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Mateusz Gładysz

De Quervain release

· MD · FEBOPRAS · FEBHS

De Quervain's tenosynovitis is a stenosing tenosynovitis of the first extensor compartment, the tunnel over the radial styloid through which the abductor pollicis longus and extensor pollicis brevis tendons pass.

Last clinically reviewed

1. Indications

  • Pain over the first extensor compartment that persists or recurs despite a splint and one or more corticosteroid injections. An injection, with a splint as an adjunct, is the recommended first treatment12. In an insurance database of 33,420 patients, a single injection was the only treatment recorded in 71.9 per cent of those injected; 19.7 per cent had a repeat injection and 8.4 per cent went on to surgery3.
  • Wrists in which injection fails often have a separate compartment for the extensor pollicis brevis: 22 of 30 wrists released after a failed injection had one4.
  • The diagnosis is clinical5. In the the examiner grasps the thumb and deviates the wrist ulnarly; the thumb-in-fist manoeuvre, often misnamed as Finkelstein's6, can give a false-positive result and lead to inappropriate surgery78. The had a sensitivity of 0.99 but a specificity of 0.29 against ultrasound6.
  • Ultrasound before surgery is optional. It can show the thickened compartment and a septum; a meta-analysis that recommends its use found a septum in 67 per cent of operated wrists against 35 per cent of cadaver wrists9.

2. Contraindications

  • Active infection of the hand or wrist.
  • Symptoms that began in pregnancy or while breastfeeding and may still settle. In a small trial, 8 of 9 women treated with a splint had spontaneous resolution at the end of lactation10. In a separate comparison, 1 of 30 postpartum women needed surgery, against 25 of 30 non-pregnant women given the same splint, physiotherapy and anti-inflammatory treatment11. A corticosteroid injection is not contraindicated in the third trimester or during breastfeeding12. Release is considered when symptoms persist after delivery or weaning despite a splint and an injection.
  • Another cause of radial-sided wrist pain. Thumb-base arthritis () must be distinguished5. An associated should be identified before release; otherwise release may give incomplete relief or aggravate the neuritis13.
  • A corticosteroid injection within the previous 90 days is a relative contraindication, and the timing is discussed with the patient; surgery is then deferred or goes ahead at the patient's request, with an early wound review. The 90-day interval comes from trigger-finger release, where deep infection was commoner when surgery followed an injection within 90 days14. In a national database study of De Quervain release, an injection within 60 or 90 days before surgery was not associated with more surgical-site infection15.

3. Relevant anatomy

The first extensor compartment is a fibro-osseous tunnel under the over the radial styloid. In a cadaver study of 87 wrists, its proximal and distal borders lay about 20 mm and 8 mm from the radial styloid process, and the retinaculum over it extended about 15 mm along the compartment16.
The compartment often departs from the textbook pattern17. Across 21 studies, a septum was present in 43.7 per cent of cadaver wrists and 62.2 per cent of operated wrists, and 58.5 per cent of septa were incomplete18. In a prospective series of 130 releases, 37 per cent of compartments were single, 55 per cent had two subcompartments and 8 per cent three; the abductor pollicis longus had multiple slips in 78 per cent, while the extensor pollicis brevis was a single tendon in 92 per cent19. The extensor pollicis brevis lay in a separate subcompartment in 102 of 143 operated wrists against 18 of 90 cadaver wrists20. Septation and accessory tendons may lead to inadequate decompression17. In a cadaver study the mean septum length was about 5 mm, and its authors recommend exposure to 5 mm proximal to the radial styloid so that a subcompartment is not overlooked21.
The is the structure at risk22. It crossed the compartment in 59.5 per cent of cadaver wrists16, and at least one branch was encountered in 61 per cent of releases19. Its lateral dorsal digital branch to the thumb arose about 50 mm proximal to the radial styloid and passed directly over the compartment along its whole length in 8 of 20 forearms22.

4. Patient positioning

Supine, with the arm on a hand table and the forearm in neutral rotation so that the thumb is uppermost. The incision is marked before infiltration, together with the course of the superficial radial nerve where it can be felt. The operation is done under local infiltration with an upper-arm tourniquet at 250 mmHg, without an anaesthetist: 5 to 8 mL of 0.4% lignocaine with 1:250,000 adrenaline (within 1 to 1.5 mL/kg) is infiltrated along the planned incision and around the compartment. No antibiotic prophylaxis is given, because this is a clean operation without an implant.
is an alternative: buffered 1% lignocaine with 1:100,000 adrenaline is infiltrated, no tourniquet is used, and the patient moves the thumb actively at the end to confirm the release. Release under WALANT has been reported as safe and effective12. General anaesthesia is a further option.

