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Stenosing tenosynovitis of the extensor carpi ulnaris
Stenosing tenosynovitis of the extensor carpi ulnaris Stenosing tenosynovitis of the extensor carpi ulnaris, to our knowledge, has not been previously reported. This condition, although uncommon, should be considered in the differential diagnosis of pain over the dorsoulnar aspect of the wrist. We report three cases with good response to surgical decompression of the sixth dorsal compartment of the wrist. (J HAND SURG llA:51920, 1986.)
Ahmad A. Hajj, M.D., and Michael B. Wood, M.D., Rochester, Minn.
Stenosing tenosynovitis over the dorsum of the wrist is an entity of the first'· 2 and, very rarely, the second,3 third,4 fourth,s and fifth 6 . 7 compartments. To our knowledge, it has not been reported to occur in the sixth compartment. We describe three patients with stenosing tenosynovitis of the sixth compartment of the wrist, involving the extensor carpi ulnaris (ECU) tendon. The three patients seen at our institution during a 7-year period had prolonged histories of chronic pain and tenderness in the wrist, mainly over the dorsum of the distal ulna. One patient had a definite history of trauma, and another patient had a vague history. The symptoms were temporarily relieved by cast immobilization and steroid injections. All three patients had complete relief of their symptoms after surgical release of the sixth compartment. The pathologic findings at operation were consistent with stenosing tenosynovitis. Stenosing tenosynovitis of the sixth compartment should be considered in patients with chronic dorsoulnar wrist pain. Surgical release is the treatment of choice if conservative treatment fails. Case reports Case 1. A 31-year-old right-handed woman complained of thickening just distal to the dorsum of the ulna of the right wrist. The area was tender to pressure, and she had pain on gripping and twisting. There was no history of trauma. Examination revealed tenderness over the ECU tendon and the ulnar head, and the wrist was painful on ulnar deviation and
From the Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, Minn. Received for publication Sept. 9, 1985; accepted in revised form Nov. II, 1985. Reprint requests: M. B. Wood, M.D., Mayo Clinic, 200 First St. SW., Rochester, MN 55905.
Fig. 1. Case I. Operative decompression of the sixth dorsal compartment of the wrist. Note constriction of the ECU tendon.
resistive dorsiflexion. Injections of steroids and cast immobilization provided temporary relief to the patient. Repeated x-ray films of the wrist and trispiral tomograms showed no abnormalities. Surgical exploration showed that the ECU tendon was severely constricted at the sixth dorsal compartment, where a distal bulbous deformity was present (Fig. I). The fibro-osseous canal of the tendon was released on its radial aspect, and the overlying extensor retinaculum was tightly repaired. After the operation, the patient's wrist was immobilized for 3 weeks in a position of 20° extension in a short arm cast. After the procedure, the patient had complete relief of symptoms and normal wrist activity. She was asymptomatic at 18-month follow-up. Case 2. A 31-year-old right-handed woman had a long history of chronic pain over the dorsoulnar aspect of the left wrist when engaging in activities. There was no history of trauma. Examination showed localized tenderness over the
THE JOURNAL OF HAND SURGERY
519
520
The Journal of HAND SURGERY
Hajj and Wood
Extensor retinaculum /
~j- -Triquetrum r---s=-
.I
--Pisiform
Surgical reconstruction Fig. 2. Diagram showing operative technique of release of the sixth dorsal compartment. Note release of the radial septum of the sixth dorsal compartment and repair of the extensor retinaculum over the dorsum of the tendon course. distal ulna, with pain at the extremes of pronation and supination. X-ray films, wrist scans, and arthrograms were normal. Injections of steroids and cast immobilization provided transient relief of the pain. At surgical exploration, the fibroosseous canal of the ECU tendon was particularly thickened over the distal ulna, and tenosynovitis was present within the tendon sheath. Treatment was identical to that in the first case. The patient had complete relief of her symptoms and had resumed normal activities 14 months postoperatively. Case 3. A 23-year-old right-handed man fell down a flight of stairs, landing on his right hand. He had persistent pain and tenderness over the ulnar aspect of the wrist. The pain was temporarily relieved by injections of steroids and cast immobilization. On examination, he had tenderness over the ECU tendon and pain elicited by wrist flexion and radial deviation. X-ray films showed a fracture of the ulnar styloid, which was related to old trauma. Operative and postoperative management was identical to that in cases I and 2. After the operation, the patient had complete relief of symptoms and returned to normal activities.
