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https://upload.orthobullets.com/topic/6026/images/extensor compartments_moved.jpg
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 (3)

(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%

(47/3485)

2

Complex regional pain syndrome

0%

(13/3485)

3

Failure to decompress the EPB sub-sheath

73%

(2536/3485)

4

Failure to decompress the EPL sub-sheath

8%

(275/3485)

5

Failure to decompress the APB sub-sheath

17%

(593/3485)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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%

(27/2474)

2

Carpal tunnel

2%

(47/2474)

3

First dorsal compartment near the radial styloid

90%

(2224/2474)

4

A1 pulley of thumb

1%

(18/2474)

5

At the crossing of the first and second dorsal compartments

6%

(150/2474)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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