import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 2-5 branches cross subcutaneous tissue at various angles, often directly over first compartment. Dorsal sensory branches to thumb and radial hand. **Protection**: Use loupe magnification (2.5-3.5x), careful spreading dissection, identify ALL branches before compartment release, place vessel loops for gentle retraction, transverse incision parallel to nerves, avoid cautery near nerves. **Location**: Lies deep and volar to first compartment, passes beneath APL tendons in anatomical snuffbox. Approximately 5-8mm volar to compartment floor. **Protection**: Stay dorsal during dissection, release only dorsal/radial half of retinaculum (preserve volar floor), avoid deep dissection into snuffbox, recognize pulsatile bleeding immediately if encountered. **Location**: In 20-30% of cases, fibrous septum creates separate dorsal/ulnar sub-compartment for EPB, distinct from volar/radial APL compartment. **Protection**: After main release, actively inspect for white fibrous septum between APL and EPB, if present release septum completely, verify EPB gliding independently, test excursion of EPB specifically. **Location**: 50-80% have 2-4 APL slips within first compartment, can be hidden beneath main slip or in separate fascial planes. **Protection**: After initial release, use probe to separate and count all APL slips, ensure each slip glides freely, extend release if additional slips found constricted, incomplete release of all slips causes persistent symptoms. **Location**: Small branch from radial sensory nerve crosses radial border of anatomical snuffbox, provides sensation to dorsoradial thumb. **Protection**: Particularly at risk with longitudinal incision, identify early in dissection, retract gently with vessel loop, avoid traction injury during retinaculum release, preserve during closure. ## Clinical Indications **Primary Indication**: Symptomatic De Quervain's stenosing tenosynovitis with failed conservative management **Specific Criteria**: - Pain over radial styloid worse with thumb/wrist movement - Positive Finkelstein test (90% sensitivity, 80% specificity) - Failed conservative treatment: thumb spica splinting 4-6 weeks PLUS NSAIDs PLUS corticosteroid injection (1-2 attempts) - Significant functional impairment: inability to grip, lift objects, ADL limitations - Symptom duration typically 3-6 months minimum **Finkelstein Test Technique**: - Examiner passively flexes patient's thumb fully into palm (opposition) - Examiner then ulnar deviates the wrist while maintaining thumb flexion - **Positive**: Sharp pain reproduced over radial styloid/first compartment - **Eichoff modification**: Patient makes fist over thumb, then actively ulnar deviates wrist **Differential Diagnoses to Exclude**: 1. **CMC (Thumb Basilar Joint) Arthritis** - Grind test positive (axial load + rotation = crepitus/pain) - Radiographs show joint space narrowing, osteophytes, sclerosis - Pain more at thumb base, not radial styloid 2. **Intersection Syndrome** - Pain 4-6cm PROXIMAL to radial styloid (not AT styloid) - EPB/ECRL crossing point (second compartment crosses first) - Crepitus and swelling more prominent - Different conservative treatment (rest, ice, injection more proximal) 3. **Radial Styloid Fracture** - History of trauma (often missed initially) - Radiographs show fracture line or non-union - Point tenderness over radial styloid bone, not tendons 4. **Wartenberg Syndrome (Radial Sensory Neuritis)** - Superficial radial nerve compression/irritation - More burning/tingling pain, paresthesias - Tinel's sign over nerve course - Negative Finkelstein test 5. **FCR Tendinitis** - Pain more volar at wrist crease - Tenderness over FCR at trapezium insertion - Pain with resisted wrist flexion/radial deviation **Conservative Management (Must Document Failure)**: - Thumb spica splint: 4-6 weeks continuous wear, wrist neutral, thumb IP free - NSAIDs: Regular dosing for 4-6 weeks - Activity modification: Avoid repetitive thumb/wrist motions - Corticosteroid injection: 0.5-1mL steroid + local anesthetic into compartment - Technique: Inject into compartment (NOT intratendinous - whitening of