First Extensor Compartment Release for De Quervain's Tenosynovitis

CHAPTER 1

Hi, my name is Sudhir Rao, and I'm an orthopaedic surgeon. I will describe the surgical procedure for release of the first extensor compartment. This is commonly done for a condition known as De Quervain's tenosynovitis. The condition involves fibrous thickening of the first extensor compartment. The underlying cause could be variable. There are multiple causes, but the end result is the same. The sheath becomes thickened and fibrotic, and it actually pinches the underlying tendons of the abductor pollicis longus and extensor pollicis brevis. Patients have pain with wrist and thumb motion. And those that do not improve with non-operative treatment may choose to undergo surgical release. This case was done under local anesthesia again. I anesthetized the area with 1% lidocaine. After prep and drape, I inflated a forearm tourniquet. Most patients can tolerate this very easily for about 10 minutes, which is usually the duration of a simple procedure like this. I make a zigzag incision centered over the radial styloid. And in this situation you have to be careful with subdermal dissection because there are sensory nerve branches from the lateral cutaneous nerve of the forearm, and the radial sensory nerve that are directly in the line of your surgical incision. So as you can see in the surgical procedure I identified two sensory nerve branches, carefully dissected them out of the way, and then exposed the extensor retinaculum. We make an incision directly and expose the underlying tendons. There are two things that you commonly encounter. Number one is that the sheath is extremely thick and fibrotic, oftentimes thicker by three or four magnitudes. The second thing you often run into is a rush of synovial fluid that comes out from the sheath if there has been longstanding inflammation. Once we release the sheath proximally and distally, you want to make sure that the release is complete. You want to identify each of these tendons and draw them out into the wound. Sometimes there are multiple slips of the abductor pollicis longus. Sometimes there is an accessory compartment for the extensor pollicis brevis which was present in this situation. So you see me in the latter part of the procedure where I identified this subsheath, and then completely released the extensor pollicis longus tendon. And once this is released, we can identify all three tendons within this compartment. I also make the patient flex and extend the digit so we can demonstrate free excursion. Once I'm convinced that the release is complete, we achieve hemostasis with the bovie and repair the skin with a single layer of nylon. Patients are allowed unrestricted use right away. And usually within a few days most patients will experience complete symptomatic relief. I think the key step in this procedure is to identify the sensory nerves. Because if you accidentally traumatize them, you will typically end up with a painful neuroma. Which is very hard to treat. So I think prevention is far better than trying to fix something that could have been prevented right away. Otherwise, this seems to be a very simple surgical procedure with an excellent outcome.

CHAPTER 2

All right, we're gonna do a release of the first extensor compartment. Under local anesthesia. And I'll first start off by infiltrating some local anesthetic. Can we have the light on please? Thank you. So you're gonna feel a little poke. Right now. You okay? Yep. Good. Sorry. Yeah, that hurt. You okay now? That's the only one that hurt. All right. Are you warm enough? Yep. Okay. Good, thanks. So we try and infiltrate the local anesthetic all around the site of incision. But it's also important to infiltrate deep, close to the tendon sheath. Steve, I'm gonna have you hand this... Just the medication, to Eva. With the syringe. Yeah. 1% lidocaine. In case we need it. Very good. Should get nice and numb in five minutes. It's starting to. Yeah, and even during surgery, if you feel something let me know because I can always inject a little bit more, okay? Okay.

CHAPTER 3

So I'll have you hold your hand up like this. Just spread your fingers. We'll get it cleaned up and ready to go. All right, we're gonna lay your hand flat. I do need Bovie for this case. I've got a cold sticker I'm gonna put on your side, okay? Right here, okay? Okay. It's cold. Yep, it is.

CHAPTER 4

Okay that tourniquet's gonna get tight for about five minutes. Inflate please. Gonna get up at 250. Can you handle that for five minutes, Kay? Yeah. Okay, thank you. All right. So we'll lay your hand down. And just let it relax. I know it's kinda cold, right? Yeah, I'm okay. Hold that down.

CHAPTER 5

So we'll mark the incision directly over the radial styloid. If you feel any pain, just let me know. Yeah. I don't. Double hook.

CHAPTER 6

So sensory nerve branches are right underneath the skin. So we have to be really careful to identify them. Yeah, fine pickups. These are both the same. Yep. Hold that. So that looks like a branch of a sensory nerve. Probably the radial. So we want to make sure we don't get that in our dissection. Very tiny, very flimsy, but you can see that. So I spent some time making sure there are no nerve branches, and you can see that nerve branch even better now. Right there. There's nothing on the other side. There's another nerve branch right here. This is probably a branch of the lateral cutaneous nerve of the forearm. So if you don't identify these, you'll almost certainly end up traumatizing them. I need a small right now. So once we've done this preliminary dissection. You've freed everything up. And now we have a clear shot at the first extensor compartment.

CHAPTER 7

And so we're gonna make an incision right through it. You can see right off the bat it's thickened at least three times the normal size. So we're simply going to... You can see how tight that compartment was. And this is about three times as thick as it should be. If you come further down, you can see how it thins out. And that's the normal thickness. So that tightness pinches the tendons and causes a lot of pain when they move their thumb. So, now... I want to make sure that it's released completely.

CHAPTER 8

And now, there are usually three tendons. Sometimes two. This is the extensor pollicis brevis. And that is the abductor pollicis longus. It's actually split into two, but it's partly joint, so... We wanna make sure there are no extra compartments. Lying hidden. So I'm gonna have you retract those tendons. And we're gonna make sure. And as you see here... Okay, hold that. If you can see - right there. There is a separate compartment. Are you okay, Kay? Mmhm. We're almost done. And we're gonna release that as well. There you go. So tight. Yeah. There. If you don't look for it, you don't find it.

CHAPTER 9

Can you move your thumb for me? Up and down. Yep. There you go. Do I keep doing it or stop? You're doing fine. So that brings us back to our three tendons. There are almost always three, and we found our three tendons, one, two, and three. They're all free. We're just gonna, yeah, we're just gonna use the Bovie, get some bleeders, and get out of here. We're done. I'm just gonna sew up. All right, let's have some nylon. Let's move your thumb once again. Good. Make sure everything moves nice and easy. Nothing's getting pinched. All right, we'll be out of here in a couple minutes.

CHAPTER 10

Do you have dressings? I do. Just one. So you're gonna feel some pain from the incision. Once the anesthetic wears off. Okay. And most folks can get by with ibuprofen and Tylenol. Okay. And you can certainly put ice on it. Just alternate it? Yeah. And you can use your hand, just be gentle with it. Okay. And I'll see you back in about 10 days. Okay. In Big Rapids? Yeah. Okay. So do I call their office? Yeah, just call the office today or tomorrow. Okay. Okay, dressings. You can let the tourniquet down. Give me some more. Cast padding. ACE bandage. All finished.