Scientific Article

A Prospective Evaluation of the Anatomy of the

First Dorsal Compartment in Patients Requiring
Surgery for De Quervain’s Tenosynovitis
Jonas L. Matzon, MD1 Jack G. Graham, BS1 Kevin F. Lutsky, MD1 T. Robert Takei, MD1
Gregory G. Gallant, MD1 Pedro K. Beredjiklian, MD1

1 Division of Hand Surgery, Department of Orthopedic Surgery, The
Rothman Institute, Sidney Kimmel Medical College, Thomas
Jefferson University, Philadelphia, Pennsylvania
J Wrist Surg
Address for correspondence Jonas L. Matzon, MD, Division of Hand
Surgery, Department of Orthopaedic Surgery, The Rothman Institute,
Sidney Kimmel Medical College, Thomas Jefferson University,
925 Chestnut Street, Philadelphia, PA 19107-1216
(e-mail: Jonas.Matzon@rothmaninstitute.com).

Abstract Background We prospectively evaluated the surgical anatomy during first dorsal
compartment release for De Quervain’s tenosynovitis, with special attention to the

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superficial branch of the radial nerve (SBRN). Additionally, the incidence of tendon
instability during surgery was assessed.
Methods This prospective cohort study consisted of 130 De Quervain’s patients
undergoing first dorsal compartment release. The treating surgeons recorded the type
of incision used, the number of abductor pollicis longus (APL) and extensor pollicis
brevis (EPB) tendon slips, the number of SBRN branches encountered, additional
subcompartments created by any septations, and active/passive tendon stability.
Results A singular first dorsal compartment was found in 37% of cases, whereas 55%
of patients had two subcompartments and 8% had three. Multiple APL tendon slips
(range: 1–4) were identified in 78% of patients. In contrast, a single EPB tendon was
found in 92% of patients (range: 0–2). At least one SBRN was encountered in 61% of
cases. Following surgery, instability was evident in 9% of patients, who had tendons
perch with passive wrist flexion. In one of these patients (<1%), the tendons dislocated
Keywords volarly out of the first dorsal compartment during active flexion.
► De Quervain’s Conclusions The anatomical findings in our relatively large, prospective study of De
tenosynovitis Quervain’s patients undergoing first dorsal compartment release are consistent with
► first dorsal previous smaller and/or retrospective studies. Overall, we expect to encounter the
compartment SBRN during first dorsal compartment release in more than 50% of patients but are
► surgical anatomy unconcerned if it is not visualized during a careful approach. Tendon instability has an
► wrist incidence of 9%; however, dislocation is rare (<1%).

De Quervain’s tenosynovitis is a common condition affecting
the extensor pollicis brevis (EPB) and abductor pollicis
longus (APL) tendons as they run through the first dorsal
extensor compartment of the wrist. Several anatomical and
surgical studies have suggested that a separate compartment
for the EPB and/or multiple slips of the APL can predispose
patients to this condition and can result in symptoms that
remain refractory to nonsurgical treatment.1–4 Surgical
treatment of De Quervain’s tenosynovitis involves release
of the first dorsal compartment including the separate
compartment for the EPB (if present) and all slips of the
APL. A thorough exploration of the first compartment is

