Upper Extremity Tendinopathies (trigger digits, deQuervains, Lateral epicondylitis)-Hand Surgery Update IV: First Dorsal Extensor Compartment Release

Video Transcription

A 1.5 centimeter longitudinal incision is drawn overlying the tendons of the first dorsal extensor compartment just distal to the radial styloid.  Although other surgeons use transverse or oblique incisions, we believe that the longitudinal incision reduces the risk of injury to the superficial radial nerve.  The incision site is then infiltrated with local anesthetic.  After anesthesia has been achieved, the tourniquet is then inflated. The incision is carried just through the dermis and not into the subcutaneous fat, thus avoiding  injury to the superficial radial nerve.  Using blunt dissection, the branches of the superficial radial nerve are then identified, gently retracted, and protected throughout the case.  Dissection is then carried deeper, and the abductor pollicis longus and extensor pollicis brevis tendons are identified entering the stenosing sheath.  It should be noted that the abductor pollicis longus tendon may consist of several slips. Pulling on the extensor pollicis brevis should extend the MP joint of the thumb.  Correct placement of retractors ensures adequate visualization of the sheath in its entirety. Tenotomy scissors are then used to release the sheath.  A critical point is to perform this release on the dorsal side of the sheath. This will prevent vulvar subluxation of the released tendons.  Here it is obvious that the dorsal slip is a lot smaller than the vulvar slip, thus preventing the subluxation.  It is fairly common for the extensor pollicis brevis to course through a separate subcompartment.  In this case, the multiple slips of the APL may mislead the surgeon into performing an incomplete release.  Upon completion of the release, the tendon should therefore be gently pulled on to verify that both have been fully released.  If the NP joint of the thumb does not extend, look for another subcompartment. After the release is completed and verified, the tourniquet is let down and hemostasis is achieved.  The skin is then closed with interrupted nylon sutures and the wound is dressed. Postoperatively, a radial gutter splint with a thumb spike is placed to control postoperative  pain and protect from vulvar subluxation of the release tendons. Care must be taken to allow free movement of the thumb IP joint.

Video Summary

In this video, the surgeon demonstrates a technique to release the tendons in the first dorsal extensor compartment of the hand to treat stenosing tenosynovitis, commonly known as trigger thumb. The surgeon makes a longitudinal incision just below the radial styloid, ensuring to avoid the superficial radial nerve. The tendons are identified and protected, and a release is performed using tenotomy scissors on the dorsal side of the sheath to prevent subluxation. Multiple slips of the abductor pollicis longus tendon may be present, so it is important to verify complete release. After verifying, the wound is closed, and a splint is used for postoperative care.

Keywords

surgeon

tendons

release

trigger thumb

postoperative care