Raiyyan Tahsan

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TC(1017).(05).Orthopedics Case No 95:- De Quervain Tenosynovitis

De Quervain Tenosynovitis — বাংলা ক্লিনিক্যাল নোট

সতর্কতা: নিচের drug dose adult সাধারণ ক্লিনিক্যাল রেঞ্জ। Pregnancy, lactation, CKD, PUD/GI bleed, asthma with NSAID sensitivity, uncontrolled HTN, IHD, anticoagulant use, diabetes—এসব থাকলে NSAID/steroid injection চিকিৎসকের সিদ্ধান্ত ছাড়া নয়।

1. Definition — সংজ্ঞা

De Quervain tenosynovitis হলো wrist-এর first dorsal extensor compartment-এ থাকা দুইটি tendon—
Abductor Pollicis Longus, APL এবং Extensor Pollicis Brevis, EPB—এর tendon sheath/retinacular tunnel thickening ও stenosis-এর কারণে pain-producing entrapment। Pain সাধারণত radial styloid / thumb-side wrist-এ হয় এবং thumb movement বা wrist ulnar/radial deviation-এ বাড়ে।

2. Cause / Etiology — কারণগুলো

মূল pathophysiology

  • Repetitive overuse: বারবার thumb abduction/extension, gripping, pinching, twisting করলে APL/EPB tendon sheath-এর উপর friction বাড়ে।
  • Tendon sheath thickening: repetitive stress-এর ফলে fibrous tissue deposit, neovascularization, myxoid degeneration হয়—তাই tunnel সংকুচিত হয়ে tendon আটকে যায়।
  • Classic group: newborn baby বারবার তোলা postpartum mother; thumb abducted রেখে wrist deviation করলে pain বাড়ে।

Risk factors

  • Female sex; age 40–50 বেশি দেখা যায়।
  • Pregnancy ও postpartum/lactation period।
  • Manual labor, repetitive wrist/thumb work।
  • Acute wrist trauma।
  • Inflammatory disease, e.g., rheumatoid arthritis—rare association।
  • Anatomical variation: first dorsal compartment septum/subcompartment থাকলে steroid injection failure বা recurrence বেশি হতে পারে।

3. Symptoms — লক্ষণগুলো

  • Thumb-side wrist pain: radial styloid-এর উপর বা একটু proximal অংশে ব্যথা।
  • Pain increases with: thumb movement, gripping, lifting baby, opening jar, wringing clothes, using mobile/mouse, writing, cooking/chopping।
  • Tenderness: radial styloid-এর উপর চাপ দিলে ব্যথা।
  • Swelling: wrist-এর thumb-side-এ mild swelling বা fullness থাকতে পারে।
  • Reduced grip/pinch strength: জিনিস ধরা বা pinching করলে pain/weakness।
  • Crepitus/snapping: কিছু রোগীতে tendon চলাচলে rubbing বা clicking feeling।
  • Functional limitation: কাজ, household activity, typing, childcare করতে কষ্ট।

4. Clinical Diagnosis — clinically কীভাবে diagnose করবেন

Diagnosis বেশিরভাগ ক্ষেত্রে history + physical examination দিয়েই হয়; imaging routinely দরকার হয় না।

Specific clinical points

  • Inspection: radial wrist swelling, local warmth, visible fullness।
  • Palpation: radial styloid/first dorsal compartment tenderness।
  • Finkelstein test: thumb palm-এর দিকে flex করে examiner wrist ulnar deviation করালে radial wrist-এ sharp pain হলে positive।
  • Eichhoff test: patient thumb fist-এর ভিতরে রেখে wrist ulnar deviation করলে radial wrist pain।
  • WHAT test: wrist hyperflexion + resisted thumb abduction করলে pain; useful supportive test।
  • CMC grind test: thumb CMC osteoarthritis exclude করতে করা যায়; CMC arthritis হলে thumb base joint pain/grinding বেশি থাকে।

5. Investigations — specificভাবে কী করবেন

Routine case

  • No routine blood test needed.
  • X-ray usually needed নয়, কারণ De Quervain soft tissue/tendon sheath disorder। Mayo Clinic-ও বলছে imaging generally diagnosis-এর জন্য দরকার হয় না।

