Dorsal tendon dislocation after de Quervain's release and its surgical management: a case report

Abstract

We present a case of delayed dorsal tendon dislocation after surgery for de Quervain’s disease and a modified technique of pulley reconstruction. A 32year-old man had a 5-month history of persistent wrist pain. Finkelstein’s test and MRI results were positive for de Quervain’s disease. After an adequate period of unsuccessful non-operative treatment, we proceeded to surgery. Through a transverse skin incision, the retinaculum of the first dorsal compartment was divided longitudinally along its dorsal margin. The tendons of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) were released and checked for subluxation through passive wrist flexion and extension – single APL and EPB tendons were found without the presence of a subcompartment. The patient’s hand and thumb were placed in a bulky bandage and sutures were removed at 2 weeks. We advised avoidance of heavy mechanical activities for 6 weeks. Eight months later, he returned describing a painful snapping in his wrist. Clinical examination revealed dorsal dislocation of APL and EPB tendons during wrist extension. The patient admitted starting weightlifting shortly after suture removal and stated that the symptoms began 3 months after surgery. We proceeded to secondary surgery. The former skin incision was extended proximally and distally in a zig-zag fashion. Both tendons dislocated dorsally during wrist extension (Video 1). A longitudinal incision was made in the remaining palmar extensor retinaculum, elevating a 3 by 1.5 cm strip, distally based (Figure 1). This was passed deep to APL and EPB tendons from palmar to dorsal side (Figure 2), and then superficial to the tendons suturing it back to its origin at the palmar retinaculum with two 4-0 nonabsorbable sutures. The dorsal border of this sling was secured with two 4-0 nonabsorbable sutures to the dorsal remnant of the retinaculum (Figure 3), ensuring that tendon gliding was unobstructed with no palmar or dorsal subluxation (Video 2). Postoperatively, a thumb spica was applied for 4 weeks. Three years postoperatively the patient remains asymptomatic, with no recurrence of tendon dislocation, a normal range of motion and a negative Finkelstein test. He has returned to work.