Tendinitis involving the first extensor compartment is named after Fritz de Quervain, who reported five cases in 1895.1 Patients with this tenosynovitis describe pain and swelling about the radial aspect of the wrist that is aggravated by use of the wrist and thumb. The symptoms may develop suddenly or are gradual in onset. The pain often radiates proximally and distally along the forearm and thumb. It is aggravated by lifting, grasping, and pinching activities while relieved with rest. Some patients note paresthesias along the dorsal aspect of the thumb and index finger due to the proximity of the dorsal radial sensory nerve branches. Occasionally, patients will describe triggering, snapping, or catching that occurs with motion of the thumb.2

The dorsal wrist is separated into six fibro-osseous compartments, and de Quervain tenosynovitis develops within the first extensor compartment. Since this is a confined space, the process is considered an entrapment tendinitis, also termed stenosing tenosynovitis. The first compartment can be found by locating the volar tendons that make up the snuffbox (Fig. 46-1). Two tendons traverse within the first dorsal compartment, which is located in the region of the radial styloid. The extensor pollicis brevis (EPB) is the more dorsal of the two tendons and inserts on the base of the thumb proximal phalanx. The abductor pollicis brevis tendon lies more volar, often has two or more slips, and inserts on the base of the thumb metacarpal (Fig. 46-2). There is often a septum between the two tendons, which may lead to limited improvement following an injection and persistent pain following surgical treatment if not identified.

De Quervain tenosynovitis occurs in women more commonly than in men, most often occurs in middle age, and develops due to various factors. Most often, patients give a history of chronic overuse of the wrist. The activities include use of the thumb and specifically radial and ulnar deviation of the wrist. The symptoms can develop during pregnancy and commonly in new mothers due to infant care. Hormonal factors and awkward hand positioning with infant lifting may be related. Patients often note a traumatic event. Direct trauma to the tendon sheath may predate the symptoms, or a wrist fracture may lead to increased stresses across the tendons. The disease occurs more commonly in patients with diabetes mellitus. An inflammatory arthritis such as rheumatoid arthritis may also be related to the development of the process.

On physical examination, swelling is localized to the radial aspect of the wrist. On palpation, patients will have tenderness localized along the tendons of the first dorsal compartment. The tendon sheath will appear thickened, and prominence will be noted, which can feel as hard as bone. Occasionally, a small ganglion cyst can be palpated about the extensor retinaculum associated with the tenosynovitis. Wrist range of motion becomes limited as the tenosynovitis progresses in severity. The limitation in motion will occur with flexion, extension, and most significantly ulnar deviation. There are several provocative maneuvers that can be performed in confirming the
diagnosis of de Quervain tenosynovitis. These maneuvers are considered positive if they reproduce pain in the region of the first dorsal compartment. The Finkelstein maneuver is performed by having the patient make a fist around the thumb, and the wrist is ulnarly deviated (Fig. 46-3). Another maneuver, termed the hitchhiker sign, involves having the patient actively radially abduct the thumb against resistance (Fig. 46-4). Brunelli described a similar maneuver that is performed by having the patient actively radially abduct the thumb with the wrist in radial deviation¹ (Fig. 46-5). To specifically evaluate for triggering, the patient performs a maneuver with resisted palmar abduction of the thumb followed by adduction and flexion.