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Hand/Peripheral Nerve: Original Articles

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm

Abi-Rafeh, Jad H.B.Sc., M.Sc.; Kazan, Roy M.D., Ph.D.; Safran, Tyler M.D.; Thibaudeau, Stephanie M.D., C.M.

Author Information
Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 105-126
doi: 10.1097/PRS.0000000000006901

Abstract

De Quervain stenosing tenosynovitis is a relatively common disease of the wrist, with a reported prevalence of 0.5 percent in male patients and 1.3 percent in female patients.1 It is considered the most common tendon disorder of the wrist and hand in women with wrist- and thumb-straining occupations, and generally associated with work conditions that require repetitive overexertion and repetitive use of the thumb and wrist.2,3 Overall, it is 10 times more common in women than in men4; an increase in prevalence is also anticipated given the recent rise in text-messaging5 and video gaming6 in today’s patient population. It is characterized by swelling and thickening of the extensor retinaculum that covers the first dorsal compartment, through which the tendons of the abductor pollicis longus and extensor pollicis brevis pass.7,8 Resisted gliding of the abductor pollicis longus and extensor pollicis brevis tendons within the stenosed fibro-osseous canal results in radial-side wrist pain, decreased motion, and functional impairment.7 Presenting patients report pain, swelling, and discomfort over the radial styloid process, with a positive Finkelstein test.9

Various treatment options exist today for the management of de Quervain disease. These include surgical and percutaneous interventions to release the first dorsal compartment, and conservative nonsurgical approaches such as corticosteroid injections, splinting, physical therapy, and oral nonsteroidal antiinflammatory drug administration.10,11 Surgical management has been demonstrated to be the most effective, with a reported cure rate of 91 percent, whereas conservative management with corticosteroid injections has been shown to be less successful, with 61 to 83 percent cure rates reported in the literature.12,13 There exist several disadvantages associated with surgical management, such as cost, postoperative immobilization, and potential complications (e.g., radial nerve injury). For these reasons, conservative management is often pursued before surgical referral, and surgery is reserved for cases recalcitrant to conservative therapy.10,11 Several randomized controlled trials have been published in recent years exploring the efficacy of different modalities in the conservative management of de Quervain disease, either in isolation or in comparison to one another. However, at present, there exists no clear consensus regarding conservative treatment protocols that confer the best outcomes, nor is there adequate insight into reasons for conservative treatment failure.

The primary goal of this study was to conduct a systematic search of the literature to evaluate the current state of conservative management of de Quervain disease. With the information gathered, the authors aim to identify treatment- and patient-specific prognostic factors associated with the most successful outcomes. Gaining insight into the best conservative approaches available today will be vital in taking the next step toward the development of a globally adopted, evidence-based treatment regimen for the management of de Quervain stenosing tenosynovitis.

PATIENTS AND METHODS

A search of the National Library of Medicine (PubMed) was performed to categorize the available literature pertaining to the nonsurgical management of de Quervain disease. This was done using the search terms (“De Quervain Disease”[Mesh]) OR De Quervain*. The search was confined to the English language. Two independent reviewers assessed the resulting articles using strict inclusion and exclusion criteria in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines,14 and recommendations by Kelley and Chung.15 Nonduplicate titles were screened initially using titles and abstracts, and then for full-text relevance and data usability; any and all discrepancies between reviewers were resolved through discussion with the senior author (S.T.).

Included were studies reporting on clinical outcomes following the nonsurgical management of de Quervain stenosing tenosynovitis. Excluded were studies reporting on de Quervain thyroiditis, percutaneous or surgical interventions for de Quervain disease, diagnostic studies, or studies reporting on conservative management of complicated or irregular cases of de Quervain. Only articles with assigned levels of evidence ranging from I to II were considered for developing an evidence-based treatment protocol for the optimal nonsurgical management of de Quervain disease.16

RESULTS

A flowchart of the literature search is presented in Figure 1. The electronic literature search identified 894 articles; of these articles, 66 met the inclusion criteria for review. The final synthesis consisted of 23 case reports and 43 studies reporting on outcomes following the conservative treatment of de Quervain stenosing tenosynovitis. The latter were further classified into three categories: 22 articles reported on outcomes of different conservative treatment modalities used largely in isolation, eight studies reported on outcomes following combined treatment approaches, and 13 studies directly compared outcomes of different treatment regimens.

Fig. 1.
Fig. 1.:
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart summarizing retrieved, included, and excluded articles.

Inclusion Criteria and Patient Symptom Duration

Overall, of the 43 clinical studies reporting on outcomes following the conservative management of de Quervain disease, 34 studies (79 percent) listed a positive Finkelstein test as a criterion for patient inclusion. Thirty-two studies (74 percent) cited pain and 28 studies (65 percent) reported on tenderness over the first dorsal compartment and/or radial styloid as inclusion criteria. Criteria pertaining to patient ages were listed in only four studies (9 percent); age 18 years older was cited in three articles, and an age range of 30 to 50 years was listed in another. Inclusion criteria were not specified in five cases (Tables 1 through 3).1–116

