Thumb interphalangeal joint extension by the extensor pollicis brevis: association with a subcompartment and de Quervain's disease

Variations in the Extensor Pollicis Brevis-Extensor Pollicis Longus Tendon Complex

Despite several reports on the running of the extensor pollicis brevis (EPB) tendons, the classification of tendon insertions remains ununified due to differences in reports. This diversity in tendon patterning is attributed to the process of tendon development. In this study, we assessed the running of the EPB tendons of 44 cadaver hands fixed in ethanol/formalin in detail and examined the existing classification method. The specimens were obtained from 15 women and seven men, with an average age of 86 years. Consistent with previous reports, we observed a wide diversity in the running of the EPB tendons. Further, we found that EPB tendon insertions showed diverse variations in the proportion and running of fibers, making it difficult to classify them into independent patterns. It is speculated that the EPB tendon develops through a different process than that of the muscle body of the EPB and that the entire muscle-tendon module of the EPB is evolving. The diversity of the EPB tendons observed in this study may reflect the ongoing process of evolution. In clinical practice, a wide variation in the running of the EPB tendons should be considered.

Prediction of an intracompartmental septum and its effect on outcomes of endoscopic release for de Quervain's syndrome

LEVEL OF EVIDENCE

IV.

Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis

Importance

There is a plethora of treatment options for patients with de Quervain tenosynovitis (DQT), but there are limited data on their effectiveness and no definitive management guidelines.

Objective

To assess and compare the effectiveness associated with available treatment options for DQT to guide musculoskeletal practitioners and inform guidelines.

Data Sources

Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, and WorldCat.org were searched for published studies, and the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, The European Union Clinical Trials Register, and the ISRCTN registry were searched for unpublished and ongoing studies from inception to August 2022.

Study Selection

All randomized clinical trials assessing the effectiveness of any intervention for the management of DQT.

Data Extraction and Synthesis

This study was prospectively registered on PROSPERO and conducted and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions (PRISMA-NMA) and PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSIST) guidance. The Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations tool were used for risk of bias and certainty of evidence assessment for each outcome.

Main Outcomes and Measures

Pairwise and network meta-analyses were performed for patient-reported pain using a visual analogue scale (VAS) and for function using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale. Mean differences (MD) with their 95% CIs were calculated for the pairwise meta-analyses.

Results

A total of 30 studies with 1663 patients (mean [SD] age, 46 [7] years; 80% female) were included, of which 19 studies were included in quantitative analyses. From the pairwise meta-analyses, based on evidence of moderate certainty, adding thumb spica immobilization for 3 to 4 weeks to a corticosteroid injection (CSI) was associated with statistically but not clinically significant functional benefits in the short-term (MD, 10.5 [95% CI, 6.8-14.1] points) and mid-term (MD, 9.4 [95% CI, 7.0-11.9] points). In the network meta-analysis, interventions that included ultrasonography-guided CSI ranked at the top for pain. CSI with thumb spica immobilization had the highest probability of being the most effective intervention for short- and mid-term function.

Conclusions and Relevance

This network meta-analysis found that adding a short period of thumb spica immobilization to CSI was associated with statistically but not clinically significant short- and mid-term benefits. These findings suggest that administration of CSI followed by 3 to 4 weeks immobilization should be considered as a first-line treatment for patients with DQT.

Clinical Considerations of First Extensor Wrist Compartment (FEWC) Variants and De Quervain's Disease: A Review Study

The first extensor wrist compartment (FEWC) displays significant variants. This review highlights all possible variants that may be associated with the occurrence and pathophysiology of de Quervain's tenosynovitis. A thorough search of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted from 2002 to 2022 to evaluate all FEWC variants, including the following: 1) the presence of an inter-tendinous septum, 2) the number of tendinous slips of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles, 3) their distal insertions and 4) the presence of a bony ridge within the FEWC. A total of 3878 wrists (1277 cadaveric and 1296 de Quervain patients) were included. Of the 1234 cadavers, a total of 701 (56.8%) were males and 533 (43.2%) were females. Regarding the 883 patients, 178 (20.2%) of them were males and 705 (79.8%) were females. An inter-tendinous septum was identified in 42.9% (47% of the patients' wrists compared to 39.3% of the cadaveric wrists, p<0.0001). Cadaveric wrists presented two or more slips for the APL in a significantly higher percentage (92.5%, p < 0.0001) compared to de Quervain patients' wrists (74.5%). Regarding the EPB muscle, de Quervain patients' wrists had a single slip in 93% (p=0.0007) and two or more slips in 3.6%, compared to cadaveric wrists (a single slip in 87%, and two or more slips in 11%, p< 0.0001). A bony ridge over the radial styloid process was recorded in 58.9% of the cadaveric wrists compared to 17.8% of the patients' wrists (p < 0.0001). Remarkable diversity concerning the structures within the FEWC was reported. The presence of an inter-tendinous septum dividing the FEWC and a single EPB muscle slip is more likely to be found in patients with de Quervain's disease.

Percutaneous Release of the First Extensor Tendon Compartment in De Quervain's Disease by Acupotomy with US-Guidance: A Cadaveric Study

Background

De Quervain's disease is a painful stenosing tenosynovitis of the first dorsal compartment of the hand affecting the tendons of the abductor pollicis longus and extensor pollicis brevis. This study aimed to evaluate the safety and efficacy of percutaneous first extensor compartment releases performed on embalmed cadaveric models by acupotomy operation with or without US guidance.

