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Introduction
  • A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes
    • abductor pollicis longus (APL) 
    • extensor pollicis brevis (EPB) 
  • Epidemiology
    • demographics
      • woman > men
      • 30 - 50 years old
    • body location
      • most commonly in the dominant wrist
    • risk factors
      • overuse
        • golfers and racquet sports
      • post-traumatic
      • postpartum 
  • Pathophysiology
    • pathoanatomy
      • thickening and swelling of extensor retinaculum causes increased tendon friction
      • NOT considered an inflammatory process
        • may be related to accumulation of mucopolysaccharides
  • Prognosis
    • most cases resolve with non-operative management 
    • high recurrence rate
Anatomy
  • Extensor tendon compartments  
    • Compartment 1 (De Quervain's Tenosynovitis)
      •  APL
      •  EPB
    • Compartment 2 (Intersection syndrome )
      •  ECRL 
      •  ECRB 
    • Compartment 3
      •  EPL 
    • Compartment 4
      •  EIP 
      •  EDC 
    • Compartment 5 (Vaughn-Jackson Syndrome )
      •  EDM
    • Compartment 6 (Snapping ECU )
      •  ECU
Presentation
  • Symptoms
    • gradual onset 
    • radial sided wrist pain
    • pain exacerbated by gripping and raising objects with wrist in neutral
  • Physical exam 
    • inspection
      • tenderness over 1st dorsal compartment at level of radial styloid
    • motion
      • usually normal wrist motion
      • pain with resisted radial deviation
    • neurovascular exam
      • normal
    • provocative tests
      • Finkelstein maneuver
        • On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is painful
        • more indicative of EPB > APL tendon pathology
      • Eichhoff maneuver
        • ulnar deviated wrist while patient clenches thumb in fist, followed by relief of pain once the thumb is extended even if the wrist remains ulnar deviated
Imaging
  • Radiographs
    • recommended views
      • AP, lateral views of wrist
    • indications
      • radiographs usually not indicated
    • findings
      • may be used to rule out
        • basilar arthritis of the thumb
        • carpal arthritis
Treatment
  • Nonoperative
    • rest, NSAIDS, thumb spica splint, steroid injection
      • indications
        • first line of treatment
      • technique
        • NSAIDS, rest and immobilisation usually first step
        • steroid injections into first dorsal compartment usually second step  
      • outcomes
        • overall corticosteriods found to be superior to splinting 
        • concomitant splinting and/or NSAIDs after steriods injection does not improve outcomes
  • Operative
    • surgical release of 1st dorsal compartment 
      • indications
        • severe symptoms 
        • usually consider after 6 months of failed nonoperative management 
      • technique
        • radial based incision proximal to the wrist
        • protect the superficial radial sensory nerve
Surgical Techniques
  • Surgical release of 1st dorsal compartment 
    • approach
      • transverse incision with release on dorsal side of 1st compartment to prevent volar subluxation of the tendon
        • has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-osseous compartment
        • a distinct EPB sheath is often encountered dorsally
Complications
  • Sensory branch of radial nerve injury
  • Neuroma formation
  • Failure to decompress with recurrence 
    • may be caused by failure to recognize and decompress EPB or APL lying in separate subsheath/compartment
  • Complex regional pain syndrome
 

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Questions (2)

(OBQ12.253) A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms? Review Topic

QID:4613
1

Development of neuroma

1%

(40/3045)

2

Complex regional pain syndrome

0%

(11/3045)

3

Failure to decompress the EPB sub-sheath

73%

(2211/3045)

4

Failure to decompress the EPL sub-sheath

8%

(241/3045)

5

Failure to decompress the APB sub-sheath

17%

(527/3045)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.

De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.

Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.

Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis

Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.

Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.

Incorrect Answers
Answer 1: Given the negative Tinel’s sign on physical exam, the patient is less likely to have a neuroma.
Answer 2: Her history, symptoms and lack of skin changes are not consistent with complex regional pain syndrome.
Answers 4, 5: The first dorsal compartment is composed of the APL/EPB. The EPL is in the third dorsal compartment and the APB is in the thenar compartment.

ILLUSTRATIONS:

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(OBQ08.9) A 31-year-old mother of a 2-month-old infant complains of radial sided wrist pain. Corticosteroid injections should be directed into what anatomic area? Review Topic

QID:395
1

First carpometacarpal joint

1%

(17/1777)

2

Carpal tunnel

2%

(34/1777)

3

First dorsal compartment near the radial styloid

90%

(1601/1777)

4

A1 pulley of thumb

1%

(12/1777)

5

At the crossing of the first and second dorsal compartments

6%

(110/1777)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

There is an association between the postpartum state and de Quervain’s tenosynovitis. De Quervain’s is a pathologic process of the 1st dorsal (extensor) compartment which contains the extensor pollicis brevis and abductor pollicis longus tendons. The best choice is #3 because of the very common and known association of postpartum state and de Quervain’s as well as the potential for resolution with appropriately placed steroid injection. Answer #1 refers to basal joint arthritis which is typically seen in older patients. Answer #2 refers to carpal tunnel syndrome, which would present with paresthesias in the median nerve distribution. Answer #4 refers to a trigger thumb. Answer #5 alludes to intersection syndrome which is generally more proximal to the wrist and results from inflammation at crossing point of 1st dorsal compartment (APL and EPB) and 2nd dorsal compartment (ECRL, ECRB). To review, the wrist extensor compartments (from radial to ulnar) are: 1) APL & EPB; 2) ECRL & ECRB (common radial wrist extensors); 3) EPL; 4) EIP & EDC; 5) EDM; 6) ECU.


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