➢ Trigger Finger
Trigger finger is common in patients with diabetes.
Corticosteroid injections are effective in about 60% to 92% of cases.
Proximal interphalangeal joint contracture may occur in long-standing cases.
The outcomes of open and percutaneous releases are similar; however, surgeons are split on preferences.
➢ Intersection Syndrome
The classic finding is crepitus with wrist motion at the distal one-third of the radial aspect of the forearm.
➢ Extensor Pollicis Longus (EPL) Tenosynovitis
Corticosteroid injections should be used with caution because of the potential for rupture.
EPL tenosynovitis is very rare.
➢ de Quervain Disorder
This condition is common in postpartum women.
A positive Finkelstein test is considered to be pathognomonic of de Quervain disorder, but care should be taken to differentiate this condition from thumb carpometacarpal arthritis.
Corticosteroid injections are effective in about 80% of cases.
Patients in whom corticosteroid injections fail to provide relief of symptoms frequently have a separate extensor pollicis brevis (EPB) compartment.
The abductor pollicis longus (APL) tendon has multiple slips; care should be taken not to confuse one of these slips as the EPB.
Traction on the APL pulls up the thumb metacarpal but not the thumb tip.
Traction on the EPB extends the thumb metacarpophalangeal joint.
Care should be taken to avoid injury to the sensory branch of the radial nerve.
➢ Fourth Compartment Tenosynovitis
This uncommon condition is most often seen in patients with rheumatoid arthritis.
The condition involves a large diffuse area, as opposed to the compact dorsal ganglion cyst.
Hand and wrist pain are common complaints among patients presenting to both orthopaedic and hand surgeons. Many patients present with a specific complaint that can be easily identified and diagnosed as a form of tenosynovitis; however, in some instances, the diagnosis can be more challenging. The term tenosynovitis is used synonymously in the literature with the words tendinitis and tendovaginitis; these words can be misleading because they imply an inflammatory condition, which in reality may not be present. The term tendinosis is the most appropriate descriptor. Various provocative tests have been used to identify these disorders, but uncertainty remains with regard to their treatment. Nonoperative options are commonly used as first-line treatment, but questions remain regarding when to advance to operative intervention. The present review will focus on the current literature addressing the evaluation and treatment of specific forms of tenosynovitis of the hand and wrist.
Stenosing Tenosynovitis (Trigger Finger)
Trigger finger and thumb have been defined as the inability to flex and extend the digit smoothly as a result of a decreasing proportion of the volume of the flexor sheath to its contents1. All digits can be affected; however, the ring finger is most commonly affected, followed by the thumb2. Patients with trigger finger commonly present with digit catching, popping, locking, and an inability to fully flex or extend the digit. In some instances, patients may present with only pain and/or a nodule over the A1 pulley at the level of the volar metacarpophalangeal (MCP) joint. Trigger finger is present in approximately 2% of the general population and increases to approximately 20% in patients with diabetes mellitus3,4. Compared with trigger finger in patients without diabetes, trigger finger in the diabetic population is more common in females, frequently involves both hands, often presents in multiple digits simultaneously, and usually does not involve the index and small fingers5. On examination, patients often have tenderness at the palmar base of the digit, just proximal to the volar MCP joint. Crepitus over the A1 pulley can be palpated in early cases of trigger finger. In more severe cases, the thumb or finger will be locked in either a flexed or extended position and the patient will have difficulty obtaining full extension or flexion, respectively, at the interphalangeal joints2.
Histopathological studies have revealed the absence of inflammation6,7. A normal A1 pulley is bilaminar, comprising a deep layer of dense connective tissue covered by a layer of loose connective tissue. The A1 pulleys of patients with trigger finger are trilaminar, with an irregular connective tissue found in the deepest layer, a middle layer of normal connective tissue with some fibrocytes, and an outermost layer of loose connective tissue. Chondrocyte metaplasia is also often present within the A1 pulley6. There are also changes that manifest as localized spindle-shaped thickenings in the volar aspect of the flexor tendon1. This hypertrophy of the A1 pulley and thickening of the flexor tendon cause a discrepancy between the fibro-osseous sheath beneath the A1 pulley and the flexor tendon passing through the tunnel.