Methods

Percutaneous release was performed with an acupotomy on 59 wrists of cadavers; 23 wrists were operated with US guidance, and 39 wrists were operated without US guidance. Each arm was dissected and assessed regarding the amount of release as well as the extent of neurovascular and tendon injury. Anatomical structures were also observed in this study.

Results

Twenty cases (87%) were successfully released with ultrasound-assisted techniques, and 27 cases (75%) were successfully released with blind techniques. No neurovascular injury occurred in any arm, regardless of technique. No significant tendon injury was seen in any arm. Although minor surface scratches were visualized in 11 cases, they occurred in 3 cases (13.04%) with ultrasound assistance and in 8 cases (22.22%) with blind techniques. There was no statistically significant difference between the two groups in the measurement of the distance from the incision marks to the blood vessels and nerves. A fibrous septum and bony protrusions were found in the first dorsal compartment, which may be anatomical factors affecting the success of treatment.

Conclusion

Both traditional and US-guided percutaneous release by acupotomy of the first extensor tendon compartment can be performed for all wrists. US-guided techniques can improve the success rate and reduce damage during acupotomy operations.

Utility of Ultrasonography and Significance of Surgical Anatomy in the Management of de Quervain Disease: A Systematic Review and Meta-Analysis

BACKGROUND

The role of ultrasound in plastic surgery practice has grown significantly over the past decade, with notable applications for conditions of the upper extremity. Its utility for the management of de Quervain disease, however, remains to be established, and the prevalence of first dorsal compartment anatomical variations needs to be adequately assessed.

METHODS

A systematic review was performed to evaluate the role of ultrasound in the diagnosis, anatomical characterization, and clinical management of de Quervain disease. A meta-analysis was conducted to establish the prevalence of first dorsal compartment anatomical variations in the de Quervain disease and general population, along with the diagnostic accuracy of ultrasound for their detection. Outcomes were documented and compared to alternative treatment options.

RESULTS

Extensor retinaculum thickening, tendon sheath swelling, peritendinous edema, and tendon enlargement were the most common sonographic features of de Quervain disease. The prevalence of an intercompartmental septum in the de Quervain disease surgical population was shown to be significantly greater than in the general cadaveric population (67 percent versus 35 percent, respectively). Although the efficacy of energy-based therapeutic ultrasound remains elusive, ultrasound-guided corticosteroid injections were shown to be more accurate than manual injections (90 to 100 percent versus 40 to 100 percent), and to confer significantly better treatment outcomes (73 to 100 percent versus 59 to 83 percent success rates, respectively).

CONCLUSIONS

Ultrasound use is essential to achieve the best evidence-based outcomes in the management of de Quervain disease. The varied prevalence of first dorsal compartment anatomical variations and high accuracy of ultrasound for their detection carry significant prognostic implications.

Can Ultrasonography Be Useful in Planning Surgery for De Quervain Tenosynovitis?: A Prospective Study With Emphasis on Detection of the Superficial Radial Nerve and Dominant Pathologic Tendon

OBJECTIVES

We performed preoperative ultrasonography (US) to detect the anatomic course of the superficial radial nerve (SRN) and dominant pathologic tendon of the first extensor compartment in de Quervain tenosynovitis.

METHODS

We prospectively studied 27 patients (29 wrists) with de Quervain tenosynovitis who underwent surgical release of the first extensor compartment. Preoperatively, US was performed to evaluate the presence of the dominant pathologic tendon and the septum in the subcompartment, number of SRNs in the area of the surgical incision, and anatomic running course of the SRN. These variables were also checked intraoperatively. Cohen κ statistics were calculated to investigate agreement between US and surgical field findings.

RESULTS

There were 7 men and 20 women (mean age, 47.8 years; range, 26-67 years). For the dominant pathologic tendon, there were 2 cases (6.9%) of an abductor pollicis longus, 11 cases (37.9%) of an extensor pollicis brevis, and 16 cases (55.2 %) of a nondominant tendon (κ = 0.94). For the subcompartment, there were 10 cases (34.5%) without a septum, 8 (27.6%) with an incomplete septum, and 11 (37.9%) with a complete septum (κ = 0.95). Most SRNs crossed over the first extensor compartment (κ = 0.78).

CONCLUSIONS

Preoperative US can be useful in detecting the anatomic running course of the SRN and dominant pathologic tendon before surgery for de Quervain tenosynovitis. Classifying the anatomic course of the SRN could be essential to planning surgery, and it could be helpful to prevent injury of the SRN during surgery.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm

BACKGROUND

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes.

METHODS

A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria.

RESULTS

A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports.

CONCLUSIONS

A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Prevalence of a Septated First Dorsal Compartment Among Patients With and Without De Quervain Tenosynovitis: An In Vivo Anatomical Study

Background: The reported prevalence of a subcompartment housing the extensor pollicis brevis (EPB) tendon within the first dorsal compartment varies widely in the literature, especially regarding the rates of occurrence between genders and among those with and without De Quervain. Based on direct intraoperative observation, we hypothesized that the prevalence of a septated compartment is far greater than previously reported, particularly in those with De Quervain disease. Methods: A prospective analysis of consecutive patients who underwent first dorsal compartment release was carried out. Patients were divided into 2 groups: those with De Quervain tenosynovitis ("De Quervain" group) and a control cohort without a primary diagnosis of De Quervain ("non-De Quervain" group). The intraoperative findings of a single compartment or a separate subcompartment were recorded. The prevalence of a septated compartment was calculated and compared between genders and both patient groups. Results: A total of 102 consecutive patients were included, with a female predominance (74.5%). Overall, 79.4% of patients had a separate subcompartment for the EPB. In the De Quervain cohort, 89.1% had 2 compartments, while 71.4% of non-De Quervain patients had a subcompartment. Men and women had a similar rate of double compartments (80% and 82.4%, respectively). Conclusions: The prevalence of a septated first dorsal compartment is considerably higher than previously reported, most notably in patients afflicted with De Quervain tenosynovitis. This higher rate of septation occurs with a similar prevalence in both men and women. Owing to its consistent presence, the dual first dorsal compartment should be regarded as an expectant anatomical component of the normal wrist.