tendon = stop) - Success: 50-80% initial relief but high recurrence (30-50% recur within 1 year) - Usually offer 1-2 injection attempts before surgery **Relative Contraindications**: - Active infection at operative site - Unrealistic patient expectations - Pending litigation/workers compensation (relative) - Medical comorbidities precluding surgery ## First Dorsal Compartment Anatomy **Compartment Structure**: - Fibro-osseous tunnel at radial styloid level - **Roof**: Extensor retinaculum (thickened in De Quervain's) - **Floor**: Periosteum over radial styloid and radius - **Radial border**: Skin and subcutaneous tissue - **Ulnar border**: Second dorsal compartment (ECRL, ECRB) **Tendon Contents (2 Tendons)**: 1. **Abductor Pollicis Longus (APL)**: - **Number of slips**: 1-4 slips (50-80% have multiple slips, mean 2.2) - **Position**: More VOLAR and RADIAL within compartment - **Origin**: Posterior radius, ulna, interosseous membrane (mid-forearm) - **Insertion**: Base of first metacarpal (radial side) - **Function**: Thumb abduction (radial plane), thumb extension at CMC, radial wrist deviation - **Size**: Larger diameter than EPB (2-4mm typical) 2. **Extensor Pollicis Brevis (EPB)**: - **Number**: Usually SINGLE tendon (rarely 2) - **Position**: More DORSAL and ULNAR within compartment - **Origin**: Posterior radius and interosseous membrane (distal to APL) - **Insertion**: Base of proximal phalanx (dorsal) - **Function**: Thumb MCP and IP extension - **Size**: Smaller diameter than APL (1-2mm typical) **CRITICAL: Septum Anatomy (20-30% Prevalence)**: - Fibrous partition WITHIN first compartment - Divides compartment into TWO sub-compartments: - **Volar/radial**: APL (± multiple slips) - **Dorsal/ulnar**: EPB (separate tunnel) - Appears as white fibrous band between APL and EPB - Creates SEPARATE stenosis of EPB even if APL released - **Missed septum = #1 cause of failed surgery (accounts for 60-80% of failures)** **Radial Styloid Bony Anatomy**: - Prominent radial process extends 1-1.5cm distal to articular surface - First compartment runs obliquely across styloid - Lister's tubercle (third compartment landmark) located 2-3cm ulnar **Superficial Radial Nerve Anatomy**: - Emerges from beneath brachioradialis ~7-9cm proximal to radial styloid - Divides into 2-5 dorsal sensory branches (mean 3 branches) - Branches cross operative field at various angles (often perpendicular to incision if longitudinal) - Supply sensation: dorsoradial hand, dorsal thumb, dorsal proximal index/middle fingers - **High variability**: No consistent branching pattern - Accompanied by small venae comitantes - Injury causes painful neuroma and sensory loss **Radial Artery Relationship**: - Passes VOLAR to first compartment - Runs beneath APL tendons as it enters anatomical snuffbox - 5-8mm deep to compartment floor (safe if stay dorsal) - Accompanied by venae comitantes - Injury rare but catastrophic if not recognized **Anatomical Snuffbox Borders**: - Radial border: APL and EPB (first compartment) - Ulnar border: EPL (third compartment) - Floor: Scaphoid and trapezium - Contents: Radial artery, superficial radial nerve branches ## Step-by-Step Surgical Technique ### Patient Positioning **Position**: Supine with affected arm on radial hand table **Tourniquet**: - Upper arm tourniquet, 250mmHg typical for adults - Exsanguinate with Esmarch or elevation (avoid Esmarch if concern for DVT) - Inflate after skin prep and draping **Arm Position**: - Forearm SUPINATED (palm up) - Hand elevated on sterile towel or hand block - Thumb positioned in slight extension and abduction **Surface Marking**: - Palpate and mark first dorsal compartment (radial styloid prominence) - Passive thumb extension/abduction makes tendons prominent - Mark radial styloid tip - Mark EPL (third compartment) dorsally as reference landmark - Mark planned incision (transverse or longitudinal) ### Surgical Approach Options **Transverse Incision (PREFERRED)**: - **Advantages**: Parallel to nerve branches (lower neuroma risk), better cosmesis (hides in wrist crease), less scar contracture - **Disadvantages**: Less extensile if needed, slightly more difficult exposure - **Location**: