6: Surgical Treatment of de Quervain Tendovaginitis

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Procedure 6 Surgical Treatment of de Quervain Tendovaginitis

Brent M. Egeland, Sandeep J. Sebastin, Kevin C. Chung

See Video 3: Release of First Dorsal Compartment for de Quervain Tendovaginitis

Indications

Surgery is recommended after failure of conservative treatment measures, including the following:

• One to two injections of steroids, which should work in up to 70% of patients

• Wrist splinting for 4 to 6 weeks

• Avoidance of all inciting activities

Examination/Imaging

Clinical Examination

The patient has tenderness over the radial styloid and may have triggering of the thumb extensor tendons. The following two tests can be done to confirm the presence of de Quervain disease.

• Hitchhiker’s sign: The patient complains of pain localized to the first dorsal compartment when asked to extend and abduct the thumb, as is done when requesting a ride (Fig. 6-1).

• Finkelstein test: This is done by grasping the patient’s thumb and ulnarly deviating the wrist (Fig. 6-2A). This usually results in acute pain over the radial styloid. In the test described by Eichhoff (often misunderstood to be the Finkelstein test), the thumb is placed within the hand and held tightly by the other fingers (Fig. 6-2B). A positive test is when the wrist is painful during ulnar deviation.

• Extensor pollicis brevis (EPB) entrapment test: Some patients have separate sheaths for the EPB and abductor pollicis longus (APL), and tendovaginitis may involve either one. This test helps identify pathologic changes involving one or both compartments. The patient is asked to put the palm flat on the table with the wrist in ulnar deviation. First the EPB compartment is tested by asking the patient to lift the thumb directly up (off the table) while the examiner provides resistance over the metacarpal. Next the patient is asked to radially abduct the thumb against resistance, testing the APL. Pain during the first or second maneuvers suggests EPB tendovaginitis and APL tendovaginitis, respectively.

The examiner must evaluate for and rule out other causes of radial wrist pain. They include thumb basal joint arthritis, scaphoid fracture, Wartenberg syndrome (compression of the superficial sensory branch of the radial nerve between the extensor carpi radialis longus [ECRL] and brachioradialis [BR]), intersection syndrome (tendinitis at the crossing over of the APL and EPB muscle bellies over the ECRL and extensor carpi radialis brevis [ECRB]), scaphotrapeziotrapezoid (STT) arthritis, and Preiser disease (avascular necrosis of the scaphoid).

FIGURE 6-1

FIGURE 6-2

Imaging

Plain films should be obtained if the clinical diagnosis is unclear and one needs to consider other differential diagnoses, such as thumb carpometacarpal (CMC) arthritis.

Surgical Anatomy

Six extensor compartments have been described over the dorsum of the wrist (Fig. 6-3A).

The first dorsal compartment is involved in de Quervain tendovaginitis. It contains two tendons, the APL and the EBP (Fig. 6-3B and C). The APL tendon has multiple slips. The APL tendon is more radial and volar, whereas the EPB tendon is ulnar and dorsal. In up to 40% of subjects, there may be a separate subsheath for each of the two tendons.

The first dorsal compartment is about 2 cm long, with the floor formed by a groove on the radial surface of the radial styloid. The walls are formed by tough intercompartmental connective tissue septa extending from the bony floor to the roof, or extensor retinaculum.

The radial artery is volar to the first compartment but is closely related to the floor of the distal end of the first compartment near the radial styloid on its way to the anatomic snuff from a volar to dorsal direction.

The radial sensory nerve has several branches in the subcutaneous tissue superficial to the extensor retinaculum. Most complications during this operation are a result of traction injury of this nerve, leading to persistent pain at the incision site (Fig. 6-4).

FIGURE 6-3

FIGURE 6-4

Positioning

The patient lies supine on the operating table with the affected arm placed on a hand table.

The procedure is performed under tourniquet control and local anesthesia.

Exposures

A 3-cm longitudinal chevron incision is made extending proximally from the radial styloid over the first compartment (Fig. 6-5). As soon as the deep portion of the dermis is opened, gentle blunt dissection with a scissors should be used to expose the extensor retinaculum over the first dorsal compartment. The skin flaps can then be gently elevated to fully expose the first compartment.

FIGURE 6-5

Pearls

The scissors should be spread in a longitudinal direction to avoid injury to the longitudinally oriented branches of the superficial radial nerve.

