Carpal Tunnel Syndrome and De Quervain's Tendosynovitis

Definition

Carpal Tunnel Syndrome is a median nerve entrapment at the wrist, leading to sensory and motor symptoms in the thumb, index, middle, and radial half of the ring finger.

De Quervain’s Tenosynovitis is inflammation of the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis tendons), causing pain and swelling along the radial aspect of the wrist, especially with thumb movements

Risk Factors

Both

• Repetitive wrist or thumb activities (e.g. lifting infants, typing, certain sports)

• Pregnancy (often due to fluid retention)

Carpal Tunnel Syndrome

• Diabetes, hypothyroidism, obesity, rheumatoid arthritis

• Female sex, particularly peri-menopausal or pregnant/postpartum

• Workplace factors involving prolonged wrist flexion or vibration

De Quervain’s Tenosynovitis

• Overuse in new parents frequently lifting the baby under the arms

• Inflammatory arthropathies (e.g. rheumatoid arthritis)

Clinical Presentation

Carpal Tunnel Syndrome

• Numbness, tingling, and pain in median nerve distribution (thumb, index, middle, and half of the ring finger), sparing the palm

• Nocturnal symptoms are common, often causing patients to shake their hand to relieve tingling

• Weakness or atrophy of the thenar eminence may occur in advanced cases

De Quervain’s Tenosynovitis

• Pain localised to the radial side of the wrist, exacerbated by thumb abduction or extension

• Swelling at the base of the thumb

• Positive Finkelstein’s test (increased pain with ulnar deviation of the wrist while grasping the thumb)

Examination and Investigations

• For Carpal Tunnel Syndrome, provocative tests such as Phalen’s and Tinel’s sign can support the diagnosis

• Ultrasound may show thickening of the flexor tendons or median nerve swelling in CTS, and tenosynovitis in De Quervain’s

• Nerve conduction studies are helpful for confirming CTS severity and guiding management

• Imaging is not routinely required for De Quervain’s unless diagnosis is uncertain or there is suspicion of other pathologies

Management

Conservative Measures

• Activity modification to avoid repetitive or aggravating motions

• Use of a neutral-position wrist splint at night for CTS

• Use of a thumb spica splint for De Quervain’s, particularly in acute flares

• Non-steroidal anti-inflammatory drugs (NSAIDs) or simple analgesics to alleviate pain

• Specific hand therapy or physiotherapy exercises to improve tendon gliding, enhance wrist/thumb ergonomics, and reduce strain

• Address contributing factors such as poorly controlled diabetes or hypothyroidism in CTS

Steroid Injections

• Local corticosteroid injections can provide significant relief, especially in the early stages of both conditions

• Ultrasound guidance may improve accuracy of injection for De Quervain’s, targeting the first dorsal compartment

• In pregnancy, injections can be used with caution when splinting and simple measures are insufficient

Surgery

• Consider referral for carpal tunnel release if there is persistent or worsening median nerve dysfunction, or failure of conservative therapy

• De Quervain’s surgical decompression may be indicated if marked pain or tendon entrapment persists despite splinting and injections

• Postoperative rehabilitation helps restore grip strength and range of motion

Key Points

• Night splinting is often the first-line conservative management for CTS, especially if nocturnal symptoms predominate

• Finkelstein’s test is a hallmark clinical test for De Quervain’s

• Pregnancy-related CTS often improves spontaneously postpartum, though symptom recurrence may happen in subsequent pregnancies or menopause

• Splinting and rest are beneficial while awaiting specialist evaluation in uncertain cases of wrist or thumb pain

• Optimising comorbidities (e.g. diabetes, thyroid disease) can reduce severity or recurrence of CTS

• Early physiotherapy referral and ergonomic assessment can prevent chronicity and promote functional recovery