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Stenosing tenosynovitis

stenosing tenosynovitis, stenosing tenosynovitis foot
Stenosing tenosynovitis also known as trigger finger or trigger thumb is a painful condition caused by the inflammation tenosynovitis and progressive restriction of the superficial and deep flexors fibrous tendon sheath adjacent to the A1 pulley at a metacarpal head Repetitive forceful compression, tensile stress, and resistive flexion, causes inflammation, swelling, and microtrauma, that results in thickening commonly a nodular formation of the tendon distal to the pulley and stenosis of the tendon sheath leading to a painful digital base, limitation of finger movements, triggering, snapping, locking, and deformity progressively

Patients report a popping sound at the proximal interphalangeal joint PIP, morning stiffness with/without triggering, delayed and sometimes painful extension of the digit, and when more advanced, a locking position that requires manipulation to extend the affected finger This condition more commonly affects the middle and ring fingers occasionally the thumb, and the flexor rather than extensor tendons in the hand1

In rheumatic trigger finger or in diabetes, more than one finger may be involved Cases of stenosing peroneal tenosynovitis, have been reported where the patient presents with pain over the lateral malleolus, both with active and passive range of motion and no physical of radiographic evidence of instability23

Contents

  • 1 Two common diagnoses fall into this category
  • 2 Causes
  • 3 Signs and symptoms
  • 4 Diagnosis
    • 41 Differential Diagnosis
  • 5 Management
  • 6 See also
  • 7 References

Two common diagnoses fall into this categoryedit

  • DeQuervain's Syndrome affecting the first dorsal compartment of the wrist4
  • Trigger finger Occurs when a fibrous nodule develops in the digital flexor tendon 5

Causesedit

Stenosing tenosynovitis is most commonly caused by overuse from chronic repetitive activities using the hand or the involved finger Examples include work activities eg, computer use, materials handling or recreational activities eg, knitting, golf, racket sports Carpenters who use hammers suffer from this as well as those who continuously grip wood or other materials when cutting them due to having to use your hands as a clamp to hold things in place

Primary stenosing tenosynovitis can be idiopathic, occurring in middle age women more frequently than in men, but can present also in infancy

Secondary stenosing tenosynovitis can be caused by disease or entities that cause connective tissue disorders including the following:

  • Rheumatoid arthritis and psoriatic arthritis—therefore the clinician must assess the hands for rheumatologic deformities
  • Gout
  • Diabetes mellitus
  • Amyloidosis
  • Systemic lupus erythematosus

Others causes may include the following:

  • Direct trauma to the site
  • During the postpartum period6
  • Congenital

Signs and symptomsedit

Stenosing tenosynovitis often presents with a painful and swollen thumb with limited range of motion, or a ring finger or middle finger with similarly limited motion There is often a feeling of catching when the thumb is flexed In the ring and middle fingers, often a nodule can be felt when you press the area of the hand where the palm meets the finger7

Diagnosisedit

No specific work up is defined Stenosing tenosynovitis is a clinical diagnosis However, if rheumatoid arthritis is suspected, laboratory evaluation of is granted eg rheumatoid factor Imaging studies are not needed to diagnose the condition However, they can be valuable adjuvants to achieve a diagnosis An ultrasound or MRI the most reliable studycitation needed can demonstrate increased thickness of the involved tendons Thickening and hyper-vascularization of the pulley are the hallmarks of trigger fingers on sonography8

Differential Diagnosisedit

  • Triggering at decussation of superficial flexor over the deep flexor
  • MP joint locking
  • Flexor digitorium profundus avulsion/rupture
  • Extensor tendon rupture
  • Failure of digit extension from chronic dislocation of the metacarphophalangeal
  • Posterior interosseous nerve syndrome

Managementedit

Splinting, non-steroidal anti inflammatory drugs NSAIDs, and corticosteroid injections are regarded as conservative first-line treatments for stenosing tenosynovitis7 However, NSAIDs have been found to be ineffective as a monotherapy Early treatment of trigger thumb has been associated with better treatment outcomes7 Surgical treatment of trigger thumb can be complicated by injury to the digital nerves, scarring, tenderness, or a contracture of the joint A significantly higher rate of symptom improvement has been observed when surgical management is paired with corticosteroid injections when compared to corticosteroid injections alone7