The nerve should be identified and protected. It is best to avoid dissection of the nerve, but where required, a thick cuff of perineural fat should be maintained to prevent adhesions of the nerve to the skin or the scar (Fig. 6-6).

FIGURE 6-6

Pitfalls

Overzealous retraction of the radial sensory nerve is the major cause of persistence of pain postoperatively.

Procedure

Step 1

The first dorsal compartment is opened along its entire length with a no. 15 scalpel blade (Fig. 6-7). One should inspect the compartment for presence of any subsheaths, which should be individually released (Fig. 6-8).

Any hypertrophic synovium should be excised.

Release is visually confirmed and verified by taking the thumb through a full range of motion (Fig. 6-9).

FIGURE 6-7

FIGURE 6-8

FIGURE 6-9

Step 1 Pearl

Instead of dividing the first dorsal compartment in the midline, dividing it on the dorsal ulnar border will decompress the compartment, while preventing volar subluxation of the tendons.

Step 1 Pitfall

One should not mistake the multiple slips of the APL for the EPB (see Fig. 6-8). Traction on the tendons after release should be used to differentiate between the tendons. The EPB subsheath is often hidden under the groove on the radial styloid and easily missed (see Fig. 6-8).

Step 2

The tourniquet is released, and careful hemostasis is achieved using bipolar electrocautery, with care taken to avoid cautery injury to the radial sensory nerve.

The wound is closed with simple cutaneous 4-0 nylon sutures, and a soft dressing is applied.

Postoperative Care and Expected Outcomes

The patient should wear the gentle compression dressing for several days followed by liberalization of movement as the wound heals.

The majority of patients (>90%) should have nearly immediate relief of symptoms after release of the first compartment. If symptoms persist, one must consider inadequate release of unrecognized subsheaths within the first compartment.

Occasionally patients with prolonged symptoms and stiffness may require progressive therapy for active and passive motion and progressive strengthening. This can begin immediately after surgery.

If a patient develops a sensitive scar, desensitization therapy should be recommended with close clinical follow-up.

Ahuja NK, Chung KC. Fritz de Quervain, MD (1868-1940): stenosing tendovaginitis at the radial styloid process. J Hand Surg [Am]. 2004;29:1164-1170.

This is a comprehensive review of the life of Fritz de Quervain, one of the most prominent surgeons of his era. Dr. de Quervain described and proposed surgical treatment for the inflammatory process of the tendon sheath over the first dorsal compartment. This paper also describes other maneuvers to distinguish this condition from associated diseases in this area, including thumb carpometacarpal joint arthritis. (Level V evidence)

Ta KT, Eidelman D, Thomson G. Patient satisfaction and outcomes of surgery for de Quervain’s tenosynovitis. J Hand Surg [Am]. 1999;23:1071-1077.

This is a three-part retrospective review of 43 patients who underwent surgical treatment for de Quervain tenosynovitis. Follow-up averages 3 years and includes subjective survey data as well as clinical exam data. There was a 5% recurrence rate, one patient (2%) with radial sensory nerve injury, and another with scar tenderness. The cure rate was 88% with a 91% satisfaction rate. (Level IV evidence)

Weiss AC, Akelman E, Tabatabi M. Treatment of de Quervain’s disease. J Hand Surg [Am]. 1994;19:595-598.

This longitudinal cohort study of 93 patients with a mean follow-up time of 13 months compared conservative management with splinting versus steroid injection or a combination of the two in treating de Quervain tenosynovitis. This study indicated that any injection had a higher success rate than splinting alone. Ultimately, nearly half of patients underwent surgical release for failure of conservative management. The authors recommend steroid injection without splinting as initial treatment of de Quervain disease. (Level IV evidence)

Witt J, Pess G, Gelberman RH. Treatment of de Quervain tenosynovitis: a prospective study of the results of injection of steroids and immobilization in a splint. J Bone Joint Surg [Am]. 1991;73:219-222.

This prospective study evaluated outcomes of lidocaine-steroid injection in 99 wrists with this condition. Satisfactory results occurred in 62% of the wrists, and failure of injection related to potentially missing the abductor pollicis brevis (APB) subcompartment during the injections. The lack of responsiveness with steroid injection may be related to missing the first compartment or missing the separate compartment for the APB tendons. (Level III evidence)

Related

Operative Techniques Hand and Wrist Surgery