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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?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
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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.
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.
Alegado RB, Meals RA.
J Hand Surg Am. 1979 Mar;4(2):185-6. PMID: 217905 (Link to Abstract)
Alegado, JHS 1979
Ashurst JV, Turco DA, Lieb BE.
J Am Osteopath Assoc. 2010 May;110(5):294-6. PMID: 20538752 (Link to Abstract)
Ilyas AM, Ast M, Schaffer AA, Thoder J.
J Am Acad Orthop Surg. 2007 Dec;15(12):757-64. PMID: 18063716 (Link to Abstract)
Ilyas, JAAOS 2007
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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?
First carpometacarpal joint
First dorsal compartment near the radial styloid
A1 pulley of thumb
At the crossing of the first and second dorsal compartments
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.
Obstet Gynecol. 1986 Sep;68(3):411-4. PMID: 3488531 (Link to Abstract)
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We present you the technique for Dequervain's release
Demonstrates 1st extensor compartment anatomy and injection technique
Shows Dequervain's 1st extensor compartment release