This document provides information on various hand conditions including trigger finger/thumb, De Quervain's tenosynovitis, mallet finger, PIP joint dislocations, and Dupuytren's disease. It describes the presentation, typical mechanisms of injury, conservative and surgical treatment approaches for each condition. The key points are that splinting and injections are usually first-line treatments while surgery is reserved for cases that fail conservative care or have more significant injuries/deformities.

1. Dan Purtell
Hand / Occupational
Therapist

2. Trigger finger / thumb
De Quervain’s
Mallet Finger
PIPJ Dislocations
Dupuytren’s disease
Simple #’s

3.  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

5.  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

6.  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

7.  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

8.  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

9. Patients often reluctant to
have cortico-steroid injection,
even more reluctant to have
surgery
Conservative measures should
be 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

10.  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

11.  Cortisone injection
for trigger fingers
and thumbs relieves
symptoms in 47% to
94% of affected
digits.

12.  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.

13.  Oedema and wound management
 Scar management once wound healed
 Active tendon gliding exercises
 Stretching long finger flexors
 Strengthening only if necessary
Conclusion
 Surgery remains the most successful treatment
option
 Splinting and exercise program good alternative for
those patients reluctant to consider a CSI or surgery

14.  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

15.  Most cases it is a
tendinopathy like
trigger finger,
tennis elbow etc
that leads to
tenosynovitis.

16.  Finklesteins test and clinical Hx confirm
diagnosis.

17.  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)

18.  Treatment:
 Steroid (won’t fix
tendinopathy)
 Splint and rest
 Kinesio tape
 Surgery (last resort)

19.  Surgery

20.  Any injury that causes
a mallet deformity of
the distal phalangeal
joint

21.  Disruption of the terminal extensor tendon as it
inserts into distal phalanx +/- fracture

23. MECHANISM OF
INJURY
 Flexion force on
extended DIP joint
 Direct crush
 Ball to tip of finger
 Often occurs in
ball sports.

24. Signs & Symptoms
 Inability to extend
distal phalanx actively
 Can still passively
extend within pain
limits
 Swelling
 Bruising
 Redness

25. Volar plate laxity = swan
neck deformity

26.  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

27.  Mallet splint reduces the
fragment

28.  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

29.  Off the shelf stack
splint often fit
poorly
 Patient may end up
with a lag at DIP
joint

30.  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

31.  Large Fragment
 Fixed with K-wire or 2

33. - Conservative approach
only if small fragment with
no joint subluxation.
- Splint for 6/52 in barrel
splint
DIPJ can be free.
- Larger fragments with joint
subluxation can be ORIF’d.

34. = Boutonniere Deformity
= FFD of PIPJ
= Very hard to fix

36.  Mechanism of Injury – hyperextension of the
PIP joint
 with or without dislocation
 often initial injury seems trivial

37.  Dislocation of the
PIPJ
 Avulsion # of
middle phalanx
 Disruption of volar
plate over the PIP
joint

38. Signs & Symptoms
• Swelling
• Bruising
• Pain volar aspect of
PIP joint
• Instability or pain
on stress of volar
plate
• Decreased range of
motion particularly
flexion

39.  If dislocation without #
OR
If # fragment less than 30% joint
surface
→ reduce then manage
conservatively in dorsal
blocking splint (DBS)

40. Dorsal blocking splint
• PIPJ in 30 degrees
flexion
•volar structures
off
stretch
•slowly increase
out
to neutral

43.  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

44. • 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

45.  If volar plate repaired post surgical
management same but progress
slower
 Occasionally flexion exercises are
delayed if stability is a concern

46.  5th Metacarpal
 Assess ROM and digit
Rotation
 Usually managed
conservatively

47.  4th Metacarpal Spiral #
 Assess ROM and digit
Rotation
 Tendency to rotate
 Impacted #’s result in
extension lag = poor
function.

48. Treat conservatively in splint
unless joint subluxation
occurring

49. Treat conservatively in splint
unless joint subluxation or
stenners lesion is present.
- Usually characterised by
lots of oedema, nil end point
of stability.
- Very difficult to assess with
certainty
- U/s scan to confirm