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We report a patient with duplicate extensor pollicis longus tendons, who complained of inability to extend the thumb fully because of impingement of the musculotendinous junction of the duplicate tendons. Extension of the thumb recovered completely after Lister's tubercle was excised and the extensor retinaculum was released. Selective windowing with highlighting of the soft tissue in the axial T1-weighted magnetic resonance image at the level of the distal radioulnar joint showed two tendons in the third extensor compartment.

We present 2 cases of extensor pollicis longus tenosynovitis caused by the unusual course of the extensor pollicis longus tendon. The extensor pollicis longus tendon passed through the first extensor compartment and was constricted severely. The symptoms were similar to those of de Quervain's disease. The clinical presentation, diagnosis, and surgical technique of this very rare anatomic condition are discussed.

De Quervain's tenosynovitis can be treated either by conservative or operative measures. Harvey et al. (1990) have shown that treatment by local injection of corticosteroid into the lateral extensor compartment can effect cure in 80% of cases without surgical intervention. However, the lateral extensor compartment may be anatomically divided by septa into subcompartments, and this prevents the distribution of steroid throughout the compartment, and hence may lead to failure of conservative treatment. This study was undertaken to develop an injection technique that will ensure that, even if septa are present, both subcompartments are penetrated by the needle and receive steroid. The technique is shown to enhance the accuracy of injection and hence should further increase the proportion of patients treated conservatively with success. © 1993 Wiley-Liss, Inc.

The basic anatomy of the first extensor compartment is presented with a review of the pathology of de Quervain’s stenosing tenovaginitis. The results in 100 medicolegal cases of de Quervain’s disease are analysed and reasons are sought for the poor results. A review of the known factors associated with the causation of de Quervain’s disease is presented with recommendations about the management of this condition.

We report a rare case of a 10-year-old girl with anomalous course of extensor pollicis longus (EPL) muscle, which exists with absence of thenar muscles and muscles in the 1st extensor compartment. Her chief complaint was severe atrophy on the right thenar eminence. On physical examination, there was no obvious functional abnormality on her right thumb. On magnetic resonance imaging, we found that the abductor pollicis brevis, opponens pollicis, abductor pollicis longus, and extensor pollicis brevis muscles were absent. The tendon of the EPL muscle was found, but it had abnormal insertion on the radial side of the proximal phalanx, not on the distal phalanx. This variation was thought to have played a major role in compensating for impaired abduction of the thumb, which is usually accompanied by agenesis of major abductors of the thumb.

Introduction Chronic compartment syndrome is well recognised, although rare in the forearm. In our chronic compartment syndrome clinic, we successfully identified and treated four cases. This prompted a literature review searching for normal ranges of forearm compartmental pressures. Existing normal forearm pressure ranges are based on lower limb measurements. This study aimed to establish normal pre- and postexercise forearm pressures. Methods Using a Stryker intracompartmental pressure monitor, 41 participants underwent pressure measurements of the superficial extensor and flexor forearm compartments before and after exercise. Results Normal ranges for pre-exercise extensor compartment (2–27 mm Hg, upper CI 18.8 to 25.2 mm Hg), postexercise extensor compartment (2–24 mm Hg, upper CI 16.8 to 22.8 mm Hg), pre-exercise flexor compartment (1–19 mm Hg, upper CI 13.3 to 17.4 mm Hg) and postexercise flexor compartment (0–19 mm Hg, upper CI 16–21.4 mm Hg) pressures were established. No significant pressure difference was found after exercise (extensor pressures; p=0.41, flexor pressures; p=0.21). There was no correlation between whether pressures increased or decreased following exercise. There was significant sex difference (extensor pressures; p=0.04, flexor pressures; p=0.008). Normal ranges for the extensor compartment were; 0–25.2 mm Hg and for the flexor compartment; 0–21.4 mm Hg. Conclusions This study showed a significant difference in normal forearm compartment pressures between sexes. A normal reference range of forearm compartment pressures to aid diagnosis of chronic compartment syndrome has been determined. This may also prove useful in aiding diagnosis of acute forearm compartment syndrome.

