HAND ORTHO

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TRIGGER FINGER
Also known as: Snapping Finger
Digital Tenovaginitis Stenosans
Definition
Thickening and constriction of the mouth of a fibrous digital
sheath interference with the free gliding of the contained
flexor tendons
Incidence
Peak age 50-60 yrs (adult)
Also in infants and children (infantile)
4 F > M

SNAPPING FINGER
Aetiology
Unknown
Systemic:
Collagen Vascular Diseases Rheumatoid Arthritis
Diabetes Mellitus
Psoriatic Arthritis
Hypothyroidism Sarcoidosis
Amyloidosis

Highly repetitive or forceful use of the finger and thumb. Prolonged,

strenuous grasping, such as with power tools, may also aggravate the
condition. Thus seen in farmers, musicians, imdustrial workers
Congenital
nodule of the flexor pollicis longus

Infection
TB

Digital Tenovaginitis
Stenosans
Pathology
mismatch between the size of the flexor tendon
and its fibrous flexor sheath
proximal part of the fibrous flexor sheath at the
base of a digit becomes thickened thereby
constricting the mouth of the sheath
thus leading to disproportionate width of the
tendon ie decrease in the width opposite to the
constriction and swelling proximal to it
the nodular or swollen segment enters the
narrowed opening of the sheath with difficulty
with an attempt to extend the finger associated
snapping sound.

Trigger Finger
Clinical Features
**Adults: 3rd & 4th fingers esp **Children: thumb
Tenderness at the base of affected finger
Locking of finger in full flexion
Locking may be overcome by either forceful effort or
passive extension of the fingers with the other hand
Extension results in a click or snap
Examination reveals a palpable nodule (usually
slightly tender) at the base that will move with the
tendon
**Infantile sometimes mistaken for a dislocation
thumb or congenital anomaly

Snapping Finger
Investigations
Trigger finger is a clinical diagnosis. Radiological studies are of
little value.
Diagnosis ?
Clinical grading and documentation

Greens Classification
Grade 1 : Pretriggering Pain; history of catching that is not
demonstrable on clinical examination; tenderness over the A1
pulley
Grade 2 : Active Demonstrable catching but the patient can
actively extend the digit
Grade 3 : Passive Demonstrable locking requiring passive
extension (grade 3A) or inability to actively flex (grade 3B)
Grade 4 : Contracture- Demonstrable catching with fixed flexion
contracture of the proximal interphalangeal joint.

Digital Tenovaginitis
Stenosans
Treatment: dependent on the severity and duration
Mild, infrequent
Rest
To prevent the overuse of the fingers change or curtail daily
activities that requires repeated gripping action.
Splinting
Keeping the affected finger in a splint in the extended position
for several weeks will aid in resting the joint. It also prevents
curling of the fingers during sleep which may exacerbate the
condition on waking.
Gentle Finger Exercises & massage
This helps in maintaining the mobility of the fingers .Massage
will help to reduce the pain.
Soaking in warm water
May help to reduce the catching sensation.

Digital Tenovaginitis
Stenosans
Treatment: dependent on the severity and duration
Severe
Use of non steroidal anti inflammatory drugs.
This helps in reducing the inflammation and swelling of the tendon
sheath
Injection of steroids into the tendon sheath may help reduce
inflammation.
- 25 gauge needle to inject a mixture of 0.5-1.0 mL of 40 mg/mL
corticosteroid (eg, methylprednisolone) and 0.5 mL of 1%
lidocaine (without epinephrine).
-second corticosteroid injection may be performed 3-4 weeks later.
-cure rate for this conservative type of management is > 95%. It is
thought however that if two injections have not solved the
triggering it is unlikely that further injections will and additional
injections risk weakening the tendons with subsequent tendon
rupture.

Digital Tenovaginitis
Stenosans
Treatment: dependent on the severity and duration
Surgical Intervention
Indications
Failure of splint / injections
Irreducibly locked finger
Trigger thumb in infants (without release via surgery these infants are likely to
develop a fixed flexion deformity of the interphalangeal joint.)