Directly over first compartment at radial styloid level - **Length**: 1.5-2cm - **Orientation**: Gentle curve following natural skin creases **Longitudinal Incision (Alternative)**: - **Advantages**: More extensile if needed, easier exposure of proximal/distal extent - **Disadvantages**: Higher nerve injury risk (perpendicular to nerve branches), worse cosmesis, more scar contracture - **Location**: Along radial border of first compartment - **Length**: 2-3cm - **Orientation**: Parallel to tendons, slightly dorsal to radial styloid tip ### Step 1: Skin Incision - Make transverse (preferred) or longitudinal incision with #15 blade - Incise skin and subcutaneous fat carefully - Use fine-toothed forceps or skin hooks for retraction - Deepen incision cautiously - nerves immediately below skin ### Step 2: Subcutaneous Dissection - NERVE IDENTIFICATION **CRITICAL STEP - Highest Risk for Nerve Injury** - Apply **loupe magnification** (2.5-3.5x recommended) - Use fine tenotomy scissors or Stevens scissors - **Spreading technique**: Spread scissors parallel to nerve course - Identify **superficial radial nerve branches**: - Typically 2-5 branches visible in operative field - Appear as white cords with small accompanying vessels - Variable anatomy - no predictable pattern - Some branches cross directly over compartment - Place **vessel loop** around EACH identified nerve branch - Gently retract nerves to sides with vessel loops - Continue dissection until first compartment retinaculum visible **Avoiding Nerve Injury**: - Never use blind sharp dissection in subcutaneous tissue - Avoid cautery in subcutaneous plane (use only after nerves protected) - Gentle retraction - excessive traction causes neuropraxia - Identify ALL branches before proceeding to compartment release ### Step 3: Expose First Dorsal Compartment - Retract nerves gently to expose retinaculum - Identify **thickened, white, glistening retinaculum** overlying tendons - Palpate tendons beneath retinaculum: - May feel thickened, nodular (tenosynovitis) - Passive thumb motion demonstrates tendon excursion beneath retinaculum - Clear overlying tissue off dorsal surface of retinaculum - Visualize proximal extent (2-3cm proximal to styloid) - Visualize distal extent (1cm distal to styloid) - Mark planned **longitudinal incision line on retinaculum**: - Along RADIAL (dorsal) border of compartment - Keeps ulnar (volar) rim intact (prevents volar subluxation) ### Step 4: First Compartment Release - Retinaculum Incision **CRITICAL STEP - Adequate Release** - Use #15 blade or tenotomy scissors - Incise retinaculum **LONGITUDINALLY** along **RADIAL/DORSAL border** - Start **2cm proximal** to radial styloid - Extend **1cm distal** to styloid - Incise only **ROOF (dorsal half)** of compartment - **PRESERVE FLOOR (volar half)** - prevents volar subluxation - Spread scissors beneath retinaculum to ensure complete release - Tendons should **BULGE out** of opened compartment (confirms adequate release) - If tendons don't bulge, extend release further proximally/distally **Key Principle**: Release ROOF only, preserve FLOOR (volar rim as pulley) ### Step 5: Identify APL - Check for Multiple Slips - After main release, **INSPECT compartment contents** - Identify **APL tendon(s)**: - More VOLAR and RADIAL - Often **multiple slips** (50-80% have 2-4 slips) - Use fine probe or scissors tip to **separate and count APL slips** - Each slip must glide freely after release - If additional slips found constricted, extend release to include them - APL inserts on base of thumb metacarpal (confirm by passive thumb motion) **Tenosynovium**: - Often thickened, hypertrophic, nodular - If markedly thick: partial tenosynovectomy (excise thickened synovium) - Preserve some paratenon (don't strip tendons bare) ### Step 6: CRITICAL - Identify EPB and Check for SEPTUM **MOST IMPORTANT STEP - Prevents Surgical Failure** - Identify **EPB tendon**: - More DORSAL and ULNAR than APL - Usually SINGLE tendon (smaller diameter) - Inserts on proximal phalanx base (not metacarpal) - **INSPECT for SEPTUM** (present in 20-30%): - Look for **white fibrous band** separating APL and EPB - Septum creates TWO sub-compartments: - APL in volar/radial compartment - EPB in dorsal/ulnar compartment (SEPARATE tunnel) - Use probe to feel for septum between tendons - Palpate EPB - if tethered despite main release, septum likely present - **IF SEPTUM FOUND**: - Incise septum **COMPLETELY** from proximal to distal - Release EPB sub-compartment thoroughly - Verify EPB glides freely and independently after septum release **Failure to release septum = #1 cause of persistent postop symptoms** ### Step 7: Verify Complete Release - Tendon Excursion Test **Intraoperative Assessment** - Passively **extend and abduct thumb**: - APL and EPB should glide smoothly WITHOUT catching - Tendons should **subluxate DORSALLY** out of compartment (bulge out) - All APL slips should glide independently - EPB should glide independently - Passively **flex and adduct thumb**: - Tendons glide back easily into compartment - **If tendons catch or remain in tunnel**: - Release is INCOMPLETE - Extend retinaculum incision further proximally/distally - Re-check for missed septum or APL slip **This test is crucial to prevent inadequate release** ### Step 8: Hemostasis and Closure - **Release tourniquet** - Achieve hemostasis with **bipolar electrocautery**: - Avoid monopolar near nerves - Cauterize bleeding vessels carefully - Irrigate wound with sterile saline **DO NOT REPAIR RETINACULUM** (would recreate stenosis) - Leave tendons **uncovered dorsally** (allows dorsal subluxation - normal) - Close **subcutaneous layer** with 4-0 absorbable suture (Vicryl or Monocryl): - Approximates skin edges - Provides additional nerve protection - Close **skin** with 5-0 nylon or 5-0 Monocryl subcuticular: - Simple interrupted or running subcuticular - Avoid tension - Apply **sterile dressing** - Apply **short thumb spica splint**: - Wrist neutral - Thumb included (IP free to allow motion) - For comfort only (remove 1-2 weeks) ## Alternative Approaches and Special Situations ### Endoscopic First Compartment Release **Technique**: - 1-2 small portal incisions (proximal and distal) - Endoscopic visualization of compartment - Release retinaculum under direct visualization **Advantages**: - Smaller incisions (better cosmesis) - Potentially lower nerve injury risk (limited dissection) - Faster recovery **Disadvantages**: - Cannot adequately assess for septum (higher failure rate) - Specialized equipment required - Learning curve - Limited ability to perform tenosynovectomy - **NOT recommended if septum suspected** **Evidence**: Open release remains gold standard (more thorough septum inspection) ### Wide-Awake Local Anesthesia No Tourniquet (WALANT) **Technique**: - Local anesthetic (1% lidocaine with epinephrine 1:100,000) - Inject subcutaneously and around compartment - No tourniquet needed (epinephrine provides hemostasis) - Patient awake and cooperative **Advantages**: - Patient can actively move thumb (dynamic assessment of release) - Immediate feedback on adequacy of release - Avoid tourniquet discomfort - Can perform in procedure room (not OR) - Lower cost **Disadvantages**: - Patient must tolerate awake surgery - Slightly more bleeding (but manageable with epinephrine) - Distortion of anatomy from local anesthetic volume **Growing popularity for hand procedures including De Quervain's release** ### Revision Surgery for Failed Primary Release **Indications**: Persistent pain and positive Finkelstein test after primary surgery **Most Common Cause**: Missed septum with unreleased EPB sub-compartment (60-80%) **Preoperative Assessment**: - Confirm persistent De Quervain's (positive Finkelstein) - Exclude other causes: CMC arthritis, intersection syndrome, neuroma - Ultrasound or MRI can identify septum and EPB sub-compartment **Surgical Technique**: - Reopen previous incision or make new incision if scar problematic - Identify and protect radial sensory nerve branches (in scar) - Inspect for: - **Septum** (most common) - release completely - Inadequate proximal/distal extent of release - extend - Missed APL slips - release - Scar/adhesions - excise and free tendons - Thorough inspection of ALL compartment contents - Verify complete release with excursion testing **Success Rate**: 70-85% if