A 24 year old combat medic was admitted to the field hospital at Tomislavgrad in Bosnia, with a suspected forearm, fracture. Radiographs did not show any bony injury. Clinical examination showed marked swelling and tenderness over the extensor compartment. The pain became more severe over the following 12 hours with the pain becoming most intensely felt in the extensors on passive extension. Fasciotomy for suspected acute compartment syndrome was carried out. Acute compartment syndrome is a common complication of extremity injury, and is a clinical diagnosis which should be suspected in all injuries with marked swelling and severe pain.

A septum between the abductor pollicis longus tendon and the extensor pollicis brevis tendon in the first extensor compartment is frequently encountered during the surgical treatment of de Quervain’s disease. But de Quervain’s disease associated with a bone tumor and an osseous septum is very rare. We treated a patient with de Quervain’s disease who had a bone tumor and an osseous septum between the abductor pollicis longus tendon and the extensor pollicis brevis tendon in the first extensor compartment. After the excision, the pain was relieved and Finkelstein’s test was negtive. We report upon this case, and includea brief review of the literature.

Free muscle transplantation with motor innervation offers the possibility to add contractile elements to upper extremities with extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture). The functional cross section area and the mean resting fiber length determine the maximum power and the contracting amplitude of the donor muscle. Although considerably weaker than the finger flexors to be replaced, the gracilis muscle was the preferred donor muscle because of its neurovascular pedicle and the minimal donor site morbidity. In a series of 15 gracilis transplantations, all 13 muscles that survived regained function. Finger motion was dependent on the preoperative condition of tendons and joints. Even after complete loss of the flexor and extensor compartment a useful upper extremity could be restored, which was preferable to the only alternative-amputation.

Free muscle transplantation with motor innervation is the only way to add contractile elements to upper extremities with extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture). The functional cross-sectional area and the mean resting fiber length determine the maximum power and the contracting amplitude of the donor muscle, respectively. Although considerably weaker than the finger flexors to be replaced, the gracilis muscle was the preferred donor muscle because of the consistent anatomy of its neurovascular pedicle and the minimal donor site morbidity. In a series of 15 gracilis transplantations, all 13 muscles that survived regained function. Finger motion was dependent on the preoperative condition of tendons and joints. Even after complete loss of the flexor and extensor compartment after direct trauma or infection, a useful upper extremity could be restored, which was preferable to the only alternative--amputation.

We studied 300 wrists from cadavera and the wrists of forty patients with de Quervain disease to determine the variation in the pattern of the tendons and septa in the first extensor compartment. In 75 per cent of the wrists from cadavera, we found that the number of tendons within the compartment differed from what is considered standard; there was complete or partial septation in 40 per cent. In about a third of the specimens from cadavera, the first extensor compartment was divided by a septum and two tendons or more were present within the major subcompartment. These features might readily result in inadequate decompression of the compartment in the treatment of de Quervain disease. In our prospective study of forty patients with de Quervain disease, septation was found in twenty-seven. There was no significant difference between the number of patients and the number of specimens from cadavera that had no, one, or two accessory abductor tendons.

Six patients selected from 13 patients presenting with dorsal wrist pain related in onset to repetitive dorsiflexion maneuvers are described. Clinical examination revealed tenderness over the fourth extensor compartment. Wrist dorsiflexion reproduced their symptoms. All patients were relieved by selective bupivacaine (Marcaine) block of the posterior interosseous nerve 3 cm proximal to the wrist joint. Of the 13 patients presenting, seven improved on immobilization and anti-inflammatory drugs. The six patients not relieved underwent surgical exploration with the specific findings of an enlarged, fibrotic, posterior interosseous nerve. Histologic analysis revealed perineural fibrosis without inflammatory changes. The perineural fibrosis was four times greater in affected nerves than in control specimens. We propose distal posterior interosseous nerve syndrome as another entity causing dorsal wrist pain that is distinct from the usual causes, such as dorsal ganglia, degeneration of the scapholunate ligament, and dorsal wrist syndrome.