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First Dorsal Compartment Surgical Anatomy Matzon et al.
necessary to ensure adequate release of all tendon slips,
which otherwise may result in persistent postoperative
symptoms if not completely decompressed.
Aside from the failure to identify and to release all tendon
slips, two other complications involving anatomical variables
can occur during De Quervain’s surgery but have received far
less attention in the literature. First, the superficial branch of
the radial nerve (SBRN) is at a risk during surgical release. It
emerges from between the brachioradialis and the extensor
carpi radialis longus 7 to 9 cm proximal to the radial styloid and
begins to branch approximately 5 cm proximal to the styloid.5–7
Based on cadaveric studies, these branches are found overlying
the first dorsal compartment directly in the De Quervain’s
surgical field in a large proportion of people.6,7 Second, once
the retinaculum has been released, the tether maintaining the
EPB and APL tendons in the first dorsal compartment has been
removed. This can result in postoperative volar subluxation of
the tendons.8–10 The recommended surgical technique is to
release the first dorsal compartment along its dorsal margin,
leaving a sling of retinaculum to restrain the tendons and
prevent volar subluxation.11 The effectiveness of this has not
been studied extensively.
Most of the existing data on the anatomical variability in
patients treated surgically for De Quervain’s tenosynovitis
comes from retrospective or cadaveric studies. The purpose
of this study was to prospectively evaluate the surgical anatomy
during De Quervain’s release with special attention to the SBRN
and to assess the incidence of tendon instability during surgery.
Materials and Methods
Institutional Review Board approval was obtained prior to
initiation of the study. Patients who underwent a primary
surgical decompression of the first dorsal compartment of
the wrist between September 2016 and February 2018 by a
group of 14 board-certified, fellowship-trained hand sur-
geons were evaluated prospectively. Demographic data and
intraoperative anatomical data from 130 patients formed the
basis of this study. All cases were unilateral. The study cohort
comprised 108 women and 22 men. This female predomi-
nance (83%) is comparable to the demographics of other De
Quervain’s studies.1–3
All surgeries took place under local anesthesia with or
without sedation. Each surgeon performed the decompres-
sion using their preferred technique—either a longitudinal or
a transverse/oblique incision along Langer’s lines. Branches
of the SBRN were identified and protected when encoun-
tered, and the retinaculum of the first dorsal compartment
was incised at its dorsal-most aspect. The contents of the first
dorsal compartment were explored, and all subsheaths were
released. Once released, the stability of the tendons within
the first dorsal compartment was tested passively in full
flexion and extension. Then, the patient was asked to fully
flex and extend the wrist actively, and the active stability was
assessed. The tendons were classified as stable if they
remained within the first dorsal compartment, perched if
they rode up onto the volar ridge of the first dorsal compart-
ment but did not dislocate, or unstable if they dislocated
Journal of Wrist Surgery
volarly from the first dorsal compartment in flexion. The
treating surgeons completed a questionnaire detailing the
type of incision used, the number of APL tendon slips,
number of EPB tendon slips, the number of SBRN branches
encountered, the number of additional subcompartments
created by any septations, and active/passive tendon stabi-
lity. Statistical analysis was performed using Fisher’s exact
test for comparison of nonparametric data.
Results
The mean age of the group was 57 years (range: 24–82). The
average age of the female patients was 58 years compared
with 52 years for the men (p ¼ 0.03). A transverse/oblique
incision was made along Langer’s lines of the skin in 108
(83%) of cases, whereas the remaining 22 (17%) procedures
were performed with a longitudinal incision. In 48 wrists
(37% of cases), a singular first dorsal compartment without
subsheaths was noted intraoperatively. Two total subcom-
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partments were identified in 71 (55%) wrists, and three
subcompartments were identified in 11 (8%) wrists.
There was substantial variation in the number of tendon
slips discovered intraoperatively. Multiple APL tendon slips
were noted 78% of the time (102 of 130 cases). A single APL
tendon slip was found in 28 (21%) cases, two in 66 (51%), three
in 30 (23%), and four in 6 (5%). A single EPB tendon was
identified in 120 (92%) cases, two slips were found in 6 (5%)
cases, and the EPB was absent in the remaining 4 (3%) cases.
One or two SBRN were encountered in 50 and 11% of cases,
respectively. Zero SBRN were encountered in 39% of the
surgeries. There was no significant difference in the number
of branches encountered based on the incision type (p ¼ 0.8).
Following first dorsal compartment release, the APL and
EPB tendons were found to be stable both actively and
passively in 91% of cases. Tendon instability was noted in
9% of wrists after first dorsal compartment decompression:
12 patients were classified as perched with passive wrist
flexion. In one of these patients (<1% of total cohort), the
tendons dislocated volarly during active wrist flexion testing.
This patient was immediately treated with a first dorsal
compartment reconstruction using a brachioradialis tendon
flap. Eight of the remaining 11 patients with perched ten-
dons had the radial retinacular flap sutured to the subcuta-
neous tissues, as described by Bahm et al, and immediate
postoperative thumb spica splinting, as advocated by McMa-
hon et al.1,9 The other three patients had no additional
intraoperative treatment or postoperative splinting.
Discussion
Various studies have demonstrated a higher incidence of
subsheaths dividing the APL and EPB in De Quervain’s
patients compared with normal cadavers.1–3,12 Furthermore,
De Quervain’s patients tend to have multiple APL tendon
slips but only a single EPB.1,2,12 In a recent systematic review,
Lee et al summarized the existing first dorsal compartment
anatomical data from various De Quervain’s case series.12 A
septated first dorsal compartment was present in 59% of 470
 First Dorsal Compartment Surgical Anatomy
patients (7 case series), multiple APL slips were noted in 73%
