First Dorsal Compartment

Fibro Osseous Tunnel

Figure 30—4. The tendons of the abductorpollicis longus (APL) and the extensor pollicis brevis (EPB) pass through a fibro-osseous tunnel formed by a groove in the radial styloid and overlying extensor reti-naculum.

(Fig. 30—4). The tendons deviate as they pass through the tunnel, and the angle increases with ulnar deviation of the wrist. Anatomic studies of the fibro-osseous canal have documented that in 94% of specimens the abductor pollicis tendon has two to four slips. Multiple EPB tendons are found in only 2%. Multiple sub-compartments were recorded in 47% of patients and 75% of specimens. Multiple APL tendon slips and two subcompartments are the rule rather than the exception in normal anatomy.

Despite the fact that many anatomy texts still suggest that the tendons of the EPB and APL are contained in a single compartment under the extensor retinaculum, several anatomic and surgical studies have convincingly demonstrated this to be true in less than 25% of operative cases. Accordingly, one should be certain to identify the EPB and APL tendons at the time of operation.

Nonoperative Management

Negative radiographs and clinical examination determine conservative treatment, starting with a custom thumb spica splint (Fig. 30-5). In addition, antiinflammatory medications and a corticosteroid injection (Fig. 30-6) into the first dorsal compartment are important adjuvants. These are most successful within the first 6 weeks after injury. Some authors have reported a high rate of success with injections,

1st Dorsal Compartment ReleaseFirst Dorsal Compartment Syndrome

Figure 30—6. Corticosteroid injection into the first dorsal compartment.

Figure 30—5. Conservative treatment starting with a custom thumb spica splint.

Figure 30—6. Corticosteroid injection into the first dorsal compartment.

Compartment SyndromeIncision Quervain

Figure 30—7. Cadaveric demonstration of the transverse incision for Figure 30—8. Cadaveric demonstration of the superficial radial de Quervains tenosynovitis (ICM proximal to the radial styloid). nerve in relation to the first dorsal extensor compartment.

although a series of two injections may be necessary. Harvey et al reported that with an injection of steroids and local anesthetic into the tendon sheath, relief was seen in 80% of cases. However, when pain persists, surgical intervention is recommended.

Surgical Management

The first dorsal compartment is exposed through a skin incision that runs from dorsal to volar in a transverse to oblique direction, parallel with the skin crease over the area of tenderness (Fig. 30—7). Dissection is continued through the dermis, avoiding branches of the superficial radial nerve (Fig. 30-8). A longitudinal incision is made through the entire length of the dorsal carpal ligament, exposing the tendons in the first dorsal compartment. With the thumb abducted and the wrist flexed, the APL and the EPB tendons are carefully lifted from the compartment (Fig. 30-9). Be sure that there is not an additional tendon in a separate sheath. In this case, the short extensor tendon of the thumb did not lie together with the long abductor tendon, but in a separate compartment. This compartment was opened and the fibrous partition between the two compartments was excised.

One of the functions of the fibrous retinaculum covering the first extensor compartment is to prevent anterior displacement of the APL and EPB tendons during

First Dorsal Compartment Syndrome
Figure 30—9. Complete release (proximal and distal) of the tendons during testing with blunt resection.

palmar flexion of the wrist. This function should be preserved by dividing the retinaculum near its dorsal line of attachment with the radius, thus preserving the ligament as a sling. Frequently, the APL and EPB may be located within separate spaces formed by an intracompartmental septum in the first compartment. Both tendons may also be duplicated; therefore, the first compartment may contain three or even four tendons in some individuals. Thus, it is important at the time of release to be sure that any intracompartmental septum has been divided. The surgeon should not assume that a complete release has been obtained when two tendons have been exposed.

The skin is closed and a small pressure dressing is applied. The dressing is removed after 48 hours and a patch dressing is applied. Motion of the thumb and hand is encouraged and increased as tolerated.

Complications

To avoid complications, careful attention to surgical technique at the initial release is essential. A common complication due to surgical technique is superficial radial nerve injury. Other complications include tendinous adhesions, which can cause neuritis and limit hand and wrist function, and volar tendon subluxation. Persistence of symptoms is also possible. If repeat cortisone injections fail to relieve symptoms, surgical reexploration may be necessary.

Suggested Readings

Arons MS. De Quervain's release in working women: a report of failures, complications, and associated diagnoses. J Hand Surg [Am] 1987;12A:540-544.

Chow SP. Triggering due to de Quervain's disease. Hand 1979;11:93-94.

Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg [Am] 1930;12A:509-540.

Harvey FJ, Harvey PM, Horsley MW. De Quervain's disease: surgical or nonsurgical treatment. J Hand Surg [Am] 1990;15A:83-87.

Jackson WT, Viegas SF, Coon TM. Anatomical variations in the first extensor compartment of the wrist. A clinical and anatomical study. J Bone Joint Surg [Am] 1986; 68A:923-926.

McMahon M, Craig SM, Posner MA. Tendon subluxation after de Quervain's release: treatment by brachioradialis tendon flap. J Hand Surg [Am] 1991;16A:30-32.

Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. J Hand Surg [Am] 1994;19A:595-598.

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