Tendinopathies: FCU, ECU, de Quervain’s, and Intersection Syndrome




de QUERVAIN’S DISEASE


Basic Science and Pertinent Anatomy


Several terms are used to describe the condition of tendon entrapment. Although frequently referred to as tenosynovitis, de Quervain’s disease is more accurately termed tendovaginitis (from the Latin for “tendon sheath” and Greek for “inflammation”) or stenosing tendovaginitis. Tenosynovitis suggests inflammation of the synovium; however, biopsy of the synovium in de Quervain’s disease has shown little in the way of inflammatory tissue. In de Quervain’s disease, the retinacular sheath covering the tendons of the first compartment is swollen and inflamed. Over time, the inflammatory process leads to narrowing of the rigid retinacular sheath, and this may progress to a condition that may be irreversible and is best described as stenosing tendovaginitis.


The first dorsal compartment is a site of considerable anatomic variation. The compartment is an osteoligamentous tunnel formed by an osseous groove at the radial styloid and the overlying extensor retinaculum. The tunnel contains the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). Although anatomic texts often show only a single APL tendon traversing the compartment, this is generally not the case. In fact, there are two or more slips of the APL tendon in 50% to 94% of patients. Conversely, the EPB tendon has been found to be absent in 5% to 7% of subjects.


The EPB and APL tendons are divided by a septation in the first compartment in 20% to 60% of people. This septation effectively creates separate compartments for the radial APL tendons and the ulnar EPB tendon. A third compartment holding an anomalous tendon has also been described. Several series have reported the incidence of separate compartments—discovered during surgical release—to be higher than in earlier anatomic studies. This suggests that conservative treatment in patients with a subdivision of the first compartment is more likely to fail.


The EPB entrapment test was described as a method of determining which patients may have a separate compartment for the EPB tendon. The test compares resisted thumb metacarpophalangeal extension to resisted palmar abduction. Patients whose pain is greater with thumb extension are more likely to have a separate compartment for the EPB tendon. The EPB entrapment test was found to be 81% sensitive.


Indications and Differential Diagnosis


Patients with de Quervain’s disease typically present with pain, swelling, and tenderness over the first dorsal compartment approximately 1 cm proximal to the radial styloid. The condition most commonly affects those in the sixth and seventh decades of life and is more common in women than in men.


Finkelstein’s test is a useful diagnostic test to help identify patients with tendovaginitis of the first dorsal compartment. Finkelstein originally described a maneuver in which the patient’s thumb is grasped and used to ulnarly deviate the hand. Eichoff, however, actually described the test that often is misnamed as Finkelstein’s, in which the thumb is clasped in the fist and then ulnarly deviated. Both maneuvers produce symptoms, but Eichoff’s test at times produces symptoms in normal individuals.


Several conditions present in a manner similar to that of deQuervain’s disease. Intersection syndrome is tendovaginitis of the second dorsal compartment. Patients also present with pain, swelling, and tenderness of the distal radial forearm, but the pain can generally be localized to a point more proximal than that of the typical presentation of de Quervain’s tenosynovitis.


First carpometacarpal (CMC) joint arthritis, scaphotrapeziotrapezoid (STT) joint arthritis, and Wartenberg’s syndrome all may be mistaken for de Quervain’s disease. On physical examination, noting the location of joint tenderness along with radiographs allows differentiation of de Quervain’s disease from arthritis of either the CMC or STT joint. Patients with Wartenberg’s syndrome, or neuritis of the superficial radial nerve, present with pain along the radial styloid and may have a positive Finkelstein’s test result. Unlike de Quervain’s patients, those with Wartenberg’s syndrome may have a positive Tinel’s sign to percussion over the superficial radial nerve and may have decreased sensation in the radial sensory nerve distribution.