Anatomical relationship between the sagittal band and extensor tendon of the thumb: a focus on variations of the extensor pollicis brevis tendon insertion

The sagittal band of the finger is an aponeurosis-like structure surrounding the metacarpophalangeal joint. Sagittal band rupture causes extensor tendon dislocation from the dorsal side of the metacarpophalangeal joint. The thumb has two extensor tendons: extensor pollicis longus and extensor pollicis brevis tendons. Multiple studies have reported variations of extensor pollicis brevis tendon insertion. However, it remains unclear how the thumb sagittal band envelopes the extensor pollicis longus and extensor pollicis brevis tendons. This study investigated the anatomical relationship between the sagittal band and the two extensor tendons of the thumb. One hundred hands (47 right, 53 left) from 54 cadavers were examined to assess the detailed structure of the thumb sagittal band and extensor pollicis longus and extensor pollicis brevis tendons. We found that the thumb sagittal band enveloped both the tendons either separately (type I) or collectively (type II). Thirty-four cases (34.0%) were type I and 66 cases (66.0%) were type II. The extensor pollicis longus and extensor pollicis brevis tendons enveloped in the type I thumb sagittal band were inserted on different sites, respectively, whereas those tendons enveloped in the type II thumb sagittal band were inserted on the same sites. This study demonstrated that differences in the type of thumb sagittal band are closely associated with variations in extensor pollicis brevis tendon insertion. We predicted that these differences contribute to the sliding distance between the extensor pollicis brevis and extensor pollicis longus tendons and affect the pathophysiology of extensor tendon dislocation.

A Prospective Evaluation of the Anatomy of the First Dorsal Compartment in Patients Requiring Surgery for De Quervain's Tenosynovitis

Background  We prospectively evaluated the surgical anatomy during first dorsal compartment release for De Quervain's tenosynovitis, with special attention to the superficial branch of the radial nerve (SBRN). Additionally, the incidence of tendon instability during surgery was assessed. Methods  This prospective cohort study consisted of 130 De Quervain's patients undergoing first dorsal compartment release. The treating surgeons recorded the type of incision used, the number of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon slips, the number of SBRN branches encountered, additional subcompartments created by any septations, and active/passive tendon stability. Results  A singular first dorsal compartment was found in 37% of cases, whereas 55% of patients had two subcompartments and 8% had three. Multiple APL tendon slips (range: 1-4) were identified in 78% of patients. In contrast, a single EPB tendon was found in 92% of patients (range: 0-2). At least one SBRN was encountered in 61% of cases. Following surgery, instability was evident in 9% of patients, who had tendons perch with passive wrist flexion. In one of these patients (<1%), the tendons dislocated volarly out of the first dorsal compartment during active flexion. Conclusions  The anatomical findings in our relatively large, prospective study of De Quervain's patients undergoing first dorsal compartment release are consistent with previous smaller and/or retrospective studies. Overall, we expect to encounter the SBRN during first dorsal compartment release in more than 50% of patients but are unconcerned if it is not visualized during a careful approach. Tendon instability has an incidence of 9%; however, dislocation is rare (<1%).

Histological assessment of a septum in the first dorsal compartment: a fresh cadaver study

Resistance of de Quervain's disease to conservative treatment has been associated with an intertendinous septum in the first compartment; little is known about the histological features of such a septum. This study aimed to examine the intertendinous septum histologically and note its variations. After dissecting the first extensor compartment of 24 hands from 12 fresh frozen cadavers, the presence of any intertendinous septa was determined. The length of the extensor retinaculum and intertendinous septum was measured; histological findings of the first compartment with or without septa were studied and compared with those of the third/fourth compartment. Intertendinous septa were observed in 12 of 24 wrists. Histological assessment of the intertendinous septum revealed tissue similar in composition to the retinaculum observed between the third and fourth compartments.

Evaluation of Extensor Pollicis Brevis as a Recipient of Tendon Transfer for Thumb Extension

Introduction  Rerouting of the extensor pollicis longus (EPL) is the standard part of tendon transfer surgery for thumb extension. It is done to overcome the ulnar vector of the EPL action. Extensor pollicis brevis (EPB), however, produces better thumb abduction and extension by virtue of its radial vector. The described anatomical variation of EPB extending the thumb interphalangeal joint (IPJ), therefore, gives the "best combination" of movements by a single-thumb extensor tendon. Materials and Methods  We performed this transfer in six patients in whom the EPB was found to be extending the IPJ while checked intraoperatively. Three of these six patients were cases of radial nerve palsy and the other three presented with brachial plexus palsy. The outcome was assessed by measuring palmar and radial abduction of the thumb, Kapandji's score, and Bincaz's scale. Results  We found satisfactory results in all the six patients. In our series, patients had an average radial extension of the thumb of 29.2 degrees and an average palmar abduction of the thumb of 65.7 degrees. On evaluation with the Bincaz score; one patient had excellent result, three patients had good results, and two patients had fair results. Conclusion  In situations where EPL rerouting is not possible (as in cases where the donor tendon needs to reach the thumb from the ulnar side, for example, flexor carpi ulnaris), transfer to the EPB, provided it is extending the thumb IPJ, would produce better extension and abduction of the thumb than the transfer to the EPL.

