Stenosing Tenosynovitis of the Wrist and Hand

De quervain disease

Stenosing tenosynovitis of the APL and EPB tendons typically occurs in adults 30 to 50 years old; however, in women of childbearing age radial-sided wrist pain is commonly related to de Quervain tenosynovitis from repetitive ulnar deviation required in newborn care. Women are affected 6 to 10 times more frequently than men. The cause is almost always related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable. The Finkelstein test usually is positive: “on grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating.” Although Finkelstein stated that this test is “probably the most pathognomonic objective sign,” it is not diagnostic; the patient’s history and occupation, the radiographs, and other physical findings also must be considered. Similar symptoms also can be caused by arthritis in the trapeziometacarpal, scaphotrapeziotrapezoid, and radiocarpal joints; superficial radial nerve entrapment or neuroma; and tenosynovitis at the crossing of the EPB and APL over the extensor carpi radialis longus and brevis (intersection syndrome).

Conservative treatment consisting of splint wear and the injection of a steroid preparation ( Fig. 76.1 ) may be successful early after onset. Initial treatment with steroid injections may yield complete pain relief in over 70% of patients. When pain persists, surgery is the treatment of choice.

Anatomic variations are common in the first dorsal compartment, and separate compartments have been noted in 21% of anatomic specimens. Reports of separate compartments found at surgery vary from 20% to 58%. More than half of patients may have “aberrant” or duplicated tendons (usually the APL). These tendons sometimes insert more proximally and medially than usual, into the trapezium ( Fig. 76.2 ), the abductor pollicis brevis muscle ( Fig. 76.3 ), the opponens pollicis muscle, or the muscle fascia. The EPB is considered a “late” tendon phylogenetically and is absent in about 5% of wrists. The presence of these variations and failure to deal with them at the time of surgery may account for any persistence of pain.

Trigger finger and thumb

Trigger thumb in adults is a distinctly separate entity from “congenital” trigger thumb. Stenosing tenosynovitis, leading to inability to extend the flexed digit or flex the extended digit often produces a palpable “triggering” and usually is seen in individuals older than 45 years of age. When associated with a collagen disease, several fingers may be involved (most often the long and ring fingers). Patients may note a lump or knot in the palm. The lump may be the thickened area in the first annular pulley or a nodule or fusiform swelling of the flexor tendon just distal to it. The nodule can be palpated by the examiner’s fingertip and moves with the tendon. The tendon nodule usually is just proximal to the anulus at the metacarpophalangeal joint level; however, in a rheumatoid patient, a nodule distal to this point may cause triggering. Patients may experience triggering after operative release because of catching of the tendon on the palmar aponeurosis transverse fibers, which usually resolves with time. Occasionally, a partially lacerated flexor tendon at this level heals with a nodule sufficiently large to cause triggering. Local tenderness may be present but is not a prominent complaint. Pressure accentuates the apparent snapping or triggering of the more distal joints. Patients frequently state that the problem is in the proximal interphalangeal joint with trigger finger or in the interphalangeal joint with trigger thumb. Other conditions, such as intraarticular disorders (e.g., loose bodies, degenerative joint disease, and fractures) and common extensor tendon subluxation, can cause similar symptoms and must be considered to determine effective treatment for idiopathic trigger finger.

Initial treatment of trigger digits usually is nonoperative, especially in uncomplicated conditions in patients with a short duration of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and ice. Corticosteroid injection is effective, with 60% achieving success after one injection. In their study of 292 corticosteroid injections for trigger digits, Dardas et al. found that repeat injections provided symptomatic relief for a year or more in 50% of patients; they recommended consideration of repeat injections in patients who prefer nonoperative management.

Patients with diabetes mellitus may be more refractory to nonoperative management; however, corticosteroid injections may elevate serum glucose levels for 5 days or more, and patients with unstable diabetes may be better treated without injection. Database review (153,479 injections and 70,290 releases) found that preoperative hypoglycemia increased infection risk after both procedures. In a cost analysis study, immediate surgical release in the clinic was identified as the most cost-effective treatment strategy for trigger finger in diabetic patients.

Surgical release reliably relieves the problem for most patients: approximately 97% of patients have complete resolution after operative treatment. Persistence of triggering is more common than recurrence. Trigger release should be done with a local block so that the cessation of triggering of a particular finger can be evaluated. Some adjacent finger triggering may become obvious only after a given finger is released; both can be released at the same surgical setting.

The safety and effectiveness of percutaneous trigger finger release using a needle or a push knife have literature support. Incomplete pulley release and damage to the flexor tendons and digital nerves, especially in the index finger and thumb, remain of some concern, especially with limited exposure techniques.