INTRODUCTIONANATOMIC CONSIDERATIONANATOMY OF THE TENDON SHEATH:Tendon nutrition is derived from:• Synovial fluid from tenosynovialsheath• Vincular blood supplyAfter injury healing occurs by•Extrinsic – peripheral fibroblast•Intrinsic – fibroblast from tendonitself
Flexor synovial sheath for index,middle and ring finger begins atthe level of metacarpal neck 1 cmproximal to the proximal borderof deep transverse metacarpalligament.It is doubled walled hollow tubesealed at both hand.FUNCTION:Gliding and bathing the tendonwith synovial fluid
Retinacular portion of flexor tendonsheath overlies these synovial layersRetinacular portion include 5 annularpulleys and 3 cruciform pulleys andalso palmar aponeurosis pulleyA1 At MCP JointA2 Proximal phalanxA3 Proximal IP jointA4 Middle phalanxA5 Distal IP jointC1 Near head of proximal phalanxC2 Base of middle phalanxC3 Distal end of middle phalanx
Function: Annular pulley prevent bowstringing during fingerflexion and cruciate pulley make tendon sheath able to conformto the position of flexion by allowing annular pulley toapproximate each other.A2 and A4 pulleys are most functionally important so must beprevented or reconstructed in flexor tendon surgery to preventbowstringing.Flexor synovial sheath for thumbstarts proximal to carpal canal andits retinacular portion has 2 annularpulleys and an oblique pulleyA1 – At MCP jointA2 – At IP jointOblique – Middle of proximalphalanx
DEFINATION:What Is STENOSING TENOSYNOVITIS?It is a group of conditions in which there is mismatch betweenthe size of the tendon sheath and tendon which passes throughit.It may result from enlargement of tendon as seen in TriggerFINGEROrFrom narrowing and fibrosis of tendon sheath as seen in DEQUERVAIN’S TENOSYNOVITIS.
TRIGGER FINGER or stenosingtenosynovitis is caused by a noduleor thickening of flexor tendon whichcatches on the proximal edge of A1pulley when the finger is activelyflexed.Most common in1. Ring finger2. Thumb3. long4. index5. small fingerMore common in women than men
AETIOLOGY:•Congenital•Repetitive trauma•Medical conditions of rheumatoid arthritis, gout, diabetes,hypothyroidism, amyloidosis and certain infections — includingtuberculosis and sporotrichosis, a fungal infection.•Other rare causes are: -Collateral ligament may catch on a bonyprominence on the side of metacarpal head.-Rarely abnormal seasmoid may catch on the metacarpal head-Capsule may become interposed when it is split transversely bytrauma-Extensor tendon may slip off the head of metacarpal anddisplace ulnarward over the interdigital cleft.
PATHOPHISIOLOGYWhen the tenosynovium becomesinflamed from repetitive strain injuryor overuse or due to inflammatoryconditions such as rheumatoidarthritis,the space within the tendon sheathbecome narrow and constricting.The tendon cant glide through thesheath easily, at times catching thefinger in a bent position beforepopping straight.With each catch, the tendon itselfbecomes irritated and inflamed,worsening the problem. With prolonged inflammation, fibrosis can occur and bumps (nodules) can form
SIGNS AND SYMPTOMS•Pain at the root of finger•Swelling•Tenderness•Palpable nodule•When hand is opened up from a clenchedposition then affected finger remain inflexionWith more forceful effort or passivelyopening by other hand it may extend withjerky release or often a palpable or audibleclick.More symptomatic in morning improvingthrough the day
EAST WOOD CLASSIFICATIONGrade 0 : mild crepitus in a non triggering digitGrade 1 : uneven movement of the digitGrade 2 : clicking without lockingGrade 3 : locking of the digit that is either actively or passively correctableGrade 4 : locked digit
TreatmentIt depends on etiology:Initial treatment of the condition caninclude:Rest. To prevent the overuse of affectedfinger.Splinting. To keep the affected finger in anextended position for several weeks. Thesplint helps to rest the joint. Splinting alsohelps prevent you from curling your fingersinto a fist while sleeping, which can make itpainful to move your fingers in themorning.
Finger exercises. Perform gentle exercises with the affected finger.This help you to maintain mobility in finger.Soaking in water. Placing the affected hand in warm water for fiveto 10 minutes, especially in the morning, may reduce the severity ofthe catching sensation during the day. If this helps, it can berepeated throughout the day.Massage. Massaging the affected fingers may feel good andhelp relieve pain, but it wont affect the inflammation For more serious symptoms, Nonsteroial anti-inflammatory drugs (NSAIDs). Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve the inflammation and swelling that led to the constriction of the tendon sheath and trapping of the tendon.
