De Quervain's Release
Instead of conducting a De Quervain's release on a patient with stenosing extensor tenosynovitis, Dr. Asif Ilyas walks through the procedure on a cadaver, demonstrating the approach to the first dorsal extensor retinaculum and providing tips to release it without injuring the radial sensory nerve.
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My name is Asif Ilyas. I'm a professor of orthopedic surgery and the program director of hand surgery at the Rothman Institute in Philadelphia at the Thomas Jefferson University. We will be going over a De Quervain's release surgery. De Quervain's is a common condition - also known as stenosing extensor tenosynovitis of the first extensor compartment. It's a common condition of the wrist due to a number of etiologies, but ultimately, if the condition becomes painful and recalcitrant or resistant to nonoperative treatment, such as splinting and injections, then surgery is often indicated. The release primarily involves- the surgery primarily involves a release of the first dorsal extensor retinaculum and an associated tenosynovectomy of the APL and EPB tendons. During the procedure, I'll show you how to approach this compartment, some tips and tricks on how to release it, how to look for subsheaths, and how to avoid injury to the radial sensory nerve.
This is a De Quervain's release procedure. A De Quervain's release is a release of the abductor pollicis longus and the extensor pollicis brevis tendons. They travel in this direction, and it's important to appreciate the direction with which they travel. They travel towards the thumb, and they start dorsal, and they travel volar. So I think it's helpful to kind of mark out the path of that tendon, so you have a sense of where it's going to. Now, how you place your incision is up to you. There's a few options. You can play them longitudinally. You can place them transversely, or you can place them obliquely. There's no right or wrong way. Whatever better - whatever is better in your hands is fine. I try to avoid the transverse because it increases the odds of injury of the radial sensory nerve, which is one of the primary hazards in this approach. You don't want to injure or transect the radial sensory nerve. It's a highly sensitive nerve that even with a successful release can plague the patient with persistent neuritic symptoms. So I place essentially a transverse incision, like - I'm sorry an oblique incision, or a longitudinal incision, like so.
I'll preinject this in - incision typically with 1% lidocaine, 9 cc of that and a cc of bicarb, and I'll do these surgeries often with the patient completely awake. Again, as mentioned, the main issue in the beginning is avoiding injury to the radial sensory nerve. That's the first issue, to avoid failure of the surgery. The two other major things to consider when doing this surgery is complete release of both the APL and the EPB tendons. And when I mean complete release, is that oftentimes there are subsheaths where some of the tendons slips can be living, and we'll look for that today.
So if we go through the subcu- very little cutting - it's mostly spreading - and I'm spreading longitudinally. By doing that, the nerves will become evident. And you wouldn't know where those nerves are throughout the release. One of the nerves- one of the nerves is here. And then another one. Another branch, right here, this is a more prominent branch. This is a branch of the radial sensory nerve. There's typically anywhere from one to three branches at this level, and you want to find them and make sure they are not in your field. And that requires you to avoid any inadvertent releasing. Indiscriminate releasing, I should say. Once you're satisfied, place your retractors in. You can use a self retainer like this or a standard retractor, like a Senn or a small equivalent small retractor. Now this patient is a cadaver obliviously, so they will not have as pronounced - pronounced first compartment because they did not necessarily have De Quervain's tenosynovitis of the wrist. To make sure you're in the right place, you can move the tendons around a little bit just to confirm.
So, here is our APL tendon. She does not have a very robust first compartment. But you'll see where our marking that we had before the skin incision is exactly accurate, and if you see our markings here, it's in line with the first compartment tendon. And the release for it is very straightforward; you release longitudinally. Now when you did the release, you want to cheat your release along the dorsal border of the first compartment. And the reason for that is one of the other issues with this surgery - potential other issues - is sublux - subluxation of the first compartment tendons with wrist motion. And I don't slide because I don't know where the nerve is at all times, so I do a limited release as we go. And I'll do the same thing distally. Either with a scissor or, excuse me, or with a knife. So we have a complete release of the tendon.
So then, after I release the tendon, I want to find both APL and EPB and make sure we have them fully released. So the more prominent tendon and the stouter tendon is the APL tendon. Okay, and you'll notice it has multiple slips within it. And these can have subcompartments, so you want to be mindful of that. So this one looks fine, so I'm going to retract that. And then we're going to look at the APL - the A - I'm sorry, the EPB tendon. You'll see how it's smaller, and you can see how it's often in it's own sheath. Even though we release the compartment, it appears to be following it's own sheath, and it can have a subcompartment. And one of the most common causes for failure of injections to manage De Quervain's tenosynovitis is subcompartments of the APL and APB, and it's most commonly of the EPB tendon - and this is the case here. You'll see how she has her own compartment that she's following that I'm going to release in this direction.
So now, I should be able to isolate them fully. Here is her EPB tendon. I'm going to bring that over to me, this way. And her APL tendon I'll bring to myself this way, like so. And once I - I've confirmed complete decompression, I look inside the floor - make sure there's nothing further of issue. I should only see the radius and the insertion of the brachioradialis tendon, which is a sessile insertion, doesn't move at this level, and nothing more. And that's what we see here. You can move the thumb, have the patient move the thumb, to confirm it's released as well. Once done, release the - your retractors. Again, take one more look at your radial sensory nerve - make sure you're satisfied, that it's not injured in any way. Remember there's multiple slips. We found a couple slips on the way in. They look fine.
Now you're going to wash that wound. And then you're going to close this, and with each suture, you're going to confirm that you have not inadvertently placed a stitch in the radial sensory nerve. And the way to do that is lift up, show yourself every throw, until you're confident that there is no inadvertent sewing in or injury of the radial sensory nerve. Now, with the patient awake, you can have them move the wrist as well before you close and confirm complete release of both tendons. Also, complete - confirm that there is no subluxation of the tendons occurring. I place a soft dressing on after this. I have them leave the dressing on for two to three days. After two to three days of leaving it on and dry, they can remove the dressing. I allow them to shower and wash normally. Starting at that point, the incision can get wet. I ask them to, in addition - looking again for the nerve, no nerve. In addition to showering and washing, I have them clean the incision twice a day with some rubbing alcohol to disinfect the incision and sutures, clear away any oil and sweat that normally forms on the skin, and apply a dry dressing of their choice. I find it is helpful if they do wear a splint as the wrist can be a little bit sore after these procedures. I'll see them back in the office in about ten days, plus or minus two days, for suture removal. I do not routinely recommend therapy, but occasionally, it will be necessary. And there you go.
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