Optimal surgical approach for the treatment of Quervains disease: A surgical-anatomical study

Anatomic location of the first dorsal extensor compartment for surgical De-Quervain's tenosynovitis release: A cadaveric study

BACKGROUND

De-Quervain's tenosynovitis is a disorder arising from the compression and irritation of the first dorsal extensor compartment of the wrist. Patients who fail conservative treatment modalities are candidates for surgical release. However, risks with surgery include damage to the superficial radial nerve and an incomplete release due to inadequate dissection. Currently, there is a paucity of literature demonstrating the exact anatomic location of the first dorsal extensor compartment in reference to surface anatomy. Thus, this cadaveric study was performed to determine the exact location of the first extensor compartment and to devise a reliable surgical incision to prevent complications.

AIM

To describe the location of the first dorsal compartment in relation to bony surface landmarks to create replicable surgical incisions.

METHODS

Six cadaveric forearms, including four left and two right forearm specimens were dissected. Dissections were performed by a single fellowship trained upper extremity orthopaedic surgeon. Distance of the first dorsal compartment from landmarks such as Lister's tubercle, the wrist crease, and the radial styloid were calculated. Other variables studied included the presence of the superficial radial nerve overlying the first dorsal compartment, additional compartment sub-sheaths, number of abductor pollicis longus (APL) tendon slips, and the presence of a pseudo-retinaculum.

RESULTS

Distance from the radial most aspect of the wrist crease to the extensor retinaculum was 5.14 mm ± 0.80 mm. The distance from Lister's tubercle to the distal aspect of the extensor retinaculum was 13.37 mm ± 2.94 mm. Lister's tubercle to the start of the first dorsal compartment was 18.43 mm ± 2.01 mm. The radial styloid to the initial aspect of the extensor retinaculum measured 2.98 mm ± 0.99 mm. The retinaculum length longitudinally on average was 26.82 mm ± 3.34 mm. Four cadaveric forearms had separate extensor pollicis brevis compartments. The average number of APL tendon slips was three. A pseudo-retinaculum was present in four cadavers. Two cadavers had a superficial radial nerve that crossed over the first dorsal compartment and retinaculum proximally (7.03 mm and 13.36 mm).

CONCLUSION

An incision that measures 3 mm proximal from the radial styloid, 2 cm radial from Lister's tubercle, and 5 mm proximal from the radial wrist crease will safely place surgeons at the first dorsal compartment.

Cutaneous nerve distribution around first extensor compartment of the wrist: Clinical implications for ultrasound-guided injections

Purpose

To evaluate the course of the cutaneous nerve regarding the first extensor compartment to determine whether the dorsal or volar approach is safer for local injection into the first extensor compartment guided by ultrasound.

Methods

We dissected the radial side of the wrists from 28 cadavers (52 wrists). Four-points along the imaginary line were set: the styloid process and 1 cm, 2 cm, and 3 cm proximal to the styloid process. The numbers of superficial radial nerve (SRN) and lateral antebrachial cutaneous nerve (LACN) branches were counted, and distances from the imaginary line at these points and nerve diameters were recorded. Digital images were superimposed to observe overall distribution of cutaneous nerve.

Results

There were means of 3.3 SRN and 0.9 LACN branches observed in each wrist. The mean number of both SRN and LACN branches was 2.3 on the dorsal side and 1.9 on the volar side. The superimposed images indicated that both the dorsal and volar sides comprised abundant cutaneous nerves and that their paths varied markedly between patients. However, we observed that larger nerves with meaningful diameters were more abundant on the dorsal than the volar side.

Conclusion

There were similar numbers of cutaneous nerves on both the dorsal and volar sides; however, we observed greater abundance of thicker cutaneous nerves on the dorsal side, and these were closer to the reference line than on the volar side. This anatomical study suggests that the risk imposed to cutaneous nerves would therefore be reduced when injection on the volar side.

Isometric thumb extension exercise as part of a multimodal intervention for de Quervain's syndrome: A randomised feasibility trial

Introduction

de Quervain's syndrome is a painful condition commonly presented to hand therapists. Exercise is utilised as an intervention, but isometric exercise has not been investigated. We aimed to assess the feasibility and safety of isometric thumb extension exercise for de Quervain's syndrome and to explore differences between high-load and low-load isometric exercise.

Methods

This parallel-group randomised clinical feasibility trial included individuals with de Quervain's syndrome. All participants underwent a 2 week washout period where they received an orthosis, education, and range of motion exercises. Eligible participants were then randomised to receive high or low-load isometric thumb extension exercises, performed daily for 4 weeks. Feasibility and safety were assessed by recruitment and drop-out rates, adherence, adverse events, and participant feedback via semi-structured interviews. Secondary outcomes included patient-reported outcomes for pain and function, and blinded assessment of range of motion and strength.

Results

Twenty-eight participants were randomised. There were no drop-outs after randomisation, and no serious adverse events. Adherence to exercise was 86.7%, with 84% of participants stating they would choose to participate again. There were clinically and statistically significant improvements in pain and function over time (p < 0.001) but not in range of motion or strength. There were no statistically significant between-group differences.

Conclusions

Isometric thumb extension exercise within a multimodal approach appears a safe and feasible intervention for people with de Quervain's syndrome. A large multi-centre trial would be required to compare high- and low-load isometric exercises. Further research investigating exercise and multimodal interventions in this population is warranted.