কখন investigation করবেন

  • X-ray wrist/hand AP-lateral-oblique: trauma history, fracture suspicion, thumb CMC osteoarthritis, radial styloid/scaphoid pain থাকলে।
  • Ultrasound wrist: diagnostic uncertainty, steroid injection planning, septum/subcompartment identify করা, sheath thickening/fluid/hyperemia দেখা। US-guided injection pain outcome ভালো হতে পারে।
  • MRI wrist: atypical pain, failed treatment, mass/ganglion/tumor suspicion, occult fracture, inflammatory pathology সন্দেহ হলে।
  • ESR/CRP/RF/anti-CCP/uric acid: যদি inflammatory arthritis, RA, gout, infection, systemic disease সন্দেহ থাকে।

6. Differential Diagnosis

  • Thumb CMC osteoarthritis
  • Scaphoid fracture
  • Radial styloid fracture
  • Wartenberg syndrome / superficial radial nerve neuritis
  • Intersection syndrome
  • Trigger thumb
  • Ganglion cyst
  • Rheumatoid/inflammatory tenosynovitis

7. Complications — রোগটি untreated থাকলে কী হতে পারে

  • Chronic radial wrist pain: pain দীর্ঘদিন থাকলে hand use কমে যায়।
  • Grip ও pinch weakness: daily work, writing, typing, cooking, baby lifting কষ্টকর হয়।
  • Functional disability: untreated pain রোগীর work productivity কমাতে পারে।
  • Recurrence: repetitive activity না বদলালে আবার হতে পারে।
  • Treatment-related complications: steroid injection বারবার/ভুল plane-এ দিলে skin hypopigmentation, fat atrophy, tendon weakening/rare rupture হতে পারে। Surgery করলে superficial radial nerve injury, tendon subluxation, wound infection, hypertrophic scar হতে পারে।

8. Treatment / Management — Stepwise

Non-pharmacological management

  • Activity modification: pain-causing repetitive thumb/wrist activity কমানো।
  • Thumb-spica splint: wrist neutral + thumb immobilized, সাধারণত 3–4 weeks; injection দিলে splint সহ outcome ভালো।
  • Ice pack: painful area-তে 15 minutes, দিনে 3–4 বার; skin-এর উপর direct ice নয়।
  • Ergonomic correction: mobile grip, mouse, keyboard, baby lifting technique বদলানো।
  • Hand therapy: acute pain কমার পর gentle ROM, tendon gliding, gradual strengthening।
  • Steroid injection + thumb-spica immobilization: 2023 JAMA Network Open systematic review অনুযায়ী local corticosteroid injection + thumb-spica immobilization 3–4 weeks first-line হিসেবে strongest evidence-supported option।
  • Surgery: severe case বা conservative treatment/injection ব্যর্থ হলে first dorsal compartment release। AAOS বলছে severe বা nonsurgical treatment-এ improvement না হলে surgery consider করা যায়।

9. Pharmacological Drugs — Bangladesh practice-oriented list

A. Paracetamol — pain relief, inflammation কমায় না

  1. Generic name: Paracetamol
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Non-opioid analgesic
  4. Why used: mild pain control; NSAID contraindicated হলে safer option।
  5. Adult dose: 500 mg 6–8 hourly PRN; usual max 3 g/day; liver disease/alcohol use হলে কম dose।
  6. Duration: 3–5 days PRN।
  7. Side effects: nausea, rash rare; overdose → hepatotoxicity।
  8. Interaction: alcohol, warfarin long-term high dose, other paracetamol-containing combination avoid।
  9. Bangladesh available brands: Napa 500 mg, Ace 500 mg, Fast 500 mg; MedEx-এ paracetamol analgesic/antipyretic description ও these brands listed আছে।

B. NSAIDs — pain + inflammation control

1) Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID
  4. Why used: radial wrist pain ও inflammatory swelling কমাতে।
  5. Adult dose: 200–400 mg every 6–8 hours after food; MedEx dose: 200–400 mg 3–4 times/day, max 1200 mg/day.
  6. Duration: 3–5 days; prolonged use avoid।
  7. Side effects: dyspepsia, gastritis, ulcer/bleeding, renal impairment, BP rise, bronchospasm in NSAID-sensitive asthma।
  8. Interaction: anticoagulant/antiplatelet, steroid, SSRI, ACEI/ARB + diuretic, lithium, methotrexate।
  9. Bangladesh brands: Profen 400 mg, Rapofen 400 mg, Rebufen 400 mg, Inflam 400 mg.

