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COMPARTMENT RECONSTRUCTION FOR DE QUERVAIN'S DISEASE
COMPARTMENT RECONSTRUCTION FOR DE QUERVAIN’S DISEASE J. W. LITTLER, D. M. FREEDMAN and M. M. MALERICH From the C. V. Starr Hand Surgery Center, St. Lukes’/Roosevelt Hospital Center, New York, USA
A new surgical treatment for De Quervain’s disease is presented, in which the anatomy and function of the first dorsal compartment is preserved. Our findings in 11 wrists in ten patients revealed complete relief of the pre-operative symptoms in all instances. The advantages of this technique are its ease, its restoration of normal anatomy, and the prevention of tendon prolapse. Journal of Hand Surgery (British and European Volume, 2002) 27B: 3: 242–244 monofilament suture. A dressing is applied, followed by a splint or cast with the wrist held in 10–201 extension and 101 ulnar deviation. The wrist is immobilized for 2 weeks.
INTRODUCTION De Quervain’s disease is a common cause of wrist pain which frequently requires surgical treatment. Complications following incision or excision of the first dorsal compartment sheath are uncommon, but can be very troublesome when they occur. We describe a new technique of reconstruction of the first dorsal compartment, and review the outcome of this procedure.
RESULTS All patients had complete relief of their pre-operative symptoms and none experienced radial border wrist pain with activities. Particular attention was paid to symptoms of subluxation (‘‘popping, snapping, clicking, or abnormal rubbing’’) which were absent in all patients. Complete sensibility was noted in all cases, effectively ruling out any radial sensory nerve injury. All patients would elect to repeat the surgery again, and all would recommend it to a friend or family member.
PATIENTS AND METHODS The operative reports of patients treated by the senior authors (JWL, MMM) were reviewed, and 23 patients who underwent this technique of de Quervain’s release were contacted by mail. Ten patients returned a questionnaire designed to assess patient satisfaction with the surgery. In total, 11 reconstructions in 10 patients were available for review. The average age at surgery was 56 (range, 28–77) years, and the average follow-up time from surgery was 7 (range, 1.4–15.9) years. The dominant side was operated upon in seven of 11 wrists. In eight of 11 wrists, a septum dividing the first dorsal compartment was identified and excised.
DISCUSSION In 1892, Tillaux described an inflammation localized to the groove of the tendons of the extensor pollicis brevis and abductor pollicis longus, causing intense pain with thumb motion (Leao, 1958). In 1893, the 13th edition of Gray’s anatomy referred to an inflammation in the same area after excessive work, and named it ‘‘washerwoman’s sprain’’ (Strandell, 1957). However, Fritz de Quervain is credited with describing a fibrosing, stenosing tendovaginitis of the first dorsal compartment in 1895, and the disease now bears his name (Leao, 1958). The anatomy of the first extensor compartment has been well studied (Jackson et al., 1986; Keon-Cohen, 1951; Lacey et al., 1951; Leao, 1958; Loomis, 1951; Strandell, 1957). Typically, it contains multiple tendons or tendon slips as the abductor pollicis longus muscle has two or more tendons in 75% of cases (Keon-Cohen, 1951; Leao, 1958). Approximately 34% of cadavers have a septum between the extensor pollicis brevis and abductor pollicis longus tendons (Leslie et al., 1990). The potential complications following surgical treatment include damage to the superficial branch of the radial nerve, scar hypertrophy, extensor tendon adherence, incomplete release with persistent symptoms, and palmar tendon subluxation. The operative technique employed most commonly involves incision of the compartment, with subtotal or complete excision of
SURGICAL TECHNIQUE The procedure is performed under tourniquet control with local or regional anesthaesia. A transverse incision is made just through the dermis in line with the skin creases over the first dorsal compartment. Careful dissection is performed so as to protect the variable branches of the superficial radial nerve. A dorsal incision is made in the sheath, and the compartment is carefully explored for the tendon of the extensor pollicis brevis, and the multiple tendon slips of the abductor pollicis longus. Using an atraumatic technique, tension is placed on each of the tendons to simulate their function and aid proper identification. If a septum is present, it is completely excised. The extensor pollicis brevis tendon is retracted out of the dorsal compartment, and the sheath of the first dorsal compartment is then reapproximated over the abductor pollicis longus tendon(s) using 5–0 absorbable sutures (Fig 1). The tourniquet is deflated and hemostasis is obtained. The skin is closed with a running 4–0 non-absorbable 242
