How to perform a De Quervain's release

Local Anesthesia

1. Slowly inject local anesthetic, such as lidocaine with or without adrenaline, starting proximally from the planned incision, approximately 4 cm proximal to the radial styloid.

2. Continue injecting further distally through the already anesthetized parts to fully cover the operative area.

Skin Incision

The goal is to incise just the skin to avoid damaging the underlying cutaneous nerve branches running in the subcutaneous layer.

1. Keep the skin tight with your other hand and, using a scalpel, incise only the epidermal and dermal layers following the planned line. Be careful to only incise the skin and not further into the subcutaneous tissue.

2. Cauterize any bleeding vessels. Note that the radial nerve can course very superficially, so cautery can also be left for later after the nerve has been protected.

Advancing Through the Subcutaneous Tissue

The main goal is not only to expose the extensor compartment but to detect and protect the cutaneous nerves. Typically, the dorsal cutaneous branch of the radial nerve runs in the area. Potentially, branches of the lateral antebrachial cutaneous nerve might also cross the surgical field. All these nerve structures must be protected.

1. Carefully use tenotomy scissors to bluntly advance through the subcutaneous fat. Slight elevation of the skin edges, grasping only the skin, with forceps can be done if the nerve is not in the field.

2. After locating the dorsal cutaneous branch of the radial nerve, carefully draw it aside; it is often easiest to move it dorsally.

3. Any bleeding vessels can now be cauterized.

4. If you are unsure which way to advance, you can use your finger to carefully palpate the tendons while moving the patient’s thumb, as flexion tightens the sheath and the tendons.

5. Using retractors unforcefully, expose the extensor compartment.

Incising the Compartment

The aim is to release the constricting part of the first extensor compartment without damaging the tendons. The incision should be long enough to fully decompress the first dorsal compartment, but not excessively long, as over-release can lead to subluxation or instability of the tendons.

1. Verify the location of the thickened part of the compartment by palpating and asking the patient to move the thumb, if necessary.

2. Use a scalpel to carefully make a small incision in the retinaculum along the tendons. Be careful not to damage the underlying tendons while opening the compartment.

3. Continue to open the thickened parts of the compartment proximally and distally under direct visualization, using scissors. The tightest area is often distal.

4. Verify the sufficient release of the tendons by flexing and extending the thumb. If the thumb moves freely and the tendons appear decompressed, the incision is likely sufficient.
   Note that the EPB may have its own subcompartment, formed by a septum, also referred to as the subsheath of the EPB. A lack of awareness of this anatomical variance can lead to misidentification of the multiple APL tendon slips as the EPB, resulting in the EPB not being released at all. Therefore, it is important to correctly identify the EPB.

5. Release any remaining tightness, if necessary. If the EPB has its own subcompartment, ensure its release as well.

Wound Closure

1. Release the tourniquet, if used, and coagulate any bleeding vessels.

2. Verify that the radial nerve branch is still intact and does not interfere with closure.

3. The only layer that requires suturing is the skin. Use 4-0 or 5-0 interrupted monofilament sutures. Ensure to avoid taking excessively deep bites that could potentially catch the underlying nerve branches.

4. Apply a non-bulky hand surgical dressing that permits maximal postoperative hand mobility, especially thumb ROM.