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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 39-41

Anatomical variation in the first extensor compartment during treatment of De Quervain'S tenosynovitis


Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Submission18-Apr-2020
Date of Acceptance23-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Shilp Verma
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_24_20

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  Abstract 


Background: De Quervain's disease is ste¬nosing tenosynovitis of the abductor pollicis longus and the extensor pollicis brevis within the first extensor retinaculum compartment of the wrist. The patient usually present with clinical symptoms like pain and a painful range of motions of the thumb which occur either due to increased friction force or due to increase in contain within the compartment during the gliding of the adductor pollicis longus (APL) and the extensor pollicis brevis (EPB) first extensor compartment. Following conservative trials of rest, moist heat, NSAID, and local steroid injections, surgical release of the first compartment are effective treatment modalities for De Quervain's disease, but these even leads to failure of treatment as there may be variation on the anatomy of first extensor compartment of wrist. We had done this study to find out anatomical variation in first extensor compartment during treatment of De Quervains tenosynovitis. Method: Anatomical Variations like presence or absence of septum between APL and EPB, number of tendon slip of APL and EPB in the first extensor compartment were studied in 16 patients of dequervains tenosynovitis who underwent open surgical release as the treatment. Result: 7/16 (43.75%) of patient has partial or complete Sub compartment in the fibro-osseous tunnel and 4/16 (25%) patient has extra Abductor Pollicis Longus (APL) tendon sheath in first extensor compartment. Conclusion: We found significant increase in variation of anatomy in first extensor compartment of De Quervains tenosynovitis patient which will be for the surgeon during the surgical release of first extensor compartment.

Keywords: Anatomical variation in the first extensor compartment, De Quervain's tenosynovitis, number of APL and extensor pollicis brevis tendons, open surgical release


How to cite this article:
Verma S, Agrawal AC. Anatomical variation in the first extensor compartment during treatment of De Quervain'S tenosynovitis. J Orthop Traumatol Rehabil 2020;12:39-41

How to cite this URL:
Verma S, Agrawal AC. Anatomical variation in the first extensor compartment during treatment of De Quervain'S tenosynovitis. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Aug 8];12:39-41. Available from: http://www.jotr.in/text.asp?2020/12/1/39/287714




  Introduction Top


De Quervain's disease is compressive synovitis of the abductor pollicis longus and the extensor pollicis brevis (EPB) tendon sheath within the first extensor retinaculum compartment of the wrist, formed by the dorsal carpal ligaments. The patient usually presents with clinical symptoms such as pain at the base of the thumb with a painful range of motion thumb. Pain is either due to increased friction force in the first compartment or due to an increase in its contents during the gliding of the abductor pollicis longus (APL) and the EPB. Various treatment options are available to relieve this pain and to increase the physical quality of life of patients with De Quervain's tenosynovitis, of which the nonsurgical therapy involves resting the thumb and wrist, which can be achieved by the application of the thumb spica or steroid infiltration into the first extensor compartment. However, only 50% of patients respond by corticosteroid injection in the first extensor compartment,[1] which might be due to the presence of subcompartment in the first extensor compartment which restricts the distribution of injected corticosteroids and results in undesirable treatment outcomes.[2] Moreover, if the nonsurgical treatment fails, open surgical release of the first compartment is an effective treatment modality for De Quervain's tenosynovitis patients. Unrecognized septum during surgical release of the first extensor compartment may lead to incomplete release and treatment failure.[3]

In order to improve these treatment modalities, morphological variations of the presence or absence of septum between APL and EPB and the number of tendon slip of APL and EPB in the first extensor compartment were studied in patients with De Quervain's tenosynovitis who underwent open surgical release as the treatment. It is, therefore, important to know these variations in the practice of hand surgery.