of 320 patients (5 case series), and a single EPB was observed
in 94% of 307 patients (4 case series). However, most of the
available data come from retrospective studies. In our pro-
spective study of 130 patients undergoing first dorsal com-
partment release, we found comparable rates of subsheaths
(63%), multiple APL slips (78%), and a single EPB (92%). These
findings in our prospective study with a relatively large
cohort serve to substantiate the concordant findings from
previous smaller and/or retrospective studies.
Unlike subsheath and tendon variability, however, less
consideration has been given to other important anatomical
variables in De Quervain’s tenosynovitis. Specifically, the
SBRN is vulnerable to injury given its close proximity to
the first dorsal compartment and its susceptibility to form
painful neuromas.6,7,13 In a cadaveric study, Auerbach et al
found that 75% (15/20) of specimens had an SBRN directly
overlying the typical transverse incision for De Quervain’s
tenosynovitis.6 Similarly, Abrams et al found that the nearest
SBRN was on average only 4 mm away from the first dorsal
compartment and laid directly on top of the first dorsal
compartment in 35% (7/20) of cadaveric specimens.7 Despite
this anatomical data, the SBRN was commonly not encoun-
tered during our De Quervain’s surgery.
It is unclear why we identified fewer SBRNs than expected
given the existing data from cadaveric studies. Potentially, this
relates to the inherent differences between surgical approaches
and anatomical studies; we were performing our standard
surgical approach with routine retraction of soft tissues without
trying to discretely dissect out the SBRN. Surgeons should be
aware that the SBRN is at a risk given its proximity to the
incision and the first dorsal compartment; however, it may not
need to be directly visualized. Alternatively, as seen with tendon
and subsheath variability, it is possible that the branching
pattern of the SBRN may differ in patients with De Quervain’s
tenosynovitis versus normal cadavers and that therefore the
incidence of overlying branches is less in surgical patients.1–3,12
While the true incidence of SBRN injury following first dorsal
compartment release is unknown, our findings may help to
explain why it is a relatively uncommon complication.
Similar to SBRN injury, tendon instability following first
dorsal compartment release is a commonly discussed potential
complication and an appropriate theoretic concern, but few
reports documenting its occurrence or treatment exist.8–10 To
prevent subluxation of the tendons, Burton and Littler recom-
mended incision of the first dorsal compartment over the EPB
at its dorsal margin, Bahm et al described transcutaneous
fixation of the retinacular flap to prevent anterior displacement
of the APL tendon, and McMahon et al emphasized the impor-
tance of thumb immobilization for 7 to 10 days in order to
maintain proper alignment of the tendons over the radius as
the soft tissues heal.1,9,11 While it is possible that these
techniques minimize the risk of postoperative subluxation,
the incidence of this complication remains unknown.
In our study, we found that 9% (12/130) of patients demon-
strated some tendon instability following first dorsal compart-
ment release. All of these patients perched with passive wrist
flexion but only one (<1%) dislocated with active wrist flexion.
Matzon et al.
The single patient with dislocating tendons had an immediate
first dorsal compartment reconstruction using a brachiora-
dialis tendon flap, as described by McMahon et al.9 Eight of the
11 patients with perched tendons had the radial retinacular
flap sutured to the subcutaneous tissues, as described by Bahm
et al, and immediate postoperative thumb spica splinting, as
advocated by McMahon et al.1,9 The other three patients had
no additional intraoperative treatment or postoperative
splinting. In all 12 instances, the decision regarding whether
to augment first dorsal compartment release was made
intraoperatively by the individual surgeon. Since our study is
isolated to intraoperative findings, it is unknown if any of our
patients developed postoperative instability and/or if aug-
menting first dorsal compartment release made any clinical
difference. However, in patients with stable tendons during
intraoperative passive and active testing, it seems less likely
that late instability would develop.
The strengths of this study include its relatively large
number of patients and prospective methodology. Also, we
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evaluated anatomy relevant to potential complications that
have been frequently discussed but inadequately assessed in
the literature. We feel that these data provide surgeons with
information regarding the SBRN and instability factors that
may be encountered during the actual De Quervain’s surgery.
There are also several limitations. Since this was an obser-
vational study, we do not have outcome data. Therefore, we do
not know the percentage of patients who developed post-
operative SBRN symptoms or whether any patients developed
late, symptomatic tendon instability. Moreover, while the 14
participating surgeons defined tendon instability in an iden-
tical fashion, the assessment of instability inherently remains
somewhat subjective. However, we feel that this is reflective of
clinical practice and generalizes our results.
Based on our data, we expect to encounter the SBRN during
first dorsal compartment release in more than 50% of patients
but are unconcerned if it is not visualized during a careful
approach. Provided that the soft tissues are gently retracted
and that the first dorsal compartment is directly visualized
during release, we would expect the likelihood of SBRN injury
to be low. Furthermore, we counsel our patients that tendon
instability following first dorsal compartment release is rare.
However, we assess the stability of the tendons intraopera-
tively to identify patients in whom instability may be an issue.
If perching is encountered, we consider retinacular flap aug-
mentation and postoperative splinting. If the tendons were
fully dislocated, we contemplate addressing this immediately
with brachioradialis reconstruction in order to avoid poten-
tially symptomatic, postoperative instability.
Ethical Approval
This study was approved by our Institutional Review
Board.
Funding
None.
Conflict of Interest
None declared.
Journal of Wrist Surgery
First Dorsal Compartment Surgical Anatomy Matzon et al.
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