cause identified and corrected (septum release) ### Concomitant CMC Arthroplasty **If both De Quervain's AND CMC arthritis present**: - Can address both in same surgery - Release first compartment first - Then perform CMC arthroplasty (trapeziectomy ± LRTI, ± implant) - Use same or separate incisions (separate usually preferred for exposure) ## Evidence-Based Outcomes ### Success Rates **Primary Open Release**: - **Excellent results**: 85-95% of patients - **Good results**: 90-97% of patients - **Immediate pain relief**: 95% of patients - **Recurrence rate**: Less than 5% - **Patient satisfaction**: 90-95% **Factors Associated with Better Outcomes**: - Thorough inspection for and release of septum - Complete release of all APL slips - Release extended adequately proximal and distal - Protection of radial sensory nerve **Factors Associated with Failure**: - Missed septum (most common - 60-80% of failures) - Incomplete release (inadequate proximal/distal extent) - Missed APL slips - Wrong diagnosis (intersection syndrome, CMC arthritis) ### Time to Recovery **Pain Relief**: Immediate (most patients - 95%) **Return to Activities**: - Light activities: 2-4 weeks - Normal activities: 4-6 weeks - Heavy lifting/sports: 6-8 weeks **Range of Motion**: - Full ROM typically by 2-4 weeks - No long-term stiffness in most patients **Strength**: - Temporary weakness first 2-4 weeks (normal) - Full strength recovery by 6-8 weeks ### Conservative vs. Surgical Treatment **Corticosteroid Injection**: - Initial success: 50-80% - Recurrence: 30-50% within 1 year - Best for: Acute onset, first episode, pregnancy-related - Multiple injections: Decreasing returns, tendon weakening risk **Surgery**: - Success: 85-95% (superior to injection long-term) - Definitive treatment for failed conservative management - Low recurrence (less than 5%) **Cost-Effectiveness**: Surgery more cost-effective than repeated injections after 2-3 failed attempts ### Special Populations **Pregnancy/Postpartum De Quervain's**: - High incidence in new mothers (repetitive lifting baby) - Often resolves spontaneously 6-12 months postpartum - Conservative management preferred initially - Surgery if persistent beyond 6-12 months postpartum **Workers' Compensation Cases**: - Slightly lower success rates (70-85%) - Longer time to return to work - Litigation/secondary gain may affect outcomes ### Key Studies **Septum Prevalence**: - Cadaveric studies: 20-30% have septum creating separate EPB compartment - Clinical series: Missed septum accounts for 60-80% of failed primary releases **Nerve Complications**: - Nerve injury rates: 5-10% (most common complication) - Transverse incision: Lower nerve injury risk vs longitudinal - Most nerve injuries are neuropraxias (resolve spontaneously 6-12 weeks) - Permanent neuromas: 1-2% **Australian Context**: - Medicare MBS item: 46414 (release of tendon sheath, wrist or hand) - Typical out-of-pocket: $500-1500 depending on surgeon/facility - PBS: Not applicable (surgical procedure, not medication) ### Comprehensive Operative Technique **Step 1: Patient Positioning and Marking** Patient supine, arm on hand table, forearm supinated. Upper arm tourniquet (250mmHg). Mark first dorsal compartment at radial styloid, mark radial styloid tip, mark planned incision (transverse preferred). **Technical Tip**: Passive thumb extension and abduction makes first compartment tendons prominent for accurate surface marking. Mark EPL (third compartment) dorsally as reference landmark. - Incorrect identification of first compartment (operating on wrong structure) - Inadequate exsanguination (poor visualization from bleeding) - Excessive tourniquet pressure or time (nerve injury, ischemia) **Step 2: Skin Incision** Transverse incision (preferred) 1.5-2cm over first compartment at radial styloid level. Alternative longitudinal incision along radial border. Incise skin and subcutaneous fat carefully. **Technical Tip**: Transverse incision PREFERRED - parallel to radial sensory nerve branches (lower neuroma risk), better cosmesis (hides in wrist crease). Longitudinal incision perpendicular to nerves (higher injury risk). - Incision too deep initially (nerve