Comment Spinner and Kaplan 8 have described the anatomy of the sixth dorsal compartment of the wrist and reported
the presence of a well-developed, separate fibro-osseous canal for the tendon. This anatomic arrangement is distinct from that in the second through the fifth compartments but is similar to that in the first compartment of the wrist, where it is well known that stenosing tenosynovitis can occur. (Presumably, this similarity of structure may account for the similarity of pathologic changes in these two compartments.) In either case, simple release of the thickened tight fibro-osseous canal of the tendon should be curative. Care must be taken however, to avoid destabilization of the ulnar restrainin~ portion of the tendon sheath on release to prevent subluxation of the tendon. 9 We have found that release of the canal of the ECU tendon over the extreme radial aspect with careful tight repair of the extensor retinaculum has been curative, without the development of tendon subluxation (Fig. 2). REFERENCES 1. Finkelstein H: Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 12:509-40, 1930 2. Burman M: Stenosing tendovaginitis of the dorsal and volar compartments of the wrist. Arch Surg 65:752-62, 1952 3. Lapidus PW, Fenton R: Stenosing tenovaginitis at the wrist and fingers: Report of 423 cases in 369 patients with 354 operations. Arch Surg 64:475-87, 1952 4. Mogensen BA, Mattsson HS: Stenosing tendovaginitis of the third compartment of the hand: Case report. Scand J Plast Reconstr Surg 14:127-8, 1980 5. Spinner M, Olshansky K: The extensor indicis proprius syndrome: A clinical test. Plast Reconstr Surg 51: 134-8, 1973 6. Drury BJ: Traumatic tendovaginitis of the fifth dorsal compartment of the wrist. Arch Surg 80:554-6, 1960 7. Hooper G, McMaster MJ: Stenosing tenovaginitis affecting the tendon of extensor digiti minimi at the wrist. Hand II :299-30 I, 1979 8. Spinner M, Kaplan EB: Extensor carpi ulnaris: Its relationship to the stability of the distal radio-ulnar joint. Clin Orthop 68: 124-9, 1970 9. Burkhart SS, Wood MB, Linscheid RL: Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. J HAND SURG 7:1-3, 1982
Ahmad A. Hajj, M.D., and Michael B. Wood, M.D., Rochester, Minn.
Stenosing tenosynovitis over the dorsum of the wrist is an entity of the first'· 2 and, very rarely, the second,3 third,4 fourth,s and fifth 6 . 7 compartments. To our knowledge, it has not been reported to occur in the sixth compartment. We describe three patients with stenosing tenosynovitis of the sixth compartment of the wrist, involving the extensor carpi ulnaris (ECU) tendon. The three patients seen at our institution during a 7-year period had prolonged histories of chronic pain and tenderness in the wrist, mainly over the dorsum of the distal ulna. One patient had a definite history of trauma, and another patient had a vague history. The symptoms were temporarily relieved by cast immobilization and steroid injections. All three patients had complete relief of their symptoms after surgical release of the sixth compartment. The pathologic findings at operation were consistent with stenosing tenosynovitis. Stenosing tenosynovitis of the sixth compartment should be considered in patients with chronic dorsoulnar wrist pain. Surgical release is the treatment of choice if conservative treatment fails. Case reports Case 1. A 31-year-old right-handed woman complained of thickening just distal to the dorsum of the ulna of the right wrist. The area was tender to pressure, and she had pain on gripping and twisting. There was no history of trauma. Examination revealed tenderness over the ECU tendon and the ulnar head, and the wrist was painful on ulnar deviation and
From the Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, Minn. Received for publication Sept. 9, 1985; accepted in revised form Nov. II, 1985. Reprint requests: M. B. Wood, M.D., Mayo Clinic, 200 First St. SW., Rochester, MN 55905.
