Professional Documents
Culture Documents
10.1055@s 0039 1688700 PDF
10.1055@s 0039 1688700 PDF
10.1055@s 0039 1688700 PDF
1 Division of Hand Surgery, Department of Orthopedic Surgery, The Address for correspondence Jonas L. Matzon, MD, Division of Hand
Rothman Institute, Sidney Kimmel Medical College, Thomas Surgery, Department of Orthopaedic Surgery, The Rothman Institute,
Jefferson University, Philadelphia, Pennsylvania Sidney Kimmel Medical College, Thomas Jefferson University,
925 Chestnut Street, Philadelphia, PA 19107-1216
J Wrist Surg (e-mail: Jonas.Matzon@rothmaninstitute.com).
Abstract Background We prospectively evaluated the surgical anatomy during first dorsal
compartment release for De Quervain’s tenosynovitis, with special attention to the
De Quervain’s tenosynovitis is a common condition affecting patients to this condition and can result in symptoms that
the extensor pollicis brevis (EPB) and abductor pollicis remain refractory to nonsurgical treatment.1–4 Surgical
longus (APL) tendons as they run through the first dorsal treatment of De Quervain’s tenosynovitis involves release
extensor compartment of the wrist. Several anatomical and of the first dorsal compartment including the separate
surgical studies have suggested that a separate compartment compartment for the EPB (if present) and all slips of the
for the EPB and/or multiple slips of the APL can predispose APL. A thorough exploration of the first compartment is
necessary to ensure adequate release of all tendon slips, volarly from the first dorsal compartment in flexion. The
which otherwise may result in persistent postoperative treating surgeons completed a questionnaire detailing the
symptoms if not completely decompressed. type of incision used, the number of APL tendon slips,
Aside from the failure to identify and to release all tendon number of EPB tendon slips, the number of SBRN branches
slips, two other complications involving anatomical variables encountered, the number of additional subcompartments
can occur during De Quervain’s surgery but have received far created by any septations, and active/passive tendon stabi-
less attention in the literature. First, the superficial branch of lity. Statistical analysis was performed using Fisher’s exact
the radial nerve (SBRN) is at a risk during surgical release. It test for comparison of nonparametric data.
emerges from between the brachioradialis and the extensor
carpi radialis longus 7 to 9 cm proximal to the radial styloid and
Results
begins to branch approximately 5 cm proximal to the styloid.5–7
Based on cadaveric studies, these branches are found overlying The mean age of the group was 57 years (range: 24–82). The
the first dorsal compartment directly in the De Quervain’s average age of the female patients was 58 years compared
surgical field in a large proportion of people.6,7 Second, once with 52 years for the men (p ¼ 0.03). A transverse/oblique
the retinaculum has been released, the tether maintaining the incision was made along Langer’s lines of the skin in 108
EPB and APL tendons in the first dorsal compartment has been (83%) of cases, whereas the remaining 22 (17%) procedures
removed. This can result in postoperative volar subluxation of were performed with a longitudinal incision. In 48 wrists
the tendons.8–10 The recommended surgical technique is to (37% of cases), a singular first dorsal compartment without
release the first dorsal compartment along its dorsal margin, subsheaths was noted intraoperatively. Two total subcom-
patients (7 case series), multiple APL slips were noted in 73% The single patient with dislocating tendons had an immediate
of 320 patients (5 case series), and a single EPB was observed first dorsal compartment reconstruction using a brachiora-
in 94% of 307 patients (4 case series). However, most of the dialis tendon flap, as described by McMahon et al.9 Eight of the
available data come from retrospective studies. In our pro- 11 patients with perched tendons had the radial retinacular
spective study of 130 patients undergoing first dorsal com- flap sutured to the subcutaneous tissues, as described by Bahm
partment release, we found comparable rates of subsheaths et al, and immediate postoperative thumb spica splinting, as
(63%), multiple APL slips (78%), and a single EPB (92%). These advocated by McMahon et al.1,9 The other three patients had
findings in our prospective study with a relatively large no additional intraoperative treatment or postoperative
cohort serve to substantiate the concordant findings from splinting. In all 12 instances, the decision regarding whether
previous smaller and/or retrospective studies. to augment first dorsal compartment release was made
Unlike subsheath and tendon variability, however, less intraoperatively by the individual surgeon. Since our study is
consideration has been given to other important anatomical isolated to intraoperative findings, it is unknown if any of our
variables in De Quervain’s tenosynovitis. Specifically, the patients developed postoperative instability and/or if aug-
SBRN is vulnerable to injury given its close proximity to menting first dorsal compartment release made any clinical
the first dorsal compartment and its susceptibility to form difference. However, in patients with stable tendons during
painful neuromas.6,7,13 In a cadaveric study, Auerbach et al intraoperative passive and active testing, it seems less likely
found that 75% (15/20) of specimens had an SBRN directly that late instability would develop.
overlying the typical transverse incision for De Quervain’s The strengths of this study include its relatively large
tenosynovitis.6 Similarly, Abrams et al found that the nearest number of patients and prospective methodology. Also, we