Variations of extensor pollicis brevis tendon in Indian population: A cadaveric study and review of literature

OBJECTIVES

Variations of the tendons of the first dorsal compartment of the wrist may be one of reasons of treatment failure and recurrence in De Quervain's tenosynovitis (DQT). The present cadaveric study was designed to look into the variations of the Extensor pollicis brevis (EPB) tendon in Indian population.

METHODS

Seventy-seven formaldehyde-fixed cadaveric upper limbs of Indian origins were dissected to observe the number of EPB tendons and its variations.

RESULTS

The EPB muscle was found to be absent in one hand (1.3%). The EPB muscle was found with single tendon, two tendons and three tendons in 73 limbs (94.8%), 2 limbs (2.6%) and one limb (1.3%) respectively. The muscle originated from the posterior surface of the radius and the adjacent interosseous membrane. The EPB muscle with single tendon was found to be inserted into the distal part of dorsal surface of the proximal phalanx of the thumb in 44 limbs (57.1%). In limbs with bitendinous EPB, the tendon slips were inserted into the base of proximal phalanx and into the base of distal phalanx of the thumb. An Osseo-fibrous septum separating EPB from Abductor Pollicis Longus (APL) was observed in 45 limbs (58%).

CONCLUSION

EPB in first extensor compartment of Indians is usually monotendinous. It mostly inserts into the distal part of dorsal surface of proximal phalanx of thumb and into the base of distal phalanx. In majority of the wrists, one may find an osseofibrous ridge separating EPB from APL. These anatomical variations may be helpful to guide proper treatment in de Quervain's tenosynovitis.

Clinical Examination of the Extensor Pollicis Brevis: Anatomical Study and Description of a Novel Clinical Sign

Background: The Extensor Pollicis Brevis (EPB) is an extrinsic thumb muscle whose main function is extension of the first metacarpophalangeal joint (MCPJ). It is subject to significant anatomical variation and may be absent, vestigial or have an anomalous distal attachment. Clinical examination of EPB is notoriously difficult and no reliable test has yet been described. We propose a novel test for the accurate examination of EPB. We sought to clarify the anatomical variations of EPB and to validate our clinical test using human cadaveric anatomical tests.

Methods: A structured literature review of all human cadaveric anatomical studies describing the attachments of EPB was performed using MEDLINE and Embase with the key words “Extensor Pollicis Brevis”. A cadaveric anatomical study was performed using 18 unembalmed upper limbs. Positive and negative tests were simulated by manipulating the tendons of EPB, Extensor Pollicis Longus (EPL) and Flexor Pollicis Longus (FPL). Changes in tendon tension and joint position were measured and recorded. The EPB anatomy was then determined by dissection.

Results: Anatomical variations were present in the majority of wrists, with only 35% of EPB tendons having a distal attachment to the proximal phalanx alone. EPB was absent in 5% of specimens. There was a significant difference between the change in MCPJ position between a positive (36 degrees; 95% CI 25 to 47 degrees) and negative (19 degrees; 95% CI 14 to 25 degrees) clinical test (p = 0.002).

Conclusions: The functional importance of EPB depends on its congenital architecture in addition to the functional demands of the patient. We report a novel clinical test which is effective in demonstrating the integrity of the EPB. A positive test result is observed when a change in MCPJ position that occurs while the interphalangeal joint is brought into flexion from full thumb extension is 25 degrees or more.

Tenosynovitis of the Hand and Wrist: A Critical Analysis Review

Trigger FingerTrigger finger is common in patients with diabetes.Corticosteroid injections are effective in about 60% to 92% of cases.Proximal interphalangeal joint contracture may occur in long-standing cases.The outcomes of open and percutaneous releases are similar; however, surgeons are split on preferences. Intersection SyndromeThe classic finding is crepitus with wrist motion at the distal one-third of the radial aspect of the forearm. Extensor Pollicis Longus (EPL) TenosynovitisCorticosteroid injections should be used with caution because of the potential for rupture.EPL tenosynovitis is very rare. de Quervain DisorderThis condition is common in postpartum women.A positive Finkelstein test is considered to be pathognomonic of de Quervain disorder, but care should be taken to differentiate this condition from thumb carpometacarpal arthritis.Corticosteroid injections are effective in about 80% of cases.Patients in whom corticosteroid injections fail to provide relief of symptoms frequently have a separate extensor pollicis brevis (EPB) compartment.The abductor pollicis longus (APL) tendon has multiple slips; care should be taken not to confuse one of these slips as the EPB.Traction on the APL pulls up the thumb metacarpal but not the thumb tip.Traction on the EPB extends the thumb metacarpophalangeal joint.Care should be taken to avoid injury to the sensory branch of the radial nerve. Fourth Compartment TenosynovitisThis uncommon condition is most often seen in patients with rheumatoid arthritis.The condition involves a large diffuse area, as opposed to the compact dorsal ganglion cyst.

