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De Quervain's Syndrome

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De Quervain's Syndrome is stenosing tenosynovitis of the first dorsal compartment of the wrist. This will cause pain and swelling over the radial side (thumb side) of the wrist (Figure 1).

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It occurs due to inflammation, thickening and stenosis of the synovial sheath. This condition is more common in women and the patient will complain of pain with movement of the wrist as well as swelling with tenderness over the styloid process.

Activities that may cause De Quervain's Syndrome
Activities that may cause De Quervain's Syndrome include twisting or wringing out wet towels, hammering, skiing, racquet sports, playing the piano, lifting heavy objects, and it may be postpartum or post-traumatic.

Pain from De Quervain's syndrome is usually located at the base of the thumb and to the side of the wrist (Figure 2).

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Differential Diagnosis
Differential diagnosis of De Quervain's syndrome includes carpometacarpal joint arthritis, which is arthritis of the basal joint or thumb CMC joint (Figure 3).

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Intersection Syndrome may also be a differential diagnosis (Figure 4). Pain felt on the top of the forearm where two muscles cross over the underlying wrist tendons. This pain is located about 4 cm from the wrist joint.

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Wartenberg's Syndrome is compression of the superficial branch of the radial nerve. This pain is located 8 cm proximal to the radial styloid (Figure 5). There will be pain and paresthesia on the dorsum of the hand and a positive Tinel's sign.

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It is hard to differentiate between De Quervain's syndrome and basal thumb joint arthritis. The Finklestein's test is used to diagnose De Quervain's syndrome (Figure 6). The test is conducted by having the patient make a first with the fingers closed over the thumb and the wrist is bent towards the little finger. The hand is pulled so that the involved tendons are stretched, causing sharp, local pain (if injury and inflammation is present). The Grind Test is used to diagnose basal thumb arthritis (Figure 6). By axial loading, pushing and rotating the thumb metacarpal bone, grinding may be felt within the joint. Pain will be located on the volar aspect of the wrist.

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Treatment
The treatment of De Quervain's syndrome will begin conservatively. Conservative treatment includes anti-inflammatory medication, thumb spica brace and steroid injections. When using a steroid injection, inject steroids into the tendon sheath of the first dorsal compartment with the wrist over a rolled up towel (Figure 7).

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Surgery will be done after the failure of non-operative treatment. Surgical release of the first dorsal compartment will take place. The radial sensory nerve will need to be protected. The tendon may have separate compartments and each compartment should be identified and released. Also, the abductor pollicis longus tendon may have multiple slips. Pain may occur after surgery due to neuroma, inadequate decompression, or instability and scarring of the tendons.

De Quervain's Release Surgery
This surgery is a release involving the first dorsal compartment at the wrist. Complete decompression of the first dorsal compartment including any additional slips and compartments. The abductor pollicis and extensor pollicis brevis tendons are freed from the surrounding retinaculum and tendon sheath. It is important to protect the radial sensory nerve (Figure 8).

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