Not clearly / consistently defined Triggering of the digital flexor tendons at the fibrooseous tunnel formed by the metacarpal neck and A1 pulley In thumb the sesamoid bones may also be site of constriction Generally affects FDS rather than FDP because it lies directly under A1 pulley
Primary trigger finger most commonly found in middle aged women, 2–6 X more than men Most commonly affects thumb (30- 50%) Then ring, long, index, & little
Stenosing tendovaginitis Digital flexors susceptible to compression and shear at level of wrist and MP joints where they enter fibrooseous tunnels Blunt trauma or sustained tool use causing direct compression at A1 pulley Secondary TF in individuals with connective tissue disorders
Discrepancy between the size of the A1 finger pulley lumen and tendon volume Hypertrophy of the pulley Poor tendon vascularity between A1 and A2 pulley makes tendons more susceptible to degenerative changes Tendons develop nodules from tenosynovitis
Pain over site of tendon disorder aggravated by movement Symptoms vary from stiffness, to uneven movement, catching, blocking, or complete locking of tendon Pain can also be referred to distal joint or proximally up forearm Local swelling and thickening creating a palpable nodule over distal palmar crease (A1 pulley area) Local tenderness over A1 Patient may present with acute, subacute or chronic disorder
Patients often reluctant tohave cortico-steroid injection,even more reluctant to havesurgeryConservative measures shouldbe trialled for 4-6 weeks Thermoplastic hand based splint to limit MCP flexion (stops triggering through A1 pulley) Splinting works better for fingers than for thumbs
Trigger Thumb - Thermoplastic barrel splint, IP joint at 10 degrees flexion Passive tendon gliding exercises Soft tissue massage of nodule and tendon. +/- Ultrasound +/- NSAID gel
Cortisone injection for trigger fingers and thumbs relieves symptoms in 47% to 94% of affected digits.
Most reported success rates are above 90%. Decompression of pulley to allow flexor tendon to glide Turowski, 1997: n=59, 97% complete resolution. No post-op nerve or tendon damage. Eastwood, 1992: Percutaneous release, n=35, 94% complete resolution. No complications. Not for thumb Thorpe, 1988: n = 53, 60% complete resolution, success correlated with surgeon skill.
Oedema and wound management Scar management once wound healed Active tendon gliding exercises Stretching long finger flexors Strengthening only if necessaryConclusion Surgery remains the most successful treatment option Splinting and exercise program good alternative for those patients reluctant to consider a CSI or surgery
de Quervain’s tenosynovitis is the entrapment tendonitis/tenosy novitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius
Most cases it is a tendinopathy like trigger finger, tennis elbow etc that leads to tenosynovitis.
Finklesteins test and clinical Hx confirm diagnosis.
10 x more Common in Women than men. Common in pre-post natal and menopause. Often caused by repetitive strain or sustained posture of the wrist = strain on EPB and APL. Can occur post direct trauma to the area (rare)
Treatment: Steroid (won’t fix tendinopathy) Splint and rest Kinesio tape Surgery (last resort)
depends on size of fragment and position of joint If complete tendon rupture without fracture If # is less than 30% joint surface → Conservative management - splinting If # greater than 30% joint surface or joint is significantly displaced needs surgical intervention
Splint DIP in hyperextension 6 – 8/52 Splint strictly 24/24 Clear instructions and demonstration re changing and wearing routine Advice re skin care PIP flexion exercises May return to sport with splinting
Off the shelf stack splint often fit poorly Patient may end up with a lag at DIP joint
Wean splint slowly after 6-8 weeks Keep on at night and for work a further 2 weeks Initially active flexion exercises to gain full flexion Start off 30 degrees flexion first week and increase slowly ie 20 degrees per week May take 4 – 6 weeks to regain full flexion If lag reoccurs → RESPLINT Passive flexion only added if needed
- Conservative approachonly if small fragment withno joint subluxation. - Splint for 6/52 in barrelsplintDIPJ can be free.- Larger fragments with jointsubluxation can be ORIF’d.
= Boutonniere Deformity = FFD of PIPJ = Very hard to fix
Mechanism of Injury – hyperextension of the PIP joint with or without dislocation often initial injury seems trivial
Dislocation of the PIPJ Avulsion # of middle phalanx Disruption of volar plate over the PIP joint
Signs & Symptoms• Swelling• Bruising• Pain volar aspect of PIP joint• Instability or pain on stress of volar plate• Decreased range of motion particularly flexion
If dislocation without # OR If # fragment less than 30% joint surface→ reduce then manage conservatively in dorsal blocking splint (DBS)
Dorsal blocking splint• PIPJ in 30 degrees flexion•volar structuresoffstretch•slowly increaseout to neutral
splint 4 - 6/52 weekly adjustments PIPJ from 30 flexion → full extension as stability increases• Coban for swelling• Flexion exercises within splint• Isolated FDP & FDS flexion important to prevent adherance to volar plate• Early mobilisation also assists oedema
• If collaterals involved need to buddy strap when out of splint• Tape/splint for work for 6 -8/52• Watch for FFC PIPJ in late stages → may need to include extension splinting
If volar plate repaired post surgical management same but progress slower Occasionally flexion exercises are delayed if stability is a concern
5th Metacarpal Assess ROM and digit Rotation Usually managed conservatively
4th Metacarpal Spiral # Assess ROM and digit Rotation Tendency to rotate Impacted #’s result in extension lag = poor function.
Treat conservatively in splintunless joint subluxationoccurring
Treat conservatively in splintunless joint subluxation orstenners lesion is present.- Usually characterised bylots of oedema, nil end pointof stability.- Very difficult to assess withcertainty- U/s scan to confirm