2) Naproxen / Naproxen sodium

  1. Generic name: Naproxen sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID
  4. Why used: longer-acting NSAID; persistent pain/swelling-এ useful।
  5. Adult dose: 250–500 mg twice daily after food।
  6. Duration: 5–7 days; risk থাকলে PPI cover।
  7. Side effects/interactions: NSAID class-এর মতো GI bleed, renal risk, BP rise; anticoagulant/antiplatelet/steroid/ACEI/ARB interaction।
  8. Bangladesh brands: Naproxen 500 mg, Naproxin 250/500 mg, Napryn 250/500 mg, Naprox gel 10% w/w, Napryn gel 10% w/w.

3) Diclofenac sodium — oral/topical

  1. Generic name: Diclofenac sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID
  4. Why used: acute pain/inflammation; topical gel local pain relief-এ safer GI profile।
  5. Adult oral dose: 50 mg 2–3 times daily after food; max 150 mg/day।
  6. Topical dose: 1–2% gel thin layer painful area-তে দিনে 3–4 বার, 7–14 days।
  7. Side effects: oral—GI ulcer/bleed, renal dysfunction, BP rise, CV risk; topical—skin irritation।
  8. Interaction: anticoagulant/antiplatelet/steroid/SSRI/ACEI/ARB/diuretic/lithium/methotrexate।
  9. Bangladesh brands: Diclofen 50 mg, Volpro 50 mg, Volifen gel 1%, Voligel gel 1%, Voligel Max 2%, Voltafen gel 1%, Voltagel 1%, Voltagel DS 2%.

4) Aceclofenac

  1. Generic name: Aceclofenac
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID
  4. Why used: musculoskeletal pain/inflammation; Bangladesh prescription practice-এ common।
  5. Adult dose: 100 mg twice daily after food।
  6. Duration: 5 days; risk থাকলে PPI।
  7. Side effects/interactions: NSAID class-এর মতো।
  8. Bangladesh brands: Aros 100 mg, Avenac 100 mg, Celofen 100 mg, Claim 100 mg, Claim ER 200 mg, Labenac SR 200 mg, Ufenac SR 200 mg, Vaxtin 100 mg.

5) Etoricoxib — COX-2 selective NSAID

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Why used: pain/inflammation; GI risk তুলনামূলক কম হলেও CV/BP risk বেশি বিবেচ্য।
  5. Adult dose: 60 mg once daily; severe inflammatory pain-এ 90 mg once daily short course।
  6. Duration: 3–5 days; lowest effective dose।
  7. Side effects: edema, hypertension, dyspepsia, renal impairment, CV thrombotic risk।
  8. Interaction: warfarin/anticoagulants, ACEI/ARB/diuretics, lithium, methotrexate।
  9. Bangladesh brands: Etorix 60/90/120 mg, Oricox 30/60/90/120 mg, Recox 60/90/120 mg, Etoshine 60/90/120 mg, Ribox 60/90/120 mg, Etorica 60/90/120 mg.

