal traction to the thumb in the direction of an ulnar deviated wrist. WHAT test – Active provocative test – Patient flexes his wrist and tries to fully extend and abduct his thumb against resistance. This test is considered to be more sensitive & specific than the Eichhoff & Finklestein tests.
INVESTIGATION: Plain radiographs do not usually reveal any abnormality in De Quervain’s disease. However, they are useful to exclude the differential diagnoses. Ultrasound and MRI may aid in identifying the tenosynovitis in difficult diagnostic presentations.
ALTERNATIVE TREATMENTS: I use steroid injection as the first line of treatment in all cases of De Quervain’s at first presentation. A Cochrane review published in 2006 concluded that the steroid injection is a safer and more effective modality when compared to other conservative methods. Splints, rest and NSAIDs have all been tried with varied results. Cavaleri in 2016 showed that a combination of steroid and splints has better outcome than a single modality used alone.
Regional axillary block is my preferred method of anaesthesia. Although local infiltration of anaesthetic agents is used by a number of surgeons, it obviates the tissue planes along with a risk of causing iatrogenic injury to the Superficial Radial Nerve with the hypodermic needle tip. The patient is placed supine with the arm outstretched on a Hand Table. A “lead hand” may be used to stabilize the hand. An upper arm tourniquet with exsanguination of the limb allows for a bloodless field and accurate visualization of the structures. I do not routinely administer antibiotics for this procedure.
Dressings can be reduced in 5 days along with gentle mobilisation of the wrist. Suture ends are trimmed at 2 weeks, following which mobisation exercises are intensified and scar massage commenced. I advise light routine activities as soon as the patient feels comfortable. I prefer to avoid heavy activities for 4 weeks.
Potential Complications:
Superficial infection
Painful scar and keloid – avoided by meticulous tension free closure of skin.
Neuroma following injury to the superficial radial nerve – can vary from “neuropraxia” to “neuroma in continuity” to painful “end neuroma.” It is avoided by careful dissection and gentle retraction of the nerve. If neuroma occurs, it usually requires surgical neurolysis to improve the symptoms.
Persistent symptoms – usually due to wrong diagnosis, inadequate release or presence of concomitant underlying degenerative arthritis. However, a specific cohort of patients pursuing medicolegal claims, might never show improvement due to altered and mislaid perception of this disease being caused by repetitive work.
Tendon dislocation – I have not yet encountered this complication although it is described in literature to be an occasional occurence.
Rare complications include recurrence and Complex Regional Pain Syndrome
Eichhoff E. Zur pathogenese der tendovaginitis stenosans, Bruns’ Beitr z klin Chir. 1927;139:746-55.
Finklestein H: Stenosing tendovaginitis at the radial styloid process, J Bone Joint Surg Am 12:509-540, 1930
Goubau JF, Goubau LA, Van Tongel A, Van Hoonacker P, Kerckhove D, Berghs B. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff’s Test.Journal of Hand Surgery (European Volume). 2014 Mar;39(3):286-92.
Ashraf MO, Devadoss VG. Systematic review and meta-analysis on steroid injection therapy for de Quervain’s tenosynovitis in adults. European Journal of Orthopaedic Surgery & Traumatology. 2014 Feb 1;24(2):149-57. These authors echoed the conclusion of the Cochrane review and confirmed that the steroid injection was safer and more effective than other conservative methods.
Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clinical Anatomy. 2008 Jan 1;21(1):38-45. The authors studied the anatomy of the superficial branch of radial nerve in cadaver wrists and noted that the traditional transverse incision had underlying nerve branches in all cases. They concluded that a longitudinal incision proximal to the radial styloid avoided this in 68% cases.
Lee ZH, Stranix JT, Anzai L, Sharma S. Surgical anatomy of the first extensor compartment: A systematic review and comparison of normal cadavers vs. De Quervain syndrome patients. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2017 Jan 31;70(1):127-31. The authors confirm that there is a significant increase in anatomic variance in patients with De Quervain’s disease with a higher incidence of separate sub-compartments.
Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain’s stenosing tenosynovitis. International orthopaedics. 2009 Oct 1;33(5):1301-3. A review of 94 surgical decompressions over a 10 year period showed an excellent improvement in the symptoms of this condition following the procedure.
Kay NR. De Quervain’s disease: changing pathology or changing perception?. Journal of Hand Surgery. 2000 Feb;25(1):65-9. The author examined 100 cases of DeQuervains disease undergoing medicolegal claims. 90% of the surgically treated patients continued to claim disability due to persistent symptoms.He concluded that there is no evidence to support that repetitive work causes the condition. However, public perceptions are mislaid and patients are more likely to show poor outcomes following surgery in this specific cohort.
