First Extensor Compartment Release for De Quervain's Tenosynovitis

De Quervain's tenosynovitis is commonly characterized by a stenosing tenosynovitis of the first dorsal compartment of the wrist.¹ This condition is predominantly observed in middle-aged individuals, with a notably higher prevalence among women, particularly in the peripartum period.^2,3 It is estimated that the condition affects 0.6–2.8% of working-age adults, with incidence rates being significantly higher in occupations requiring repetitive hand and wrist movements.⁴ Conservative management is initially pursued through various modalities, including non-steroidal anti-inflammatory medications, activity modification and ergonomic adjustments, thumb spica splinting, and corticosteroid injections.^5,6 When non-operative treatments fail to provide adequate relief after 3–6 months, surgical intervention may be considered. The first extensor compartment release has been demonstrated to provide successful outcomes in most cases.⁷

This video provides detailed step-by-step instruction for performing first dorsal compartment release in De Quervain's tenosynovitis, with particular emphasis on anatomical landmarks, proper tissue handling, and identification of important neurovascular structures.

The procedure begins with the administration of local anesthesia through the infiltration of 1% lidocaine in the surgical area. The anesthetic is carefully distributed both superficially and deeply near the tendon sheath to ensure complete anaesthesia throughout the procedure. Following appropriate skin preparation and draping, a forearm tourniquet is applied and inflated. The procedure is typically completed within 10 minutes, which is well within the tourniquet tolerance time for most patients under local anesthesia.

A zigzag incision is created, with its center positioned over the radial styloid. Keyhole incisions are ill advised to avoid nerve injury. Particular attention is paid to the subdermal dissection due to the presence of sensory nerve branches. The lateral cutaneous nerve of the forearm and radial sensory nerve branches are carefully identified and protected throughout the procedure. Injury to these sensory nerve branches can lead to a painful neuroma. The extensor retinaculum is exposed and incised longitudinally to access the underlying tendons.

The first extensor compartment contains the abductor pollicis longus and extensor pollicis brevis tendons. The former often has multiple slips. The latter is usually a thin tendon and may be enclosed in a separate sub compartment that requires complete release as well. Failure to recognize this is one reason for persistent symptoms following surgery. In some cases there may be hypertrophic tenosynovitis and a limited synovectomy is performed. In some instances the retinaculum is very thick and fibrotic. A portion may be excised to prevent adhesions and recurrence. The patient is asked to move the thumb to confirm complete release of all tendons. This is a vascular area and meticulous hemostasis must be achieved prior to skin closure. The wound is closed with a single layer of 4-0 nylon sutures. It is important to avoid snagging or traumatizing sensory nerve branches during closure.

A soft dressing is applied. Immobilization is not necessary. The patient is allowed to use the hand as tolerated, and over-the-counter pain medications are used as needed. Sutures are removed at 10–12 days at which time most patients have achieved full recovery.

The surgical release of the first extensor compartment for De Quervain's tenosynovitis is a well-established procedure with consistently favorable outcomes when proper surgical technique is employed. When performed with attention to these technical details, the procedure provides reliable relief of symptoms with a low complication rate.

This surgical technique video would be particularly valuable for orthopaedic and hand surgery residents, as well as practicing surgeons who seek to refine their approach to first extensor compartment release. The detailed demonstration of nerve identification and the management of anatomical variations, especially the emphasis on finding accessory compartments, provides crucial technical aspects which help surgeons avoid complications and improve patient outcomes.

The patient referred to in this video has given their informed consent to be filmed and is aware that information and images will be published online.

We would like to thank the patient, Kay Wright, who graciously participated in this study and wanted to be mentioned by name.