Table 1. - Summary of Studies Reporting on Different Conservative Treatment Modalities, Used Largely in Isolation, for the Nonsurgical Management of de Quervain Disease
Modalities Reference (Study Type) Inclusion Criteria Pertinent Patient Information (Conclusions) Time since Symptom Onset No. of Patients No. of Wrists Treatment Information Injection Agent Follow-Up Outcome
Corticosteroid injections Akram et al., 201481 (prospective) Positive Finkelstein test; tenderness at radial styloid; prior treatment with NSAIDs (mean, 6 wk) showing no response n/a Unknown 80 80 Initial injection into FDC; second injection at 2 wk if needed; third injection if needed 1 ml (40 mg) of methylprednisolone acetate plus 1 ml lidocaine hydrochloride 2% 28 wk Pain relief (VAS) and negative Finkelstein test in 98.75% of patients: 65% after first injection, 30% after second injection, and 3.75% after third injection
Corticosteroid injections Anderson et al., 199182 (prospective) Positive Finkelstein test; pain and tenderness at radial styloid; resolution of symptoms with injection of 1% lidocaine Prior treatment with NSAIDs and splinting in 90% of patients (no mention of influence on outcome relative to nontreated population) Unknown 55 56 Lidocaine injected initially then methylprednisolone; 1 or 2 reinjections as needed 0.5 ml (40 mg) methylprednisolone acetate plus 1.5 ml lidocaine 1% 4 yr Pain relief, negative Finkelstein test, and subjective patient estimation of pain and functional improvement in 90% of patients: 57.7% single injection plus 32.7% multiple injections
Corticosteroid injections Apimonbutr and Budhraja, 200383 (prospective) Positive Finkelstein test; pain and tenderness at radial styloid n/a Unknown 103 115 Suprafibrous corticosteroid injection, NSAID with or without additional injections if persistent pain and restricted function 0.5 ml (5 mg) triamcinolone acetonide plus 0.5 ml lidocaine hydrochloride 1% 34 mo Pain relief and restored functionality in 77.4% of patients following 1–3 suprafibrous injections
Corticosteroid injections Christie, 199584 (prospective) Positive Finkelstein test; pain and tenderness at radial styloid n/a Mean, 6 mo (range, 4 wk–3 yr) 20 20 Intrasynovial injection of procaine followed by hydrocortisone; additional injections with symptom recurrence 1 ml (25 mg) hydrocortisone acetate plus 1 ml procaine hydrochloride 2% 3 mo 70% of patients symptom-free for periods exceeding 3 mo following 1 injection
Corticosteroid injections Earp et al., 201559 (prospective) Positive Finkelstein test; pain and tenderness over FDC; pain with resisted radial thumb abduction n/a Unknown 50 50 Single 2-ml intrasynovial injection plus splinting until symptom relief; repeated with symptom recurrence 1 ml (10 mg) triamcinolone acetonide or (10 mg) dexamethasone plus 1 ml lidocaine 1% 12 mo Resolution of symptoms in 82% of patients at 6 wk; surgical release required for 14% of patients
Corticosteroid injections Goldfarb et al., 200785 (randomized double-blind study) Positive Finkelstein test; pain and swelling over FDC; pain with thumb adduction during wrist ulnar deviation 5 patients with diabetes mellitus (no mention of influence on outcome) Unknown 37 37 Single intrasynovial injection 1 ml (40 mg) methylprednisolone acetate plus 0.5 ml lidocaine 1% plus 0.5 ml bupivacaine 0.5% with or without 0.3 ml sodium bicarbonate 6 wk VAS pain score means decreased from 5.2 to 1.0 at 6 wk; flare reaction observed in 41% of patients; pH-balanced injection did not significantly decrease risk of a flare reaction
Corticosteroid injections Harvey et al., 199086 (retrospective) Positive Finkelstein test; pain at radial styloid; tenderness over APL and EPB tendons 10 patients with a recent childbearing history (no mention of influence on outcome; mention of increased susceptibility for de Quervain disease) Unknown n/s 63 1–2 corticosteroid injections Hydrocortisone acetate or methylprednisolone acetate plus local anesthesia 20 mo (1 injection) or 30 mo (2 injections) 83% success rate after two injections, defined as avoidance of surgical intervention
Corticosteroid injections McKenzie, 197287 (prospective) n/s n/a 5 wk–9 mo 30 30 Intrasynovial corticosteroid injection; repeated injection at 2 wk if symptoms persisted 25 mg hydrocortisone acetate plus 1 ml lidocaine 2% 18 mo 90% of patients symptom-free following 1–2 injections
Corticosteroid injections Oh et al., 201758 (retrospective) n/s Comorbidities in some patients included diabetes, hypothyroidism, Dupuytren’s and carpal tunnel syndrome; splinting used in some patients (hypothyroidism and carpal tunnel syndrome demonstrated increased odds of treatment failure; however, the difference was not statistically significant) Unknown 199 222 Hand surgeons, nurse practitioners or physician assistants performing 1–2 corticosteroid injections into FDC 3–6 mg betamethasone or 10–40 mg triamcinolone or 4 mg dexamethasone plus 5–10 mg lidocaine n.s. Complete relief of symptoms achieved in 51.8% of patients after 1 injection; 73.4% of patients after 2 injections
Corticosteroid injections Pagonis et al., 201128 (randomized controlled trial) Positive Finkelstein test; pain and tenderness over FDC; prior treatment with NSAIDs and splinting (minimum, 8 wk) showing no response Weight training male athletes Unknown 24 24 4-point corticosteroid injection technique; repeat injections if necessary within 2-wk intervals with or without NSAIDs Betamethasone sodium phosphate-betamethasone acetate mixture (3 + 3 mg/ml in 1-ml vial) 12 mo 84% of patients symptom-free after 1–4 injections; treatment failed in 4%, necessitating surgery
24 24 2-point corticosteroid injection technique; repeat injections if necessary within 2-wk intervals with or without NSAIDs 50% of patients symptom-free after 1–4 injections; treatment failed in 50% necessitating surgery
Corticosteroid injections Peters-Veluthamaningal et al., 200988 (prospective) Positive Finkelstein test; pain and tenderness at radial styloid; crepitations on palpation of radial styloid 47% of participants received placebo sodium chloride injection earlier in study (no mention of influence on outcome) Unknown 17 17 Corticosteroid injection into FDC; additional injection 1 wk later with persisting symptoms 1 ml (10 mg) triamcinolone acetonide 2 wk Surgical intervention avoided in 71% of patients
