2. INTRODUCTION
ANATOMIC CONSIDERATION
ANATOMY OF THE TENDON SHEATH:
Tendon nutrition is derived from:
• Synovial fluid from tenosynovial
sheath
• Vincular blood supply
After injury healing occurs by
•Extrinsic – peripheral fibroblast
•Intrinsic – fibroblast from tendon
itself
3. Flexor synovial sheath for index,
middle and ring finger begins at
the level of metacarpal neck 1 cm
proximal to the proximal border
of deep transverse metacarpal
ligament.
It is doubled walled hollow tube
sealed at both hand.
FUNCTION:
Gliding and bathing the tendon
with synovial fluid
4. Retinacular portion of flexor tendon
sheath overlies these synovial layers
Retinacular portion include 5 annular
pulleys and 3 cruciform pulleys and
also palmar aponeurosis pulley
A1 At MCP Joint
A2 Proximal phalanx
A3 Proximal IP joint
A4 Middle phalanx
A5 Distal IP joint
C1 Near head of proximal phalanx
C2 Base of middle phalanx
C3 Distal end of middle phalanx
5. Function: Annular pulley prevent bowstringing during finger
flexion and cruciate pulley make tendon sheath able to conform
to the position of flexion by allowing annular pulley to
approximate each other.
A2 and A4 pulleys are most functionally important so must be
prevented or reconstructed in flexor tendon surgery to prevent
bowstringing.
Flexor synovial sheath for thumb
starts proximal to carpal canal and
its retinacular portion has 2 annular
pulleys and an oblique pulley
A1 – At MCP joint
A2 – At IP joint
Oblique – Middle of proximal
phalanx
6. DEFINATION:
What Is STENOSING TENOSYNOVITIS?
It is a group of conditions in which there is mismatch between
the size of the tendon sheath and tendon which passes through
it.
It may result from enlargement of tendon as seen in Trigger
FINGER
Or
From narrowing and fibrosis of tendon sheath as seen in DE
QUERVAIN’S TENOSYNOVITIS.
7. TRIGGER FINGER or stenosing
tenosynovitis is caused by a nodule
or thickening of flexor tendon which
catches on the proximal edge of A1
pulley when the finger is actively
flexed.
Most common in
1. Ring finger
2. Thumb
3. long
4. index
5. small finger
More common in women than men
8. AETIOLOGY:
•Congenital
•Repetitive trauma
•Medical conditions of rheumatoid arthritis, gout, diabetes,
hypothyroidism, amyloidosis and certain infections — including
tuberculosis and sporotrichosis, a fungal infection.
•Other rare causes are: -Collateral ligament may catch on a bony
prominence on the side of metacarpal head.
-Rarely abnormal seasmoid may catch on the metacarpal head
-Capsule may become interposed when it is split transversely by
trauma
-Extensor tendon may slip off the head of metacarpal and
displace ulnarward over the interdigital cleft.
9. PATHOPHISIOLOGY
When the tenosynovium becomes
inflamed from repetitive strain injury
or overuse or due to inflammatory
conditions such as rheumatoid
arthritis,
the space within the tendon sheath
become narrow and constricting.
The tendon can't glide through the
sheath easily, at times catching the
finger in a bent position before
popping straight.
With each catch, the tendon itself
becomes irritated and inflamed,
worsening the problem.
With prolonged inflammation, fibrosis can occur
and bumps (nodules) can form
10. SIGNS AND SYMPTOMS
•Pain at the root of finger
•Swelling
•Tenderness
•Palpable nodule
•When hand is opened up from a clenched
position then affected finger remain in
flexion
With more forceful effort or passively
opening by other hand it may extend with
jerky release or often a palpable or audible
click.
More symptomatic in morning improving
through the day
11. EAST WOOD CLASSIFICATION
Grade 0 : mild crepitus in a non triggering digit
Grade 1 : uneven movement of the digit
Grade 2 : clicking without locking
Grade 3 : locking of the digit that is either actively or
passively correctable
Grade 4 : locked digit
12. Treatment
It depends on etiology:
Initial treatment of the condition can
include:
Rest. To prevent the overuse of affected
finger.
Splinting. To keep the affected finger in an
extended position for several weeks. The
splint helps to rest the joint. Splinting also
helps prevent you from curling your fingers
into a fist while sleeping, which can make it
painful to move your fingers in the
morning.
13. Finger exercises. Perform gentle exercises with the affected finger.
This help you to maintain mobility in finger.
Soaking in water. Placing the affected hand in warm water for five
to 10 minutes, especially in the morning, may reduce the severity of
the catching sensation during the day. If this helps, it can be
repeated throughout the day.