Nonoperative measures are the mainstay of treatment for trigger finger, with the goal of obtaining smooth, painless, and full range of motion of the digit. Observation with activity modification can be trialed in early cases of trigger finger; however, this approach can be difficult because the precipitating event is often never identified. Some authors have recommended splinting as a first step in management. Early on, a thermoplastic splint blocking proximal interphalangeal (PIP) joint flexion can be worn for four to six weeks. Such splints have demonstrated improvement on numeric pain-rating scales, a decrease in triggering events during ten active fists, and an increase in participant-perceived improvement with no change in grip strength8. MCP splints are better tolerated by patients and have better outcomes when compared with splints blocking distal interphalangeal (DIP) joint motion, which also have been suggested as a splinting protocol9. In a prospective study, fifty patients who were managed with splinting of the MCP joint in 10° to 15° of flexion for an average of six weeks were compared with fifty patients who were managed with betamethasone sodium phosphate injection; the injection group had a significantly better rate of successful treatment than the splinting group (82% compared with 66%; p < 0.05)10. The authors recommended splinting as an option if patients had a strong objection to cortisone injection; however, many surgeons do not use splinting as a first-line treatment because of the lack of patient compliance and mediocre results.
Corticosteroid injection into the tendon sheath at the level of the A1 pulley is the mainstay of nonoperative treatment. Betamethasone is the corticosteroid of choice because it is water-soluble and does not leave a residue. Both triamcinolone and methylprednisolone have been used successfully and have been studied extensively. While the mechanism by which corticosteroid works to resolve the symptoms of trigger finger is still unknown, it is thought to decrease tendon or pulley thickness despite the lack of inflammation seen on histological studies. Corticosteroid injection has been shown to be substantially more effective than lidocaine injection alone11. Several studies, comprising several hundred patients in total, have investigated the efficacy of corticosteroid on trigger finger and have shown promising results. Injection of the involved flexor tendon sheath provides long-term relief of symptoms in 60% to 92% of patients after as many as three injections2. In a prospective study of 108 digits in seventy-four patients, 84% of digits and 92% of trigger thumbs were cured at a mean of 3.5 years after a single injection of triamcinolone12. With a repeat injection, these values increased to 91% and 98%, respectively. In a large retrospective review of 577 trigger fingers, the recurrence rate was 20.3%, with the average efficacy lasting 315 days in the failure group13. Recently, an observational study of a prospectively recruited series of seventy-one trigger digits demonstrated complete remission in 69% of injected digits after an average duration of follow-up of eight years14. Interestingly, thumbs had a higher rate of success (81%) compared with all other digits (56%). Using ultrasound guidance for A1 pulley injection was not shown to improve outcomes or to decrease the rate of recurrence in a recent prospective randomized controlled study15.
Recurrence following corticosteroid injection is dependent on many host-related factors. In a large prospective randomized study of 124 trigger fingers that were treated with triamcinolone injection, seventy digits (56%) had a recurrence of symptoms at a median of 5.6 months16. Younger age, insulin-dependent diabetes mellitus, involvement of multiple digits, and a history of other tendinopathies of the upper extremity were all found to be factors that increased the failure rate. Similarly, Baumgarten et al. found that corticosteroid injection was much more likely to fail in diabetic patients as compared with nondiabetic patients17. Advanced diabetes, as indicated by nephropathy and neuropathy, was associated with higher rates of surgery. The authors concluded that, in diabetic patients, the need for surgery is not decreased by corticosteroid injection compared with placebo. It is important to make diabetic patients aware that blood sugar levels can be elevated considerably for twenty-four to forty-eight hours after the injection of a corticosteroid18. Although not curative in all cases, corticosteroid injection is a safe and effective treatment option for trigger finger before proceeding to operative treatment.