Corticosteroid injections Rankin and Rankin, 199889 (retrospective) Positive Finkelstein test; pain and tenderness over FDC 40% of patients with history of other hand abnormalities: carpal tunnel, trigger finger, carpometacarpal arthritis (no mention of influence on outcome) Unknown 58 58 Corticosteroid injection into FDC; repeated injections with symptom recurrence 0.5 ml (5 mg) triamcinolone acetate plus 0.5 ml lidocaine 1% 1–3 yr 84% of patients symptom-free following 1–2 injections; treatment failed in 12% necessitating surgery
Corticosteroid injections Roh et al., 201757 (prospective) Positive Finkelstein test; pain and tenderness over FDC (VAS ≥ 5); age ≥ 18 yr Metabolic syndrome ≥3 mo 64 64 Single corticosteroid injection into FDC 1 ml (10 mg) triamcinolone acetonide plus 1 ml lidocaine 1% 6 mo 57% success rate, defined as absence of pain, avoidance of surgery, and negative Finkelstein test
Age- and gender-matched control group 64 64 80% success rate, defined as absence of pain, avoidance of surgery, and negative Finkelstein test
Corticosteroid injections Sakai, 200290 (prospective) Positive Finkelstein test; pain and tenderness over FDC; pain on resisted thumb extension and abduction n/a Mean, 6.9 mo (range, 3–37 mo) 50 53 Selective corticosteroid injection into EPB tenosynovium 0.25 ml (10 mg) triamcinolone plus 0.25 ml lidocaine 1% 2.1 yr Avoidance of surgery in 100% of cases after up to 3 injections
Corticosteroid injections Sawaizumi et al., 200627 (prospective) Positive Finkelstein test; pain and tenderness over FDC n/a Mean, 17 wk (range, 2–45 wk) 17 18 Single-point intrasynovial corticosteroid injection; repeat for maximum of 3 injections 1 ml triamcinolone plus 1 ml lidocaine hydrochloride 1% 3 yr 78% success rate, defined as absence of or occasional pain, but no disruption of daily life after a mean of 1.4 injections
19 20 2-point intrasynovial corticosteroid injections (over APL and EPB tendons); repeat for maximum of 3 injections 100% success rate, defined as absence of or occasional pain, but no disruption of daily life after a mean of 1.4 injections
Corticosteroid injections Zingas et al., 199891 (prospective) Positive Finkelstein test; pain and tenderness over FDC 16% postpartum (no mention of influence on outcome) Unknown 19 19 Single manual corticosteroid injection targeting APL tendon sheath and EPB tendon sheath, when possible; radiographic evaluation demonstrated 84% accuracy 1 ml (6 mg) Celestone plus 1 ml Omnipaque 300 plus 3 ml lidocaine 1% 3 mo 58% of patients symptom-free after single injection
Ultrasound-guided corticosteroid injections Danda et al., 201651 (prospective) Prior treatment with NSAIDs, splinting (3 wk), and rest, showing no response n/a Unknown 50 51 Compartmentalization assessed using ultrasound; appropriate injections to ensure infiltration of all affected compartments 1 ml (40 mg) methylprednisolone plus 1 ml lidocaine 2% 6 mo 100% symptom resolution in patients with either no compartmentalization, or compartmentalization with both compartments separately injected; resolution in 63% of patients with compartmentalization in which only 1 compartment was injected
Ultrasound-guided corticosteroid injections Bing et al., 201892 (prospective) Positive Finkelstein test; tenderness of radial wrist n/a Mean, 5.9 mo (range, 1–36 mo) 28 28 Compartmentalization and tendon involvement assessed using ultrasound; appropriate injections to ensure infiltration of all affected compartments Two doses: 1 ml (20 mg) triamcinolone plus lidocaine 2% 31 days Significant reduction in VAS score; significant symptomatic relief in 95.7% of patients, subjective pain reduction in 82%
Ultrasound-guided corticosteroid injections Hajder et al., 201354 (retrospective) Positive Finkelstein test; tenderness at FDC/radial styloid; age ≥ 18 yr; diagnosis confirmed by ultrasound 52% of patients received prior NSAID or splinting treatment (outcomes were not significantly different); 29% of patients received prior non–ultrasound-guided corticosteroid injections (no mention of influence on outcome) Unknown 62 71 Ultrasound assessment; ultrasound-guided corticosteroid injection; injection of both compartments in presence of septum; second injection if necessary; splinting offered to 39% of patients 1 ml (30–40 mg) triamcinolone plus 0.2–0.3 ml lidocaine 1% or bupivacaine 0.5% 12 mo 73% success rate after one injection; 91% success rate after two injections (defined as absence of clinical signs); outcomes in patients with splinting, as assessed in this study, were not significantly different
Ultrasound-guided corticosteroid injections Jeyapalan and Choudhary, 200993 (retrospective) n.s. One patient had type 2 diabetes, five patients had one non–ultrasound-guided injection, 2–5 mo prior (no mention of influence on outcome) Unknown 17 17 Ultrasound assessment and diagnosis confirmation; ultrasound-guided corticosteroid injection to appropriate compartments; postinjection imaging to confirm location of injectate 20 mg triamcinolone plus 1 ml bupivacaine 0.5% 7 wk 93% of patients experienced significant symptomatic relief; all patients with prior non–ultrasound-guided injections experienced symptomatic relief
Physiotherapy Rabin et al., 201564 (case series) 5 of 7 of Batteson et al. screening criteria 75% of patients received NSAID and splinting treatment without avail (no mention of influence on outcome) 6 wk–6 mo 4 4 Median of 8 treatment sessions, two times per week: mobilizations, eccentric training, high-voltage electric stimulation n/a 6 mo Further treatment (corticosteroid injections) avoided in 75% of patients
Topical herbal medicinal patch Leung et al., 201671 (prospective) n.s. n/a Unknown 5 5 Patch with 3 medicinal herb extracts plus Borneol applied over wrist at base of thumb; changed daily until 6 wk n/a 6 wk 52% decrease in morning pain; 53.8% decrease in evening pain
n/a, not applicable; ; FDC, first dorsal compartment; VAS, visual analogue scale; NSAID, nonsteroidal antiinflammatory drug; APL, abductor pollicis longus; EPB, extensor pollicis brevis; n/s, not significant.

