Pain along the radial side of the right wrist, provoked by activities involving lifting, in a patient with a history of two previous operations for carpal tunnel syndrome whose job demanded a lot of typing. The Finkelstein manoeuvre was positive.
The patient presented with pain along the radial side of her right wrist, provoked by activities involving picking up or lifting things with her right hand. Her job demanded a lot of computer work with long hours of typing. She had a history of two previous operations for carpal tunnel syndrome of her right wrist. On clinical examination a minor soft tissue swelling was evident over the radial styloid process. The Finkelstein manoeuvre was positive (pain on the radial border of the wrist produced by an abrupt ulnar deviation of the wrist by the examiner while the patient's thumb is enclosed in the palm ).
An MRI of the right wrist was performed, with spin echo T1-weighted and STIR sequences in the coronal plane and a turbo spin echo T2-weighted fat-suppressed sequence in the axial plane. This showed findings of minor thickening of the tendon sheath of the first extensor compartment and increased signal around the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB)(Figs 1,2). A small quantity of fluid was also present within the synovial tendon sheath. Increased signal within the tendinous slips of the APL evident on the axial turbo spin echo T2-weighted fat suppressed sequence was indicative of concomitant tendinitis (Fig. 3). A diagnosis of De Quervain's tenosynovitis was made and conservative treatment was begun.
De Quervain's tenosynovitis is the most common tenosynovitis of the Extensor compartments of the wrist. It more commonly affects females (77%) and can be bilateral in up to 30% of patients [1,2]. In approximately one third of cases there is history of a substantial direct trauma or repetitive low grade trauma in a setting of an overuse injury. Other clinical settings include systemic disorders such as rheumatoid arthritis and gout. It is a stenosing tenosynovitis of the first extensor compartment of the wrist at the radial styloid [1-3]. There is inflammation of the tendon sheath of the first extensor compartment, which comprises the tendons of the APL and the EPB. The tendons are situated in a fibroosseous tunnel created between a groove along the radial styloid process and the overlying extensor retinaculum. The APL tendon often consists of more than one tendinous slip and in some patients it is found to be separated from the EPB tendon by a fibrous septum [3]. It has been proposed that the presence of a septation producing separate compartments may predispose patients to De Quervain's tenosynovitis and to failure of response to injection of steroid agents [2]. Progression of the disease may result in scar production due to chronic inflammation [1,3].
Clinical findings include soft tissue swelling over the radial aspect of the wrist and a positive Finkelstein manoeuvre [1,3]. MR imaging findings include thickening of the APL-EPB tendon sheath, hyperintensity surrounding the tendons on T2-weighted images and presence of fluid within the synovial tendon sheath. Tendon thickening has also been described [1,5].
Treatment is initially conservative with immobilisation and antiinflammatory medication. Steroid injection may diminish swelling and pain. For intractable cases surgical decompression of the tendons may be elected [2,3].
De Quervain's tenosynovitis
Based on the provided wrist MRI images, the following main features have been observed:
Considering the patient’s history (multiple wrist operations, long-term typing, radial wrist pain, positive Finkelstein test) and the imaging findings, the following diagnoses should be taken into account:
Taking into account the patient’s age, history of two carpal tunnel syndrome surgeries, prolonged repetitive keyboard use, positive clinical findings (positive Finkelstein test), and MRI findings indicating thickening and inflammatory changes of the tendon sheath in the first dorsal compartment, the most likely diagnosis is: De Quervain’s Tenosynovitis.
Rehabilitation should be tailored to the degree of symptom relief, following a gradual, individualized approach prioritizing safety:
In patients with special conditions (e.g., joint degeneration, compromised cardiopulmonary function, or other chronic illnesses), exercise intensity and methods should be modified accordingly to ensure safety.
Disclaimer:
This report is a reference analysis based solely on the available images and the patient’s provided history. It does not replace an in-person consultation or individualized evaluation by a professional physician. If you have further questions or if your symptoms worsen, please seek prompt medical attention and consult with a specialist.
De Quervain's tenosynovitis
