TRIGGER FINGER (DIGITAL TENOVAGINOSIS)
(Subset of stenosing tenosynovitis)
Introduction:
It is a common disorder characterized
by catching, trapping or locking of the
involved finger flexor tendon due to
thickening at the entrance to its
sheath and on forced extension it
passes the constriction with a snap
(‘triggering’).
A secondary nodule can develop on
the tendon.
Etiology:
The underlying cause is unknown but association with
DM
Rheumatoid disease (may develop synovial
thickening or intratendinous nodules which
can also cause triggering)
Ageing
Clinical features:
i. Common in female
ii. Patients may note a lump or knot in the palm. and click as
the finger is flexed
iii. When the hand is unclenched, the affected finger initially
remains bent at the PIP joint but with further effort it
suddenly straightens with a snap.
iv. Any digit may be affected,
v. The ring (1), thumb (2), and middle fingers most
commonly;
vi. Sometimes several fingers are affected. (in collagen
disease)
vii. Palpable tender nodule (notta’s nodule) can be felt that
moves with the tendon
Treatment
A. Conservative – in adult & early cases
Rest, splinting, NSAIDS
injection of corticosteroid –
Needle placed at the
mouth of the tendon
sheath.
Recurrent triggering up to
6 months later occurs in
over 30 % of patients
Particularly young with
diabetes -may needed a
second injection.
B. Operative - Refractory cases
Surgical release of mouth of tendon sheath (A1 or A1 & A3
pulley)
Percutaneous release
Flexor synovectomy with excision of one slip of flexor
digitorum superficialis
Grade I (pre triggering)— Pain, tenderness but no locking
Grade II (active)— catching, but the patient can actively
extend the digit
Grade III (passive)— catching requiring passive extension
(grade IIIA) or
inability to actively flex (grade IIIB)
Grade IV (contracture)— catching, with a fixed flexion
contracture of the PIP
Joint
Congenital trigger thumb
Usually show persistent flexion deformity rather than trigger
Occurs – 2-3%, Bilateral – 25%
Mucopolysaccharides
Narrowing and thickening of sheath with formation of ganglion cyst
Treatment
30% resolve sponteniously
surgical - relase
Pathology:
neurovascular bundles during surgery. The risk is greatest in the
thumb (where the nerves are close to the midline) and the index
finger (where the radical digital nerve crosses the tendon).
In patients with rheumatoid arthritis the fibrous pulley must be
carefully preserved; damage to this structure will predispose to
ulnar deviation of the fingers.
is preferred.
INFANTILE TRIGGER THUMB
Parents sometimes notice that their baby or infant cannot extend
the thumb tip. The diagnosis is often missed, or the condition is
wrongly taken for a ‘dislocation’.
Very occasionally the child grows up with the thumb permanently
bent. This condition must be distinguished from the rare
congenitally clasped thumb in which both the IP joint and the MCP
joint are flexed because of congenital insufficiency of the extensor
mechanism (see Chapter 15).
De Quervain’s disease
Introduction:
Stenosing tenosynovitis of the 1st dorsal
compartment of the wrist characterized by
pain over styloid process of radius and
palpable nodule in the course of APL & EPB
is known as de Quervain’s disease.
Aetiology:
Clinical features
The patient is usually a woman aged 40–50,
history of unaccustomed activity such as
pruning roses or wringing out clothes.
pain on the radial side of the wrist during
movement
Sometimes there is a visible swelling over
the radial styloid
On examination
the tendon sheath feels thick and hard.
Tenderness is most acute at the very tip of the radial styloid.
Specific test:
o Finkelstein’s test - + ve The pathognomonic sign
o hitch-hiker’s sign - + ve
(Resisted thumb extension is also painful.)
Finkelstein’s test : The examiner places
the patient’s thumb across the palm in
full flexion and then, holding the
patient’s hand firmly, turns the wrist
sharply into adduction. In a positive test
this is acutely painful; repeating the
movement with the thumb left free is
relatively painless.
The
differential diagnosis includes
arthritis at the base of the thumb,
scaphoid non-union and
the intersection syndrome
radial styloiditis
Treatment
A. Conservative – in early case
Rest, splintage, NSAIDS
Local corticosteroid injection into the
tendon sheath,
sometimes combined with hand therapy
(ultrasound, frictions, splintage).
B. Operative
a. Indication –
i. Failure to conservative treatment
ii. Resistant cases
b. Procedures –
i. slitting the thickened tendon sheath or
ii. ‘de-roof’ the offending tendon sheath
Sometimes there is duplication of tendons and even of
the sheath, in which case both sheaths need to be
divided. Care should be taken to prevent injury to the
dorsal sensory branches of the radial nerve, which may
cause intractable dysaesthesia.
A similar entity had been reported in the 1893 edition of Gray's Anatomy and named
“washerwoman's sprain.”
is said to produce friction at the rigid retinacular sheath, with subsequent swelling
and/or narrowing of the fibroosseous canal.[102,][159] Acute angulation of the tendons at
the retinaculum occurs with wrist extension, and increased angulation of the tendons
in women was suggested by Bunnell to help explain their markedly increased
prevalence of the disease