Surgically incise the fibro-osseous canal to allow the thickened tendon to glide
without restraint. This may be done under local anaesthesia on an outpatient basis
and gives the added benefit of noting the disappearance of the pathology by
asking the patient to flex and extend the affected digit.
The opening of the sheath is deemed sufficient when triggering is no longer noted.
Post surgery the patient should be advised to begin moving the finger to prevent
tissue adhesion at the surgical site.
Non-steroidal anti-inflammatory drugs and elevation are advised for a period of
two to three days afterwards.
A simpler procedure involves releasing the friction by percutaneously tearing the
sheath with the use of a wide bore needle.

Trigger Finger
Complications
Neurovascular damage
*The thumb is particularly more vulnerable as the
bundle lies closer to the anterior midline of the digit
and is in closer proximity to the constricting tendon
sheath
Infection
Stiffness and scarring.

De Quervains Stenosing
Tenovaginits
Also known as: Tenovaginitis of the abductor pollicis longus &
extensor pollicis brevis
Definition
Stenosing tenovagynitis of the tendons in the first
dorsal extensor compartment of the hand, causing
pain over the radial styloid on movement.
Incidence
Middle aged
5/8 ? F > M

De Quervains Stenosing
Tenovaginits
Aetiolgy
Unknown
Repetitive forceful ulnar deviation of the wrist with the
thumb adducted and flexed as during lifting of objects is
a common inciting factor.
** Thus more common in mothers of infants , women who
wash, those with jobs that require recurrent activity of
the hands-typing.
Also seen in pregnancy, congestive cardiac failure and
chronic renal failure due to peripheral edema.

De Quervains Stenosing
Tenovaginits
Pathology
The fibrous sheaths of the abductor pollicis longus and
extensor pollicis brevis tendons are thickened where they
cross the tip of the radial styloid process ie. at a point where
the direction of the tendons changes; thus the tendons
appear normal.
Excessive friction from overuse inflammation of the
tendons within their fibrous sheath beneath the extensor
retinaculum associated swelling within a confined space
+/- entrapment of the superficial branch of the radial nerve.
Nerve entrapment resultant pain & the swelling may
further accentuate the obstruction to movement

De Quervains Stenosing
Tenovaginits
Clinical Features
Middle aged female, complaining of pain over the
dorsolateral aspect of the wrist provoked by lifting
activities or movement of the wrist and thumb.
Examination reveals local tenderness at the point
where the tendons cross the radial styloid
process. The thickened fibrous sheaths are usually
palpable as a firm nodule

De Quervains Stenosing
Tenovaginits
Investigations
Finklestein's Test
Place thumb in palm and cover with all fingers and
move wrist into
ulnar deviation. If pain is reproduced at radial
styloid region,
then suggestive of tenosynovitis of 1st compartment

De Quervains Stenosing
Tenovaginits
Diagnosis
Clinical
Treatment
Initially conservative ,pain persistence surgery

Conservative
Analgesia with physiotherapy and occupational modification
Rest the thumb and wrist by wearing a wrist and thumb spica splint
Steroid injections with methylprednisone to help decrease the inflammation and
swelling. This is most successful within the first six weeks after onset of the pain;
injected adjacent and parallel to the tendon sheath at the area of maximal
tenderness, just distal to the radial styloid. This peritendinous infiltration may be
repeated one or two times at one to two week intervals, if necessary.

Surgical
Almost always curative and performed on an outpatient basis
Involves a longitudinal incision of the tendon sheaths under local anaesthetic
( de- roofing). Take care to avoid the sensory branch of the radial nerve .This
allows for unrestrained tendon gliding.

De Quervains Stenosing
Tenovaginits
Complications
neuroma formation due to severing the branch of the
radial nerve
volar subluxation of tendon because too much of the
sheath is removed
failure to find and release a separate aberrant tendon
within a separate compartment
hypertrophy of scar due to the longitudinal skin incision

Carpal Tunnel

Carpal Tunnel Syndrome

Carpal tunnelorcarpal canalis the passageway on
thepalmarside of thewrist connecting the forearm to
the middle compartment of the deep plane of the palm.
Consists of:
flexor digitorum profundus(4 tendons)
flexor digitorum superficialis(4 tendons)
flexor pollicis longus(1 tendon)
median nerve
bones
connective tissue
lymphatics
fat

