First dorsal compartment tendonitis is also known as stenosing tenosynovitis of the first extensor compartment or more commonly as de Quervain’s tendonitis or tenosynovitis. It is a condition producing pain in and around the dorsal and radial aspect of the radial styloid at the base of the thumb. Patients typically present with pain and discomfort as well as swelling on the dorsal radial aspect of the base of the thumb and wrist. The pain may appear gradually or suddenly. The pain can be localized to that area or sometimes radiates down to the thumb or more proximally to the forearm. The pain is often made worse by forceful grasping or twisting of the wrist as well as sometimes by excessive pinching of the thumb to the index finger.
Pathophysiology
The cause of the pain is thought to be secondary to irritation of the abductor muscle tendon within the first extensor compartment tunnel at the base of the thumb. It is thought to be caused by repetitive activities albeit it is sometimes secondary to unusual positioning of the hand as well as hormonal fluctuations associated with pregnancies. Wrist fractures can predispose the patient to de Quervain’s tendonitis.
Diagnosis
The diagnosis of de Quervain’s tenosynovitis is a clinical one with patients exhibiting tenderness directly over the first extensor compartment at the wrist. Patients usually have a positive Finkelstein test where the patient exhibit worsening of the pain and discomfort with clasping the fingers and making a fist while the examiner is bending the wrist towards the little finger. The patient’s skin exhibits some swelling and crepitus in and around the first compartment. A fullness in and around the area is often noted.
The differential diagnosis does include CMC (carpo-metacarpal) arthritis of the thumb, which is typically ruled out by a normal examination of the CMC joint of the thumb as well as routine X-rays of the hand and wrist.
Tenosynovitis of the second extensor compartments should also be ruled out. Those patients typically presents with tenderness 4 cm proximal to the second compartment on the dorsal and radial aspect of the forearm. There is also some edema and crepitus in and around that site. Both de Quervain’s and second compartment tenosynovitis can coexist with patients presenting with somewhat less localized pain.
Treatment
Initial treatment of de Quervain’s tenosynovitis is geared towards avoiding activities that are causing or worsening the pain. Resting the thumb by adding a splint can also be helpful. Oral nonsteroidal anti-inflammatories can also be recommended. If these measures fail after 2-3 weeks, a steroid injection in and around the first extensor compartment may be recommended.
When non-operative modalities fail, surgical release of the first compartment is indicated. The surgery is typically done under either local anesthesia or local anesthesia with sedation ( MAC ) and as an outpatient surgery. At surgery, the first extensor compartment is released so that normal tendon gliding ensues without any constriction. Patients are usually able to gently increase use of the involved hand 2-3 days after surgery and are often able to return to all their previous activities 6-8 weeks after the surgical release. Occupational therapy is sometimes required for patients who are slow to improve. Complications of surgery are rare but do include scar hypertrophy as well as nerve injury.
Conclusion
In conclusion, first dorsal compartment tendonitis is a fairly common condition presenting as an aggravating ailment in the hand. Early recognition and treatment by a hand trained surgeon and well qualified hand therapist are essential to obtain a successful outcome.
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