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Figure 1. Anteroposterior view of the hand.
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Figure 2. Lateral view of the hand.
A 31-year-old woman presents with left wrist and thumb pain that has been present for 3 months. The patient has young children at home and notices the pain when she picks them up off the ground. She is now having pain when grabbing a cup or twisting a door knob. She reports trying 6 weeks of intermittent use of a thumb spica splint and nonsteroidal anti-inflammatory drugs, which didn’t seem to relieve her pain. Radiographs are taken (Figures 1 and 2). On physical examination, the patient has a positive Finkelstein test and pain with thumb range of motion.
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The first dorsal compartment of the wrist is located at the base of the thumb and is made of a fibrous band that allows the extensor tendons of the thumb to glide underneath. These tendons include the abductor pollicis longus (APL) and the more dorsal extensor pollicis brevis (EPB). As these tendons glide underneath this fibrous band, the tendons can become inflamed with repetitive thumb motion. De Quervain (stenosing tenosynovitis) is a condition in which the tendons become inflamed and swollen, which causes friction and pain at the first dorsal compartment during thumb motion.1,2
The Finkelstein test is a reliable test to make the diagnosis and includes tucking the thumb in a clenched fist and ulnar deviating the wrist. Radiography of the thumb can help rule out carpometacarpal (base of the thumb) arthritis. A period of rest and immobilization with a thumb spica splint is recommended initially to help reduce the friction of the tendons gliding under the fibrous tissue of the first dorsal compartment.1,2
Corticosteroid injections offer a successful treatment option should more conservative treatments fail. Many patients get complete relief after 1 injection. Nearly all patients will have relief of symptoms with a combination of corticosteroid injection and intermittent immobilization at 6 months. If a patient fails 2 injections and continues to have pain, surgical treatment with an open release of the first dorsal compartment is an effective option.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Ilyas AM, Ast M, Schaffer AA, Thoder J. De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 2007;15(12):757-764. doi:10.5435/00124635-200712000-00009
2. Larsen CG, Fitzgerald MJ, Nellans KW, Lane LB. Management of de Quervain tenosynovitis: a critical analysis review. JBJS Rev. 2021;9(9). doi:10.2106/JBJS.RVW.21.00069.
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