5. Approach

A longitudinal incision 2 to 3 cm long is made over the first extensor compartment, in line with it and centred 1 cm proximal to the tip of the radial styloid. A transverse incision of about 2 cm is the alternative. The evidence for either is weak: a 2026 meta-analysis of 243 wrists found superficial radial nerve injury in 5.4 per cent after longitudinal and 7 per cent after transverse incisions, a difference that was not significant, and no significant difference in hypertrophic scarring23; an earlier review of three trials found very-low-certainty evidence that the longitudinal incision may slightly reduce nerve injury and scar hypertrophy24. One small series associated the longitudinal incision with poor scar appearance and nerve injury25.

6. Key steps

  1. 1. Marking and infiltration

    The radial styloid, the line of the compartment and the 2–3 cm incision are marked, with the palpable course of the superficial radial nerve, before any local anaesthetic is given. The skin-shop mix is then infiltrated along the incision and around the compartment, and the tourniquet is inflated.

  2. 2. Skin incision and protection of the superficial radial nerve

    The skin is incised with a No. 15 blade. The subcutaneous tissue is spread longitudinally with blunt tenotomy scissors only. Branches of the superficial radial nerve are identified, mobilised and protected throughout with skin hooks, and no branch is retracted under tension. The thumb branch may run directly over the compartment along its whole length22.

  3. 3. Exposure and opening of the retinaculum

    The compartment is exposed from 2 cm proximal to the radial styloid to its distal edge. The retinaculum is incised along its dorsal margin over its whole length, leaving a palmarly based flap of retinaculum to prevent palmar subluxation of the tendons with wrist flexion26. Series using a dorsal opening, a partial dorsal resection of the retinaculum or a retinacular flap reported no palmar subluxation or tendon dislocation272829.

  4. 4. Tendon identification and the extensor pollicis brevis subcompartment

    Each abductor pollicis longus slip and the extensor pollicis brevis are delivered from the compartment in turn. The tendons are distinguished by traction: the abductor pollicis longus lifts the thumb metacarpal, and the extensor pollicis brevis extends the metacarpophalangeal joint, and an accessory abductor slip must not be mistaken for the extensor pollicis brevis5. A separate extensor pollicis brevis subcompartment is sought specifically in the dorsal and distal part of the compartment and, where present, opened along its full length. The compartment is also inspected proximally for a proximal septum.

  5. 5. Confirmation of release and tendon stability

    The wrist is moved through flexion, extension and ulnar deviation with the thumb abducted and extended. Free excursion of every tendon, without perching or subluxation, is confirmed. Under WALANT the patient abducts and extends the thumb with the wrist flexed, then moves the wrist through flexion and ulnar deviation. In a prospective series of 130 releases, the tendons perched with passive wrist flexion in 9 per cent and dislocated palmarly in under 1 per cent19. When they perch or dislocate, the finding is recorded and a removable thumb splint is used for 2 weeks (section 7).

  6. 6. Thickened tenosynovium or a ganglion

    The state of the tendon sheath is recorded. A thickened tenosynovium is excised from the tendons and sent for histology. An intracompartmental ganglion is excised with the compartment lining; in one series of 33 releases, 8 patients had a ganglion within the extensor pollicis brevis subcompartment27.

  7. 7. Haemostasis

    The tourniquet is released (under WALANT there is none). Haemostasis is secured with bipolar diathermy, and the wound is irrigated with saline.

7. Closure

The skin is closed with a 4-0 Monocryl subcuticular suture and Steri-Strips, so there are no sutures to remove. A non-adherent dressing and a soft, bulky, non-circumferential wool and crepe dressing are applied with the thumb free. No splint is used when the tendons are stable. If the tendons perched or dislocated on the table, a removable thumb spica splint with the interphalangeal joint free is added for 2 weeks; in a randomised trial, tendon subluxation measured on ultrasound did not affect clinical outcome30.

8. Aftercare

  • Day case. Elevation when comfortable; immediate active thumb, finger and wrist movement; light, pain-free use of the hand from day 1.
  • Paracetamol and an anti-inflammatory regularly for 48 to 72 hours.
  • The bulky dressing is reduced to a light dry dressing at 48 to 72 hours, at the GP practice or a dressings clinic; the wound is kept dry until it is checked.
  • Wound check and Steri-Strip removal at 10 to 14 days.
  • A single early hand-therapy consultation: thumb and wrist range of motion, oedema and scar management, desensitisation of the radial nerve territory if there is tingling, and return-to-work advice.
  • Scar massage from 2 weeks, once the wound has healed.
  • Driving when the wheel can be gripped comfortably and strong analgesics have stopped, typically after 1 to 2 weeks. Desk work within the first week, once the dressing is reduced; manual work at 3 to 4 weeks.
  • Tingling over the back of the thumb from handling of the superficial radial nerve usually settles over weeks; a tender scar may take 3 months.
  • After an injection within the previous 90 days: wound review at 5 to 7 days and a low threshold for antibiotics.
  • Increasing pain, swelling, redness, discharge or fever: see the GP or go to the emergency department.
  • Clinic review at 6 weeks.
Early movement without a splint is supported by a randomised trial in which immobilisation after release gave no advantage in tendon displacement or clinical outcome over early mobilisation30. In a series of 154 wrists treated by complete excision of the sheath and no immobilisation, no tendon subluxation occurred31.

