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Mr Ndiyamba highlights anatomical variation as a cause of hand and wrist pain in musicians. This, ofcourse, has been a well-recognized phenomenon inmusicians over the years and there is extensive litera-ture on many of the variations. This literature is well I read with interest the article in the September issue summarized by Professor Allieu et al.1 Further com- by Butler and Winspur1 about musicians’ return to ments regarding anatomical variations in musicians playing their instruments following hand surgery, but was left wondering whether the researchers came Mr Ndiyamaba also comments on separate compart- across any variant anatomy contributing to the dis- ments within the first extensor compartment and the orders. Variant anatomy recognized during surgery relationship of such compartments to the development provides a framework for reviewing common mor- and treatment of de Quervain’s tenovaginitis. The phology, embryogenesis, and potential medical and presence of such compartments is found in 40% of surgical implications to reinforce the concept of random dissections and the clinical experience of most patient individuality for the individualization of surgeons matches this.3 There seems to be no corre- lation between the presence of such compartments and An example of these variations, normal rather than the development of clinical symptoms and this is well abnormal, is the incidence of separate osseofibrous explained by the fact that the pathology in de compartments for the two main tendons (EPB and APL) Quervain’s disease seems to lie principally in the tendon or for their accessory tendons in de Quervain’s disease.3 sheath, where myxoid degeneration is the most striking Decompression of the main fibro-osseus canal may not finding and tendonitis appears to be secondary.4 Of the relieve the symptoms of the disease if an accessory two surgical releases performed in our series, one had an tendon remains unrecognized and is left compressed in extra compartment. The importance of the extra com- its own fibrous canal.4 Likewise an accurate injection partment is seen in treatment. Failure to release such a into both the EPB and APL tendon sheaths by the compartment surgically is a recognized cause of per- two-point injection method may be more effective for sisting symptoms following surgical release.5 Failure to de Quervain’s disease rather than the techniques that do alleviate symptoms with a steroid injection may be due not take the anatomical variation into consideration.5 to an extra compartment, which may not have been I would be interested in knowing if they came across penetrated and may require a repeat injection.3 any variants and if not, I suggest that future research Mr Ndiyamba is correct that all treating personnel and documents such findings for teaching a very impor- surgeons should be aware of anatomical variations and tant concept in anatomy that may affect function, as their implications not only in musicians and should document when such variations are shown to exist.
Bishop Auckland General Hospital, County, Durham, UK Email: [email protected]: 10.1258/ht.2009.009029 1 Butler K, Winspur I. Retrospective case review of time taken for 130 professional musicians to fully return to playingtheir instruments following hand surgery. Hand Ther 1 Allieu Y, Hamitouche K, Roux J-L, Beaton Y. Unique surgi- cal conditions. In: Winspur I, Wynn Parry CB, eds. The 2 Zucconi WB, Guelfguat M, Solounias N. Approach to the Musician’s Hand: A Clinical Guide. Oxford: Martin Dunitz, educational opportunities provided by variant anatomy, illustrated by discussion of a duplicated inferior vena cava.
2 Butler K, Norris R. Assessment and treatment principles for the upper extremities of instrumental musicians. In: Rehabi- 3 Gouscheh J, Yavari M, Arasteh E. Division of the first dorsal litation of the Hand. 6th edn). Philadelphia: Elsevier (in press) compartment of the hand into two separated canals: rule 3 Leslie BM, Ericson WB, Morehead JR. Incidence of septum or exception? Arch Iran Med 2009;12:52–4 within the first dorsal compartment of the wrist. J Hand 4 Giles KW. Anatomical variations affecting the surgery of de Quervain disease. J Bone Joint Surg Am 1960;42B:352–5 4 Clark MT, Lyall MA, Grant JW, Matthewson MH. The his- 5 Sawaizumi T, Nanno M, Ito H. De Quervain’s disease: effi- topathology of De Quervain’s Disease. J Hand Surg cacy of intra-sheath triamcinolone injection. Int Orthop 5 Kay NRM. De Quervain’s Disease. J Hand Surg 2000;25B:65–9

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