DE QUERVAIN TENOSYNOVITIS
First Dorsal Compartment | APL and EPB | Finkelstein Test | Injection
TREATMENT
Critical Must-Knows
- First dorsal compartment contains APL and EPB
- Finkelstein test is pathognomonic
- Injection success 70-80%
- Watch for aberrant EPB septum
- Common in new mothers (repetitive lifting)
Examiner's Pearls
- "Finkelstein: fist over thumb, ulnar deviate wrist
- "New mothers: repetitive baby lifting
- "Superficial radial nerve at risk during surgery
- "Separate septum for EPB in 30-50%
Clinical Imaging
Imaging Gallery
Critical De Quervain Concepts
Anatomy
First dorsal compartment contains APL and EPB. These tendons pass over radial styloid. Stenosing tenosynovitis causes pain with thumb/wrist movement.
The tendons may have a separate septum which must be released at surgery.
Finkelstein Test
Make fist over thumb, ulnar deviate wrist. Positive test reproduces radial wrist pain. Pathognomonic for de Quervain.
The test stretches the APL and EPB tendons.
Injection
Corticosteroid injection is first-line treatment. 70-80% success rate. Inject into tendon sheath, not tendon.
May repeat once if partial response.
Septum
Separate septum for EPB in 30-50% of cases. If EPB in separate compartment, both compartments must be released at surgery.
This is the most common cause of failed release.
At a Glance
De Quervain Tenosynovitis At a Glance
| Feature | Key Points |
|---|---|
| Definition | Stenosing tenosynovitis of 1st dorsal compartment (APL, EPB) |
| Classic presentation | New mother with radial wrist pain, worse with lifting |
| Key test | Finkelstein test - fist over thumb, ulnar deviate - reproduces pain |
| First-line treatment | Corticosteroid injection (70-80% success) |
| Surgical indication | Failed conservative treatment (2 injection trials) |
| Critical surgical point | Check for separate EPB septum (30-50%) - release both compartments |
APL EPBFirst Dorsal Compartment
Memory Hook:APL and EPB are in first dorsal compartment!
SQUEEZEDEQUERVAIN - Key Facts
Memory Hook:SQUEEZE thumbs up for de Quervain!
1-2-3-4-5-6Dorsal Compartments
Memory Hook:Six dorsal compartments - know them all!
Overview and Epidemiology
Risk Factors
New mothers are classic patients due to repetitive lifting of babies with thumbs extended. Also common in occupations with repetitive wrist/thumb motion.
The condition is caused by overuse of the first dorsal compartment tendons.
Pathophysiology and Mechanisms
First Dorsal Compartment
Contents:
- Abductor pollicis longus (APL)
- Extensor pollicis brevis (EPB)
Location: Over radial styloid
Septum variant: EPB in separate compartment in 30-50%
Understanding anatomy is key to successful treatment.
Classification Systems
Clinical Staging
| Stage | Description | Management |
|---|---|---|
| Mild | Intermittent pain with activity | Splinting, activity modification |
| Moderate | Constant pain, positive Finkelstein | Corticosteroid injection |
| Severe | Failed injection, chronic symptoms | Surgical release |
Clinical staging helps guide treatment intensity.
Clinical Assessment
History
- Radial wrist pain
- Pain with thumb use
- Worse with gripping
- Swelling over radial styloid
- New parent or repetitive work
Ask about repetitive thumb/wrist activities.
Examination
- Tenderness over first dorsal compartment
- Positive Finkelstein test
- May have visible swelling
- Crepitus with movement
Finkelstein is the key diagnostic test.
Finkelstein Test Technique
Make fist over thumb, then ulnar deviate wrist. This stretches APL and EPB over the radial styloid. Reproduction of radial wrist pain is positive.
This test is pathognomonic for de Quervain tenosynovitis.
Investigations
Usually Not Required
De Quervain is a clinical diagnosis.
Finkelstein test + radial styloid tenderness is sufficient.
Imaging rarely needed unless diagnosis uncertain.
Management Algorithm
First-Line Treatment
Splint:
- Thumb spica splint
- Rest the first dorsal compartment
Injection:
- Corticosteroid into tendon sheath
- Success rate 70-80%
- May repeat once
Activity modification:
- Avoid aggravating activities
- Ergonomic advice
Conservative treatment is effective in majority of cases.
Surgical Technique
First Dorsal Compartment Release
Incision: Transverse or longitudinal over first DC
Steps:
- Protect superficial radial nerve branches
- Identify first dorsal compartment
- Release retinaculum longitudinally
- CHECK for separate EPB septum (30-50%)
- Release EPB compartment if present
- Ensure both tendons glide freely
Always look for separate EPB compartment.
Separate EPB Septum
Always look for separate EPB compartment. Present in 30-50% of patients. If only APL compartment released, EPB remains stenosed and symptoms persist. This is the most common cause of failed surgery.