Anatomical variations in the first extensor compartment: a cadaver study

BACKGROUND

Anatomical variations in the first extensor compartment are associated with the pathogenesis of de Quervain's disease. Here, we report two novel anatomical variations of the first extensor compartment.

METHODS

The wrists of two adult cadavers were dissected to reveal the anatomical variations in the first extensor compartment.

RESULTS

In one of the cadavers, no septum was present in the first extensor compartment. However, the extensor pollicis brevis tendon and its proximal muscle belly were absent. The abductor pollicis longus (APL) tendon had multiple slips, and one of them inserted on the dorsal base of the proximal thumb phalanx. In another cadaver, a septum was present in the first extensor compartment. One of the multiple APL tendon slips ran into the septum alongside the extensor pollicis brevis tendon for 4 mm, which then exited the septum and inserted into the base of the first phalanx together with the APL tendon.

CONCLUSION

Our findings may help to improve the awareness of the anatomical variations in the first extensor compartment.

Ultrasonography could be used to predict extended insertion of the EPB tendon noninvasively

INTRODUCTION

An abnormal distal insertion of the extensor pollicis brevis (EPB) tendon into the thumb interphalangeal joint (IP) has been observed in refractory cases of de Quervain's disease. This is associated with the extensor being wider at the midpoint of the proximal phalanx; however, there is no method to noninvasively measure this. This study evaluated the accuracy of measuring the extensor width using ultrasonography, to establish a noninvasive method for predicting an EPB extending the IP insertion.

MATERIALS AND METHODS

Of 23 arms from 12 fresh frozen cadavers, the extensor tendon width at the midpoint of the proximal phalanx was measured using ultrasonography and directly at dissection. The association between these values was evaluated using correlation analysis. A cut-off value of extensor tendon width was obtained using receiver operating characteristic analysis.

RESULTS

A strong correlation was observed between the ultrasonography and the measured values. The EPB tendons were normal in 13 arms (57%) and extended in 10 (43%), with a significant difference between these groups in the mean width of the extensor tendon (6.8 ± 1.1 vs. 8.4 ± 1.0 mm). A cut-off extensor tendon width of 8.0 mm yielded an EPB extending the IP.

CONCLUSION

An EPB extending the IP tendon can be predicted by measuring the extensor tendon width at the midpoint of the proximal phalanx using ultrasonography. The cut-off tendon width value of ≥ 8.0 mm may be useful for assessments prior to surgery and for conservative care.

Anatomical study of the first dorsal extensor compartment for the treatment of de Quervain's disease

INTRODUCTION

Anatomical variations of the first dorsal extensor compartment (1st EC) are commonly noted.

MATERIALS AND METHODS

Forty cadaver hands were dissected to define the 1st EC. Through the gross findings, we classified the contents according to the presence of septation, subcompartment, and variation of tendons. Bony cross-section of the wrist was performed to reveal any bony pattern within the 1st EC. We also measured the anatomical structures of the 1st EC.

RESULTS

A septum that results in subcompartments was present in 24, complete in 2 and incomplete in 22 hands distally. The mean size of the 1st EC was 20.69±12mm in length, and 8.65±0.67mm in width. The mean length of the septum was 11.18±5.18mm, while the mean width of the subcompartment was 3.18±0.40mm. All the subcompartments enclosed only extensor pollicis brevis (EPB) tendons. The mean number of abductor pollicis longus and EPB tendon slips was 2.6±0.5 and 1.1±0.2, respectively. The bony floor of the 1st EC was classified into five types. Two distinctive grooves separating two tendons with protruding osseous ridge (type I, n=9), two distinctive grooves separating two tendons without protruding osseous ridge (type II, n=10), a single distinct groove with osteophytes (type III, n=16), indistinct groove with fibrous septum separating two tendons (type IV, n=4), and indistinct groove without fibrous septum (type V, n=1).

CONCLUSION

Knowledge about the 1st EC abnormality is mandatory for the successful treatment of de Quervain's disease.

Analysing orthotic designs for de Quervain's disease based on in vivo gliding distance of extensor pollicis brevis tendon

Background/Aims:

To reconsider orthotic designs used for de Quervain's disease based on in vivo information obtained from ultrasound images.

Methods:

The hands (n=40) of 20 healthy adult men and women participants with no history of thumb injury or deformation were examined. A two-dimensional tissue tracking system was used to quantitatively measure in vivo gliding distance in the extensor pollicis brevis tendon during thumb interphalangeal joint autonomic movement while wearing a thumb spica orthosis.

Findings:

Results revealed anatomical variations in the insertion of the extensor pollicis brevis tendon in 9 (22.5%) hands. A septum was noted in the first dorsal compartment of the extensor tendon in 23 (57.5%) hands. Multiple comparison testing of gliding distance across four groups, classified by the presence or absence of anatomical variations and/or septa using Tukey's test, revealed significant differences for gliding distance between groups with and without anatomical variations, regardless of whether septa were observed (p=0.01).

Conclusions:

It is necessary to evaluate physical characteristics such as septa and anatomical variations based on advanced screening with ultrasound examinations before considering thumb fixation range for patients in the acute inflammation phase or those exhibiting recurrence of de Quervain's disease.

Snapping wrist due to multiple accessory tendon of first extensor compartment

BACKGROUND

Snapping phenomena result from the sudden impingement between anatomical and/or heterotopical structures with subsequent abrupt movement and noise. Snaps are variously perceived by patients, from mild discomfort to significant pain requiring surgical management. snapping syndrome occurs at various site like hip, knee, shoulder and wrist. There are many cadaveric studies shows accessory tendon in first extensor compartment of wrist.

