Orthopaedic Surgery/DeQuervain's Tendinitis
Dequervain's tenosynovitis of the first dorsal extensor compartment is a common affliction in any hand practice. The predisposing anatomic variation of a separate compartment for the extensor brevis has been emphasized. There is frequently an instigating unaccustomed increase in activity described. Post partum incidence is especially noteworthy with the proposed reason being the manner in which a newborn is cradled in the palm with the thumb abducted to broaden the grasp.
Conservative modalities for treatment include NSAIDS, splints and corticosteroid injections alone or incombination. A recent literature review favors injection alone between these three having the best overall success rate of 83%. conservative treatment
Stenosing tenovaginitis captures the effect observed when decompressing the tendons of the first dorsal extensor compartment. A separate compartment for the extensor pollicus brevis is encountered in 80% of cases. Typically a release including the division or excision of the septum between the abductor longus and extensor brevis achieves the aim. Releasing along the dorsal margin of the compartment affords a shelf of supra-tendinous retinaculum which is sufficiently broad to prevent subluxation of the tendons. Care to retain the thinner portions of the retinaculum proximally and distally may also help in avoiding this complication. Respect for the branching radial sensory nerve avoiding forceful retraction, an assistant should only need finger tips to hold the retractors which if they are protecting the nerve should be repositioned periodically as an extra assurance against post operative dysesthesia. Bulky and inflammed tenosynovium is excised. Grossly dissociated tendon substance is debrided where it interferes with gliding. The ridge of bone between the EPB and AbPL is left undisturbed. Closure with 5-0 nylon, usually 4 sutures simple or horizontal mattress is sufficient. Infiltration of the subcutaneous layer with 0.25% marcaine helps with post operative analgesia. A soft dressing of xeroform 4 by 4 gauze sponges cast padding and a 2 inch ace wrap is sufficient. If there is concern for the possilibility of subluxation the retinaculum can be reconstructed with partial additional release enabling a width of retinaculum to be repaired over the tendons creating a capacious oblique pulley. Anchoring to the dermis creates undesirable dimpling. Splinting post operatively for a few weeks is an interum measure when simple release seems worrisome from the standpoint of potential subluxation or if a reconstruction of the retinaculum has been performed. Circumduction exercises with the thumb may mitigate against adhesion formation if immobilization is needed.