Clinical Question: What is the most effective treatment for de Quervain's tenosynovitis?

Setting: Population-based

Study Design: Systematic review

Synopsis: De Quervain's tenosynovitis is characterized by pain in the wrist joint localized to the first dorsal wrist extensor compartment at the radial styloid. The authors searched MED-LINE and Ovid databases (it is unclear whether the search included the Cochrane Registry of Clinical Trials) for articles on the treatment of de Quervain's tenosynovitis. Of an initial 35 articles, only seven evaluated comparable treatments. Diagnostic criteria included pain at the radial wrist, tenderness at the first dorsal wrist extensor compartment, and a positive result on the Finkelstein test. All seven studies were of extremely poor quality—none was randomized, and none used a control group.

The most frequent treatment modality for patients with de Quervain's tenosynovitis was steroid injection. Eighty-three percent of wrists that received injection alone were symptomatically cured, 61 percent of wrists that received injection and splint immobilization were cured, and 14 percent of those receiving splinting only were cured. Rest alone and nonsteroidal antiinflammatory drugs (NSAIDs) were not useful.

Because information was not provided about the individual study settings, it is difficult to determine how much referral bias occurred. These studies were performed mainly in orthopedic offices; therefore, it is likely that most of these subjects were patients who had previously failed to respond to other less invasive treatments, such as splinting or NSAIDs. Thus, the actual cure rate of these other modalities in the real world may be much better.

Bottom Line: Steroid injection alone may be the most effective treatment for de Quervain's tenosynovitis. The quality of current evidence in the literature is extremely poor. This is one of the major potential problems with systematic reviews: “garbage in = garbage out.” It is reasonable to consider other less invasive approaches such as ice, thumb spica splinting, and NSAIDs when first treating this disorder. (Level of Evidence: 4)