9. Complications

10. Evidence

Open release is effective. Besides the meta-analysis above32, a prospective cohort of 707 patients found that pain fell by a mean of 44 points on a 100-point scale at 3 months; smoking, younger age, a longer duration of complaints, concomitant surgery and higher pain at intake were associated with more pain afterwards, but together explained only 11 per cent of the variance40. In a retrospective series of 43 patients, 88 per cent were fully satisfied, and complications were associated with dissatisfaction37. In 94 patients treated through a longitudinal incision under local infiltration and a tourniquet, the outcome was successful in all, with a negative Finkelstein test at long-term follow-up35.
How to open the retinaculum is debated. Leaving a palmarly based flap was proposed after a case of symptomatic subluxation26, and Le Viet's technique, with subcutaneous fixation of a retinacular flap, gave no tendon dislocation, neuroma or recurrence in 80 wrists at a mean of 9.5 years29. Against this, a randomised trial of 46 patients found that a dorsoulnar opening had no advantage over a midline opening, and that tendon subluxation did not affect clinical outcome30; complete excision of the sheath in 154 wrists was followed by no subluxation or reoperation over a mean of 7 months31.
Endoscopic release is an alternative in experienced hands. In a randomised trial of 52 patients it gave earlier improvement, fewer transient nerve injuries (3 against 9) and greater scar satisfaction; pain and disability scores no longer differed at 24 weeks34; a comparative study with a mean follow-up of 7.21 years found earlier return to work and equivalent long-term results after tendoscopic release36.
The evidence is limited by small, mostly retrospective series and few randomised trials; the incision meta-analyses rest on three or four studies each2324.
For patients — plain-language summary
De Quervain's tenosynovitis causes pain on the thumb side of the wrist, where two tendons run through a tight tunnel. Many people get better with a steroid injection, a splint or both. If the pain keeps coming back, a short operation opens the tunnel. It is done as a day case under local anaesthetic, with a cuff on the upper arm. A cut of 2 to 3 cm is made along the line of the tendons, and a small skin nerve is protected. The roof of the tunnel is opened along its back edge, leaving a flap on the palm side to help stop the tendons slipping forward, and a second, hidden tunnel is looked for and, if there is one, opened. The stitch dissolves, and usually no splint is needed. You can use the hand for light tasks from the first day. Most people return to desk work within the first week, drive after 1 to 2 weeks and do manual work after 3 to 4 weeks. You are seen in clinic at 6 weeks. In studies, about 5 in 100 people still have some pain, and about 11 in 100 have a complication, such as tingling over the back of the thumb or a tender scar.

FAQ Frequently asked questions

When is an operation worth considering?
When pain over the thumb side of the wrist keeps coming back or does not settle despite a splint and one or more steroid injections. One injection is enough for about 7 in 10 people. When the condition starts in pregnancy or while breastfeeding, it usually settles by itself, so surgery is rarely needed then.
Will I be awake?
Usually. The operation is a day case under local anaesthetic: numbing medicine is injected around the wrist, and a cuff on the upper arm stops the bleeding. Sometimes it is done wide awake without the cuff, or under a general anaesthetic.
Do I need a splint afterwards?
Usually not. You move the thumb, fingers and wrist straight away. In a randomised trial, keeping the wrist still after surgery gave no better result than early movement. If the tendons are loose at the end of the operation, you wear a removable thumb splint for 2 weeks.
When can I go back to work and drive?
Most people return to desk work within the first week and to manual work after 3 to 4 weeks. You can drive when you can grip the wheel comfortably and are off strong painkillers, usually after 1 to 2 weeks. The wound is checked at 10 to 14 days and you are seen at 6 weeks.
What can go wrong?
About 11 in 100 people have a complication. Tingling over the back of the thumb from handling a small skin nerve is usually temporary. The scar can be tender for about 3 months. Rarely, the tendons slip forward, or a hidden tunnel is missed and the pain continues, which may need a second operation.

References

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