injury) - Incision too proximal or distal (inadequate exposure) - Excessive incision length (unnecessary nerve exposure) **Step 3: Subcutaneous Dissection - Radial Sensory Nerve Identification** Apply loupe magnification (2.5-3.5x). Carefully dissect subcutaneous tissue using spreading technique with fine scissors. Identify 2-5 superficial radial nerve branches crossing field. Place vessel loop around EACH identified branch for protection and gentle retraction. **Technical Tip**: MOST CRITICAL STEP for nerve protection. Identify ALL nerve branches before proceeding. Nerves appear as white cords with small accompanying vessels. Variable anatomy - no predictable pattern. Transverse incision helps (parallel to nerves). - Transecting nerve branch (painful neuroma, sensory loss - MOST COMMON COMPLICATION 5-10%) - Missing a nerve branch (injured during subsequent steps) - Excessive nerve retraction (neuropraxia) - Cautery injury to nerve **Step 4: Expose First Dorsal Compartment Retinaculum** Retract nerves gently to expose thickened white retinaculum overlying tendons. Palpate tendons beneath (may feel thickened/nodular). Clear overlying tissue. Visualize proximal extent (2-3cm proximal to styloid) and distal extent (1cm distal). Mark longitudinal incision line on RADIAL/DORSAL border of retinaculum. **Technical Tip**: Retinaculum markedly thickened in chronic De Quervain's. Plan release of RADIAL/DORSAL half only (preserves VOLAR floor as pulley to prevent volar tendon subluxation). - Inadequate exposure of proximal/distal extent (incomplete release) - Injury to underlying tendons during exposure **Step 5: First Compartment Release - Incise Retinaculum** Using #15 blade or tenotomy scissors, incise retinaculum LONGITUDINALLY along RADIAL/DORSAL border. Start 2cm proximal to radial styloid, extend 1cm distal to styloid. Incise ROOF (dorsal half) only, preserve FLOOR (volar half). Spread scissors beneath retinaculum to ensure complete release. Tendons should BULGE out (confirms adequate release). **Technical Tip**: Release ROOF only, preserve FLOOR (prevents volar subluxation). Tendons bulging dorsally out of compartment = adequate release. If tendons don't bulge, extend release further. Complete decompression essential. - Incomplete release (residual constriction, persistent symptoms - 2-5%) - Cutting underlying tendons with blade - Complete circumferential release (volar subluxation - rare but problematic) - Not extending release adequately proximal/distal **Step 6: Identify APL - Count and Release All Slips** After main release, INSPECT compartment contents. Identify APL tendon(s) - more VOLAR and RADIAL. Use probe to separate and count APL slips (50-80% have multiple slips, 2-4 common). Ensure EACH slip glides freely. If tenosynovium markedly thickened, perform partial tenosynovectomy (preserve some paratenon). **Technical Tip**: APL has MULTIPLE SLIPS in 50-80% - MUST identify and release ALL slips. Missed APL slip = persistent symptoms. APL inserts thumb metacarpal base (palpate with passive thumb motion). Tenosynovectomy only if marked synovitis. - Missing additional APL slips hidden beneath main slip (incomplete decompression) - Transecting APL slip inadvertently - Excessive tenosynovectomy (adhesions, poor gliding) **Step 7: CRITICAL - Identify EPB and Check for Septum** Identify EPB tendon - more DORSAL and ULNAR than APL, usually single, inserts proximal phalanx base. ACTIVELY INSPECT for SEPTUM (white fibrous band between APL and EPB). Septum present in 20-30%, creates SEPARATE EPB sub-compartment. IF SEPTUM FOUND: incise septum COMPLETELY from proximal to distal, release EPB sub-compartment thoroughly, verify EPB glides freely independently. **Technical Tip**: MISSED SEPTUM = MOST COMMON CAUSE OF FAILED SURGERY (60-80% of failures). MUST inspect for septum after main release. Look for white fibrous band separating APL/EPB. Use probe to palpate between tendons. If septum present, EPB in separate dorsal/ulnar tunnel - MUST release separately. This step is THE MOST IMPORTANT to prevent failure. - MISSING SEPTUM AND SEPARATE EPB SUB-COMPARTMENT (most common cause of surgical failure) - Assuming single compartment without