  Methods Top


The study is done on 16 consecutive patients who presented with the clinical sign and symptoms of De Quervain's tenosynovitis in the department of orthopedics and had not responded to the conservative line of management for 3 weeks. Patients with rheumatoid arthritis, tuberculosis, uncontrolled diabetes mellitus, and who had previously undergone the same surgery for the same were excluded from the study. After discussing the risks and benefits of the procedure and all possible complications, they were taken up for open surgical release of the first extensor compartment.

The anatomical study was made during the surgical release of the first extensor compartment of De Quervain's tenosynovitis. Under anesthesia, a 2-cm-long transverse skin incision was made over the first extensor compartment. Special care was taken to identify and visualize the superficial branch of the radial nerve, which was retracted laterally. The EPB tendon was exposed and identified in the first extensor compartment. After lifting the EPB tendon, the extensor retinaculum covering the EPB and abductor pollicis longus was incised longitudinally on its dorsal side. Attention was given to the presence or absence of the subcompartment and variation in the number of tendons of APL and EPB in the first extensor compartment.


  Results Top


A total of 16 wrists, seven males and nine females, were examined intraoperatively during the open surgical release of De Quervain's tenosynovitis. The result showed that 7/16 (43.75%) patients had partial or complete subcompartment in the fibro-osseous tunnel [Figure 1] and 4/16 (25%) patients had extra APL [Figure 2] tendons, and in one patient, APL tendon was absent [Figure 3]. Rest of the 4/16 (25%) patients presented without any septum with single APL and EPB in the first extensor compartment [Figure 4]. One EPB tendon was constantly noted in the first compartment.
Figure 1: One APL and one extensor pollicis brevis tendon with subcompartment

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Figure 2: Extra APL and one extensor pollicis brevis tendon without subcompartment

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Figure 3:Absent APL and one extensor pollicis brevis tendon without subcompartment

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Figure 4:One APL and one extensor pollicis brevis tendon without subcompartment

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  Discussion Top


De Quervain's tenosynovitis is a chronic illness which occurs due to inflammation of the tendon sheath within the first extensor compartment. Inflammation may be due to direct injury over the wrist, scar tissue over and around the wrist which can restrict the movement of the tendon, repeated particular movement over the thumb, pregnancy, old age, and inflammatory arthritis such as rheumatoid arthritis. Various treatment options available for De Quervain's tenosynovitis include conservative trials of rest, moist heat, nonsteroidal anti-inflammatory drugs, local steroid injections, and surgical release of the first compartment, but these even lead to failure of treatment as there may be variation on the anatomy of the first extensor compartment of the wrist.

It is essential to understand the anatomy of the first extensor compartment in patients with De Quervain's tenosynovitis. There have been various studies reported about the variation in the first extensor compartment in English literature. The most common pattern is the presence of septum between APL and EPB in the first extensor compartment,[4] two or more abductor pollicis tendon,[5] and presence of extensor pollicis tertius[6] as an accessory tendon in the first extensor compartment.

During the open surgical release of the first extensor compartment of 16 wrists in patients with De Quervain's tenosynovitis, we found that 7/16 patients had a partial or complete septum in the first extensor compartment [Figure 1]. Similar reports had also been noted by the study of Loomis,[5] Jackson et al.,[3] and Bahm et al.[7] This finding supports the suggestion that decrease in the size of the first extensor compartment due to the presence of partial or complete septum as an anatomical variation is involved in the etiology of De Quervain's tenosynovitis. However, a study done by Minamikawa et al. in 1991[8] reported that 47% of De Quervain's patients have multiple subcompartments, which contrasts with our study result.

In our study, during the open surgical release of the first extensor compartment, we found that 4/16 patients had more than one APL tendon sheath, which may cause an increase in its contents, leading to increase in the frictional force during gliding of APL and EPB tendons in the compartment [Figure 2]. Accessory or aberrant APL tendon slips had also been reported by Martinez and Omer, 1985.[9] They found four tendon slips of APL, and some authors found seven tendon slips,[10] with incidence even as high as 84%–98%.[3] We encountered one patient without APL tendon, which was the first of its type, and we could not find any similar case reported in English literature [Figure 3].