C. Corticosteroid injection — most disease-specific treatment

1) Triamcinolone acetonide injection

  1. Generic name: Triamcinolone acetonide
  2. Therapeutic category: Anti-inflammatory steroid injection
  3. Pharmacological class: Glucocorticoid corticosteroid
  4. Why used: first dorsal compartment tendon sheath inflammation/thickening কমিয়ে pain relief; splint সহ দিলে outcome ভালো।
  5. Dose: tendon sheath/local injection commonly 10–40 mg; specialist/orthopedic/PMR/hand surgeon দ্বারা aseptic technique-এ।
  6. Duration: single injection; reassess 4–6 weeks; repeated injection হলে adequate interval রাখতে হবে।
  7. Side effects: post-injection flare, local pain, infection rare, skin hypopigmentation, fat atrophy, tendon weakening/rare rupture, transient hyperglycemia in diabetes।
  8. Interaction/caution: diabetes, anticoagulant use, local infection, immunosuppression।
  9. Bangladesh brands: Alfacort 40 mg/ml, Cenolon 40 mg/ml, Cynocort 40 mg/ml, Emicort 40 mg/ml, Intracort 40 mg/ml, Trecilon 40 mg/ml, Triacin 40 mg/ml, Trialon 40 mg/ml, Triamon 40 mg/ml, Trimcort 40 mg/ml.

2) Methylprednisolone acetate injection

  1. Generic name: Methylprednisolone acetate
  2. Therapeutic category: Anti-inflammatory steroid injection
  3. Pharmacological class: Glucocorticoid corticosteroid
  4. Why used: local corticosteroid injection alternative to triamcinolone; tendon sheath inflammation/pain reduce।
  5. Dose: commonly 20–40 mg local tendon sheath injection; specialist-only।
  6. Duration: single injection; reassess; repeat only if clinically indicated।
  7. Side effects/interactions: triamcinolone-এর মতো; diabetes-এ transient glucose rise।
  8. Bangladesh brands: Depo-Medrol 40 mg/ml, Depo-Medrol 80 mg/2 ml, Depo-pred 40 mg/ml, Depomed 40 mg/ml, Depomed 80 mg/2 ml, Methsolon 40 mg/ml.

D. Lidocaine injection — steroid injection-এর সময় local anesthesia

  1. Generic name: Lidocaine hydrochloride injection
  2. Therapeutic category: Local anesthetic
  3. Pharmacological class: Amide local anesthetic
  4. Why used: steroid injection দেওয়ার সময় immediate local pain control/diagnostic anesthetic response; disease cure করে না।
  5. Dose: 1% lidocaine 0.5–1 ml local infiltration/tendon sheath mixture—specialist-only।
  6. Side effects: local numbness, dizziness, metallic taste, allergy rare, toxicity if intravascular/high dose।
  7. Interaction/caution: antiarrhythmic drugs, severe heart block, liver disease; intravascular injection avoid।
  8. Bangladesh brands: Jasocaine 1%, Jasocaine 2%, G-Lidocaine 2%, Locaine 2%, Lidocaine 2%, Chemocain 2%.

E. PPI — NSAID gastric protection

  1. Generic name: Pantoprazole / Omeprazole / Esomeprazole
  2. Therapeutic category: Anti-ulcerant / gastroprotection
  3. Pharmacological class: Proton pump inhibitor
  4. Why used: NSAID-induced gastritis/ulcer risk কমাতে, especially PUD history, age >60, steroid/anticoagulant use।
  5. Dose: Pantoprazole 20–40 mg once daily before breakfast; NSAID যতদিন, ততদিন বা clinician decision।
  6. Side effects: headache, diarrhea/constipation, abdominal discomfort; long-term use—B12/Mg deficiency, infection risk।
  7. Interaction: clopidogrel interaction concern বেশি omeprazole/esomeprazole-এর সঙ্গে; warfarin monitoring; long-term methotrexate caution।
  8. Bangladesh brands: Pantodac 20/40 mg, Pantonix 20/40 mg, Pantogut 20/40 mg, Pantolok 20/40 mg, Protocid 20/40 mg, Pantofast 20 mg.

