De Quervain's Release Info Evidence Consent
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
Why this operation has been suggested
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. De Quervain's release is an operation that opens the tunnel of tissue around two thumb tendons at the wrist, so the tendons can glide without catching. We usually offer it when other treatments have not given you enough relief.
Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your wrist, and arrange imaging if it is needed to confirm the cause of your pain. For this condition, non-operative care usually comes first. That means a cortisone injection, which is the preferred initial treatment, often with a splint and hand therapy. A single cortisone injection relieved symptoms in 82% of patients, with over half remaining symptom-free for at least 12 months. Repeat injections can also work well. Surgery is considered when injections and splinting have not settled your pain, or when your symptoms are severe enough to affect daily life. The operation aims to relieve pain and let you use your thumb and wrist normally again.
Before the operation
Your surgeon will confirm the diagnosis at your appointment, usually with a gentle wrist examination and, if needed, imaging such as an X-ray, ultrasound or MRI scan to plan the operation. Most people need nothing more before surgery day. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. On the day, stop eating seven hours beforehand; we ask for this so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to skip. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing with a sleeve that slides up past your wrist.
On the day
You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist. This operation can be done under local anaesthetic (an injection that numbs just the area of surgery, with you awake) or under general anaesthetic (fully asleep). Most people choose local: recovery is quicker and you can go home soon after. If you'd prefer to be asleep, that's also a reasonable choice; discuss it with your surgeon and anaesthetist.
You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery.
What the operation involves
The operation is called a release of the first dorsal compartment. That is the tunnel of tissue on the thumb side of your wrist that squeezes two tendons as they pass through it. Your surgeon makes a small cut over that tunnel, on the thumb side of the wrist, and opens the tunnel so the tendons can glide freely.
Sometimes one of the two tendons sits in its own separate space within the tunnel, divided off by a wall of tissue. If your surgeon finds that during the operation, they open that space as well, so both tendons are freed.
Once the tendons glide without catching, your surgeon closes the cut with stitches and covers it with a dressing. You keep the dressing on for about 10 days, as described in the section after this one.
The whole operation is a short, focused procedure on a small part of your wrist. You will go home the same day with instructions on caring for the wound.
After the operation
You wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. Someone should stay with you for the first 24 hours. Your wrist will have a dressing over the stitches, and we leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can move your fingers, thumb and wrist as comfort allows, and most people use their hand for light tasks straight away. Many people feel relief within the first day or two.
Recovery
Many people notice relief within the first day or two, once the tight tunnel has been opened and the tendons can glide. Some soreness and swelling around the wound is normal in the early days. Resting with your hand raised on a pillow eases this, as does gentle movement of your fingers, thumb and wrist as comfort allows.
You can use your hand for light tasks straight away. Keep the dressing clean and dry, and leave it on until we review it. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Your hand therapist will guide you through simple exercises so the tendons keep gliding smoothly, and will make a splint for you if one is needed.
As the swelling settles, everyday activities become easier. You will find your grip and thumb movement return gradually. Once you can grip and turn a steering wheel without protecting your hand, and the wound is comfortable, you can usually drive again; see our page on Driving after upper-limb surgery. Work and other activities can resume as your comfort and strength allow.
Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you along the way.
What can go wrong
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
Sometimes the tight tunnel is not fully opened, or a tendon slips out of its groove as it glides. You might notice the same catching or pinching feeling you had before the operation, or a snapping sensation at the base of your thumb when you move it. If that happens, bring it up at your next review. Further surgery can rebuild the tunnel and hold the tendons in place if they keep slipping.
The nerves that give feeling to the back of your hand and thumb run close to the tunnel. If one is irritated during surgery, you may notice tingling, numbness or a sharp, electric feeling in your thumb or the back of your hand. Most of these feelings settle, but tell your surgeon if they do not, or if they seem to be getting worse rather than better.
Recovery can also take longer than you hoped. Some people find the soreness and stiffness linger for weeks rather than days, and this can be frustrating. If your wrist is still painful after a reasonable time, or the relief you expected has not arrived, raise it at your review appointment so we can look at what is going on.
Occasionally a cortisone injection given before surgery does not work as well as expected, and the pain continues. If that has been your experience, it does not mean anything has gone wrong with your wrist. It simply means the next step, surgery, is the right one for you.
The complications table on this page lists typical rates if you want the specifics.
When to call us
Most people recover without problems, but some symptoms need urgent attention. Call us if you have a fever, if the wound becomes more red or starts to leak fluid, or if your pain suddenly gets much worse. Go to emergency if you have swelling or pain in your calf, or shortness of breath. Call us straight away if your hand or thumb goes numb and stays that way, or if you cannot move your fingers or thumb. When in doubt, call us.