DE QUERVAIN’S DISEASE
the fibrous roof in cases with excessive sheath thickening. The mechanical complications associated with this approach include incomplete release due to compartmental subdivision with persistent symptoms, and tendon prolapse. Burton and Littler (1975) have proposed a dorsal incision in the compartment, preserving a radiodorsal palmar-based flap to prevent tendon subluxation. There have been several case reports of symptomatic tendon prolapse requiring reconstruction of a tendon restraint (Arons, 1987; Belsole, 1981; McMahon et al., 1991; White and Weiland, 1984). In certain situations, the tendon subluxation has been associated with excision of the entire sheath. An additional complication has been reported by Alegado and Meals (1979), where tendon motion against the
243
dorsal fibrous remnant of the sheath produced dysesthesias in the superficial radial nerve. Reconstruction of the first dorsal compartment has previously been described. Belsole (1981) describes a longitudinal Z-plasty release of the canal, with apposition of the point of each flap. There are several advantages to our technique. Firstly, the actual dimensions of the compartment are not affected, thereby preserving the physiologic pulley mechanism. Rather, the canal is decompressed by removal of the extensor pollicis brevis tendon, and septum if present. In addition, closure of the compartment virtually ensures smooth gliding of the overlying superficial radial nerve branches, the extensor pollicis brevis tendon, and the scar. Finally, as the function of
244
the abductor pollicis longus is to abduct the first metacarpal, the replacement of this tendon in the decompressed sheath restores mechanical advantage and precludes tendon subluxation. In our patient review, all patients had complete resolution of their symptoms which demonstrates that the procedure is probably as effective in decompressing the first dorsal compartment as a simple incisional release. In addition, none of our patients had any symptoms of tendon subluxation or superficial radial neuritis. While admittedly rare, with the reconstruction described these complications should be predictably prevented. References Alegado RB, Meals RA (1979). An unusual complication following surgical treatment of de Quervain’s disease. Journal of Hand Surgery, 4A: 185–186. Arons MS (1987). De Quervain’s release in working women: a report of failures, complications, and associated diagnoses. Journal of Hand Surgery, 12A: 540–544. Belsole RJ (1981). De Quervain’s tenosynovitis: diagnostic and operative complications. Orthopedics, 4: 899–903. Burton RI, Littler JW (1975). Nontraumatic soft tissue afflictions of the hand. In: Ravitch MM (Ed): Current Problems in Surgery. Chicago, Year Book Medical Publishers, Inc., July, 1975: 32–34. Jackson WT, Viegas SF, Coon TM, Stimpson KD, Frogameni AD, Simpson JM (1986). Anatomical variations in the first extensor compartment of the
THE JOURNAL OF HAND SURGERY VOL. 27B No. 3 JUNE 2002 wrist: a clinical and anatomical study. Journal of Bone and Joint Surgery, 68A: 923–926. Keon-Cohen B (1951). De Quervain’s disease. Journal of Bone and Joint Surgery, 33B: 96–99. Lacey T, Goldstein LA, Tobin CE (1951). Anatomical and clinical study of the variations in the insertions of the abductor pollicis longus tendon, associated with stenosing tendovaginitis. Journal of Bone and Joint Surgery, 33A: 347–350. Leao L (1958). De Quervain’s disease: a clinical and anatomical study. Journal of Bone and Joint Surgery, 40A: 1063–1070. Leslie BM, Ericson Jr WB, Morehead JR (1990). Incidence of a septum within the first dorsal compartment of the wrist. Journal of Hand Surgery, 15A: 88–91. Loomis LK (1951). Variations of stenosing tenosynovitis at the radial styloid process. Journal of Bone and Joint Surgery, 33A: 340–346. McMahon M, Craig SM, Posner MA (1991). Tendon subluxation after de Quervain’s release: Treatment by brachioradialis tendon flap. Journal of Hand Surgery, 16A: 30–32. Strandell G (1957). Variations of the anatomy in stenosing tenosynovitis at the radial styloid process. Acta Chirurgie Scandinavia, 113: 234–240. White GM, Weiland AJ (1984). Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease. Journal of Hand Surgery, 9A: 704–706.
