Definition

The condition is characterized not by inflammation but by thickening of the tendon sheath and most notably by the accumulation of mucopolysaccharide, an indicator of myxoid degeneration. These changes are pathognomonic of the condition and are not seen in control tendon sheaths. The term stenosing tenovaginitis is a misnomer; de Quervain disease is the result of intrinsic, degenerative mechanisms rather than of extrinsic, inflammatory ones.

de Quervain tenosynovitis is classically defined as a stenosing tenosynovitis of the synovial sheath of tendons of the abductor pollicis longus and extensor pollicis brevis muscles in the first compartment of the wrist due to repetitive use. Fritz de Quervain first described this condition in 1895. Histologic studies have found that this disorder is characterized by degeneration and thickening of the tendon sheath and that it is not an active inflammatory condition.

In fact, de Quervain described thickening of the tendon sheath compartment at the distal radial end of the extensor pollicis brevis and abductor longus. Extensor triggering, which is manifested by locking in extension, is rare but has also been reported in de Quervain tenosynovitis with a prevalence of 1.3%.

de Quervain tenosynovitis was linked to repetitive use of the wrist. Many activities have been linked to this condition, including household chores, playing piano, crafting, bowling, and fishing. In more recent years, excessive use of the text-messaging feature on a cellular phone has now also been linked to this painful condition.

Work related activities such as such as pinching, grasping, pulling, and pushing have been reported in the past as having caused de Quervain tenosynovitis. A systemic review and meta-analysis in 2013 questions this common belief that de Quervain is secondary to vocational repetitive use. In a meta-analysis, there was no sufficient scientific evidence confirming a causal relationship between de Quervain tenosynovitis and occupational risk factors.

For a majority of cases, the onset of de Quervain tenosynovitis is gradual and not associated with a history of acute trauma, although several authors have noted a traumatic etiology, such as falling on the tip of the thumb. de Quervain tenosynovitis primarily affects women (gender ratio approximately 10:1) between the ages of 35 and 55 years. There is no predilection for right versus left side, and no racial differences have been observed. de Quervain tenosynovitis is associated with pregnancy, the postpartum period, and lactation.

Symptoms

Patients may complain of pain in the lateral wrist during grasp and thumb extension. They may also describe pain with palpation over the lateral wrist. Symptoms can include swelling and are aggravated by resisted motion of the thumb. Radial deviation and extension can also worsen the pain. Symptoms are often gradual in onset and persist for several weeks or months. Pain is the most prominent symptom quality, but some patients report stiffness as well. Pain is often described as severe and may be sufficiently intense to render the hand useless. Paresthesia in the distribution of the anterior terminal branch superficial radial nerve is uncommon.

Physical Examination

A comprehensive examination of the neck and entire upper extremity should be performed before the wrist examination to rule out radiating pain from a more proximal problem, such as a herniated cervical disc. Strength and sensation are expected to be normal in patients with de Quervain tenosynovitis. However, strength, particularly grip and pinch strength, may be decreased from pain or disuse secondary to pain.

On examination, the findings of local tenderness and moderate swelling around the radial styloid are likely to be present. A positive Finkelstein test result can confirm the diagnosis. The Finkelstein test is performed by grasping the patient’s thumb and quickly abducting the hand in ulnar deviation ( Fig. 28.1 ). Reproduction of pain is a positive test result. A similar test, described by Eichhoff in 1927, provides ulnar deviation while the patient is flexing the thumb and curling fingers around it. Pain should disappear the moment the thumb is again extended, even if the ulnar abduction is maintained. The Eichhoff test is sometimes erroneously called the Finkelstein test. The Brunelli test maintains the wrist in radial deviation while forcibly abducting the thumb ( Fig. 28.2 ). Pain over the radial styloid from these provocative stretch maneuvers differentiates de Quervain tenosynovitis from arthritis of the first metacarpal joint.

Finkelstein test (A) and Eichhoff test (B).

Brunelli test.

Assessment of the first carpometacarpal joint, including range of motion, palpation for tenderness and crepitus, and radiographic investigation, should also be performed because injury to this joint can give a false-positive Finkelstein test result. Typically, physical examination and history alone are diagnostic.

Functional Limitations

Functional impairment is believed to be caused by impaired gliding of the abductor pollicis longus or extensor pollicis brevis tendon through a narrowed fibro-osseous canal. Functional impairment of the thumb is a result of mechanical impingement or pain. Activities of daily living, such as dressing, can be impaired. Fastening of buttons often causes significant pain. In addition, household chores can be limited secondary to pain. Limits in recreational activities, such as bowling, fly-fishing, sewing, and knitting, are also seen in de Quervain tenosynovitis. Workers with jobs requiring repetitive motions, such as pushing or pulling in a factory setting, can have pain with work tasks due to de Quervain tenosynovitis. Thus, pain from the condition can have a significant economic impact. It is not established, however, that jobs with repetitive motions cause de Quervain tenosynovitis.