Where to read more about the condition
This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the De Quervain's Tenosynovitis page.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology
First Extensor Compartment Anatomy
- A common septum is found between the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in 80% of patients requiring surgical release for de Quervain tenosynovitis [2].
- The first dorsal compartment of the wrist contains the APL and EPB tendons [7].
- The fibrous and osseous components of the first extensor compartment of the wrist have been characterized in cadaveric studies [1].
Wrist Bony Anatomy
- The wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints, as well as the eight carpal bones and their proximal and distal articulations [3].
- The proximal row of carpal bones consists of the scaphoid, lunate, triquetrum, and pisiform [3].
- The distal row of carpal bones consists of the trapezium, trapezoid, capitate, and hamate [3].
- The distal radius has three articular components: the scaphoid fossa, the lunate fossa, and the sigmoid notch [7].
- The concave elliptical distal radius is oriented in the sagittal plane with an average of 11 degrees of volar tilt [7].
- In the frontal plane, the average radial inclination of the distal radius is 23 degrees [7].
- Radial length is measured from the tip of the radial styloid to the ulnar articular surface and averages 13 mm [7].
- The distal ulnar convexity articulates at the lesser sigmoid notch of the distal radius [3].
- There is about a 20-degree inclination of the distal ulna at its articulation with the radius [3].
Wrist Ligaments and Soft Tissue
- Extrinsic carpal ligaments connect the radius or the ulna to the carpus [8].
- In general, volar wrist ligaments are stronger than dorsal ligaments [8].
- The triangular fibrocartilage complex (TFCC) attaches to the ulnar margin of the lunate fossa of the radius and includes the ulnar collateral ligament, dorsal and volar radioulnar ligaments, articular disc, meniscal homologue, extensor carpi ulnaris sheath, and ulnolunate and ulnotriquetral ligaments [3].
- The space of Poirier is a relatively thin area on the palmar side of the carpus situated between the radiolunotriquetral ligament and the radioscapocapitate ligament, overlying the palmar surface of the lunate [3].
- The space of Poirier is a weak area vulnerable to instability where the distal carpal row separates from the lunate during a perilunate dislocation [8].
- The dorsal radiocarpal ligament has a trapezoidal shape and passes from the dorsal rim of the distal radius to the lunate and the triquetrum [8].
- The scapholunate interosseous ligament is C-shaped, consisting of dorsal, palmar, and interosseous portions, with the dorsal portion being the strongest and thickest [8].
- The lunotriquetral interosseous ligament is C-shaped, with the volar portion being the thickest and strongest [8].
Wrist Biomechanics and Kinematics
- The radius bears 80% of the axial load transmitted through the radiocarpal joint, while the ulna bears 20% in neutral ulnar variance [8].
- Approximately 62° of wrist extension occurs through the radiocarpal joint [8].
- Approximately 62% of wrist flexion occurs through the midcarpal joint [8].
- The midcarpal joint is mostly responsible for 20° of radial deviation and 40° of ulnar deviation [8].
- The midcarpal joint is responsible for the “dart thrower’s motion,” which involves moving from radial extension into ulnar flexion positioning of the wrist [8].
- During wrist flexion from neutral, the proximal row translates dorsally [8].
- During wrist extension from neutral, the proximal row translates palmarly [8].
- The extensor carpi ulnaris (ECU) ulnarly deviates the wrist when the forearm is in pronation and extends the wrist when the forearm is supinated [2].
- The ECU provides both static and dynamic support to the wrist [2].
- The volar ECU sheath is adjacent to the TFCC, and ECU injury may coexist with concomitant TFCC injury [2].
Pathophysiology and Associated Conditions
- Tenosynovitis of the ECU is a common cause of ulnar-sided wrist pain [2].
- Painful dorsal wrist swelling may be the presenting symptom in rheumatoid arthritis, and tenosynovial swelling may contribute to de Quervain disease [11].
- In rheumatoid arthritis, synovitis can spread and cause massive swelling in the shape of an hourglass, with the middle constricted by the extensor retinaculum [11].
- The human wrist is described as the most complex articular system in the human body, with each carpal bone capable of moving in different degrees or directions dependent on hand position, motion, and force generation [4].
Physical Examination
- Patients with ECU tenosynovitis present with tenderness over the ECU tendon [2].
- Patients with ECU tenosynovitis present with swelling [2].
- Patients with ECU tenosynovitis present with pain with resisted wrist extension [2].
- Patients with ECU tenosynovitis do not have instability [2].
- The ECU synergy test helps distinguish a TFCC injury from ECU tenosynovitis [2].
- In the ECU synergy test, the patient rests the elbow of the supinated forearm on a table with the digits extended [2].