Received: 15 September 2000 Accepted after revision: 22 February 2001 Dr Douglas M. Freedman, 10666 N. Torrey Pines Rd, Mail Slot 116 La Jolla, California 92037, U.S.A. E-mail: [email protected] r 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0715, available online at http://www.idealibrary.com on
A new surgical treatment for De Quervain’s disease is presented, in which the anatomy and function of the first dorsal compartment is preserved. Our findings in 11 wrists in ten patients revealed complete relief of the pre-operative symptoms in all instances. The advantages of this technique are its ease, its restoration of normal anatomy, and the prevention of tendon prolapse. Journal of Hand Surgery (British and European Volume, 2002) 27B: 3: 242–244 monofilament suture. A dressing is applied, followed by a splint or cast with the wrist held in 10–201 extension and 101 ulnar deviation. The wrist is immobilized for 2 weeks.
INTRODUCTION De Quervain’s disease is a common cause of wrist pain which frequently requires surgical treatment. Complications following incision or excision of the first dorsal compartment sheath are uncommon, but can be very troublesome when they occur. We describe a new technique of reconstruction of the first dorsal compartment, and review the outcome of this procedure.
RESULTS All patients had complete relief of their pre-operative symptoms and none experienced radial border wrist pain with activities. Particular attention was paid to symptoms of subluxation (‘‘popping, snapping, clicking, or abnormal rubbing’’) which were absent in all patients. Complete sensibility was noted in all cases, effectively ruling out any radial sensory nerve injury. All patients would elect to repeat the surgery again, and all would recommend it to a friend or family member.
PATIENTS AND METHODS The operative reports of patients treated by the senior authors (JWL, MMM) were reviewed, and 23 patients who underwent this technique of de Quervain’s release were contacted by mail. Ten patients returned a questionnaire designed to assess patient satisfaction with the surgery. In total, 11 reconstructions in 10 patients were available for review. The average age at surgery was 56 (range, 28–77) years, and the average follow-up time from surgery was 7 (range, 1.4–15.9) years. The dominant side was operated upon in seven of 11 wrists. In eight of 11 wrists, a septum dividing the first dorsal compartment was identified and excised.
DISCUSSION In 1892, Tillaux described an inflammation localized to the groove of the tendons of the extensor pollicis brevis and abductor pollicis longus, causing intense pain with thumb motion (Leao, 1958). In 1893, the 13th edition of Gray’s anatomy referred to an inflammation in the same area after excessive work, and named it ‘‘washerwoman’s sprain’’ (Strandell, 1957). However, Fritz de Quervain is credited with describing a fibrosing, stenosing tendovaginitis of the first dorsal compartment in 1895, and the disease now bears his name (Leao, 1958). The anatomy of the first extensor compartment has been well studied (Jackson et al., 1986; Keon-Cohen, 1951; Lacey et al., 1951; Leao, 1958; Loomis, 1951; Strandell, 1957). Typically, it contains multiple tendons or tendon slips as the abductor pollicis longus muscle has two or more tendons in 75% of cases (Keon-Cohen, 1951; Leao, 1958). Approximately 34% of cadavers have a septum between the extensor pollicis brevis and abductor pollicis longus tendons (Leslie et al., 1990). The potential complications following surgical treatment include damage to the superficial branch of the radial nerve, scar hypertrophy, extensor tendon adherence, incomplete release with persistent symptoms, and palmar tendon subluxation. The operative technique employed most commonly involves incision of the compartment, with subtotal or complete excision of
SURGICAL TECHNIQUE The procedure is performed under tourniquet control with local or regional anesthaesia. A transverse incision is made just through the dermis in line with the skin creases over the first dorsal compartment. Careful dissection is performed so as to protect the variable branches of the superficial radial nerve. A dorsal incision is made in the sheath, and the compartment is carefully explored for the tendon of the extensor pollicis brevis, and the multiple tendon slips of the abductor pollicis longus. Using an atraumatic technique, tension is placed on each of the tendons to simulate their function and aid proper identification. If a septum is present, it is completely excised. The extensor pollicis brevis tendon is retracted out of the dorsal compartment, and the sheath of the first dorsal compartment is then reapproximated over the abductor pollicis longus tendon(s) using 5–0 absorbable sutures (Fig 1). The tourniquet is deflated and hemostasis is obtained. The skin is closed with a running 4–0 non-absorbable 242