Nonoperative Treatment


A variety of injectable steroid preparations are acceptable for the treatment of de Quervain’s disease. Our preference is to use a mixture of 1 mL betamethasone (6 mg/mL) and 3 mL 1% lidocaine without epinephrine. The lidocaine is helpful in confirming accurate placement of the injection, since proper placement of local anesthetic into the first compartment usually results in immediate improvement of symptoms. Regardless of the mixture used, one should be aware of potential adverse effects such as skin hypopigmentation and subcutaneous atrophy.


A 25- or 27-gauge needle can be used to inject the first compartment approximately 1 cm proximal to the radial styloid. The APL and EPB tendons are generally easily palpated along the radial wrist. A pop may be felt on entering the tendon sheath, and a progressing fluid wave may be observed as the steroid mixture fills the first compartment. Patients who do not respond may undergo a second injection after approximately 4 weeks. Repeated injections are discouraged because of the potential for adverse effects. Although the literature does not necessarily support the use of splinting, we still offer a thumb spica splint to patients in addition to the injection.


Operative Treatment


When nonoperative treatment fails to provide relief, surgical release of the first dorsal compartment may be performed with either local or regional anesthesia. The use of a tourniquet allows for easier identification of the pertinent anatomy and especially for identification of the sensory branches of the radial nerve. With local anesthesia alone, patients are generally able to tolerate the tourniquet for the short time required for the procedure. In addition, intravenous sedation is a useful adjunct for patient comfort.


A 2-cm longitudinal or transverse incision is made in the skin starting 1 cm proximal to the radial styloid ( Fig. 59-1 ). Oblique or Z-shaped incisions are also options, but we feel that the transverse incision is aesthetically superior, whereas the longitudinal incision allows for a more extensile exposure if required. Once through the skin, blunt dissection should be used to reach the antebrachial fascia while retracting the subcutaneous tissue and sensory branches of the radial nerve ( Figs. 59-2 and 59-3 ). The use of forceps to grasp the subcutaneous tissue should be avoided to help protect the sensory branch of the radial nerve from potential injury.




FIGURE 59-1


Longitudinal skin incision for release of the first extensor compartment .



FIGURE 59-2


Identification and protection of the superficial branch of the radial nerve .



FIGURE 59-3


The first dorsal compartment retinaculum .


The retinaculum overlying the first compartment is incised sharply along its radial border releasing the tendons ( Fig. 59-4 ). The compartment should then be explored, ensuring that all slips of both the APL and EPB tendons have been released ( Figs. 59-5 and 59-6 ). If an intracompartmental septum is present, it should be divided. The wrist should be ranged through full flexion and extension while the clinician observes for tendon subluxation. Tendon subluxation can be treated by loose suturing of the retinaculum or by postoperative splinting.




FIGURE 59-4


Incision releasing the first dorsal compartment .



FIGURE 59-5


Released first dorsal compartment .



FIGURE 59-6


Inspection for complete release of all abductor pollicis longus and extensor pollicis brevis tendons .


Complications


Relatively few complications arise from operative treatment of de Quervain’s disease. Injury to the radial sensory nerve is by far the most serious complication of first dorsal compartment release. Pain from injury to the radial nerve can be disabling and frequently is worse than the patient’s symptoms from de Quervain’s disease. Other complications include incomplete pain relief, incomplete tendon release secondary to failure to identify an intracompartmental septum, palmar or dorsal subluxation of the tendons, and hypertrophic scarring.


Outcomes


In 1895, Fritz de Quervain, a Swiss surgeon, was the first to describe tendovaginitis of the first dorsal extensor compartment, the condition that now bears his name.


De Quervain’s disease is a condition of tendon entrapment affecting the common sheath of the APL and EPB tendons. The condition generally results from inflammation of the first extensor compartment as a result of repetitive motion or, less frequently, from acute trauma. De Quervain’s disease is a common cause of wrist pain, and physicians should be well versed in its diagnosis and treatment.