- In the ECU synergy test, the examiner grasps the patient’s thumb and long finger and asks the patient to deviate the thumb radially against resistance [2].
- In the ECU synergy test, the examiner’s other hand gently palpates the ECU and flexor carpi ulnaris [2].
- The presence of pain during the ECU synergy test suggests pathology in the ECU rather than intra-articular pathology [2].
Imaging
- Ultrasonography can be used to distinguish tenosynovitis from ECU subsheath injury in patients whose examination is equivocal [2].
- MRI can be used to distinguish tenosynovitis from ECU subsheath injury in patients whose examination is equivocal [2].
Investigations
Magnetic Resonance Imaging
- MRI has been an important diagnostic tool for hand and wrist imaging since its first report in 1986 [9].
- The primary advantages of MRI compared with CT and radiography are improved tissue characterization, especially of soft tissues such as ligamentous structures and synovium, and the lack of ionizing radiation [9].
- MRI is the modality of choice for imaging radiographically occult fractures of the hand and wrist [9].
- Early MRI was limited by low magnetic field strength (0.15 T) and limited image options and processing [9].
- Modern MRI is generally performed at 1.5T or 3T with a wide variety of imaging options and powerful image processing [9].
- 3T MRI is much preferred for hand and wrist imaging, especially for imaging small fields of view [9].
- Dedicated extremity magnets have been marketed, but their image quality is poor compared with conventional MR imaging [9].
- 7T MRI has recently become approved for clinical use and has the potential to become a powerful tool for hand and wrist imaging as applications are developed [9].
- MRI with contrast enhancement is most commonly used to determine whether soft-tissue lesions are solid or cystic or to better visualize erosions and synovial burden in rheumatologic imaging [9].
- Dynamic contrast enhancement has been used with inconsistent results to assess for the presence of avascular necrosis in the lunate or scaphoid after injury [9].
- MR angiography of the hand and wrist can be helpful in situations such as the diagnosis of hypothenar hammer syndrome [9].
- MR arthrography can be performed for evaluation of triangular fibrocartilage and intercarpal ligament tears, but this is generally unnecessary with the increasing availability of high-field MRI [9].
- The use of MRI for hand and wrist imaging was first reported in 1986 [9].
Radiography and Computed Tomography
- Hybrid SPECT/CT has been used for the diagnosis of radiographically occult fractures of the wrist [5].
- Cone-beam CT has been used in the diagnosis of scaphoid fractures [5].
- CT and MRI have a diagnostic impact on wrist injuries in young adults [5].
- Distal radioulnar joint stress radiography has been used for detecting radioulnar ligament injury [5].
- Cine MRI has been used as a new approach to the diagnosis of scapholunate dissociation [5].
- Radiographic stress views have been compared for scapholunate dynamic instability in a cadaver model [5].
- Cone-beam computed tomography arthrography is an innovative modality for the evaluation of wrist ligament and cartilage injuries [5].
- Simple plain radiographic signs and measures have been evaluated for the accuracy of diagnosing acute scapholunate ligament injuries of the wrist [10].
- Radiographic clues have been used for determining carpal instability and treatment protocols for scaphoid fractures [10].
References
[1] Campbell S Operative Orthopaedics 4 Volume Set. ANATOMIC RECONSTRUCTION OF THE DISTAL RADIOULNAR LIGAMENTS > ANATOMY AND BIOMECHANICS.
[2] Aaos Comprehensive Orthopaedic Review 3. Tendinopathy of the Hand and Wrist* > VII. Extensor Carpi Ulnaris Tenosynovitis.
[3] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > ANATOMY.
[4] Green S Operative Hand Surgery. INTRODUCTION.
[5] Campbell S Operative Orthopaedics 4 Volume Set. ANATOMIC RECONSTRUCTION OF THE DISTAL RADIOULNAR LIGAMENTS > RADIOGRAPHIC TECHNIQUES.
[7] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > FRACTURES AND DISLOCATIONS OF THE DISTAL AND MID-FOREARM.
[8] Aaos Comprehensive Orthopaedic Review 3. Carpal Instability* > II. Anatomy and Biomechanics (See Chapter 92).
[9] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Imaging: Advances in Imaging of the Hand and Upper Extremity > Magnetic Resonance Imaging.
[10] Campbell S Operative Orthopaedics 4 Volume Set. ANATOMIC RECONSTRUCTION OF THE DISTAL RADIOULNAR LIGAMENTS > DIAGNOSIS AND EVALUATION.
[11] Campbell S Operative Orthopaedics 4 Volume Set. THUMB CARPODNETACARPAL ARTHRODESIS WITH KIRSCHNER WIRE OR BLADE-PLATE FIXATION > SYNOVITIS OF THE WRIST.
