6: Surgical Treatment of de Quervain Tendovaginitis

Published on 18/04/2015 by admin

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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.

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