Operative intervention has been shown to be superior to conservative therapy for the treatment of stenosing tenosynovitis19. Open release of the A1 pulley is performed commonly with the patient under local anesthetic, with or without sedation, and with or without a tourniquet. The exception is in patients with rheumatoid arthritis, in whom triggering is treated with synovectomy rather than A1 pulley release. A transverse, longitudinal, or oblique incision is used along with blunt dissection to expose the A1 pulley. Once exposed, the A1 pulley is released completely, usually with some of the proximal palmar aponeurosis, and with careful consideration of the neurovascular bundle20. Turowski et al., in a retrospective review, reported that 97% of seventy-five patients had complete resolution of symptoms following open release of a symptomatic trigger finger21. Only one patient in that series required reoperation, and no tendon bowstringing, nerve injuries, or infections were noted. Similarly, in a retrospective review evaluating 234 consecutive patients undergoing open A1 pulley release, 254 of the 276 affected digits had complete resolution of triggering, with 98% of patients regaining full range of motion, after an average duration of follow-up of 14.3 years22. In that series, there were nine complications, including six transient neurapraxias (five involving the radial digital sensory nerve of the thumb), two superficial skin infections, and one case of delayed wound-healing.
Percutaneous release is another surgical option following the failure of conservative treatment of a symptomatic trigger finger. This technique has been used for more than fifty years and has been shown to be effective, with a success rate of 100% in a series of fifty-two patients23. Most authors have used a beveled needle to provide a release; however, flat-blade knives and small hooked knives have also been used24. Some surgeons fear that the neurovascular bundle is at risk during percutaneous release; however, Schramm et al. reported that the closest distance of the needle to the tract was 2.7 mm and that the distance did not differ between the digits25. Eastwood et al. used a 21-gauge needle for percutaneous release in thirty-five patients, reporting complete relief of symptoms in thirty-three patients (94%) and partial relief in the other two26. The authors concluded that percutaneous release of trigger finger was effective, convenient, safe, and well tolerated by the patient. They did note that the obliquity of the radial digital nerve of the thumb required particular attention to avoid injury. Pope and Wolfe, in an anatomical study of percutaneous A1 release, found that 90% of the pulley was released27. In their surgical series of eleven patients with thirteen trigger fingers, the pulley was examined under direct open visualization following percutaneous release. The authors found that only eight of thirteen digits had full release of the pulley but reported that zero of the five patients with incomplete release complained of any symptoms. Ragoowansi et al., in a study of 240 trigger fingers that were treated with a 19-gauge needle and the “lift-cut” technique, reported a 94% success rate, with ten patients experiencing recurrent symptoms28. No neurovascular injuries were encountered. In a prospective randomized controlled study of 100 trigger digits that were treated with either open or percutaneous release of the A1 pulley, open release resulted in a success rate of 96% whereas percutaneous release resulted in a success rate of 100%29. Percutaneous surgery resulted in shorter operative times as well as less pain and time to recovery compared with the open technique. In a meta-analysis in which 199 patients who had been randomly assigned to percutaneous treatment were compared with 198 who had been assigned to open release, there were no differences between the two groups in terms of the rates of either recurrence or complications30. Both open and percutaneous release demonstrated superior results compared with corticosteroid treatment; however, because of the ease of use and low morbidity, corticosteroids are recommended as first-line treatment. While complications following trigger finger release are infrequent, the most common include incomplete release (especially with percutaneous techniques), nerve injury (especially in the thumb and small finger), bowstringing (very rare), infections (most frequently seen in diabetic patients), residual PIP joint contracture (especially in long-standing cases), and persistent triggering (most frequently due to intertendon impingement or some A2 pulley impingement). In rare cases, one slip of the flexor digitorum superficialis may need to be resected to debulk the tendon mass in order to prevent further triggering despite complete pulley release20. Table I lists treatments for trigger finger along with their levels of evidence.
