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De Quervain's Release

intermediate Level

Primary Indication

De Quervain's tenosynovitis (first dorsal compartment stenosing tenosynovitis) refractory to 3-6 months of conservative treatment (splinting, NSAIDs, corticosteroid injection) with persistent pain and positive Finkelstein test

Danger Structures

  • Superficial radial nerve branches (primary concern)
  • Radial artery in anatomical snuffbox
  • APL tendon
  • EPB tendon
  • First dorsal compartment retinaculum
  • Cephalic vein tributaries

Visual Atlas

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Step-by-Step Technique

1

Position supine with arm on hand table, pronate forearm, apply tourniquet

Surgeon's Tip
EXAM KEY: Transverse incision follows skin creases and gives better cosmesis than longitudinal
Danger Zone
  • Superficial radial nerve injury
  • Wrong compartment release
2

Identify first dorsal compartment at radial styloid, mark superficial radial nerve branches

Surgeon's Tip
EXAM KEY: Superficial radial nerve branches are variable and cross this area - essential to identify and protect
Danger Zone
  • Superficial radial nerve injury (painful neuroma)
  • Branch transection
3

Make 1.5-2cm transverse incision at level of radial styloid

Surgeon's Tip
EXAM KEY: Transverse incision in skin crease, then longitudinal dissection in subcutaneous tissue to find nerve branches
Danger Zone
  • Vertical skin incision (poor cosmesis)
  • Cutting through nerve during skin incision
4

Dissect carefully through subcutaneous tissue identifying and protecting radial sensory nerve branches

Surgeon's Tip
EXAM KEY: Branches fan out over anatomical snuffbox - use loupe magnification to identify all branches
Danger Zone
  • Missing small nerve branches
  • Excessive retraction causing neuropraxia
5

Retract nerve branches dorsally with vessel loops to protect throughout procedure

Surgeon's Tip
EXAM KEY: Protect nerves at all times - neuroma from nerve injury causes chronic pain worse than original condition
Danger Zone
  • Nerve transection
  • Retractor pressure injury
6

Identify first dorsal compartment sheath - may appear thickened and fibrotic

Surgeon's Tip
EXAM KEY: First dorsal compartment contains APL and EPB - sheath often significantly thickened
Danger Zone
  • Wrong compartment
  • Incomplete identification
7

Incise retinaculum longitudinally on its dorsal/radial aspect (away from volar subluxation direction)

Surgeon's Tip
EXAM KEY: Release on dorsal/radial side prevents volar subluxation of tendons - important technical point
Danger Zone
  • Volar release causing subluxation
  • Incomplete release
8

Identify APL and EPB tendons - look for separate subcompartment for EPB

Surgeon's Tip
EXAM KEY: 30-50% have separate EPB subcompartment - MUST be released separately or will fail
Danger Zone
  • Missing EPB subcompartment (most common cause of failure)
  • Tendon injury
9

Release any EPB subcompartment separately - probe to confirm complete release

Surgeon's Tip
EXAM KEY: Probe each tendon separately to ensure free gliding in each direction
Danger Zone
  • Leaving EPB septum intact
  • Inadequate release
10

Ensure complete release from proximal to distal extent of thickened retinaculum

Surgeon's Tip
EXAM KEY: Retinaculum thickening can extend 2-3cm - release entire involved segment
Danger Zone
  • Incomplete proximal release
  • Incomplete distal release
11

Verify tendons glide freely with thumb extension and abduction

Surgeon's Tip
EXAM KEY: Active motion demonstrates free gliding of both APL and EPB
Danger Zone
  • Residual tethering
  • Missing additional slip
12

Note any APL accessory slips (common - may have 2-5 slips)

Surgeon's Tip
EXAM KEY: APL frequently has multiple slips - all should glide freely after release
Danger Zone
  • Missing accessory APL slip
  • Confusing anatomy
13

Irrigate wound, release tourniquet, achieve hemostasis

Surgeon's Tip
EXAM KEY: Meticulous hemostasis prevents hematoma which can cause adhesions
Danger Zone
  • Hematoma formation
  • Post-operative adhesions
14

Close skin only (do not repair retinaculum), apply soft dressing

Surgeon's Tip
EXAM KEY: Do NOT repair retinaculum - will cause recurrence. Skin closure only.
Danger Zone
  • Retinacular repair causing recurrence
  • Tight skin closure
15

Apply thumb spica splint for comfort for 1 week, then begin active ROM

Surgeon's Tip
EXAM KEY: Early motion prevents adhesions. Splint for comfort only, not protection.
Danger Zone
  • Prolonged immobilization
  • Adhesion formation