The distribution of fiber types in selected leg and thigh muscles of three male Cynomolgus monkeys were determined. Almost all fibers could be classified as fast-glycolytic (FG), fast-oxidative glycolytic (FOG), or slow-oxidative (SO) according to the qualitative histochemical staining scheme described by Peter et al. (1972). Most muscles showed regional variations in fiber-type distributions, i.e., the percent SO was higher and the percent FG was lower in the deep, compared to the superficial, regions of the muscle. Exceptions were the soleus and plantaris muscles, which contained similar distributions of fiber types throughout their cross sections. In the extensor compartment of the leg, a layering of fiber types from deep to superficial were evident in the triceps surae and plantaris complex with the deepest muscle, the soleus, having primarily SO fibers. A similar layering arrangement was observed in the extensor compartment of the thigh, with the deepest muscle, the vastus intermedius, having a much larger proportion of SO fibers than the other muscles in the quadriceps complex. These results indicate that Cynomolgus monkey hindlimb muscles, unlike human leg muscles (Saltin and Gollnick: Handbook of Physiology, L.D. Peachey, ed. American Physiological Society, MD, pp. 55-631, 1983) have a regional distribution of fiber types similar to that observed in many subprimate mammals. Further, the presence of compartmentalization of fiber types within the cross section of several of the muscles studied is suggestive of structure-function interrelationships related to motor control.

The extensor indicis proprius was used to restore mobility to a variety of hand movements in 27 patients. Retained independent index finger extension was obtained in a majority of patients postoperatively. Potential postoperative complications of index extension lag and deviation may be avoided if the extensor indicis proprius is sectioned immediately proximal to the dorsal hood. A corresponding laboratory study was undertaken to better define the anatomic constraints limiting independent finger extension. Distinct differences between juncturae tendinum and extensor compartment musculature help explain why the index finger may function as a relatively independent unit.

Attention has been drawn to the variations found in the anatomy of the tendons of the abductor pollicis longus and extensor pollicis brevis muscles as they lie in the first extensor compartment of the wrist. Such variations involve reduplication of the abductor pollicis longus tendon and more rarely the extensor pollicis brevis tendon. An accessory tendon may occasionally lie in a separate osseo-fibrous canal. It is not unusual to find the abductor pollicis longus and extensor pollicis brevis tendons lying in separate compartments, because an accessory fibrous septum is subdividing the first extensor compartment into two parts. Furthermore, the extensor pollicis brevis tendon may also lie in its own separate fibrous canal in the depths and the more distal part of this common compartment. Such variation could lead to two possible misinterpretations during the course of surgical decompression for de Quervain's disease and these misinterpretations could reasonably be linked with the failure rate for this particular operation. 1. The finding of the abductor pollicis longus and its accessory tendon in a single compartment (12 per cent of wrists in the series) after a limited surgical incision could be mistaken for the abductor pollicis longus and extensor pollicis brevis tendons. Such a mistake would lead to failure to decompress the extensor pollicis brevis. 2. A failure to identify the deeper-lying separate canal for the extensor pollicis brevis in the distal part of the compartment would again be responsible for failure to decompress the extensor pollicis brevis (14 per cent of wrists in this series).

Background The integrity of the flexor tendon pulley apparatus is crucial for unimpaired function of the digits. Although secondary reconstruction is an established procedure in multi-pulley injuries, acute reconstruction of isolated, closed pulley ruptures is a rare occurrence. There are 3 factors influencing the functional outcome of a reconstruction: gapping distance between tendon and bone (E-space), bulkiness of the reconstruction, and stability. As direct repair is rarely done, grafts are used to reinforce the pulley. An advantage of the first extensor retinaculum graft is the synovial coating providing the possibility to be used both as a direct graft with synovial coating or as an onlay graft after removal of the synovia when the native synovial layer is present. Methods A graft from the first dorsal extensor compartment is used as an onlay graft to reinforce the sutured A4 pulley. This technique allows reconstruction of the original dimensions of the pulley system while stability is ensured by anchoring the onlay graft to the bony insertions of the pulley. Results Anatomical reconstruction can be achieved with this method. The measured E-space remained 0 mm throughout the recovery, while the graft incorporated as a slim reinforcement of the pulley, displaying no bulkiness. Conclusions The ideal reconstruction should provide synovial coating and sufficient strength with minimal bulk. Early reconstruction using an onlay graft offers these options. The native synovial lining is preserved and the graft is used to reinforce the pulley.

Either an anomalous extensor indicis proprius muscle or an extensor digitorum brevis manus may coexist with a dorsal wrist ganglion. To assure relief of symptoms, treatment must include division of the fourth dorsal extensor compartment in the case of the former muscle, and excision in the case of the latter.