Intersection syndrome is a rare disorder that occurs when the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) bellies rub on the extensor carpi radialis longus and brevis tendons31. It is thought to occur secondary to repetitive flexion and extension movements during occupation or sporting activities32. The area of inflammation is usually found 3.5 to 4.5 cm proximal to the Lister tubercle33. Intersection syndrome is diagnosed on the basis of clinical findings such as tenderness, swelling, and occasional crepitus over the affected area and needs to be differentiated from other sources of wrist pain such as de Quervain disorder, Wartenberg syndrome (neuritis of the dorsal sensory branch of the radial nerve as it exits from under the brachioradialis tendon in the forearm), tendinitis of the second or third compartment, muscle strain, and ganglion cyst33. Both magnetic resonance imaging (MRI) and ultrasound have been shown to be useful examinations when the clinical diagnosis is not clear as both are able to show anatomical variations within the tendon sheaths as well as exclude other pathological conditions34,35. The treatment of intersection syndrome is similar to that of other overuse injuries, beginning with the cessation of the aggravating activity and the use of nonsteroidal anti-inflammatory drugs (NSAIDs)31. Splinting of the wrist in slight extension, including the thumb to the interphalangeal joint, along with the use of NSAIDs and rest was shown to relieve symptoms in approximately 60% of 124 patients within two to three weeks32. Kaneko and Takasaki reported that taping of the forearm for three weeks relieved symptoms and improved Disabilities of the Arm, Shoulder and Hand (DASH) scores at both four weeks and one year of follow-up36. Local corticosteroid injections are often used when splinting and rest have failed; however, we are not aware of any studies that have examined the effectiveness of this treatment modality. Surgical decompression of the second dorsal compartment has yielded successful results only after exhaustion of all nonoperative therapies37,38.
Extensor Pollicis Longus Tenosynovitis
Extensor pollicis longus (EPL) tenosynovitis is a rare condition in which the EPL tendon becomes thickened and inflamed. It presents with pain and triggering at the level of the Lister tubercle of the third extensor compartment39,40. Attenuation of the EPL tendon can result from chronic tenosynovitis resulting from repetitive activity (drummer palsy), inflammatory conditions such as rheumatoid arthritis, and inflammation resulting from minimally displaced distal radial fractures41,42. Corticosteroid injection has been used with success in some instances; however, caution must be used because of the irritation and the risk of rupture of the EPL tendon in these cases40. Surgical release of the tendon sheath showed good results in a case report and was advocated for the prevention of EPL tendon rupture40. Additional studies are needed to better understand the pathophysiology of and treatment options for EPL tenosynovitis prior to making treatment recommendations for this diagnosis.
de Quervain Disorder
de Quervain disorder involves the first dorsal compartment of the wrist. Many names have been given to the condition, including stenosing tendovaginitis (as used by de Quervain himself), styloid tendovaginitis, peritendinitis, stenosing tendinitis, and stenosing tenosynovitis43. As with other conditions grouped in the “tenosynovitis” category, these names may be misnomers as they imply an inflammatory pathoetiology, whereas some studies have shown that de Quervain disorder actually represents an attritional and degenerative process within the first dorsal compartment43.
de Quervain disorder affects approximately 0.5% of men and 1.3% of women and may be more common in pregnant or postpartum women44,45. It typically presents as a gradual onset of pain over the radial aspect of the wrist and is exacerbated by grasping, thumb abduction, and ulnar deviation of the wrist. While repetitive lifting, typing, and texting have been considered to be risk factors, a recent meta-analysis of work-related causes of de Quervain disorder failed to demonstrate sufficient evidence to confirm a causal relationship46.
As with trigger finger, the histopathological studies of de Quervain disorder have not supported an inflammatory pathophysiology; rather, increased friction within the first dorsal compartment is thought to be responsible. Clarke et al. found that in patients with de Quervain disorder, the extensor retinaculum of the first dorsal compartment was up to five times thicker than normal and that this finding was due to increased vascularity, mucopolysaccharide accumulation, and other fibrous tissue deposition47. The synovial membranes that line the compartment were histologically normal47.