Table 2. - Summary of Studies Reporting on Combinatorial Treatment Approaches for the Nonsurgical Management of de Quervain Disease
Modalities Reference (Study Type) Inclusion Criteria Pertinent Patient Information (Conclusions) Time since Symptom Onset No. of Patients No. of Wrists Treatment Information Injection Agent Follow-Up Outcome
Splinting, physiotherapy, and NSAIDs Capasso et al., 200294 (prospective) Positive Finkelstein test; thickened retinaculum of FDC on ultrasonography Postpregnancy de Quervain disease ≤3 mo after delivery 30 30 Splinting for 2 wk, physiotherapy (massage, cryotherapy, therapeutic ultrasound), and 7-day course of NSAIDs n/a 6 mo Conservative treatment failed in only 1 patient necessitating surgery
Non–pregnancy-related de Quervain disease ≤3 mo 30 30 Conservative treatment failed in 25 patients necessitating surgery
Corticosteroid injections and splinting Otto and Wehbe, 198695 (retrospective) n/s n/a Unknown n/s 55 1–2 manual corticosteroid injections targeting FDC and splinting 1:1 solution of betamethasone and lidocaine 0.5% 8 mo 51% of patients required no further treatment; 12% of patients required surgery
Corticosteroid injections and splinting Witt et al., 199138 (prospective) Positive Finkelstein test; pain at radial styloid and on passive thumb and wrist movement; tenderness and swelling over FDC Carpal tunnel syndrome, trigger finger, or osteoarthritis in 19% of patients (no mention of influence on outcome) Unknown 95 99 Single manual corticosteroid injection targeting FDC and splinting for 3 wk 1 ml (40 mg) methylprednisolone acetate and 1 ml lidocaine 1% 18 mo Absence of tenderness and Finkelstein test findings in 62% of patients
Corticosteroid injections, splinting, and NSAIDs Pagonis et al., 200962 (prospective) Positive Finkelstein test; pain and tenderness over FDC Weight training male athletes; prior GH abuse; 5/9 patients continued GH abuse during treatment Unknown 9 9 21-day course of 50 mg indomethacin two times per day and splinting; corticosteroid injections using “4-point technique” (1/4 dose at each location); repeat injections for persisting symptoms Betamethasone sodium phosphate–betamethasone acetate mixture (3 + 3 mg/ml in 1-ml vial) 24 mo 100% success rate (avoidance of surgery) using conservative approaches in group without prior GH abuse; failure of conservative treatment in 78% of patients with prior GH abuse, necessitating surgery
Weight training male athletes with no prior GH abuse 10 10
Corticosteroid injections, splinting, and NSAIDs Skoff, 200196 (retrospective) Positive Finkelstein test; pain at radial styloid; tenderness over FDC; swelling or crepitation Postpartum de Quervain disease in 40% of patients; splinting and NSAID compliance unregulated (77% success rate in postpartum patients; not statistically significant) Unknown 100 119 1–2 manual corticosteroid injections targeting FDC, splinting, and NSAIDs n/s 6 mo 70% success rate, defined as avoidance of surgery
Ultrasound-guided corticosteroid injections and splinting De-Keating Hart et al., 201639 (prospective) Positive Finkelstein test; pain on radial wrist; tenderness over FDC 3 postpartum patients; 2 patients received previous corticosteroid injections (no mention of influence on outcome) Unknown 41 41 Ultrasound assessment of APL and EPB tendons, retinaculum and septum; ultrasound-guided injection around affected tendon and splinting for 3 wk 0.25–0.5 ml cortivazol 16 mo Conservative treatment failed in 24% of patients necessitating surgery; presence of intercompartmental septum associated with treatment failure
Ultrasound-guided corticosteroid injections plus splinting McDermott et al., 201255 (prospective) Pain, tenderness, and/or swelling over FDC n/a Unknown 40 41 Ultrasound assessment; ultrasound-guided corticosteroid injection; in case of compartmentalization, septum pierced, half of injectate administered around each tendon; splinting for 6 wk 0.5 ml (20 mg) of triamcinolone acetonide and 0.5 ml lidocaine 1% 11 mo 86% success rate after single injection at last follow-up; 14% of patients experienced symptom recurrence necessitating further intervention (injection or surgery)
Sclerosing therapy and eccentric training Knobloch et al., 200877 (case series) Positive Finkelstein test; pain over FDC n/a Unknown 3 3 Polidocanol sclerosing therapy (0.25% 1 ml), compression dressing for 24 hr; initiation of 12-wk course of eccentric training 72 hr later n/a 0 Two-thirds of patients pain-free after sclerosing therapy and 12 wk of eccentric training; 1 patient, who did not abide with training protocol, underwent surgical release
NSAID, nonsteroidal antiinflammatory drug; FDC, first dorsal compartment; n/a, not applicable; n/s, not significant; GH, growth hormone; APL, abductor pollicis longus; EPB, extensor pollicis brevis.