Occupational therapy is based on relieving the symptoms and reducing the inflammation Overall cure rate, for dutifully applied non-operative treatment, is over 95% Several modalities of treatment exists, depending on the chronicity and severity of the condition

  • Modification of hand activities
  • Exercise & stretching
  • Local heat
  • Extension splinting during sleep custom metacarpophalangeal joint MCP joint blocking splint, which has reported better patient's symptomatic relief and functionality9 and a distal interphalangeal DIP joint blocking splint

Treatment consists of injection of methylprednisolone often combined with anesthetic lidocaine at the site of maximal inflammation or tenderness The infiltration of the affected site can be performed blinded or sonographically guided, and often needs to be repeated 2 or three times to achieve remission An irreducibly locked trigger, often associated with a flexion contracture of the PIP joint, should not be treated by injections10

  • Transection of the fibrous annular pulley of the sheath

For symptoms that have persisted or recurred for more than 6 months and/or have been unresponsive to conservative treatment, surgical release of the pulley may be indicatedcitation needed The main surgical approaches are percutaneous release and open release The percutaneous approach, is preferred in some centers due to its reported shorter time of recuperation of motor function, less complications, and less painful11 Complication of the surgical management include, persistent trigger finger, bowstringing, digital nerve injury, and continued triggering12

Of note, diabetes seems to be a poor prognostic indicator for nonoperative treatment and may develop stiffness after surgical releasecitation needed

See alsoedit

  • Repetitive stress injury

Referencesedit

  1. ^ Foye, MD, Patrick M "Physical Medicine and Rehabilitation for Trigger Finger Clinical Presentation" WebMD, LLC 
  2. ^ Andersen, MD, Erik 1987 "Stenosing Peroneal Tenosynovitis Symptomaticall Simulating Ankle Instability" The American Journal of Sports Medicine 15 3: 258–259 doi:101177/036354658701500313 
  3. ^ Gunn, DR March 14, 1959 "Stenosing Tenosynovitis of the Common Peroneal Tendon Sheath" Br Med J 1 5123: 691–692 PMC 1993081  PMID 13629094 doi:101136/bmj15123691 
  4. ^ "De Quervain Tenosynovitis: eMedicine Physical Medicine and Rehabilitation" Retrieved 2010-08-03 
  5. ^ Oxford Textbook of Rheumatology NY, USA: Oxford University Press, Inc 1993 p 951 
  6. ^ John H Kippel; Paul A Deppe 1998 Rheumatology 2nd ed Mosby 
  7. ^ a b c d Crop JA, Bunt CW June 2011 "Doctor, my thumb hurts" J Fam Pract 60 6: 329–32 PMID 21647468 
  8. ^ Guerini H, Pessis; E, Theumann N; Le Quintrec JS; Campagna R; Chevrot A; Feydy A; Drapé JL Oct 2008 "Sonographic appearance of trigger fingers" J Ultrasound Med 27 10: 1407–13 PMID 18809950 doi:107863/jum200827101407 
  9. ^ Tarbhai, K; Hannah S; von Schroeder HP Feb 2012 "custom metacarpophalangeal MCP joint blocking splint and a distal interphalangeal DIP joint blocking splint" J Hand Surg Am 37 2: 243–249 PMID 22189188 doi:101016/jjhsa201110038 
  10. ^ Wheeless, III, Clifford R "Trigger Finger / Tenosynovitis" Duke Orthopaedics 
  11. ^ Pavlicný, R Feb 2010 "Percutaneous release in the treatment of trigger digits" Acta Chir Orthop Traumatol Cech 77 1: 46–51 PMID 20214861 
  12. ^ Ryzewicz M, Wolf JM Jan 2006 "Trigger digits: principles, management, and complications" J Hand Surg Am 31 1: 135–46 PMID 16443118 doi:101016/jjhsa200510013 

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    29.10.2014


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