treatment options for de quervain's tenosynovitis
De Quervain’s tenosynovitis (DQTS), also known as chronic stenotic tenosynovitis and de Quervain’s disease (DQD), is a condition affecting the thumb extensor tendons and has many non surgical and operative treatments. It is a disorder characterized by pain of varying degrees of severity in the radial side of the wrist due to restricted gliding of the tendons of abductor pollicis longus and extensor pollicis brevis in the fibro-osseous canal of the first dorsal compartment of the wrist. Around 75 percent of cases occur in women.
A) Corticosteroid injection into first dorsal compartment
B) Thumb spica splint for 3-6 weeks
C) Occupational therapy paired with ultrasound
D) Short arm cast for 3-6 weeks
Nonsurgical treatment is the primary treatment of choice for DQTS and many options exist. The goal of treatment is pain relief and restoration of a fully functioning hand and wrist. Nonsurgical options previously discussed in the literature include corticosteroid injection (CSI), nonsteroidal antiinflammatory drugs, thumb spica casting or bracing, and physical therapy.
Figure 1: Studies from 2004 and prior showing a success rate of 67 to 93 percent
There are studies suggesting ultrasound-guided steroid injections have shown better results than blind techniques in patients with de Quervain’s disease, as medication can be delivered precisely into the tendon sheath [5-6]. Correct needle placement with US guidance avoids intratendinous injection and local complications such as fat atrophy and depigmentation .
Figure 2. Complete subcompartmentalization with ultrasound guided technique approaching each side. Adopted from .
Figure 3. Ultrasound images of distal incomplete subcompartmentalization of APL and EPB. Injection technique would include targeting more proximally or injection in two areas more distally. Adopted from .
Despite successful outcomes with corticosteroid monotherapy, there is a lack of consensus on the role of immobilization with thumb spica casting or splinting. Splinting for De Quervain’s tenosynovitis has been found to decrease pain while increasing patients’ ability to continue to participate in activities of daily living . The splint must immobilize the wrist and thumb, excluding the thumb interphalangeal joint, in order to offload the APL and EPB tendons. Splints can either be rigid thermoplastic types or over the counter types made of semi-stiff fabric with metal bars for support.
Kinesiology tape, like thumb splinting, has been shown to offer short-term benefit in the conservative management of de Quervain disease . Other modalities that have been investigated include acupuncture, therapeutic ultrasound and hyaluronic acid [20-21].
Two separate studies describe treatment with platelet rich plasma or PRP. One study with 30 patients showed decreased pain scores on the visual analog scale at 6 months. Another study with 40 treatments showed corticosteroids to have better pain relief and hand function at 1 month. However, the PRP group had better pain relief and hand function testing at 6 months. No side effects were reported with PRP in either study [25-26].
Determining the efficacy of non-steroidal anti-inflammatory medications (NSAIDs) is difficult because they are often combined with other treatment modalities in most series examining their use for de Quervain’s tenosynovitis. Jirarattanaphochai et al. found no benefit to adding nimesulide, a selective cyclooxygenase-2 inhibitor, to corticosteroid injection in a randomized, double-blinded prospective study [15-16]. A case series of four de Quervain patients reported on complete symptom resolution in 75 percent of patients with only physical therapy . A more recent study with 98 patients had a success rate of 82.71% with corticosteroid injection and 65.31% with splinting, heat and ice compression and NSAID gel. The results showed a significant difference for both groups with respect to pain score and cure rate .
Figure 4: Treatment algorithm proposed for De Quervain’s tenosynovitis. Adopted from .
Surgery should be considered for recalcitrant cases that have shown no improvement with conservative measures over a 3–6-month time frame. The cure rate has been shown to be around 90 percent . The presence of a septum and multiple tendon slips are known to contribute to failure of non-operative treatment . There are many different surgical techniques reported and all require decompression. This usually involves a transverse incision with release on the dorsal side of 1st compartment to prevent volar subluxation of the tendon. Other incisions have also been described including longitudinal, lazy “s” or even specific angle technique . Close attention must be paid to the anatomy of the APL and EPB and tendon slips and compartments (as mentioned earlier).
In conclusion, the current evidence suggests a multimodal approach to conservative measures for the management of de Quervain’s tenosynovitis. Corticosteroids seem to be the most effective measure for long term relief and ultrasound is a valuable tool to identify and visualize septation or sub-compartmentalization of the APB and EPL. Ultrasound guided injections can improve accuracy and clinical cure rates with a more anatomical approach, although success rate with palpation guided injections ranges from 67 to 93 percent. Surgery is reserved for recalcitrant cases after 3-6 months and has shown to have very good outcomes around 90 percent.
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