Table 3. - Summary of Studies Comparing Outcomes of Different Treatment Regimens Used for the Nonsurgical Management of de Quervain Disease
Modalities Reference (Study Type) Inclusion Criteria Pertinent Patient Information (Conclusions) Time since Symptom Onset No. of Patients No. of Wrists Treatment Information Injection Agent Follow-Up Outcome
Full-time splinting vs. as-desired splinting Menendez et al., 201518 (prospective, randomized study) Positive Finkelstein test; tenderness over FDC; age ≥18 yr Patients not prohibited from seeking additional treatment such as corticosteroid injections or surgery (no mention of influence on outcome) Unknown 43 43 Full-time splinting for 6 wk; as-desired splinting for 2 additional wk n/a 7.5 wk Statistically insignificant differences in disability, grip strength, pain intensity, and treatment satisfaction between patients in both groups; average change in DASH and pain scores for all patients were 6.7 and 1.5, respectively
40 40 As-desired splinting for 8 wk
Splinting vs. corticosteroid injections Avci et al., 200261 (prospective) Positive Finkelstein test; tenderness over radial styloid All patients had pregnancy- or lactation-related de Quervain disease (no mention of influence on outcome) Unknown 9 10 Intrasynovial corticosteroid injection, reinjection with symptom recurrence 0.25 ml (10 mg) methylprednisolone and 0.5 ml bupivacaine 0.5% 12 mo Self-reported pain relief and negative Finkelstein test in all injected patients
9 9 Splinting n/a Pain relief only while wearing splint, pain otherwise; pain resolved spontaneously in 89% of patients 2–6 wk after cessation of breast-feeding
Splinting vs. corticosteroid injections and splinting Mehdinasab and Alemohammad, 201019 (prospective, randomized study) Positive Finkelstein test; pain and tenderness over FDC and radial styloid; pain on resisted thumb extension or abduction n/a Unknown 37 37 Corticosteroid injection into FDC and splinting for 1 mo 1 ml (40 mg) methylprednisolone acetate 6 mo 86.4% of patients achieved 90% improvement in VAS pain score, absence of pain, tenderness, and Finkelstein test findings
36 36 Splinting for 1 mo n/a 36% of patients achieved 90% improvement in VAS pain score, absence of pain, tenderness, and Finkelstein test findings
Splinting vs. corticosteroid injections vs. corticosteroid injections and splinting Weiss et al., 199422 (prospective) Positive Finkelstein test; pain at radial wrist; tenderness over FDC 8% of patients with pregnancy or postpartum De Quervain Unknown n.s. 37 Splinting 1 ml betamethasone and 1 ml lidocaine 1% 13 mo Surgery avoided in 30% of patients
n/a n/s 42 Corticosteroid injection into FDC Surgery avoided in 69% of patients
Splinting treatment before enrollment in study n/s 14 Corticosteroid injection into FDC and splinting Surgery avoided in 57% of patients; no added benefit of splinting
Splinting and NSAIDS vs. corticosteroid Injections Lane et al., 200197 (retrospective) Positive Finkelstein test; pain and tenderness over FDC Corticosteroid injection group included some patients for which splinting and NSAID treatment had failed; 19 patients had diabetes, 42 had carpal tunnel syndrome, 28 had trigger finger, 8 were pregnant (no mention of influence on outcome) Unknown n.s. 45 Splinting and 500 mg naproxen orally, twice daily n/a 2.3 yr Complete relief of symptoms achieved in 42% of cases; symptoms unchanged in 33% of cases
n.s. 276 Corticosteroid injection into FDC; repeat injections with symptom recurrence (4 mg) Celestone Soluspan and 0.6 ml bupivacaine 0.5% Complete relief of symptoms achieved in 78% of cases after 1–3 injections; symptoms unchanged in 16% of cases
Corticosteroid injections vs. corticosteroid injections and NSAIDS Jirarattanaphochai et al., 200424 (randomized double-blind placebo-controlled trial) Positive Finkelstein test; pain over FDC on resisted thumb abduction or extension; tenderness over radial styloid Previous steroid injection in 24 patients (no mention of influence on outcome) Unknown 80 82 Single corticosteroid injection and placebo two times daily for 7 days; additional injections with symptom recurrence 1 ml (10 mg) triamcinolone acetonide and 0.5 ml lidocaine 1% 13.6 mo 95% success rate after 1–4 injections in both groups, defined as 90% resolution of pain, tenderness, and negative Finkelstein test; supplemental NSAID administration does not improve outcomes of single corticosteroid injection
Previous steroid injection in 24 patients (no mention of influence on outcome) 80 83 Single corticosteroid injection and oral nimesulide two times daily for 7 days; additional injections with symptom recurrence
Corticosteroid injections vs. corticosteroid injections and splinting Ippolito et al., 201823 (prospective, randomized study) Positive Finkelstein test; pain and tenderness over FDC and radial wrist (VAS ≥ 4) n/a Unknown 9 9 Single corticosteroid injection into FDC 1 ml (40 mg) methylprednisolone acetate and 2 ml lidocaine 2% 6 mo 88% of patients experienced resolution in 2 of 3 symptoms (radial wrist pain, tenderness, and positive Finkelstein test
11 11 Single corticosteroid injection into FDC and splinting for 3 wk 73% of patients experienced resolution in two-thirds symptoms (radial wrist pain, tenderness, and positive Finkelstein test); splinting protocol described confers no additional benefit
Corticosteroid injections vs. corticosteroid injections and splinting Mardani-Kivi et al., 201421 (prospective) Positive Finkelstein test; pain and tenderness over FDC and radial wrist (pain score > 6) n/a Unknown 33 33 Corticosteroid injection into FDC and splinting for 3 wk; repeat injections at 3 wk with symptom recurrence 1 ml (40 mg) methylprednisolone acetate and 1 ml lidocaine 2% 6 mo 93% success rate, defined as absence of pain, tenderness, and negative Finkelstein test
34 34 Corticosteroid injection into FDC; repeat injections at 3 wk with symptom recurrence 69% success rate, defined as absence of pain, tenderness, and negative Finkelstein test
Corticosteroid injections and splinting vs. acupuncture and splinting Hadianfard et al., 201468 (randomized controlled trial) Positive Finkelstein test; pain and/or swelling around radial styloid n/a Unknown 15 15 5 acupuncture treatment sessions of 30-min duration, administered within 1 wk on LI-5, LU-7 LU-9 and on ashi points and splinting n/a 6 wk Mean Q-DASH and VAS scores improved significantly with both treatments, but were higher in acupuncture group relative to injection group at 6 wk
15 15 Single injection around APL and EPB tendon sheaths and splinting 1 ml (40 mg) methylprednisolone acetate and 1 ml lidocaine 2%
Corticosteroid injections vs. ultrasound-guided corticosteroid injections Kume et al., 201256 (prospective, randomized study) Positive Finkelstein test; pain over FDC aggravated by excessive use of the thumb All patients had a septated first dorsal compartment and tendinosis of EPB; patients allowed concomitant NSAID use during study (no mention of influence on outcome) Unknown 22 22 Single ultrasound-guided corticosteroid injection targeting EPB tendon 0.5 ml (20 mg) triamcinolone and 1 ml lidocaine 1% 6 wk Treatment failed in 2 patients necessitating surgery
22 22 Single manual corticosteroid injection targeting FDC Treatment failed in 9 patients necessitating surgery
Ultrasound-guided corticosteroid injections vs. ultrasound-guided corticosteroid and HA injections Orlandi et al., 201553 (randomized controlled trial) Positive Finkelstein test n/a Unknown 25 25 Ultrasound-guided injection into FDC 1 ml (40 mg) methylprednisolone acetate and 1–2 ml mepivacaine hydrochloride 2% 6 mo Addition of HA to ultrasound-guided steroid injections improves outcomes: 3 vs. 5 score change in VAS, 4 vs. 29 score change in DASH, and 0.1- vs. 1.0-mm change in retinaculum thickness in patients treated with US-guided injection vs. US-guided injection and 15-day delayed HA injection, respectively
25 25 Ultrasound-guided injection into FDC and 15-day delayed low-weight HA injection 1 ml (40 mg) methylprednisolone acetate and 1–2 ml mepivacaine hydrochloride 2%; 16 mg/2 ml HA 0.8%
Therapeutic ultrasound alone vs. therapeutic ultrasound and splinting Awan et al., 201772 (randomized controlled trial) Positive Finkelstein test; tenderness over FDC; positive EPB extension test; age 30–50 yr n/a ≥ 6 mo 15 15 12 40-min sessions, two sessions per week: heat therapy for 15 min, ultrasound therapy at 0.7 W/cm2 for 5 min over origin of APL and EPB, exercises for 10 min n/a 0 Significant changes in 7 items of Q-DASH Disability/Symptom score; significant changes in all items of Q-DASH Work Module
n/a 15 15 Above protocol and splinting to avoid thumb flexion and adduction Significant changes in 8 items of Quick DASH Disability/Symptom Score; Significant changes in all items of Quick DASH Work Module
Therapeutic ultrasound vs. low-level laser therapy Sharma et al., 201573 (prospective) Positive Finkelstein test; no history of treatment for at least 3 mo n/a Unknown 15 15 7 exposures of low-level laser therapy, applied twice per session, at 2–3 J/cm2 n/a 2 wk Both modalities resulted in improvements in tenderness, grip strength and pain (VAS); differences between modalities not significant; neither improved outcome of Finkelstein test
15 15 7 exposures of therapeutic ultrasound at 3 MHz and 0.8 W/cm2
FDC, first dorsal compartment; n/a, not applicable; DASH, Disabilities of the Arm, Shoulder and Hand; VAS, visual analogue scale; n/s, not significant; NSAID, nonsteroidal antiinflammatory drug; Q-DASH, Quick DASH; APL, abductor pollicis longus; EPB, extensor pollicis brevis; HA, hyaluronic acid; US, ultrasound.

