Dr Labosky,
Here is my participation to the ASSH letter.

De Quervain's tenosynovitis

A more appropriate and descriptive diagnostic term for the " De Quervain's tenosynovitis" would be Stenosing Tendovaginitis of the First Dorsal Retinaculum, as presented in 1895 (1) .

Let us revise the anatomical particularities of this compartment .
  • There is often an intermediate septum, individualising the Extensor Pollicis Brevis from the Abductor Pollicis Longus . This septation is seen more frequently in the surgical exploration cases than in the cadaver dissection (Loomis, 1951)

  • The Abductor Pollicis Longus is not unique. In his cadaver study, E. Zancolli found 3 to 5 slings of this tendon. The most palmar one is often a digastric muscle inserting in the thenar muscles (Abductor Pollicis Brevis ), it does create an abnormal pull on the thumb column, causing subluxation and osteo-articular pain. He describes it as the first stage of rhizarthrosis of the thumb. The other abnormal insertion is directly on the trapezial bone. Tountas and Bergman (2) mentionned 2 studies reporting accessory tendons in 90 % and 98.5 %.

Another clinical point that should be mentionned, is the participation of some neuritis of the radial sensory nerve to the pain process : Wartenberg's cheiralgia paresthetica (3) ( Gr. meaning pain in the hand ). The reactional tenosynovitis of this first dorsal retinaculum could irritate the overlaying nerve fibers. Those patients described dorsal thumb pain beyond the site of the mechanical entrapment; this description is often more frequently reported than the Finkelstein sign (maximal opposition of the thumb).

Thus the appropriate surgical management of this entity could be divided in 3 points :

  • The identification of the septation and release of the individualised Extensor Pollicis Brevis.

  • This procedure could combine a greater decompression of the first dorsal compartment by resection of the most palmar accessory Abductor tendon. This point merge the first stage treatment of a rhizarthrosis of the thumb (Zancolli) to this release procedure to further releive the associated thenar pain.

  • A simple release of the first dorsal retinaculum will cause the Abductor Pollicis Longus to subluxate. Kakandji (4) proposed a nice reconstruction of it. An incision is made obliquely over it, at each extremity of the retinaculum a small incision is done, one of it is palmar-proximal and the other is dorsal-distal, this will cause an open-wedged effect upon closure; then, the flaps are slided, creating a narrower retaining sling with his natural tenosynovium inside.

(1) Uber eine Form von chronischen Tendovaginitis Quervain, F. De, Korresp-Bl Schweiz Arz, 1895, 25, 389-394.
(2) Anatomic Variations of the upper Extremity Tountas,C. and Bergman,R., Churchill Livingston, 1993.
(3) Névrites et névromes des branches sensitives du nerf radial. Foucher,Guy,Ann Chir Main, 1991, X no 2,108-112.
(4) Plastie d'agrandissement de la coulisse radio-styloidienne A.I. Kapandji, Ann Chir Main, 1990, IX no 1,42-46.

This text can be viewed with the colored plates and surgical pictures at : http://manus.crchul.ulaval.ca
Daniel Cloutier, md, FRCS(C), Centre Hospitalier Université Laval, Québec city, Québec, Canada.
Illustration by Frederic-Charles Cloutier
2000-03-21