CASE PRESENTATION

We present a 19 year old male presents catching sensation and occasional radial side wrist pain for 6 months. Finkelstein test was negative. Radiograph showed small bony projection over the radial styloid. MRI wrist was reported as normal but retrospective analysis of image shows multiple tendons. Intraopertively we found multiple accessory tendon of extensor pollicis brevis which is causing snapping. Fibrous tunnel release with tenotomy of few accessory tendons done. On table patients catching sensation was assessed and found to be relieved. Patient is not having snapping on his follow up visit and able to carry out his daily activity without difficulties.

CONCLUSION

There are various causes for snapping wrist syndrome. Multiple accessory tendon can also cause snapping as shown in this case report. Moreover am presenting this case to highlight the diagnostic failure with non dynamic radiological investigation and to consider multiple accessory tendon as differential diagnosis for snapping wrist syndrome. Also suggest dynamic study could be a better choice of investigation to diagnosis snapping syndrome. First compartment tunnel release with few accessory tendon slip tenotomy gives good result.

Anatomic study of the first extensor compartment and the relationship between the extensor tendon width and its distal insertion

INTRODUCTION

The extensor pollicis brevis (EPB) tendon normally inserts into the base of the proximal phalanx of the thumb. However, a distal insertion of the EPB tendon into the thumb interphalangeal joint has been reported in refractory cases of de Quervain's disease. We hypothesized that the EPB tendon is wider beyond the thumb metacarpophalangeal joint in patients with extended EPB. This study aimed to evaluate the relationship between the extensor tendon width and the point of distal insertion of the EPB tendon.

MATERIALS AND METHODS

In 45 hands from 18 male and 27 female adult cadavers, the first extensor compartment was dissected and the existence of the intertendinous septum was assessed. The extensor tendon width was measured at the midpoint of the proximal phalanx, and relationships between extended EPB tendon, existence rate of the intertendinous septum, sex, and extensor tendon width were examined.

RESULTS

Of 45 cases, intertendinous septum and extended EPB tendon were observed in 37 (82.2%) and 23 (51.1%), respectively. There was no significant difference between the existence rates of both these factors and sex. The mean extensor tendon width in the extended EPB group was significantly greater than in the normal EPB group. The cut-off value of extensor tendon width in the extended EPB group was 7.12 mm.

CONCLUSIONS

The extensor tendon width was wider in the extended EPB group than in the normal EPB group, suggesting that the differences in the EPB tendon width can be used to identify various anatomical variations in extended EPB.

Surgical anatomy of the first extensor compartment: A systematic review and comparison of normal cadavers vs. De Quervain syndrome patients

PURPOSE

De Quervain syndrome or tenosynovitis is a common wrist pathology caused by stenosing tenosynovitis of the first dorsal compartment. Multiple studies have demonstrated significant anatomic variation within the first extensor compartment.

METHODS

The terms "De Quervain's tenosynovitis" and "first extensor compartment anatomy" were comprehensively searched using the PubMed, MEDLINE, and Cochrane database. The presence of a septum within the first dorsal compartment, the number of APL (abductor pollicis longus), and EPB (extensor pollicis brevis) tendon slips were identified.

RESULTS

A total of 574 articles were identified on initial search, of which 21 met inclusion criteria. There were 1901 normal cadaver specimens and 470 surgically treated De Quervain disease patients, whose data were available. A septum was present in 43.7% of normal cadavers versus 62.2% De Quervain patients with 58.5% (327 of 559) of the septi characterized as incomplete. There was a difference in the number of APL tendons with a single APL tendon slip noted in 18.3% of normal cadavers (200/1096) versus 27.2% of De Quervain patients (87/230). There was a difference in the number of EPB tendons between the normal cadavers and De Quervain's wrists with 2 or more EPB tendinous slips observed in 5.9% of normal cadavers compared with 2.9% of De Quervain patients.

CONCLUSION

Significant anatomic variability exists within the first extensor compartment. Patients with De Quervain disease were more likely to have a septum dividing the compartment and a single slip of APL. These variations are clinically relevant in the pathophysiology and treatment of De Quervain's tenosynovitis.

TYPE OF STUDY

Prognostic studies.

LEVEL OF EVIDENCE

Level III.

Extensor pollicis brevis tendon can hyperextend thumb interphalangeal joint in absence of extensor pollicis longus: Case report and review of the literature

We are reporting a case of extensor pollicis longus tendon rupture which did not require tendon transfer owing to the ability of the intact extensor pollicis brevis (EPB) to fully hyperextend the thumb interphalangeal joint. The thumb metacarpophalangeal joint was also able to be fully actively extended by the EPB. Previous anatomical studies have demonstrated that the insertional anatomy of the EPB tendon is highly variable and sometimes inserts onto the extensor hood and distal phalanx, which is likely the mechanism by which our patient was able to fully extend the thumb interphalangeal joint. Despite the potential for the EPB to extend the IP joint of the thumb, virtually all previously reported cases of extensor pollicis longus (EPL) tendon rupture had deficits of thumb IP extension requiring tendon transfer. This case highlights the potential ability of the EPB tendon to completely substitute for the function of the EPL tendon in providing thumb IP joint extension.

Sex differences in the radial grooves in the first extensor compartment

OBJECTIVE

De Quervain tenosynovitis affects the first extensor compartment of the wrist and occurs more frequently in females. This high prevalence could not be explained by soft tissue. As the osseous anatomy has been mostly neglected, we aimed to compare the distal radius between the sexes.