Carpal Tunnel

Median Nerve
Remember?
Median nerve runs within the forearm beneath the flexor digitorum superficialis .
Emerges on the radial side of the tendons lying deep to the palmaris longus tendon .
Passes through the carpal tunnel but before doing so gives off a palmar cutaneous
branch.
In the tunnel it lies just beneath the flexor retinaculum and comes in contact with it
on bending the wrist or fingers.
In the hand it gives off a muscular recurrent branch that supplies the thenar
muscles:
-flexor pollicis brevis -abductor pollicis brevis -opponens pollicis
palmar digital branches which supply the radial three and a half digits as well as the
nail beds and distal dorsal skin.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Also known as:
Most common entrapment neuropathy
Definition
Compression of the median nerve within the carpal
tunnel which lies between the carpal bones and the
flexor retinaculum leading to impaired sensory and
motor function of the hand over the distribution of
the median nerve.

Carpal Tunnel Syndrome

Incidence
30 60 years old
5 F>M
Aetiology
Due to the rigidity of this canal any factor decreasing the
space will cause pressure against the structures within.
Factors include anything leading to:
Increase in Volume of Contents
Decrease in size of the tunnel
Susceptibility

Carpal Tunnel Syndrome

Aberrant anatomy
Anomalous flexor tendons
Congenitally small carpal canal
Ganglionic cysts
Lipoma
Proximal lumbrical muscle
insertion
Thrombosed artery

Infections
Lyme disease
Mycobacterial infection
Septic arthritis

Inflammatory conditions
Connective tissue disease
Gout or pseudogout
Nonspecific flexor tenosynovitis*
Rheumatoid arthritis

Metabolic conditions
Acromegaly
Amyloidosis
Diabetes
Hypothyroidism or
hyperthyroidism

Increased canal volume

Congestive heart failure
Edema
Obesity
Pregnancy

Trauma
Repetitive hand motion: finger
and wrist flexion and extension
Labourers using vibrating
machinery as are office workers
especially typists and data entry
clerks

Carpal Tunnel Syndrome

Pathology
Increased pressure within the carpal canalischaemia to the median
nerve rather than direct nerve damage resultant symptoms.
Clinical Features
History
Pain, numbness, tingling in the distribution of the
Symptoms worse at nights with accompanying sleep disturbance
due to pain
Shaking, massaging, or elevating the hands can sometimes gain
relief.
Pain may radiate up the forearm to the elbow.
Decreased grip strength with loss of dexterity. Dropping objects and
less capable of performing fine motor movements such as gripping
or pinching.
Symptoms more common when a flexed wrist posture is assumed.

Carpal Tunnel Syndrome

Clinical Features
Physical Examination
Initially no findings
Atrophy of thenar muscles depending on severity
Blunting of sensation over median nerve

**Blunting of Sensation- this occurs over the radial 3 digits

but not over the thenar eminence which is supplied by the
palmar branch of the median nerve that comes off above the
flexor retinaculum and passes superficial to it.
**Useful in differentiating CTS from median nerve damage at a
higher level.

Carpal Tunnel Syndrome

Investigations
Tinels Test
Percussing / Tapping the volar wrist over the median nerve:a
positive sign if there is resulting shooting or shocking pain into
hand over radial 3 digits.

Phalens Test
Holding wrist in flexion for 60 seconds:a positive sign if there is
resulting tingling / paresthesia in the radial 3 digits.

Loss of two point discrimination.

Nerve Conduction Studies : investigation of choice for site and severity of
compression
Electromyography
Computed Tomography Scanning: displays bony structure but not soft tissue.
Ultra Sound: does not show soft tissue planes adequately.
Magnetic Resonance Imaging: Good soft tissue and bony imaging.

Carpal Tunnel Syndrome

Daignosis
Very dependent on the history of the patient.
Treatment: Aims to relieve pain, restore normal sensation and prevent
worsening
Conservative
Treat underlying condition
Rest or Splint to restrict movement of wrist. May be worn during the day
and/or night.
NSAIDS to relieve pain.
Steroid injections may produce temporary symptomatic relief.
Approximately 80% of patients with CTSinitially respond to conservative
treatment; however, symptoms recur in 80 % of these patients after one
year.
Surgical
More severe symptoms require surgical intervention via division of the flexor
retinaculum to decompress
the median nerve. This may be performed endoscopically.
NB. Physiotherapy may be needed in severe cases in order to regain proper

Carpal Tunnel Syndrome