DE QUERVAIN’S DISEASE
the fibrous roof in cases with excessive sheath thickening. The mechanical complications associated with this approach include incomplete release due to compartmental subdivision with persistent symptoms, and tendon prolapse. Burton and Littler (1975) have proposed a dorsal incision in the compartment, preserving a radiodorsal palmar-based flap to prevent tendon subluxation. There have been several case reports of symptomatic tendon prolapse requiring reconstruction of a tendon restraint (Arons, 1987; Belsole, 1981; McMahon et al., 1991; White and Weiland, 1984). In certain situations, the tendon subluxation has been associated with excision of the entire sheath. An additional complication has been reported by Alegado and Meals (1979), where tendon motion against the
243
dorsal fibrous remnant of the sheath produced dysesthesias in the superficial radial nerve. Reconstruction of the first dorsal compartment has previously been described. Belsole (1981) describes a longitudinal Z-plasty release of the canal, with apposition of the point of each flap. There are several advantages to our technique. Firstly, the actual dimensions of the compartment are not affected, thereby preserving the physiologic pulley mechanism. Rather, the canal is decompressed by removal of the extensor pollicis brevis tendon, and septum if present. In addition, closure of the compartment virtually ensures smooth gliding of the overlying superficial radial nerve branches, the extensor pollicis brevis tendon, and the scar. Finally, as the function of
244
the abductor pollicis longus is to abduct the first metacarpal, the replacement of this tendon in the decompressed sheath restores mechanical advantage and precludes tendon subluxation. In our patient review, all patients had complete resolution of their symptoms which demonstrates that the procedure is probably as effective in decompressing the first dorsal compartment as a simple incisional release. In addition, none of our patients had any symptoms of tendon subluxation or superficial radial neuritis. While admittedly rare, with the reconstruction described these complications should be predictably prevented. References Alegado RB, Meals RA (1979). An unusual complication following surgical treatment of de Quervain’s disease. Journal of Hand Surgery, 4A: 185–186. Arons MS (1987). De Quervain’s release in working women: a report of failures, complications, and associated diagnoses. Journal of Hand Surgery, 12A: 540–544. Belsole RJ (1981). De Quervain’s tenosynovitis: diagnostic and operative complications. Orthopedics, 4: 899–903. Burton RI, Littler JW (1975). Nontraumatic soft tissue afflictions of the hand. In: Ravitch MM (Ed): Current Problems in Surgery. Chicago, Year Book Medical Publishers, Inc., July, 1975: 32–34. Jackson WT, Viegas SF, Coon TM, Stimpson KD, Frogameni AD, Simpson JM (1986). Anatomical variations in the first extensor compartment of the
THE JOURNAL OF HAND SURGERY VOL. 27B No. 3 JUNE 2002 wrist: a clinical and anatomical study. Journal of Bone and Joint Surgery, 68A: 923–926. Keon-Cohen B (1951). De Quervain’s disease. Journal of Bone and Joint Surgery, 33B: 96–99. Lacey T, Goldstein LA, Tobin CE (1951). Anatomical and clinical study of the variations in the insertions of the abductor pollicis longus tendon, associated with stenosing tendovaginitis. Journal of Bone and Joint Surgery, 33A: 347–350. Leao L (1958). De Quervain’s disease: a clinical and anatomical study. Journal of Bone and Joint Surgery, 40A: 1063–1070. Leslie BM, Ericson Jr WB, Morehead JR (1990). Incidence of a septum within the first dorsal compartment of the wrist. Journal of Hand Surgery, 15A: 88–91. Loomis LK (1951). Variations of stenosing tenosynovitis at the radial styloid process. Journal of Bone and Joint Surgery, 33A: 340–346. McMahon M, Craig SM, Posner MA (1991). Tendon subluxation after de Quervain’s release: Treatment by brachioradialis tendon flap. Journal of Hand Surgery, 16A: 30–32. Strandell G (1957). Variations of the anatomy in stenosing tenosynovitis at the radial styloid process. Acta Chirurgie Scandinavia, 113: 234–240. White GM, Weiland AJ (1984). Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease. Journal of Hand Surgery, 9A: 704–706.
Received: 15 September 2000 Accepted after revision: 22 February 2001 Dr Douglas M. Freedman, 10666 N. Torrey Pines Rd, Mail Slot 116 La Jolla, California 92037, U.S.A. E-mail: [email protected] r 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0715, available online at http://www.idealibrary.com on