The average time of symptom duration at the time of study offset was unspecified in the majority of studies reviewed [n = 34 (79 percent)]. Where specified, symptom duration ranged from 5 weeks to 37 months, with a median of 4.3 months [n = 9 studies (21 percent)] (Tables 1 through 3).

Conservative Treatment Modalities

Twenty-two articles reported on outcomes following conservative management of 1210 wrists from approximately 1159 patients. Four treatment modalities were described and used in isolation; 16 articles (73 percent) reported on corticosteroid injections, four articles (18 percent) reported ultrasound-guided corticosteroid injections, one article (5 percent) described the use of physical therapy, and one article (5 percent) reported on topical herbal medicinal therapy. Follow-up ranged from 2 weeks to 4 years (average, 13.5 months) and success rates, according to definitions ascribed in the original articles, ranged from 50 to 100 percent (Table 1).

Combined Conservative Treatment Approaches

Eight articles reported on the outcomes of 437 treated wrists of approximately 413 patients. Combined therapeutic approaches included the use of splints, nonsteroidal antiinflammatory drugs, and physiotherapy [one study (13 percent)]; manual or ultrasound-guided corticosteroid injections with splinting [four studies (50 percent)]; corticosteroid injections, splinting, and nonsteroidal antiinflammatory drugs [two studies (25 percent)]; and sclerosing therapy with eccentric training [one study (13 percent)]. Follow-up ranged from 0 to 24 months (average, 11.1 months), and success rates, according to definitions provided by the original articles, ranged from 51 to 100 percent (Table 2).

Comparative Studies

Thirteen articles reported on 1025 wrists of approximately 1019 patients for whom outcomes of different conservative treatment approaches were compared. Four articles (31 percent) compared the use of splints alone to that of corticosteroid injections with or without supplementary splinting. Two studies (15 percent) compared the use of corticosteroid injections alone to that of corticosteroid injections and splinting. Two studies (15 percent) reported on therapeutic ultrasound use alone, either relative to supplementary splinting or low-level laser therapy. One article (8 percent) reported on nonsteroidal antiinflammatory drug supplementation to corticosteroid injections relative to corticosteroid injections alone. Another study (8 percent) compared acupuncture therapy to corticosteroid injections. One article (8 percent) directly compared manual corticosteroid injections to ultrasound-guided injections, whereas another study (8 percent) evaluated the use of the latter in conjunction with delayed hyaluronic acid injections. Average follow-up was 7.4 months and ranged from 0 to 2.3 years (Table 3).

Case Reports

Twenty-three case reports were identified reporting on the use of conservative approaches in the management of de Quervain disease. Fourteen articles (61 percent) reported on outcomes following a single treatment approach, of which corticosteroid injections made up the majority (71 percent). Nine articles (39 percent) used combined approaches. Surgery was avoided in 17 cases (74 percent), whereas complications were reported in 12 articles (52 percent). All complications arose following corticosteroid injections, which included cutaneous hypopigmentation (50 percent), tendon ruptures (33 percent), cutaneous atrophy (33 percent), in addition to temperature sensitivity and skin fragility (8 percent). (See Table, Supplemental Digital Content 1, which shows a summary of case reports pertaining to the nonsurgical management of de Quervain disease. N/a, not applicable; NSAID, nonsteroidal antiinflammatory drug; APL, abductor pollicis longus; EPB, extensor pollicis brevis, http://links.lww.com/PRS/E111.)