Understanding the relevant anatomy is paramount when considering de Quervain disorder. The first dorsal compartment is a fibro-osseous tunnel on the radial aspect of the distal part of the radius, through which the tendons of the APL and EPB travel. The APL originates on the radius, ulna, and interosseous membrane and inserts variably onto the base of the first metacarpal and trapezium; it has multiple slips (typically ranging from two to four, although as many as seven have been reported)48. The EPB originates on the dorsal aspect of the radius and interosseous membrane and inserts onto the base of the proximal phalanx of the thumb. Variations in the anatomy of the first dorsal compartment are common. Aktan et al., in a study of twenty-eight patients, found that the number of tendons within the first dorsal compartment was more than the accepted standard (two) in >80% of patients48. They also found that 46% of wrists with de Quervain disorder had septated compartments48. Bahm et al., in a study of sixty patients, found that 60% of patients with de Quervain disorder had an additional septum within the first dorsal compartment49. Classically, this so-called extra septum subcompartmentalizes the EPB tendon within the first dorsal compartment. Kutsumi et al. found that the additional septation increased the gliding resistance of the EPB tendon50. This septation may predispose such patients to the attritional changes responsible for the symptoms of de Quervain disorder.
The diagnosis of de Quervain disorder is typically made on the basis of a history and physical examination alone. Imaging is not typically necessary but may be helpful to rule in or rule out coexisting abnormalities such as thumb basal joint arthritis. Provocative maneuvers may be a helpful component of the physical examination. The Finkelstein test is the classic maneuver and is considered pathognomonic for de Quervain disorder when it reproduces the pain for which the patient has sought treatment51; this test is performed by grasping the thumb and quickly ulnarly deviating the wrist. The Eichoff maneuver, commonly confused with the Finkelstein test, is performed by having the patient clench the thumb into a fist while the examiner quickly ulnarly deviates the wrist52.
Splinting with use of a thumb spica has been used as a nonoperative method for the treatment of de Quervain disorder. It is thought that this treatment, by immobilizing the APL and EPB tendons and reducing the amount of friction between the two tendons, may decrease the pain and swelling within the first dorsal compartment. However, studies have shown that splinting alone is inferior to corticosteroid injection with or without concomitant splinting53. Corticosteroid injection is the most common and preferred method of treating tenosynovitis of the first compartment. Many patients have complete relief after just one injection44,53. Harvey et al. found that 82% of eighty-two patients had complete resolution of symptoms after one or two corticosteroid injections54. Eleven patients did not have relief after injection and went on to have surgery; ten of the eleven were found to have a separate compartment for the EPB. In a series of fifty patients who received a single corticosteroid injection, 82% of patients had complete relief at six weeks44. Only half of those patients remained asymptomatic at one year; however, all patients with recurrence of symptoms had the recurrence within the first six months. Zingas et al., in a study of nineteen patients, reported that only 84% of injections were placed in the first dorsal compartment and that the EPB sheath was missed in 68% of cases55. Supplemental use of NSAIDs has not been shown to improve the effectiveness of a single corticosteroid injection in terms of the relief of first dorsal compartment symptoms56. In patients with persistent symptoms, a repeat injection is offered usually four to eight weeks after the initial treatment, with additional splinting as necessary. If pain does not resolve after two failed injections and at least six months of nonoperative treatment, surgical intervention is recommended43.
Surgical release of the fibro-osseous tunnels of the first dorsal compartment along with decompression of the APL and EPB from adhesive tissue is the treatment of choice after failed nonoperative treatment of de Quervain disorder. It is essential that the surgeon be aware of and protect the radial sensory nerve during the procedure as iatrogenic injury to the nerve is the most common complication following decompression. The nerve has been reported to be as close as 2 mm to the first dorsal compartment and is at risk during decompression for the treatment of de Quervain disorder57. Surgical release of the first dorsal compartment has been reported to be an effective way to alleviate pain as noted in 100% of patients who were followed for more than fifteen years in a randomized, double-blind trial of 160 patients58. Interestingly, Ta et al. found that patient satisfaction had a direct correlation with the duration of symptoms59. They found that 91% of forty-three consecutive patients had an excellent result with complete relief of symptoms and that patients who had had symptoms for longer than ten months were more satisfied with the outcome than patients who had had symptoms for a shorter duration.