Fig. 1. Case I. Operative decompression of the sixth dorsal compartment of the wrist. Note constriction of the ECU tendon.
resistive dorsiflexion. Injections of steroids and cast immobilization provided temporary relief to the patient. Repeated x-ray films of the wrist and trispiral tomograms showed no abnormalities. Surgical exploration showed that the ECU tendon was severely constricted at the sixth dorsal compartment, where a distal bulbous deformity was present (Fig. I). The fibro-osseous canal of the tendon was released on its radial aspect, and the overlying extensor retinaculum was tightly repaired. After the operation, the patient's wrist was immobilized for 3 weeks in a position of 20° extension in a short arm cast. After the procedure, the patient had complete relief of symptoms and normal wrist activity. She was asymptomatic at 18-month follow-up. Case 2. A 31-year-old right-handed woman had a long history of chronic pain over the dorsoulnar aspect of the left wrist when engaging in activities. There was no history of trauma. Examination showed localized tenderness over the
THE JOURNAL OF HAND SURGERY
519
520
The Journal of HAND SURGERY
Hajj and Wood
Extensor retinaculum /
~j- -Triquetrum r---s=-
.I
--Pisiform
Surgical reconstruction Fig. 2. Diagram showing operative technique of release of the sixth dorsal compartment. Note release of the radial septum of the sixth dorsal compartment and repair of the extensor retinaculum over the dorsum of the tendon course. distal ulna, with pain at the extremes of pronation and supination. X-ray films, wrist scans, and arthrograms were normal. Injections of steroids and cast immobilization provided transient relief of the pain. At surgical exploration, the fibroosseous canal of the ECU tendon was particularly thickened over the distal ulna, and tenosynovitis was present within the tendon sheath. Treatment was identical to that in the first case. The patient had complete relief of her symptoms and had resumed normal activities 14 months postoperatively. Case 3. A 23-year-old right-handed man fell down a flight of stairs, landing on his right hand. He had persistent pain and tenderness over the ulnar aspect of the wrist. The pain was temporarily relieved by injections of steroids and cast immobilization. On examination, he had tenderness over the ECU tendon and pain elicited by wrist flexion and radial deviation. X-ray films showed a fracture of the ulnar styloid, which was related to old trauma. Operative and postoperative management was identical to that in cases I and 2. After the operation, the patient had complete relief of symptoms and returned to normal activities.
Comment Spinner and Kaplan 8 have described the anatomy of the sixth dorsal compartment of the wrist and reported
the presence of a well-developed, separate fibro-osseous canal for the tendon. This anatomic arrangement is distinct from that in the second through the fifth compartments but is similar to that in the first compartment of the wrist, where it is well known that stenosing tenosynovitis can occur. (Presumably, this similarity of structure may account for the similarity of pathologic changes in these two compartments.) In either case, simple release of the thickened tight fibro-osseous canal of the tendon should be curative. Care must be taken however, to avoid destabilization of the ulnar restrainin~ portion of the tendon sheath on release to prevent subluxation of the tendon. 9 We have found that release of the canal of the ECU tendon over the extreme radial aspect with careful tight repair of the extensor retinaculum has been curative, without the development of tendon subluxation (Fig. 2). REFERENCES 1. Finkelstein H: Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 12:509-40, 1930 2. Burman M: Stenosing tendovaginitis of the dorsal and volar compartments of the wrist. Arch Surg 65:752-62, 1952 3. Lapidus PW, Fenton R: Stenosing tenovaginitis at the wrist and fingers: Report of 423 cases in 369 patients with 354 operations. Arch Surg 64:475-87, 1952 4. Mogensen BA, Mattsson HS: Stenosing tendovaginitis of the third compartment of the hand: Case report. Scand J Plast Reconstr Surg 14:127-8, 1980 5. Spinner M, Olshansky K: The extensor indicis proprius syndrome: A clinical test. Plast Reconstr Surg 51: 134-8, 1973 6. Drury BJ: Traumatic tendovaginitis of the fifth dorsal compartment of the wrist. Arch Surg 80:554-6, 1960 7. Hooper G, McMaster MJ: Stenosing tenovaginitis affecting the tendon of extensor digiti minimi at the wrist. Hand II :299-30 I, 1979 8. Spinner M, Kaplan EB: Extensor carpi ulnaris: Its relationship to the stability of the distal radio-ulnar joint. Clin Orthop 68: 124-9, 1970 9. Burkhart SS, Wood MB, Linscheid RL: Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. J HAND SURG 7:1-3, 1982