DISCUSSION

In the present study, the authors conducted a systematic review of the literature to evaluate all nonsurgical treatment modalities presently in use for the management of de Quervain disease. The combination or direct comparison of success rates across different studies was proven difficult, given the heterogeneity that existed in the outcome assessment measures used in each study. Although corticosteroid injections were demonstrated to be the single nonsurgical treatment modality associated with the best outcomes,12,13,17 an assessment of the highest quality evidence identified (levels I to II) demonstrated that a multimodal approach using various nonsurgical modalities are associated with better outcomes. Notable risks persist, however, with corticosteroids, and their use must be exercised with caution. The authors thus discuss the present state of conservative management of de Quervain disease and present an evidence-based treatment protocol for its optimal nonsurgical management before referral for surgical decompression.

Corticosteroid Injections, Splinting, and Oral Nonsteroidal Antiinflammatory Drugs

The efficacy of corticosteroid injections in the management of de Quervain disease is well documented in the literature, with reported success rates ranging from 61 to 83 percent.12,13 A systematic review by Ashraf and Devadoss17 demonstrated that corticosteroid injections are more effective than only splint therapy, whereas Menendez et al.18 report that full-time splinting offers no benefit over as-desired splinting in the latter case. A combination of corticosteroid injections and casting has been reported to produce better outcomes than casting alone.19 In contrast, a systematic review and meta-analysis by Cavaleri et al.20 demonstrated that the combination of corticosteroid injections with splinting produces better outcomes than injections alone (p < 0.001).20,21 Two articles identified in this review, however, have argued for the contrary, reporting that adjuvant splint therapy offered no additional benefit over corticosteroid injections alone.22,23 The findings of the latter studies may be limited by their small sample sizes and the use of a single corticosteroid injection before outcome evaluation.22,23 Although additional research is warranted to further investigate these claims; the present evidence suggests that a multimodal approach using both corticosteroid injections and splint therapy confers the best treatment outcomes. Jirarattanaphochai et al.24 demonstrated that oral nonsteroidal antiinflammatory drug administration in conjunction with injection therapy does not provide any more benefit than injection alone, and thus should not be considered in this multimodal approach.

Corticosteroid Injection Frequency and Technique

Sears et al.25 used a multivariable logistic regression model to evaluate the odds of conservative treatment failure in de Quervain disease based on the number of steroid injections administered. They report that a higher frequency of injections (two to three) was associated with a lower predicted probability of surgery than only one injection.25 Kachooei et al.,26 however, report that the odds of operative management were significantly greater in patients who had received a corticosteroid injection relative to those who had not. More severe cases of de Quervain disease are more likely to receive corticosteroid injections before referral for surgery; thus, their findings may be more appropriately interpreted as a correlation rather than causation. Corticosteroid use, however, presents with significant risks; the present review identified notable complications associated with corticosteroid injections, including cutaneous hypopigmentation, tendon ruptures, cutaneous atrophy, and temperature sensitivity and skin fragility. Corticosteroid use must thus be exercised with caution and in appropriately selected patients, using the surgeon’s clinical judgment, avoiding patients with contraindications and comorbidities such as diabetes. Sawaizumi et al.27 report that a two-point injection technique, targeting both the abductor pollicis longus and extensor pollicis brevis tendons, had significantly better outcomes than only a one-point injection technique. Pagonis et al.28 further demonstrate that a four-point injection technique, corresponding to two pairs of injections proximal and distal to the points of maximum tenderness over each tendon, produced better Disabilities of the Arm, Shoulder and Hand questionnaire outcome measures than a two-point injection technique in high-resistance-training male athletes at 8 and 52 weeks after injection. These findings are likely attributable to the more appropriate targeting of both the extensor pollicis brevis and abductor pollicis longus tendons in multipoint techniques, especially in the presence of intercompartmental septa. This was corroborated by Mirzanli et al.29 in their anatomical study on cadaver wrists. Finally, in their systematic review of the anatomy of the first dorsal compartment, Lee et al.30 suggest that if a one-point injection technique is to be administered, a proximal injection is indicated over a distal injection, because of its greater likelihood of infiltrating both compartments of a septated first dorsal compartment.30–32

Imaging

Radiography, magnetic resonance imaging, and ultrasound have been explored for the diagnosis and conservative management of de Quervain disease. Chien et al.33 conducted a blinded retrospective review of radiographs from clinically diagnosed de Quervain patients and compared them to those of normal individuals. They demonstrated that visualization of focal cortical erosion, sclerosis, or periosteal bone apposition of the radial styloid sheath may aid in the diagnosis of de Quervain disease.33 However, Kazmers et al.34 report that performing wrist radiography did not influence outcome of either conservative or surgical management of this condition. The use of magnetic resonance imaging for both diagnostic and prognostic purposes has also been reported in the literature, describing thickening of the extensor pollicis brevis and abductor pollicis longus tendons and peritendinous edema presenting as the most reliable findings.35,36 Despite the reliable identification of both tendon slips and septation to appropriately guide therapy, significant associated costs render the use of magnetic resonance imaging impractical.36 Ultrasonography has proven to be a valuable asset in the diagnosis, characterization, and guidance of conservative management in de Quervain disease. The presence of a septum in the first dorsal compartment has been associated with a higher incidence rate of de Quervain disease, and a higher rate of conservative treatment failure warranting surgical intervention.37–40 Several anatomical and cadaveric studies have reported high accuracy of intercompartmental septum detection using ultrasonography, with sensitivities ranging from 83 to 100 percent.41–45 Furthermore, ultrasound-guided injections were generally shown to confer significantly better outcomes, both in terms of injection accuracy as assessed by anatomical studies,46–48 and treatment success rate in patients, especially in the presence of an intercompartmental septum.49–56 This is likely attributable to better visualization of compartmental anatomy and more accurate needle placement and targeting of both the abductor pollicis longus and extensor pollicis brevis tendons.