Effectiveness of surgical interventions for treating de Quervain's disease: A systematic review and meta-analysis

Introduction

This systematic review of randomized controlled trials was undertaken to assess whether any of the various currently used surgical interventions have better functional outcomes and less impairment or fewer surgical complications compared to the other common surgical interventions in de Quervain's disease.

Material and methods

Relevant studies related to surgical interventions in de Quervain's disease based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were identified from PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials comparing surgical interventions in de Quervain's disease published from January 2000 to December 2020. Functional outcome and impairment were the primary outcomes assessed.

Results

Three trials met the eligibility criteria which were following randomized controlled trial or quasi-experimental trial enrolling adults ≥18 years of age diagnosed with de Quervain's disease, comparing clinical outcomes between different surgical interventions, and including functional outcomes, impairment, pain and complications data. The Cochrane Risk of Bias Assessment Tool and GRADE approach were used to ascertain methodological quality. Statistical heterogeneity was tested with I-square and chi-square tests. The longitudinal skin incision probably slightly reduced superficial radial nerve injury, vein injury, scar hypertrophy, and total complications compared with the transverse skin incision with relative risk: 0.14, very low certainty by GRADE; 0.10, very low certainty by GRADE; 0.57, very low certainty by GRADE; and 0.23, very low certainty by GRADE, respectively.

Conclusion

Concerning the analysis of functional and pain scores, no significant results were able to be concluded. This study's findings must be considered in the light of quality and sample size limitations, and further high quality prospective randomized controlled clinical trials are needed to draw more firm conclusions.

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There has a various surgical treatment for radial styloid tenosynovitis. If the surgeon known the update evidence in each method will help them to deal with patient diagnosed radial styloid tenosynovitis.

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The current systematic and meta-analysis review depicted the evidence surgical options in terms of effectiveness and complications.

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This study's findings must be considered in the light of quality and sample size limitations, and further high quality prospective randomized controlled clinical trials are needed to draw more firm conclusions.

Management of de Quervain Tenosynovitis: A Critical Analysis Review

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Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments.

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For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby.

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When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision.

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For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury.

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Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.

Volar Approach to the First Extensor Compartment for Surgical Treatment of DeQuervain Tenosynovitis

Many surgical techniques have been published in regards to the operative management of DeQuervain tenosynovitis. As it has been classically described, stenosing tenosynovitis of the first extensor tendon compartment is a common tendinopathy along the radial side of the wrist causing pain and swelling in the affected area. When surgery is necessary, decompression of the abductor pollicis longus and extensor pollicis brevis tendons decreases first extensor compartment friction and has been shown to successfully alleviate symptoms. A number of varying techniques have been reported in the literature to achieve adequate decompression and minimize postoperative complications such as sensory nerve injury, incomplete decompression, and tendon subluxation. We describe a novel volar approach to the first extensor compartment, which allows direct visualization of the retinaculum and a midline retinacular release. In addition, the volar approach has an associated decreased risk of iatrogenic nerve injury by passing volar and deep to the more superficial sensory nerves that overly the retinaculum. On the basis of our experience, patients do not experience an increased risk of volar tendon subluxation with this approach.

Safe approach for fixation of first metacarpal fractures: an anatomical study

This anatomical study defines a safe zone for percutaneous or minimally invasive fixation of first metacarpal fractures in order to avoid injury of the superficial branch of the radial nerve and the dorsal branch of the radial artery. The courses of the nerve and artery branches were marked in 20 embalmed cadaver specimens. With computer-assisted surgical anatomy mapping, a large diversity in the anatomical patterns for the nerve and a consistent pattern for the artery were found. Based on these findings, we conclude that transfixation of the first and the second metacarpals with K-wires placed in the distal 75% of both the first and second metacarpals is the safest way to avoid damages to the nerve and artery branches during fracture fixation.

One portal endoscopic release of the first extensor compartment in de Quervain's disease

Objectives

We aimed to present preliminary result of one portal endoscopic assisted release of first dorsal compartment at wrist in a case series with de Quervain disease as a minimal invasive surgical method.

Materials and methods

The patients, who underwent an endoscopic-assisted release of the first extensor compartment for de Quervain's disease by same hand surgeon between 2015 and 2017, were retrospectively analyzed. Operative treatment was considered if the patients did not respond to non-operative treatment including oral anti-inflammatory medications, splinting, and steroid injection. Surgical release was recommended after minimum four months of unsuccesful non-operative treatment, including a steroid injection. 10 wrists were treated with one portal endoscopic assisted release. All patients were evaluated at an average of 16.1 months follow-up using visual analog scale (VAS) pain ratings and the Disabilities of Arm, Shoulder and Hand (DASH) score.

Results

The mean operating time was 13.9 min (range, 10–21min). The mean VAS and DASH scores were improved from 8.2 to 1.9 and 70.51 to 2.81 respectively. No significant difference was found between operated and non-operated arms in postoperative pinch and strengths. Transient superficial radial nerve paresthesia (two wrists) and significant scar tenderness (one) were identified in three cases. There was no patient that complain of unsightly scar and tendon subluxation.

Conclusions

One portal endoscopic assisted release of the extensor compartment is an effective and safe minimal invasive procedure with similar complication rates reported previously in open and endoscopic procedures in patients with de Quervain's disease who are unresponsive to non-operative treatments.

Level of Evidence

Level IV Therapeutic Study