A study done by Lee et al.[11] in 2014 for open surgical release of the first extensor compartment on 32 patients with De Quervain's tenosynovitis found mostly single tendon slip rather than multiple slips of APL; the result was similar with our study, and we found 4/16 patients with single APL and EPB tendon without septum in the first extensor compartment [Figure 4]. Single EPB tendons were found in all the 16 cases of De Quervain's tenosynovitis patients, which was similar to those reported in previous studies.[3],[7],[8] We had not encountered any case with the presence of extensor pollicis tertius tendon slip.


  Conclusion Top


We recommended a prior anatomical knowledge of subcompartment/septum in the fibro-osseous tunnel and accessory tendons of APL in the cases of De Quervain's syndrome, which may be helpful for surgeons in the complete release of the first extension compartment tendons during the surgical release and treatment of De Quervain's tenosynovitis. Single APL tendon and a single EPB tendon with subcompartment were the common pattern observed in our study. A preoperative magnetic resonance imaging scan or ultrasound examination may also give an idea of the variations prior to surgery or even before local steroid infiltration.

Need of further study

In our study, only soft-tissue structure was studied such as number of APL and EPB and presence or absence of septum in the first extensor septum. We had not studied the length and depth of grooves with or without osseous ridge in the distal end of radius, which might lead to De Quervain's tenosynovitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sawaizumi T, Nanno M, Ito H. De Quervain's disease: Efficacy of intra-sheath triamcinolone injection. Int Orthop 2007;31:265-8.  Back to cited text no. 1
    
2.
Nayak SR, Hussein M, Krishnamurthy A, Mansur DI, Prabhu LV, D'Souza P, et al. Variation and clinical significance of extensor pollicis brevis: A study in South Indian cadavers. Chang Gung Med J 2009;32:600-4.  Back to cited text no. 2
    
3.
Jackson WT, Viegas SF, Coon TM, Stimpson KD, Frogameni AD, Simpson JM. Anatomical variations in the first extensor compartment of the wrist. A clinical and anatomical study. J Bone Joint Surg Am 1986;68:923-6.  Back to cited text no. 3
    
4.
Rush J. De Quervain's disease. Curr Orthop 2000;14:380.  Back to cited text no. 4
    
5.
Loomis LK. Variations of stenosing tenosynovitis at the radial styloid process. J Bone Joint Surg Am 1951;33-A: 340-6.  Back to cited text no. 5
    
6.
Abu-Hijleh MF. Extensor pollicis tertius: An additional extensor muscle to the thumb. Plast Reconstr Surg 1993;92:340-3.  Back to cited text no. 6
    
7.
Bahm J, Szabo Z, Foucher G. The anatomy of de Quervain's disease. A study of operative findings. Int Orthop 1995;19:209-11.  Back to cited text no. 7
    
8.
Minamikawa Y, Peimer CA, Cox WL, Sherwin FS. De Quervain's syndrome: Surgical and anatomical studies of the fibroosseous canal. Orthopedics 1991;14:545-9.  Back to cited text no. 8
    
9.
Martinez R, Omer GE Jr. Bilateral subluxation of the base of the thumb secondary to an unusual abductor pollicis longus insertion: A case report. J Hand Surg Am 1985;10:396-9.  Back to cited text no. 9
    
10.
Sarikcioglu L, Yildirim FB. Bilateral abductor pollicis longus muscle variation. Case report and review of the literature. Morphologie 2004;88:160-3.  Back to cited text no. 10
    
11.
Lee HJ, Kim PT, Aminata IW, Hong HP, Yoon JP, Jeon IH. Surgical Release of theFirst Extensor Compartment for Refractory De Quervain's Tenosynovitis: Surgical Findings and Functional Evaluation Using DASH Scores. Clinics in Orthop Surg 2014;6:405-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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