Massage. Massaging the affected fingers may feel good and
help relieve pain, but it won't affect the inflammation
For more serious symptoms,
Nonsteroial anti-inflammatory drugs (NSAIDs). Medications such as
nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve the
inflammation and swelling that led to the constriction of the
tendon sheath and trapping of the tendon.
14. IN NON-RHEUMATOID PATIENTS
Non operative treatment in form of STERIOD INJECTION
Betamethasone is commonly used
Inject 0.25–0.50 ml in 1 ml of lidocaine
SITE: around the A1 pulley.
PRECAUTIONS: -Use small needle less than 21G
-Should be given in flexor tendon sheath.
-Should not be intertendinous as it may lead to tendon rupture.
- Warn the patient that it will take a few weeks to see whether
the injection is successful.
-A second steroid injection can be given 6 weeks after the initial
injection if no improvement has been noted. Sometimes the
second injection is successful even if the first resulted in little
improvement
15. IMPORTANCE:
Steroid injection around the A1 pulley may provide symptomatic relief,
which can delay the need for surgery for many month
Anderson and kyle (1991) from a prospective study found that:
61% - respond to single steroid injection.
27% - recurred
12% - Required surgical release
6% - Subcutaneous fat atrophy
0% - Infected or tendon rupture
so it should be explained to patient before hand
16. Operative Treatment
Operative treatment should be considered when two steroid
injections are unsuccessful in alleviating symptoms or when
symptoms argue against waiting 4–6 weeks for improvement.
A patient whose finger is locked in flexion also should undergo
surgical treatment. Waiting for a steroid injection to work is
impractical because of concerns about subsequent joint stiffness
due to inability to move the finger for so long a period
17. SURGERY OF CHOICE:
PERCUTANEOUS RELEASE:
PROBE BLADE
Metacarpophalangeal joint
hyperextended and 19-gauge needle
inserted just distal to the flexor crease.
Bevel of needle oriented longitudinally
with tendon.
Needle stabilized and pulley released
from proximal to distal. Loss of
grating sensation as pulley is cut
indicates completion of release.
18. OPEN SURGERY
IMPORTANT CONSIDERATION BEFORE SURGERY
Best performed under wrist block so that patient can
actively flex and extend the affected digit once the release
is performed
Tourniquet should be used on the forearm or upper arm. It is
important to have a bloodless field to prevent injury to the
nearby neurovascular bundles
Do not cut anything until you are certain that the
neurovascular bundles are protected.
A2 pulley must be preserved
20. Postoperative Care
1. Acetaminophen or nonsteroidal anti-inflammatory agents should
be adequate for postoperative pain control.
2. Keep the hand elevated to decrease swelling and decrease pain.
3. The patient should be encouraged to use the hand for light activities
within 1–2 days after surgery.
4. Remove the dressing the day after surgery, and clean with gentle
soap and water daily.
5. Apply antibiotic ointment to the suture line daily for the first few
days. Cover with dry gauze as needed.
6. After 10–14 days, remove the sutures. Instruct the patient to
increase gradually the activities performed with the hand until the
patient has resumed regular activities
21. COMPLICATIONS OF SURGERY
Percutaneous release associated with incomplete release
Surgical release includes
•Digital nerve transection
•A2 pulley injury with subsequent bowstringing of tendons
•Bothersome scars
•Recurrent symptoms
•Stiffness
•Sympathetic dystrophy
22. IN RHEUMATOID PATIENTS.
•Underlying problem is synovitis with in flexor tendon sheath
•And it weakens both tendons and surrounding synovial sheath
•Therefore first control synovitis along with programme of active
assisted exercises and splinting
•STERIOD INJECTION SHOULD NOT BE GIVEN AS THERE IS A REAL
RISK OF TENDON RUPTURE.
•If synovitis and triggering persist despite above therapy
•Then SURGICAL SYNOVECTOMY should be performed without
releasing the annular pulleys.
23. IN TRIGGER THUMB:
•Flexor sheath is much tighter than in the fingers
•So it is difficult to inject tendon sheath without injecting into
tendon
•Therefore surgeon directly proceed to operative intervention
if single injection is ineffective..
•IMPORTANT NOTE: Surgical release require retraction of
radial digital nerve which crosses directly over A1 pulley
24. CONGENITAL TRIGGER FINGER:
•Present with digits in a position of flexion
•Present at birth but not appreciated until months later
•Anomaly is secondary to either sheath stenosis or tendon nodule
or both
•Period of observation with or without splinting is recommended if
child is less than 6 months of age
•Condition is less likely to resolve in older child so surgery is
recommended
•If left untreated older child may develop fixed flexion deformity
and joint contractures
•So older child if comes like this trigger finger as well as secondary
joint contractures must be treated.