10. Bangladesh doctors commonly prescription-এ কী দেন — practical list

  • Mild pain: Paracetamol 500 mg PRN + thumb-spica splint + ice।
  • Mild–moderate inflammatory pain: Ibuprofen / Naproxen / Aceclofenac / Diclofenac short course after meal।
  • GI-risk patient: NSAID + Pantoprazole/Omeprazole/Esomeprazole।
  • Local pain prominent: Diclofenac gel local application।
  • Persistent case / functional limitation: Triamcinolone or methylprednisolone acetate local injection + thumb-spica splint 3–4 weeks।
  • Severe/recurrent/failed injection: orthopedic/hand surgery referral for first dorsal compartment release।
  • Usually not needed: antibiotics, muscle relaxants, long oral steroid, opioid—unless another diagnosis exists।

11. Prevention — কীভাবে prevent করবেন

  • Repetitive thumb pinching/gripping কমানো।
  • Mobile use করলে thumb দিয়ে continuous scrolling/typing কমিয়ে both-hand support ব্যবহার।
  • Baby lift করার সময় thumb abducted রেখে wrist bend করবেন না; forearm দিয়ে support নিন।
  • Work break: প্রতি 30–45 মিনিটে 2–3 মিনিট wrist/thumb rest।
  • Heavy lifting করলে wrist neutral position রাখুন।
  • Early pain হলে splint/rest/ice শুরু করুন; pain নিয়েই কাজ চালিয়ে যাবেন না।
  • Ergonomic mouse/keyboard, larger grip tools ব্যবহার করুন।
  • Recurrence prevent করতে hand therapist-guided strengthening ও tendon gliding করতে হবে।

Overview / Summary

De Quervain tenosynovitis হলো APL ও EPB tendon-এর first dorsal compartment stenosing tenosynovitis। Core symptom: thumb-side wrist pain, Finkelstein positive। Diagnosis mainly clinical। Investigation routinely লাগে না; US helpful if uncertain/injection planning। Best evidence-supported management: local corticosteroid injection + thumb-spica splint 3–4 weeks। NSAID/paracetamol pain control করে, কিন্তু steroid injection disease-specific inflammation/stenosis target করে।

Actionable Plan / Steps

  1. Confirm clinically: radial styloid tenderness + Finkelstein/Eichhoff/WHAT test।
  2. Start conservative: activity modification + ice + thumb-spica splint।
  3. Pain control: paracetamol or short-course NSAID; GI-risk হলে PPI।
  4. Persistent/moderate–severe case: steroid injection into first dorsal compartment by trained clinician; splint 3–4 weeks।
  5. If no response/recurrence: US evaluation ± US-guided second injection; refractory case → hand surgeon referral।
  6. Avoid: unsupervised NSAID long course, repeated steroid injections too close together, unnecessary antibiotics/opioids।

Reference List — Textbook + Guideline + DOI

Textbook references

  1. Apley & Solomon’s System of Orthopaedics and Trauma, 11th ed. Hand/wrist soft tissue disorders; stenosing tenosynovitis principles.
  2. Campbell’s Operative Orthopaedics, 14th ed. Hand tendon sheath disorders and surgical release principles.
  3. Green’s Operative Hand Surgery, 8th ed. De Quervain disease, first dorsal compartment anatomy, injection and release principles.

Guideline / clinical guidance

  1. AAOS OrthoInfo: De Quervain’s Tenosynovitis—activity modification, splinting, NSAIDs, corticosteroid injection, surgery if severe/nonresponsive.
  2. ACR Appropriateness Criteria: Chronic hand/wrist pain imaging—radiography generally first imaging for chronic wrist pain; US/MRI based on clinical differential.
  3. NCBI/StatPearls: clinical diagnosis, Finkelstein test, evaluation, steroid injection, complications.

Peer-reviewed articles with DOI

  1. Challoumas D, et al. Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis. JAMA Network Open. 2023;6(10):e2337001. DOI: 10.1001/jamanetworkopen.2023.37001.
  2. Mardani-Kivi M, et al. Corticosteroid injection with or without thumb spica cast for de Quervain tenosynovitis. J Hand Surg Am. 2014;39(1):37–41. DOI: 10.1016/j.jhsa.2013.10.013.
  3. Shin YH, Choi SW, Kim JK. Ultrasonography-guided vs blind corticosteroid injection for de Quervain’s disease. Orthop Traumatol Surg Res. 2020;106(2):301–306. DOI: 10.1016/j.otsr.2019.11.015.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-12-37-12 Pm

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