Patient-Related Prognostic Indicators

There exist several reports in the literature of patient-related factors influencing the outcome of conservative management of de Quervain disease. Roh et al.57 report that corticosteroid injections were less effective in patients with metabolic syndromes when compared to age- and sex-matched controls. Oh et al.58 reported that a body mass index over 30 kg/m2 and female sex were associated with treatment failure. However, other studies have demonstrated that age, body mass index, sex, and symptom duration were not significant predictors of conservative treatment failure.26,59,60 Sears et al.25 report that hypothyroidism and pregnancy are associated with increased and decreased likelihoods of surgery, respectively. The latter case is consistent with previous reports of de Quervain presenting as a self-limiting disease in pregnant and lactating women.61 Pagos et al.62 showed that growth hormone abuse in male body builders was associated with both a higher incidence of de Quervain disease and a higher likelihood of conservative treatment failure warranting surgical decompression. Earp et al.59 further demonstrate that a prior trigger finger or carpal tunnel diagnosis are statistically significant predictors of symptom recurrence within 1 year following corticosteroid injections. Extensor triggering has also been associated with more recalcitrant cases of de Quervain when treated conservatively.63 Kazmers et al.60 report that psychiatric illnesses and Medicaid insurance status in the United States are associated with a higher likelihood of undergoing surgical release, whereas Mendendez et al.18 also demonstrated that baseline pain anxiety, catastrophic thinking, and symptoms of depression are associated with worse outcomes.

Alternative Conservative Approaches

There exists in the literature reports of several alternative approaches for the conservative management of de Quervain disease, although high-quality evidence supporting their use is lacking. A case series of four de Quervain patients reported on complete symptom resolution in 75 percent of patients with only physiotherapy.64 Kinesiology tape, like thumb splinting, was shown to offer short-term benefit in the conservative management of de Quervain disease.65,66 Da Silva and Batigália67 propose that acupuncture therapy be considered as a potential conservative treatment modality, with Hadianfard et al.68 presenting significant short-term improvement of pain and function using this approach alongside splint therapy. Orlandi et al.53 report on the beneficial outcomes of ultrasound-guided injections of steroids supplemented with a subsequent hyaluronic acid injection 15 days later. Finally, reports proposing the use of hand therapy,20,69 mechanical diagnosis and therapy,70 topical herbal medicinal therapy,71 therapeutic ultrasound and laser therapy,72,73 spa therapy,74 dynamic thumb spica casting,75 platelet-rich plasma injections,76 and sclerosing therapy with eccentric training77 also exist, although the evidence for these interventions is poor.

Decision Analysis and Economic Evaluation

Recent studies in the Journal investigated decision analysis and economic evaluation strategies in upper extremity hand surgery.78 Although no studies were identified pertaining directly to the management of de Quervain disease, there exists pertinent literature for similarly managed conditions that may provide some insight.78 Kerrigan and Stanwix79 performed a cost-minimization analysis to identify the least costly strategy for the management of trigger finger. Among a list of five treatment approaches, ranging from single to repeated rounds of corticosteroid injections, followed by surgical release in recalcitrant cases, the authors found that two corticosteroid injections followed by surgery in failed cases was the most cost-effective approach.79 Immediate surgery was found to be most costly.79 The recommendations of the present study may therefore be in line with those reported by Kerrigan and Stanwix79 with respect to cost-utility; nonetheless, future endeavors are encouraged investigating economic evaluation models directly from within the de Quervain population.

Recommended Conservative Treatment Protocol

Based on the findings of this review, the authors propose their recommendations for a conservative treatment protocol that may be considered in future randomized controlled trials, evaluating its efficacy in clinical practice and comparing it to the current standard of care.80 If ultrasonography is accessible and the treating plastic surgeon is comfortable with its use, the authors suggest that ultrasound imaging be used initially to confirm the diagnosis of de Quervain disease and, more importantly, assess for the presence of an intercompartmental septum. Subsequently, a multipoint corticosteroid injection technique, preferably under ultrasound guidance, would be recommended. Corticosteroid use is not without its risks, and the risk-to-benefit ratio must be considered on a patient-by-patient basis and according to the surgeon’s clinical judgment before administration. Several complications associated with corticosteroid use are presented in this review, thus warranting caution, although corticosteroid use may also be contraindicated in the presence of additional comorbidities such as diabetes. Although there exists some evidence of higher success rates following repeated injections, which is likely attributable to the greater likelihood of adequate targeting of the first dorsal compartment (if the first injection failed to do so), caution must be taken when considering repeated injections before referral for surgery to avoid complications, especially if the first injection was performed adequately and shown to appropriately target the first dorsal compartment using ultrasound. Adjuvant splint therapy can be provided for patients receiving corticosteroid injections. Patients with a septated first dorsal compartment, metabolic syndrome, hypothyroidism, prior diagnosis of trigger finger or carpal tunnel, extensor triggering, psychiatric illnesses, or growth hormone abuse should be advised of their higher likelihood of conservative treatment failure. Finally, alternative modalities such as physical therapy, therapeutic ultrasound and laser therapy, acupuncture therapy, topical herbal medicinal therapy, hand therapy, mechanical diagnosis and therapy, spa therapy, and platelet-rich plasma injections may be considered only as adjuvants to this recommended treatment protocol (Fig. 2).

Fig. 2.
Fig. 2.:
Recommended treatment protocol for the conservative management of de Quervain stenosing tenosynovitis. Unfavorable conditions associated with conservative treatment failure are also presented. Pregnancy-related disease is associated with more favorable outcomes.

CONCLUSIONS

Current evidence suggests that a multimodal approach to the conservative management of de Quervain disease using both splint therapy and corticosteroid injections may be more beneficial than either used in isolation. Although there exists some evidence demonstrating that multipoint injection techniques in addition to multiple corticosteroid injections before surgical referral may provide benefit over a single-point injection technique and a single injection before surgery, caution must be taken with the administration of corticosteroid injections, especially in recalcitrant cases, because of the notable associated risks and especially in patients with contraindications to corticosteroid use. Ultrasound has proven valuable in the identification and visualization of an intercompartmental septum, the presence of which has been associated with a higher incidence of de Quervain disease and a higher likelihood of conservative treatment failure. Ultrasound-guided injections were shown to confer better outcomes, in terms of both injection accuracy and clinical cure rates. Finally, and although the mechanism for most remains elusive, several medical conditions, both prior and concurrent, may affect conservative treatment outcome in patients with de Quervain disease.

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