The effectiveness of conservative treatment in de Quervain’s disease is somewhat controversial. Immobilization with the thumb abducted and the wrist in slight extension has been shown by some to be a viable treatment option, especially in acute cases. Others feel that immobilization alone is of limited usefulness. In one prospective study, splinting alone was found to have a failure rate of nearly 70%.


Corticosteroid injection, either alone or combined with immobilization, is a more effective treatment of de Quervain’s disease. Steroid injection of the first dorsal compartment is effective in 50% to 80% of patients, especially those with acute symptoms. Patients may require more than one injection before resolution of symptoms, and success rates may be lower in patients with diabetes.


Surgical release is likely to be successful when it is performed for the correct diagnosis, with exquisite protection of the sensory branch of the radial nerve, and with thorough exploration of the compartment and release of all intracompartmental septa.




INTERSECTION SYNDROME


Etiology and Pertinent Anatomy


Intersection syndrome is a painful affliction of the forearm that results from tenovaginitis of the second dorsal wrist compartment. Patients with this condition present with pain and swelling in the region where the muscle bellies of the APL and EPB tendons intersect (or cross above) the tendons of the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). Symptoms are usually localized to a region approximately 4 cm proximal to the radial styloid. In severe cases, patients may also have erythema and crepitus, which may be palpable or audible, especially with a stethoscope.


The etiology of intersection syndrome is unclear. The process was originally thought to be secondary to friction between the radial wrist extensors and the muscle bellies of the APL and EPB, resulting in a tendinitis or bursitis. Grundberg and Reagan suggested that the syndrome is a result of tenosynovitis of the tendons of the second dorsal compartment. However, whether the disease is a true inflammatory process of the synovium, or inflammation of the tendon sheath as in de Quervain’s disease, has yet to be established.


Nonoperative Treatment


Conservative management is the mainstay of treatment for intersection syndrome. Because the process is most often a result of overuse, the majority of patients improve with behavior modification, immobilization, and an occasional steroid injection. Patients should be managed initially with splinting the wrist in approximately 15 degrees of wrist extension for a period of 2 to 3 weeks. Nonsteroidal anti-inflammatory medications may be beneficial as well.


Patients whose symptoms persist may be given a steroid injection into the second compartment. The radial wrist extensors should be palpated just distal to the APL and EPB muscle bellies to identify the second compartment. In a manner similar to that described for de Quervain’s disease, a 25- or 27-gauge needle may be used to inject a mixture of betamethasone and local anesthetic. Patients should have immediate improvement in their symptoms from the local anesthetic, confirming injection in the proper location.


Operative Treatment


Relatively few patients are unresponsive to conservative management, but those who are should be considered for operative intervention. Surgical release can be performed with either local or regional anesthesia. An upper extremity tourniquet should be used to allow proper visualization of anatomic structures.


A longitudinal incision is made in line with the radial wrist extensors, starting at the dorsal wrist crease and extending proximally to the area of greatest swelling. The extensor retinaculum and antebrachial fascia overlying the second compartment are incised longitudinally. The APL and EPB may be mobilized to divide the fascia under the muscles. The tendons of the second compartment are elevated and inspected for any pathology. Postoperatively, the wrist is then splinted in slight extension for 7 to 10 days.


Complications


As with de Quervain’s disease, few complications arise after surgery for intersection syndrome. Subluxation of the radial wrist extensors is a theoretical possibility, but has not been reported. Other potential complications are infection, nerve injury, and hypertrophic scarring.


Literature Review


Intersection syndrome was originally described by Velpeau in 1841, but was not given the name “intersection syndrome” until 1978. The syndrome has been associated with frequent or repetitive motions of the wrist and is frequently seen in athletes participating in sports such as rowing and weight-lifting. Most patients respond to nonoperative treatments without recurrence of symptoms. Operative treatment has been shown to be an effective treatment in cases recalcitrant to conservative therapy.

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Jul 10, 2019 | Posted by in ORTHOPEDIC | Comments Off on Tendinopathies: FCU, ECU, de Quervain’s, and Intersection Syndrome
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