It is important to identify and isolate both the APL and EPB tendons during decompression because the two tendons have been found to be in different subsheaths, which, if not identified, can lead to a continuation of symptoms60. Patients who had more pain with thumb MCP joint extension than with thumb abduction were found to have a greater incidence of two compartments after undergoing surgical intervention61. Endoscopic release of the first compartment has been described, but few studies have compared open and endoscopic methods. In addition, the risk to the sensory nerve has not been fully delineated62.
Complications can include hypertrophic scarring, postoperative subluxation of the tendons (avoided by not resecting the volar half of the cut first dorsal compartment and by applying a splint or thick dressing in neutral postoperatively), and neuritis or injury of the sensory branch of the radial nerve (caused by excessive dissection of the nerve secondary to the use of very small incisions with poor visualization). Postoperative immobilization with either a splint or very thick, semi-rigid dressing for seven to ten days helps to stabilize the surgical site. Table II lists treatments for de Quervain disorder and their levels of evidence.
Fourth Compartment Tenosynovitis
Fourth compartment tenosynovitis, also known as proliferative tenosynovitis, is common among patients with rheumatoid arthritis. In rare cases, tendinosis of the fifth compartment can occur. Patients often present with a painful mass on the dorsum of the hand, and tenosynovectomy has been indicated to prevent rupture of the tendons63. However, this condition also has been found in wrists not affected by rheumatoid arthritis. Cooper et al.64 retrospectively reviewed the records for eleven patients without rheumatoid arthritis who had been diagnosed with proliferative tenosynovitis of the fourth compartment. Patients presented with a painful dorsal wrist mass that moved with the extensor tendons and had substantially more pain with extension of the wrist with the fingers extended than with the fingers flexed. All eleven patients underwent tenosynovectomy after the failure of treatment with rest, NSAIDs, corticosteroid injection, and splinting. Complete relief of symptoms was reported by 91% of the patients, with one patient having a recurrence thirty months after surgery. In a case series of five patients who presented with a painful fourth compartment, triggering at the extensor retinaculum was found to be caused by an anomalous muscle, intratendinous lesion, or synovial inflammation and tendon fraying65.
Extensor Carpi Ulnaris Tenosynovitis
Ulnar-sided wrist pain resulting from repetitive motions is common in athletes who play racquet sports. It is often difficult to diagnose ulnar-sided wrist pain and to identify if it is indeed an injury to the extensor carpi ulnaris (ECU) tendon, triangular fibrocartilage complex (TFCC), or even the distal radioulnar joint. The ECU tendon is stabilized in an osseous groove and is covered with retinaculum superficially and a subsheath created by a duplication of the deep antebrachial fascia66. Tendinopathy develops gradually, usually without trauma or fall. Pain is often found with forced isometric supination, which can be accompanied by swelling and tenderness of the sheath. In a series of twenty-eight patients with ECU tenosynovitis, the majority of cases resolved in response to a decrease in the offending activity for two to twenty-four weeks66. Nachinolcar and Khanolkar suggested that the injury is due to a twisting injury that occurs more commonly in women67. In that series, seventy-nine patients with ECU tenosynovitis were managed with corticosteroid injection, with only nine patients having relief of symptoms. All other patients underwent decompression of the extensor carpi ulnaris with good results. Histologically, the ECU tendon showed hyalinization with chronic inflammatory cells within the tendon at the site of angulation around the ulnar styloid. Little evidence is available to make clear recommendations regarding the appropriate treatment of ECU tenosynovitis.
If surgical decompression of the ECU tendon is required because of refractory symptoms, thickened synovial tissue is frequently seen and should be debrided. If synovial thickening is seen, adequate decompression can be performed without releasing the entire retinaculum over the ECU tendon, thereby preventing any subluxation problem postoperatively. If the ECU tendon is irritated by chronic subluxation with wrist pronation-supination, then the ECU is usually stabilized with use of a slip of the extensor retinaculum, which is wrapped around the tendon and onto itself, forming a new sheath for stability.
Source of Funding: No external funds were received for the present study.
Investigation performed at the Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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