thorough inspection - Inadequate septum release (partial release insufficient) - Not verifying EPB gliding specifically after septum release **Step 8: Verify Complete Release - Tendon Excursion Test** Passively extend and abduct thumb - APL and EPB should glide smoothly WITHOUT catching. Tendons should subluxate DORSALLY out of compartment (bulge out). Flex and adduct thumb - tendons glide back easily. If tendons catch or remain in tunnel, release INCOMPLETE - extend retinaculum incision, re-check for septum/missed slips. **Technical Tip**: Tendon excursion test = INTRAOPERATIVE CONFIRMATION of adequate release. Passive thumb extension/abduction: tendons glide freely and subluxate dorsally (bulge out of compartment). This is NORMAL postoperatively. If tendons stay in tunnel or catch, release inadequate - extend further. Verify ALL APL slips AND EPB glide independently. - Accepting incomplete release without testing (persistent symptoms postoperatively) - Not testing tendon excursion before closure - Excessive force during testing (rare tendon rupture) **Step 9: Hemostasis and Wound Closure** Release tourniquet. Achieve hemostasis with bipolar electrocautery (avoid monopolar near nerves). Irrigate wound. DO NOT REPAIR RETINACULUM (defeats purpose). Leave tendons uncovered dorsally. Close subcutaneous layer with 4-0 absorbable suture. Close skin with 5-0 nylon or subcuticular suture. Apply sterile dressing and short thumb spica splint (wrist neutral, thumb included, IP free) for comfort - remove 1-2 weeks. **Technical Tip**: DO NOT repair retinaculum - would recreate stenosis and defeat entire surgery. Tendons left uncovered dorsally (allows normal dorsal subluxation). Dorsal tendon prominence/subluxation after release is NORMAL and EXPECTED - NOT a complication. Patients may feel tendons 'popping' or moving - reassure this is normal. Splint for comfort only, remove early (1-2 weeks) to prevent stiffness. - Repairing retinaculum (recreates stenosis, causes recurrent symptoms) - Hematoma formation (inadequate hemostasis) - Prolonged immobilization beyond 2 weeks (stiffness, poor outcome) - Tight dressing (compartment syndrome - very rare) **Step 10: Postoperative Protocol** Day 1-3: Dressing intact, elevation, ice, analgesia (paracetamol/NSAIDs). Day 3-7: Dressing change, wound check. Week 1-2: Splint removed, sutures removed (10-14 days). Begin ACTIVE ROM immediately after splint removal (thumb opposition, extension, abduction). Week 2-4: Progressive ROM, begin light activities. Week 4-6: Return to normal activities including work. Full recovery 4-6 weeks. **Technical Tip**: Results excellent: 85-95% success rate. IMMEDIATE pain relief in 95%. Full ROM by 2-4 weeks. Full function by 6 weeks. Recurrence rare (less than 5%). Patient satisfaction very high. Early active motion prevents stiffness. Formal therapy rarely required. Dorsal tendon prominence is normal - reassure patient. - Prolonged immobilization beyond 2 weeks (stiffness, adhesions, poor outcome) - Returning to heavy lifting/forceful gripping before 4 weeks (wound dehiscence risk) - Not educating patient about normal postoperative findings (dorsal subluxation, prominence) **Additional Rare Complications**: - **Tendon injury/rupture**: Less than 1%. Caused by inadvertent cutting during retinaculum release or excessive tenosynovectomy. Management: Primary repair if recognized, reconstruction/transfer if chronic. - **Hematoma**: 1-2%. Prevented by meticulous hemostasis after tourniquet release, bipolar cautery. Managed by observation if small, evacuation if expanding or compressive. - **Loss of thumb strength**: Temporary weakness common first 2-4 weeks (normal from surgical trauma). Resolves with therapy/time. Persistent weakness suggests tendon injury. - **Complex Regional Pain Syndrome (CRPS)**: Less than 1%. Disproportionate pain, swelling, stiffness, skin changes. Early recognition and aggressive therapy (desensitization, ROM, medications, sympathetic blocks) essential. - **Recurrence**: Less than 5%. Usually represents incomplete initial release (missed septum or inadequate extent). True recurrence (after adequate initial release) very rare. Management: Revision surgery with thorough inspection. ### Immediate Postoperative (Day 0-3) **Dressing**: - Bulky soft dressing with short thumb spica splint - Wrist neutral position - Thumb included (IP joint free to allow motion) - Splint for comfort only (not rigid immobilization) **Activity**: - Elevation above heart level (reduce swelling) - Ice application (20min on/off) - Finger ROM encouraged (prevents stiffness) - Keep dressing dry **Analgesia**: - Paracetamol 1g QDS regular - NSAIDs (ibuprofen 400mg TDS or celecoxib 200mg BD) if tolerated - Opioids rarely needed (only severe pain first 24-48hr) **Expected**: Immediate pain relief (95% of patients). Pre-operative De Quervain's pain should be gone immediately. ### Early Postoperative (Week 1-2) **Dressing Change** (Day 3-7): - Remove bulky dressing - Wound check (ensure clean, dry, no signs of infection) - Lighter dressing or simple adhesive strips - Continue splint for comfort if needed (can remove if comfortable) **Splint Removal** (Week 1-2): - Most patients: Remove splint 7-14 days - Earlier removal if minimal discomfort - Prolonged immobilization NOT beneficial (causes stiffness) **Suture Removal** (Day 10-14): - Remove non-absorbable sutures 10-14 days - If subcuticular absorbable used: No removal needed **Activity**: - Begin ACTIVE ROM immediately after splint removal - Thumb: Opposition, extension, abduction, flexion - Wrist: Flexion, extension, radial/ulnar deviation - NO restrictions on ROM - Light ADLs encouraged (eating, dressing, hygiene) ### Intermediate Recovery (Week 2-4) **ROM and Strengthening**: - Progressive active ROM exercises - Begin gentle strengthening (light gripping, putty exercises) - Scar massage (after sutures out, wound healed) **Activity Progression**: - Light activities: Typing, writing, light household tasks - Driving when comfortable (usually week 2-3) - Avoid heavy lifting (greater than 2-5kg) - Avoid forceful gripping **Expected**: - Full or near-full ROM by week 4 - Minimal pain with activities - Scar healing well ### Return to Full Activity (Week 4-6) **Strengthening**: - Progress resistance exercises - Functional task practice (job-specific activities) **Return to Work**: - Sedentary work: 2-3 weeks - Light manual work: 4 weeks - Heavy manual work: 6-8 weeks **Return to Sports**: - Golf, tennis, racquet sports: 6-8 weeks - Contact sports, heavy lifting: 6-8 weeks - Gradual progression, avoid pain **Expected**: - Full ROM achieved - Strength 80-90% of normal (full strength by 8-12 weeks) - Return to all normal activities - Scar maturation ongoing (continues 6-12 months) ### Long-term (Beyond 6 weeks) **Expected Outcomes**: - 85-95% excellent results - Complete resolution of De Quervain's pain - Full ROM and strength - High patient satisfaction (90-95%) - Recurrence rare (less than 5%) **Normal Postoperative Findings** (Patient Education): - **Dorsal tendon prominence/subluxation**: NORMAL. Tendons supposed to bulge dorsally. Not a complication. - **Palpable tendon movement**: Normal to feel tendons moving/popping with thumb motion. - **Scar numbness**: Common from nerve branches. Usually improves over 6-12 months. - **Scar sensitivity**: Common. Improves with scar massage and time. **When to Seek Urgent Review**: - Signs of infection (increasing redness, warmth, purulent drainage, fever) - Severe pain worse than preoperative (suggests complication) - Loss of sensation entire hand (suggests major nerve injury) - Wound dehiscence - Persistent symptoms identical to preoperative (suggests incomplete release - schedule routine follow-up) ### Therapy Referral **Most patients do NOT require formal hand therapy** (self-directed ROM sufficient) **Indications for Hand Therapy**: - Persistent stiffness beyond 4 weeks - Difficulty regaining ROM - Weak grip strength - Scar adhesions limiting motion - CRPS concerns - Occupational therapy for job modifications **Therapy Components**: - Active and passive ROM exercises - Progressive strengthening - Scar management and desensitization - Functional task training - Edema control

De Quervain's Tenosynovitis - First Dorsal Compartment Release

De Quervain's Tenosynovitis - First Dorsal Compartment Release