De Quervain tenosynovitis

Ask the patient to point with one finger to the pain. De Quervain disease localises over the radial styloid along the abductor pollicis longus and extensor pollicis brevis tendons. Symptoms worsen with lifting a baby, opening jars, gripping tools, thumb use on a phone or moving the wrist toward the little finger. Clarify trauma, a recent load increase, pregnancy or postpartum timing, inflammatory disease, skin breach and sensory disturbance. A fall or snuffbox pain requires a fracture pathway before tendon treatment.

Inspect for swelling and skin change. Palpate the first dorsal compartment directly and compare with the thumb carpometacarpal joint, anatomical snuffbox and the more proximal crossover site of intersection syndrome. Test active thumb extension and abduction against resistance, pinch and wrist movement. A Finkelstein manoeuvre should be performed gently by placing the thumb in the palm and deviating the wrist, because aggressive passive force can hurt normal wrists. The WHAT test uses active thumb abduction against resistance and may reproduce symptoms more specifically.

Examine sensation over the dorsoradial hand and percuss the superficial radial nerve; paraesthesia points away from an isolated tendon disorder. Thumb-base grind and joint-line tenderness suggest osteoarthritis. Snuffbox and scaphoid-tubercle tenderness after injury, especially with axial-load pain, mandates scaphoid immobilisation and follow-up imaging. Proximal dorsal crepitus suggests intersection syndrome. Diffuse warmth, a puncture and pain on passive movement require urgent assessment for infection.

Typical atraumatic disease is a clinical diagnosis. Plain radiographs answer a fracture, arthritis or bony-tumour question, not routine tendon confirmation. Ultrasound can show sheath thickening, fluid, tendon slips and a septated compartment and can guide injection. MRI is seldom needed, reserved for an unresolved mass, occult structural lesion or surgical uncertainty. Targeted inflammatory tests may be appropriate when several joints or tendon sheaths are active.

Initial care reduces peak thumb-wrist load while preserving general hand use. Teach two-handed infant lifting with wrists neutral, change grip diameter, alternate tasks and avoid repeated combined thumb abduction and ulnar deviation temporarily. A properly fitted thumb-spica supports the wrist and thumb metacarpophalangeal region while leaving fingers free and should not compress the superficial radial nerve. Use it for provoking tasks or a short continuous period according to irritability, then wean as strength and tolerance improve.

Hand therapy progresses pain-limited tendon glide, range and later resisted thumb abduction, extension and grip. Complete immobilisation can increase stiffness and dependency, while repeated painful stretching adds irritation. Monitor a real activity such as lifting an infant, opening a jar or holding a tool. Topical NSAID can be tried when appropriate; systemic NSAID is not automatically safe in postpartum patients, renal disease, anticoagulation or pregnancy.

Corticosteroid injection into the first dorsal compartment often produces useful relief. Use a trained aseptic technique and avoid injecting within tendon or into the superficial radial nerve. Ultrasound can identify and treat both subcompartments when a septum exists, particularly after a failed landmark injection. Counsel about post-injection flare, skin depigmentation or fat atrophy, transient glucose rise, rare infection and small tendon or nerve injury risk. Pair response with progressive return rather than indefinite splint use.

Surgery divides the constricting retinaculum and any separate subcompartment when symptoms remain disabling after appropriate non-operative care. Specialist technique protects the superficial radial nerve and avoids volar release that permits tendon subluxation. Early controlled movement and scar management follow. Pregnancy-associated cases may settle postpartum, so timing is individual unless function is severely compromised. Anticoagulants need coordinated procedural planning, and breastfeeding or pregnancy medicine choices should follow current product and national guidance.