x
x

DEQUERVAIN'S DISEASE (TENOSYNOVITIS)

Introduction

de Quervain’s disease – also known as “washer woman’s sprain” and more recently as “Blackberry thumb” – is a stenosing tenovaginitis of the first extensor compartment of the wrist. Histologically, the disease is characterized by thickening of the sheaths surrounding the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles. The pathophysiology more likely involves degenerative rather than inflammatory mechanisms. de Quervain’s disease is one of the most common diagnoses among patients presenting with wrist pain.
 

Related natomy

  • First dorsal compartment of the wrist
  • APL and EPB tendon sheaths
  • EPB often in separate sheath inside the first extensor compartment
  • APL frequently has more than one tendon slip. (2-7 tendon slips are common)

Incidence and Related Conditions

  • 6 times more prevalent in women than men
  • Common in pregnancy; more common among women with infants

Differential Diagnosis

  • Intersection syndrome
  • Osteoarthritis of the carpometacarpal joint (CMC) of the thumb
  • Osteoarthritis of a radiocarpal or intercarpal joint
  • Scaphoid fracture
  • Superficial radial nerve neuroma
  • Wartenburger’s Syndrome
ICD-10 Codes

  • DEQUERVAIN'S DISEASE (TENOSYNOVITIS)

    Diagnostic Guide Name

    DEQUERVAIN'S DISEASE (TENOSYNOVITIS)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DEQUERVAIN'S DISEASE (TENOSYNOVITIS)M65.4   

     

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Palpating for first extensor compartment
    Palpating for first extensor compartment
  • Traditional Finkelstein's Sign - Thumb is placed in palm, fingers
    Traditional Finkelstein's Sign - Thumb is placed in palm, fingers
  • Alternative Finckelstein manuever - The wrist is in neutral position while the thumb MP joint is maximally flexed. This pulls the EPB through the first extensor compartment and reproduces the patient's pain.
    Alternative Finckelstein manuever - The wrist is in neutral position while the thumb MP joint is maximally flexed. This pulls the EPB through the first extensor compartment and reproduces the patient's pain.
Symptoms
Pain radial aspect of wrist
Pain exacerbated by thumb movements
Swelling, tissue thickening, or lump on radial styloid area of the wrist
Rarely wrist clicking with thumb motion
Typical History

The patient with DeQuervain's Tenosynovitis is typically a female with pain at the base of the thumb or radial aspect of the wrist which has been present for several weeks.  It is common for the patient to be a new mother with a young infant.  It is rare for the wrist to click but this does occur in chronic cases.  Increased repetitive use of the hand may have initiated the symptoms.  Increased thumb use and power pinch often aggravates the pain.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
DeQuervain's Tenosynovitis X-ray Images
  • The patient with DeQuervain's tenosynovitis will have tenderness (red dot) but the wrist X-ray will be normal.
    The patient with DeQuervain's tenosynovitis will have tenderness (red dot) but the wrist X-ray will be normal.
DeQuervain's Tenosynovitis Ultrasound Images
  • Longitudinal ultrasound image of first extensor compartment in patient with DeQuervain’s Tenosynovitis: 1=skin; 2=extensor compartment thicken fascial sheath; 3=degenerated enlarged extensor tendons with intratendinous fluid; 4=distal radius
    Longitudinal ultrasound image of first extensor compartment in patient with DeQuervain’s Tenosynovitis: 1=skin; 2=extensor compartment thicken fascial sheath; 3=degenerated enlarged extensor tendons with intratendinous fluid; 4=distal radius
DeQuervain's Tenosynovitis Ultrasound Images
  • Transverse ultrasound image of first extensor compartment in patient with DeQuervain’s Tenosynovitis: 1=skin; 2= thicken first extensor compartment fascia; 3=fluid in first compartment; 4=extensor tendons- EPB&ABPL; 5=distal radius
    Transverse ultrasound image of first extensor compartment in patient with DeQuervain’s Tenosynovitis: 1=skin; 2= thicken first extensor compartment fascia; 3=fluid in first compartment; 4=extensor tendons- EPB&ABPL; 5=distal radius
Treatment Options
Conservative
  • Non-steroidal anti-inflammatory drugs (NSAIDS)
  • Wrist-thumb splinting
  • Corticosteroid injections
Operative

​

  • Complete release of first extensor dorsal compartment to decompression of APL/EPB tendons
    For ASSH's Hand-e Surgical Video of DeQuervain’s Release Chevron incision by Jain: ​

    For ASSH's Hand-e Surgical Video of DeQuervain’s Release Transverse incision by Trumble: ​
  • Avoid injury to the radial sensory nerve
  • Frequently, EPB has a secondary compartment within the first extensor compartment and requires an additional release