MATERIALS AND METHODS

We evaluated the presence of a bony ridge on the floor of the first extensor compartment on CT images with multiplanar imaging.

RESULTS

We included 244 wrists (72 females, 172 males) in the study. A bony ridge was present in 58 (23.8 %) and absent in 186 (76.2 %) wrists. A ridge was present in 24 (33.3 %) wrists among females and 34 (19.8 %) wrists among males. A groove with a bony ridge was statistically associated with females.

CONCLUSION

We observed two tendon groove morphologies for the first extensor compartment. A groove with a bony ridge occurs more frequently in females. Further research is needed to clarify the relationship between the high frequency of a bony ridge and increased prevalence of de Quervain tenosynovitis in females.

Modified Extensor Pollicis Longus Rerouting Technique for Boutonniere Deformity of the Thumb in Rheumatoid Arthritis

PURPOSE

To assess the outcomes of a modified extensor pollicis longus (EPL) rerouting technique for boutonniere deformity of the thumb in patients with rheumatoid arthritis.

METHODS

A total of 21 thumbs in 18 patients with a mean age of 63 years were retrospectively analyzed after an average follow-up period of 3.2 years. The preoperative deformities were classified as either mild (5 thumbs) or moderate (16 thumbs). After either metacarpophalangeal (MCP) joint synovectomy or implant arthroplasty, the ulnarly dislocated EPL tendon was reduced dorsally and sutured to the dorsal base of the proximal phalanx. If the interphalangeal (IP) joint extended with manual traction on the proximal portion of the extensor pollicis brevis tendon, no further treatment was considered. If the IP joint did not extend with this maneuver, the insertion of the extensor pollicis brevis tendon was dissected and transferred to the distal portion of the EPL tendon.

RESULTS

The average MCP joint extensor lag improved from 62° (range, 32° to 85°) before surgery to 17° (range, active extension 12° to extensor lag 70°) at the final follow-up (P < .05), whereas average MCP joint flexion decreased from 83° (range, 52° to 95°) to 68° (range, 30° to 90°) (P < .05). Hyperextension at the IP joint was improved from 30° (range, 10° to 50°) before surgery to an average extensor lag of 2° (range, extensor lag 24° to hyperextension 20°) at the final follow-up. The average combined MCP and IP motion did not significantly change. The boutonniere deformity was improved in 18 of 21 thumbs. The 3 failures all had moderate-stage deformity prior to treatment.

CONCLUSIONS

A modified EPL rerouting technique provided satisfactory results together with a low risk of IP joint extension loss.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Presence of an intracompartmental septum detected by ultrasound is associated with the failure of ultrasound-guided steroid injection in de Quervain's syndrome

The purpose of this study was to find clinical or ultrasound characteristics that might predict the failure of conservative treatment in de Quervain's syndrome. A total of 42 ultrasound-guided injections have been performed in 41 patients after clinical and ultrasound examination. Patients were immobilized for 3 weeks with a spica splint cast, and clinically evaluated at 3 and 6 weeks and by phone call at the end of the study. Ultrasound showed a septum between the tendons of the first comportment in 34% of the wrists. At last follow-up (mean 15.6 months after the injection) ten patients (24%) had undergone surgery. When comparing ultrasound and clinical characteristics of the operated and non-operated wrists, we found that patients with a high baseline visual analogue scale, with all positive clinical tests and with a persistent intracompartmental septum, had a significantly higher risk of failure following conservative treatment.

LEVEL OF EVIDENCE

III.

The anatomy of the fibrous and osseous components of the first extensor compartment of the wrist: a cadaveric study

PURPOSE

De Quervain disease is the stenosing tenosynovitis of the first extensor compartment of the wrist. It is diagnosed with a history of pain at the radial aspect of the wrist and a positive Finkelstein test. Although anatomic variations, such as a septum within the compartment, are considered as risk factors, bony anatomy of distal radius and its correlation with the septa are studied scarcely in the literature.

METHODS

We dissected 50 wrists of 26 cadavers. Presence and location of a septum within the compartment was evaluated. We also observed the grooves at distal radius and their relation to the first extensor compartment and its content.

RESULTS

The septum was absent in 23 wrists (46%). A septum was present in 27 (54%) wrists (15 incomplete 30%, 12 complete 24%). At the distal radius, we classified three radial groove types as Type 1 on 28 (56%), Type 2 on 14 (28%), and as Type 3 on 8 (16%) wrists. There was a statistically significant relation between complete type of septa and Type 1 grooves (p = 0.002).

CONCLUSION

We investigated the bony structures of the compartment along with its content and we believe our results might guide clinicians who diagnose and treat de Quervain tenosynovitis.

Anatomy of the extensor pollicis brevis associated with an extension mechanism of the thumb metacarpophalangeal joint

This study aimed to determine whether the extensor pollicis longus (EPL) or abductor pollicis longus (APL) can replace the function of thumb extension in hands in which the extensor pollicis brevis (EPB) is absent. Cadaver dissection was performed to examine anatomical association between the interphalangeal (IP) joint and metacarpophalangeal (MP) joint of the thumb, as well as extension mechanism in clinical cases. EPB insertion could be classified into eight types, and the EPB was absent in 7.6% of all cases. In hands without an EPB, the width of the EPL tendon tended to be wider, and the number of APL tendons was significantly greater than in hands with an EPB. In hands without an EPB, the EPL and APL may replace the function of the EPB. As a result, a greater load is imposed on these two tendons than in hands with the EPB.