Complications
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Superficial radial nerve injury | 5-10% | Careful dissection and protection |
| Incomplete release | 5-10% | Check for EPB septum |
| Subluxation of tendons | Rare | Preserve some retinaculum dorsally |
| Scar sensitivity | Variable | Proper incision placement |
Postoperative Care
Recovery Timeline
Soft dressing. Gentle ROM immediately. Avoid forceful gripping.
Remove sutures. Progressive thumb use. Return to light duties.
Full activity as tolerated. Complete recovery expected.
Outcomes and Prognosis
Prognostic Factors
Better outcomes: Shorter symptom duration, successful injection response, complete surgical release.
Worse outcomes: Missed EPB septum at surgery, nerve injury, delayed treatment.
Evidence Base and Key Studies
- Corticosteroid injection effective for de Quervain
- 70-80% success rate
- Superior to placebo and thumb spica splint alone
- Can be repeated once for partial responders
- Injection into first dorsal compartment sheath
- Use 25G needle, 1ml steroid + 0.5ml local anesthetic
- Inject at point of maximum tenderness
- Avoid intratendinous injection
- Separate EPB septum present in 24-34% (variable by population)
- Multiple APL slips common
- Type II anatomy requires release of both compartments
- Missed septum is commonest cause of surgical failure
- Surgical release over 95% success
- Complications: nerve injury 5-10%
- Superficial radial nerve most at risk
- Complete release of EPB compartment essential
- Minimally invasive release feasible
- Lower scar-related complications
- Similar efficacy to open release
- Ultrasound-guided techniques emerging
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: De Quervain in New Mother
"A 32-year-old new mother has 2 months of radial wrist pain. It is worse when lifting her baby. Finkelstein test is positive. There is tenderness over the radial styloid. What is your diagnosis and management?"
Scenario 2: Failed Surgical Release
"A 45-year-old woman had surgical release for de Quervain 6 weeks ago but her symptoms have not improved. The wound healed well. Finkelstein test remains positive. What is the most likely cause and how would you manage?"
Scenario 3: Injection Technique
"You are about to perform a corticosteroid injection for de Quervain tenosynovitis. Describe your technique and what complications you would warn the patient about."
MCQ Practice Points
Contents Question
Q: What tendons are in the first dorsal compartment? A: APL (abductor pollicis longus) and EPB (extensor pollicis brevis).
Test Question
Q: What is the Finkelstein test? A: Fist over thumb, ulnar deviate wrist. Positive when this reproduces radial wrist pain.
Surgical Failure Question
Q: What is the most common cause of failed surgical release? A: Missed separate EPB septum. Present in 30-50%; both compartments must be released.
Injection Success Question
Q: What is the success rate of corticosteroid injection for de Quervain? A: 70-80% success rate. It is first-line treatment. May be repeated once if partial response.
Nerve at Risk Question
Q: What nerve is at risk during de Quervain release? A: Superficial radial nerve. Branches cross the surgical field. Injury causes numbness over dorsal thumb web or painful neuroma.
Australian Context
Epidemiology in Australia:
- Common condition in hand surgery practice
- High incidence in new mothers and manual workers
- Rural populations may present later due to access issues
Healthcare considerations:
- Corticosteroid injections can be performed in primary care or specialist settings
- Surgical release covered under public hospital system
- Most cases managed conservatively with good outcomes
Workforce implications:
- May affect manual workers (agricultural, manufacturing)
- WorkCover claims for occupational cases
- Return to work typically within 2-4 weeks after injection or 4-6 weeks after surgery
Orthopaedic considerations:
- High-yield exam topic in hand surgery section
- Finkelstein test and injection technique commonly examined
- EPB septum anatomy critical knowledge
- Superficial radial nerve protection at surgery
Australian Exam Focus
For Orthopaedic examination: Know the Finkelstein test technique, injection approach, and the importance of the separate EPB septum. Be able to describe surgical release with nerve protection.
Additional Quiz Questions
DE QUERVAIN TENOSYNOVITIS
High-Yield Exam Summary
Anatomy
- •First dorsal compartment
- •APL and EPB
- •Over radial styloid
- •Separate EPB septum 30-50%
Clinical
- •Radial wrist pain
- •New mothers classic
- •Finkelstein test positive
- •Tender over radial styloid
Conservative Treatment
- •Injection: 70-80% success
- •Thumb spica splint
- •Activity modification
- •May repeat injection once
Surgery
- •Release first dorsal compartment
- •Check for EPB septum
- •Protect superficial radial nerve
- •Confirm both tendons glide
Complications
- •Superficial radial nerve injury
- •Missed EPB septum (failure)
- •Tendon subluxation (rare)
- •Scar sensitivity
- •Recurrence: usually missed septum
Key Points
- •Finkelstein is pathognomonic
- •Injection first-line
- •EPB septum is key at surgery
- •90%+ success with proper release
- •New mothers: postpartum hormones