IN NON-RHEUMATOID PATIENTSNon operative treatment in form of STERIOD INJECTIONBetamethasone is commonly usedInject 0.25–0.50 ml in 1 ml of lidocaineSITE: around the A1 pulley.PRECAUTIONS: -Use small needle less than 21G-Should be given in flexor tendon sheath.-Should not be intertendinous as it may lead to tendon rupture.- Warn the patient that it will take a few weeks to see whetherthe injection is successful.-A second steroid injection can be given 6 weeks after the initialinjection if no improvement has been noted. Sometimes thesecond injection is successful even if the first resulted in littleimprovement
IMPORTANCE: Steroid injection around the A1 pulley may provide symptomatic relief, which can delay the need for surgery for many month Anderson and kyle (1991) from a prospective study found that: 61% - respond to single steroid injection. 27% - recurred 12% - Required surgical release 6% - Subcutaneous fat atrophy 0% - Infected or tendon rupture so it should be explained to patient before hand
Operative TreatmentOperative treatment should be considered when two steroidinjections are unsuccessful in alleviating symptoms or whensymptoms argue against waiting 4–6 weeks for improvement.A patient whose finger is locked in flexion also should undergosurgical treatment. Waiting for a steroid injection to work isimpractical because of concerns about subsequent joint stiffnessdue to inability to move the finger for so long a period
SURGERY OF CHOICE: PERCUTANEOUS RELEASE: PROBE BLADEMetacarpophalangeal jointhyperextended and 19-gauge needleinserted just distal to the flexor crease.Bevel of needle oriented longitudinallywith tendon. Needle stabilized and pulley releasedfrom proximal to distal. Loss ofgrating sensation as pulley is cutindicates completion of release.
OPEN SURGERYIMPORTANT CONSIDERATION BEFORE SURGERYBest performed under wrist block so that patient canactively flex and extend the affected digit once the releaseis performedTourniquet should be used on the forearm or upper arm. It isimportant to have a bloodless field to prevent injury to thenearby neurovascular bundlesDo not cut anything until you are certain that theneurovascular bundles are protected.A2 pulley must be preserved
Postoperative Care1. Acetaminophen or nonsteroidal anti-inflammatory agents shouldbe adequate for postoperative pain control.2. Keep the hand elevated to decrease swelling and decrease pain.3. The patient should be encouraged to use the hand for light activitieswithin 1–2 days after surgery.4. Remove the dressing the day after surgery, and clean with gentlesoap and water daily.5. Apply antibiotic ointment to the suture line daily for the first fewdays. Cover with dry gauze as needed.6. After 10–14 days, remove the sutures. Instruct the patient toincrease gradually the activities performed with the hand until thepatient has resumed regular activities
COMPLICATIONS OF SURGERYPercutaneous release associated with incomplete releaseSurgical release includes•Digital nerve transection•A2 pulley injury with subsequent bowstringing of tendons•Bothersome scars•Recurrent symptoms•Stiffness•Sympathetic dystrophy
IN RHEUMATOID PATIENTS.•Underlying problem is synovitis with in flexor tendon sheath•And it weakens both tendons and surrounding synovial sheath•Therefore first control synovitis along with programme of activeassisted exercises and splinting•STERIOD INJECTION SHOULD NOT BE GIVEN AS THERE IS A REALRISK OF TENDON RUPTURE.•If synovitis and triggering persist despite above therapy•Then SURGICAL SYNOVECTOMY should be performed withoutreleasing the annular pulleys.
IN TRIGGER THUMB:•Flexor sheath is much tighter than in the fingers•So it is difficult to inject tendon sheath without injecting intotendon•Therefore surgeon directly proceed to operative interventionif single injection is ineffective..•IMPORTANT NOTE: Surgical release require retraction ofradial digital nerve which crosses directly over A1 pulley
CONGENITAL TRIGGER FINGER:•Present with digits in a position of flexion•Present at birth but not appreciated until months later•Anomaly is secondary to either sheath stenosis or tendon noduleor both•Period of observation with or without splinting is recommended ifchild is less than 6 months of age•Condition is less likely to resolve in older child so surgery isrecommended•If left untreated older child may develop fixed flexion deformityand joint contractures•So older child if comes like this trigger finger as well as secondaryjoint contractures must be treated.