Sonography of pathological changes in the hand

Everyday medical practice shows that most common problems within the hand result from overload, injuries and degeneration. Dorsal side pathologies such as de Quervain's and Wartenberg's disease, intersection syndrome or degenerative lesions of carpometa-carpal joint of the thumb discussed in the paper can be accurately diagnosed and differentiated by means of ultrasound examination. Ultrasound is similarly powerful in detection and grading of traumatic lesions involving extensor tendons and their sagittal bands or the flexor tendons and their pulleys. In the case of carpal tunnel syndrome one can not only visualize the median nerve but also other structures of the tunnel that may cause compression. Similarly ulnar nerve compression within the Guyon's canal can be well evaluated. In cases of nerve trauma one can precisely define the level, and in cases of nerve discontinuity, the distance between stumps can be measured which is important in surgery planning. Often nerve trauma is a sequelae of tendon reconstruction. In such cases scars and nerve entrapment can be depicted. Tumors within a hand are usually benign, of which the most common are ganglia. On ultrasound examination a connection between a ganglion and its source (usually a joint or sheath) can frequently be defined. The relationship of tumors to nerves, tendon sheaths or vessels may suggest their nature. Ultrasound with dynamic tissue assessment is a very valuable adjunct to clinical examination.

The role of ultrasound-guided triamcinolone injection in the treatment of de Quervain's disease: treatment and a diagnostic tool?

The purpose of this study was to describe the technique and usefulness of ultrasound-guided intrasheath injection of triamcinolone in the treatment of de Quervain's disease (dQD). Our study was retrospective in design. Seventy-one wrists of 62 patients who were treated with an ultrasound-guided triamcinolone injection for dQD were included. A literature search was performed to compare our results. In the literature we found supportive evidence that accurate injection of triamcinolone in the first dorsal compartment of the wrist is important for a good outcome. In this retrospective study we found that treatment with ultrasound-guided injections of triamcinolone is both safe and effective. After two injections, 91% of the patients had good long-term results, which is a higher cure rate than found in most other studies. Furthermore, we found that Finkelstein's test can give a false positive result. Therefore, ultrasound should not only be considered to improve the treatment outcome, but can also be useful as a diagnostic tool in the management of de Quervain's disease.

Ultrasound-guided injections for de Quervain's tenosynovitis

BACKGROUND

Nonsurgical management of de Quervain's tenosynovitis often includes corticosteroid injections. If the injection does not enter the compartment, or all subcompartments, response to the injection is variable. To ensure proper location of injections we evaluated the role of ultrasound.

QUESTIONS/PURPOSES

We determined (1) the incidence of two or more subcompartments, (2) the incidence of anatomic variations during surgical release after failed injections, and (3) the relief of pain after ultrasound-guided injections.

PATIENTS AND METHODS

A prospective series of 40 consecutive patients (42 wrists) diagnosed with de Quervain's tenosynovitis by clinical examination were referred to a radiologist for an ultrasound-guided injection. The radiologist injected the first dorsal compartment and noted any septations. Patients returned for followup where outcomes, DASH, and VAS scores were calculated. The treating surgeon was blinded to any anatomic variations. Followup was at 6 weeks and a minimum of 6 months (mean, 6 weeks, range, 3-17 months; mean, 11 months, range, 7-18 months). Four patients were lost to followup.

RESULTS

Multiple subcompartments were noted in 22 of 42 (52%) wrists. At the 6-week followup, 36 of the 37 wrists examined in 36 patients (97%) had at least partial resolution of symptoms. Multiple subcompartments were identified in 52% of cases. At last followup, the mean DASH and VAS scores were 18.4 and 2.2, respectively. However 14% of wrists had recurrence of symptoms, all of which had subcompartments on ultrasound. No adverse effects from the injections were noted.

CONCLUSION

We found ultrasound-guided injections to be useful for treatment of de Quervain's tenosynovitis. Our success with ultrasound-guided injections was slightly better than that reported in the literature and without adverse reactions.

Accuracy of intrasheath injection techniques for de Quervain's disease: a cadaveric study

The purpose of this study was to assess the accuracy of injections of dye into the first extensor compartment of the wrist using three different techniques in 150 wrists in 75 fresh cadavers. To compare injections, 50 wrists from 25 cadavers were used for each technique. After the injections, the first extensor compartment was dissected and the dispersion of dye around the abductor pollicis longus and extensor pollicis brevis tendons was investigated. In 72 % of all the wrists, acrylic dye was dispersed into one compartment containing both the abductor pollicis longus and extensor pollicis brevis tendons, but in 28% of the wrists there was a separate compartment for extensor pollicis brevis and dye entered only one of the compartments (14% for each compartment). For accurate injections, we think the injections should be made separately over the two tendons, to allow for the possibility of a septum within the compartment.

Tendon disorders of the hand and wrist

The terminology used to describe most common tendon disorders in the hand and wrist suggests that they are inflammatory in nature, although current evidence indicates that mechanical and degenerative factors are more important. Corticosteroid injections provide relief in 60% or more of cases; however, the duration of their effectiveness remains uncertain. Surgical release of the stenotic pulley or sheath is curative in well over 90% of cases; complications of surgery are rare, and relief is long-lasting. Enlightened management of these common problems demands evidence-based guidelines defining indications for surgery that will maximize outcomes and minimize costs.