​

Treatment Photos and Diagrams
  • Transverse incision in Langer's lines just distal to the tip of the radial styloid
    Transverse incision in Langer's lines just distal to the tip of the radial styloid
  • Transverse incision in Langer's lines just distal to the tip of the radial styloid incision made. Note dorsal radial sensory nerve in subcutaneous tissue superficial to first extensor fascia.
    Transverse incision in Langer's lines just distal to the tip of the radial styloid incision made. Note dorsal radial sensory nerve in subcutaneous tissue superficial to first extensor fascia.
  • First extensor compartment fascia exposed
    First extensor compartment fascia exposed
  • Fascia exposed. Nerve retracted. Longitudinal incision being made in dorsal ulnar third of first extensor fascia.
    Fascia exposed. Nerve retracted. Longitudinal incision being made in dorsal ulnar third of first extensor fascia.
  • First extensor fascia released. Note multiple tendons because AbPL has from 2-7 slips and EPB has one slip.
    First extensor fascia released. Note multiple tendons because AbPL has from 2-7 slips and EPB has one slip.
  • EPB frequently in separate compartment with first extensor compartment. EPB release verified by pulling on the tendon and observing thumb MP extension.
    EPB frequently in separate compartment with first extensor compartment. EPB release verified by pulling on the tendon and observing thumb MP extension.
  • Incision closed with subcuticular proline suture
    Incision closed with subcuticular proline suture
CPT Codes for Treatment Options

Per an agreement between Hand Surgery Resource, LLC and the American Medical Association (AMA) users are required to accept the following End User Point and Click Agreement in order to view CPT content on this website.  Please read and then click "Accept" at the bottom to indicate your acceptance of the agreement.

End User Point and Click Agreement

CPT codes, descriptions and other data only are copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. The AMA reserves all rights to approve any license with any Federal agency.

You, as an individual, are authorized to use CPT only as contained in Hand Surgery Resource solely for your own personal information and only within the United States for non-commercial, educational use for the purpose of education relating to the fundamental principles of hand surgery and the common diseases, disorders and injuries affecting the human hand. You agree to take all necessary steps to ensure your compliance with the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 330 N. Wabash Avenue, Chicago, IL 60611. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.

Common Procedure Name
First dorsal compartment release (DeQuervain's release)
CPT Description
Tendon sheath incision at radial styloid for DeQuervain's disease
CPT Code Number
25000
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications
  • Conservative: corticosteroid injections can cause depigmentation, fat necrosis and subcutaneous atrophy (rare)
  • Operative: inadequate decompression, volar subluxation of APL/EPB, radial sensory nerve injury (neurapraxia or neuroma-in-continuity), reflex sympathetic dystrophy, infection and scar adherence to the radial styloid
Outcomes
  • Splinting has shown a 70% failure rate, and shows no additional benefit over corticosteroid injection
  • Single corticosteroid injections alleviate symptoms in ~62% of patients; 2 injections are successful in ~80% of patients
  • Operative findings: ~90% of patients can be expected to have a satisfactory outcome
Video
Normal ultrasound of first extensor compartment. Radial cortex (R); Extensor tendons - extensor pollicis brevis and abductor pollicis longus.
YouTube Video
DeQuervain's Tenosynovitis (Radial Styloid Tenosynovitis)
Key Educational Points
  • A common septum is found between the APL and EPB in 80% of patients requiring surgical release. EPB release should be confirmed by traction on the tendon, demonstrating MCP joint extension and a visible muscle belly.
  • Intersection syndrome is caused by inflammation at the intersection of the first and second dorsal extensor compartments.
References

New articles

  1. Mardani-Kivi M, Karimi Mobarakeh M, Bahrami F, et al. Corticosteroid injection with or without thumb spica cast for de Quervain tenosynovitis. J Hand Surg Am 2014;39(1):37-41. PMID: 24315492
  2. Huisstede BM, Coert JH, Fridén J, Hoogvliet P; European HANDGUIDE Group. Consensus on a multidisciplinary treatment guideline for de Quervain disease: results from the European HANDGUIDE study. Phys Ther 2014;94(8):1095-110. PMID: 24700135

Reviews

  1. Stahl S, Vida D, Meisner C, et al. Systematic review and meta-analysis on the work-related cause of de Quervain tenosynovitis: a critical appraisal of its recognition as an occupational disease. Plast Reconstr Surg 2013;132(6):1479-91. PMID: 24005369 
  2. Ilyas AM, Ast M, Schaffer AA, Thoder J. De quervain tenosynovitis of the wrist. J Am Acad Orthop Surg 2007;15(12):757-64. PMID: 18063716

Classics

  1. Harvey FJ, Harvey PM, Horsley, MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg Am 1990;15;83-7. PMID: 2299173
  2. Watkins JT, Pitkin HC. Stenosing tendovaginitis of de Quervain: report of case. Cal West Med 1930;32(2):101-2. PMID: 18741294
Subscribe to DEQUERVAIN'S DISEASE (TENOSYNOVITIS)
⇡