First Dorsal Extensor Compartment Release

Loukia K. Papatheodorou, MD, PhD

Aaron I. Venouziou, MD

Filippos S. Giannoulis, MD, PhD

Dean G. Sotereanos, MD

Dr. Sotereanos or an immediate family member serves as a paid consultant to or is an employee of Arthrex, Inc., AxoGen Inc., and Smith & Nephew. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Papatheodorou, Dr. Venouziou, and Dr. Giannoulis.

INTRODUCTION

de Quervain syndrome is stenosing tenosynovitis of the first dorsal extensor compartment of the wrist. The first dorsal extensor compartment contains the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) tendons. The condition is named for the Swiss surgeon Fritz de Quervain, who, in 1895, described a painful condition involving the APL and the EPB tendon sheaths at the radial styloid process. de Quervain recommended simple release of the stenotic extensor retinaculum. In 1927, Finkelstein described the physical examination maneuver that bears his name and recommended excising a portion of the sheath when it is excessively thickened or cartilaginous in nature. Subsequently, authors have recommended various treatment approaches, including splinting, injections, limited retinaculum release, extensive retinaculum release, and retinaculum excision.¹

PATIENT SELECTION

Any patient with de Quervain tenosynovitis in whom nonsurgical treatment of splinting and/or steroid injections has failed is a candidate for surgical release of the first dorsal compartment. Patients with de Quervain tenosynovitis present with radial-sided wrist pain. The pain is exacerbated by wrist motion, particularly radial to ulnar deviation, thumb movement, especially thumb abduction and/or extension, and pain may radiate distally or proximally along the course of the APL and EPB tendons. Recent epidemiologic studies have demonstrated that risk factors for de Quervain syndrome include female sex (occurs 6 up to 10 times more frequently in females than in males), age greater than 40 years, and black race.²^,³ The condition has also been noted to commonly present in pregnant and lactating women.

Physical examination often reveals localized swelling and tenderness over the first dorsal compartment, extending 1 to 2 cm proximal to the radial styloid process. In 1930, Finkelstein⁴ described a clinical test that is pathognomonic of the disease. The test result is positive when excruciating pain over the styloid tip is generated by grasping the patient’s thumb and quickly abducting the hand ulnarward. Anatomically, the musculotendinous junction of the EPB tendon is close to the first compartment. In the Finkelstein test, when the thumb is in full flexion and the wrist is in ulnar deviation, the EPB muscle belly is pulled into the first compartment, resulting in a bulk effect. The synovial tissue around the EPB and APL tendons also might be stretched in the Finkelstein testing position, causing a tethering effect. Both bulk and tethering effects may induce pain by directly stretching synovial tissue, especially when the synovial tissue is inflamed or fibrotic, as may be the case in de Quervain disease.⁵

PREOPERATIVE IMAGING

Radiographs consisting of PA and lateral views of the wrist as well as a hyperpronated thumb view, known as a Roberts view (Figure 1), are used to differentiate de Quervain tenosynovitis from other arthritic conditions. Radiographic study should exclude arthritis of the thumb carpometacarpal joint, although this condition may coexist; scaphoid fracture; and arthrosis involving the radiocarpal or intercarpal joints.

VIDEO 39.1 First Dorsal Extensor Compartment Release. Filippos Giannoulis, MD; Douglas S. Musgrave, MD; Alexander H. Payatakes, MD; Dean Sotereanos, MD (3 min)

View Quicktime Video

Video 39.1

PROCEDURE

Room Setup/Patient Positioning

The patient is positioned supine with the hand on a table extension. The procedure can be performed under general anesthesia, local anesthesia with intravenous sedation, or wide-awake local anesthesia without tourniquet (WALANT) depending on surgeon and patient preference. The procedure is performed without the use of a tourniquet when the WALANT method is used, whereas a padded pneumatic tourniquet is applied around the upper arm and is set to 250 mm Hg (or 200 mm Hg when placed about the forearm) when general or local anesthesia with sedation is used.

FIGURE 1 Roberts view radiograph demonstrates thumb basal joint arthritis in a 67-year-old woman with radial-sided wrist pain mimicking de Quervain syndrome.

In WALANT method, using a 27-gauge needle, a total of 10 mL of 1% lidocaine with 1:100,000 epinephrine and 1 mL of 8.4% bicarbonate is injected into the area where dissection will occur.⁶^,⁷ It is preferred to inject the patient in the preoperative room 20 to 30 minutes prior the procedure to allow the epinephrine to facilitate maximal hemostatic effect.⁸

FIGURE 2 Illustration shows the course of the superficial branch of the radial nerve in the distal forearm. APL = abductor pollicis longus, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, LT = Lister tubercle, RS = radial styloid process

In case of local anesthesia with sedation, a total of 10 mL of 1% lidocaine is injected subcutaneously using a 25-gauge needle into the area about the surgical site. The injection is performed in the operating room after use of intravenous sedation of the patient and sterile prep of the arm.

Special Instruments/Equipment/Implants

The procedure is performed under loupe magnification. Magnification is essential to identify and protect the branches of the superficial radial sensory nerve. A soft-tissue set, with fine hand instruments, should be used for this operation.

Surgical Technique

During surgical intervention for de Quervain syndrome, three important principles should be kept in mind.

The first principle is that care must be taken to protect the superficial radial nerve and its branches. Several branches of the superficial radial sensory nerve lie within the subcutaneous fat overlying the first dorsal compartment (Figure 2). The first branch comes off in a radial direction and continues on to the volar aspect of the forearm and innervates the radial aspect of the thumb. The main trunk of the superficial radial sensory nerve continues distally and divides into three to five branches that pass over the extensor pollicis longus tendon. These branches travel in an ulnar direction over the dorsum of the hand, supplying the radial three digits (thumb, index finger, and long finger).⁹ Longitudinal incisions generally lead to fewer superficial nerve injuries than do transverse incisions. For this reason, we use a small longitudinal incision from the tip of the radial styloid distally for approximately 1.5 cm. (The surgical technique can be seen in the video.) Sharp dissection is then carried just through the dermis but not
into the subcutaneous fat. After retracting the skin edges, the subcutaneous fat is dissected bluntly with tenotomy scissors down to the retinaculum of the first dorsal compartment. Extreme care is taken to protect the superficial branches of the radial sensory nerve. Excessive dissection and/or retraction can result in neurapraxia or a neuroma in continuity. Thus being aware of the anatomy of the superficial radial nerve and its branches and the methods to decrease risk of injury to it is important. Symptoms related to superficial radial sensory nerve injury, if present, can ultimately present more bothersome complaints than the symptoms because of stenosing tenosynovitis of the first dorsal compartment.

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