Trigger finger

From Wikipedia, the free encyclopedia

Trigger finger
Classification and external resources
ICD-10	M65.3
ICD-9	727.03
eMedicine	orthoped/570

Trigger finger, or trigger thumb, is a type of stenosing tenosynovitis (specifically digital tenovaginitis stenosans) in which the sheath around a tendon in a thumb or finger becomes swollen, or a nodule forms on the tendon. Affected digits may become painful to straighten once bent, and may make a soft crackling sound when moved. The label of trigger finger is used because when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

More than one finger may be affected at a time, though it usually affects the thumb, middle, or ring finger. The triggering is usually more pronounced in the morning, or while gripping an object firmly.

Trigger finger is usually idiopathic, meaning that the cause is unknown. Some speculate that repetitive forceful use of a digit leads to narrowing of the fibrous digital sheath in which it runs, but there is no data to support this theory and it may unfairly stigmatize hand use. The relationship of trigger finger to work activities is debatable and scientific evidence for^[1] and against^[2] hand use as an etiological factor are sparse and of low quality.

There is some evidence that idiopathic trigger finger behaves differently in patients with diabetes.^[3]

Contents [hide] 1 Treatment 2 Recovery 3 References 4 External links

[edit]Treatment

The natural history of disease for trigger finger remains uncertain.

Injection of the tendon sheath with a corticosteroid is effective over weeks to months in more than half of patients.^[4]

The problem is predictably resolved by a relatively simple surgical procedure (usually outpatient, under local anesthesia). The surgeon will cut the sheath that is restricting the tendon.

Investigative treatment options with limited scientific support include: non-steroidal anti-inflammatory drugs, occupational or physical therapy, steroid iontophoresis treatment, splinting, therapeutic ultrasound, phonophoresis (ultrasound with an anti-inflammatory dexamethasone cream), and Acupuncture.

[edit]Recovery

Recurrent triggering is unusual after successful injection and rare after successful surgery.

Difficulty extending the proximal interphalangeal joint may persist for months and benefits from exercises to stretch the finger straighter.

[edit]References

1. ^ Gorsche R, Wiley JP, Renger R, Brant R, Gemer TY, Sasyniuk TM. Prevalence and incidence of stenosing flexor tenosynovitis (trigger finger) in a meat-packing plant. J Occup Environ Med. 1998 Jun;40(6):556-60.
2. ^ 1: Kasdan ML, Leis VM, Lewis K, Kasdan AS. Trigger finger: not always work related. J Ky Med Assoc. 1996 Nov;94(11):498-9. PMID: 8973080
3. ^ Journal of Bone and Joint Surgery (American). 2007;89:2604-2611.
4. ^ Journal of Bone and Joint Surgery (American). 2007;89:2604-2611.

[edit]External links

• Hand World Trigger Finger Page
• American Academy of Orthopaedic Surgeons information on trigger finger
• Overview page from a UK surgeon
• Information from the Mayo Clinic
• Information from eMedicine

[hide] v • d • e Soft tissue disorders (M65-M79, 725-727) Connective tissue, articular (arthropathy) Tendinopathy Enthesopathy Enthesitis: upper limb (Adhesive capsulitis of shoulder, Rotator cuff tear, Golfer's elbow, Tennis elbow) · lower limb (Iliotibial band syndrome,Patellar tendinitis, Achilles tendinitis, Calcaneal spur, Metatarsalgia) · Bone spur Other/general Tendinitis · Tendinosis Synoviopathy Synovitis/Tenosynovitis (Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome) · Transient synovitis · Ganglion cyst osteochondromatosis (Synovial osteochondromatosis) · Plica syndrome villonodular synovitis (Giant cell tumor of the tendon sheath) Bursopathy Bursitis (Olecranon, Prepatellar, Trochanteric, Subacromial) · Baker's cyst Connective tissue, nonarticular Fasciopathy Fasciitis: Plantar · Nodular · Necrotizing · Eosinophilic Fibromatosis/contracture Dupuytren's contracture · Peyronie's disease · Plantar fibromatosis · Aggressive fibromatosis Adiposopathy Panniculitis/Erythema (Erythema induratum, Erythema nodosum) Other Neuropathy Neuralgia/Neuritis Undefined Rheumatism · Fibromyalgia see also neoplasia, systemic connective tissue disorders

Categories: Ailments of unknown etiology | Fingers | Inflammations

DeQuervain's syndrome, washerwoman's sprain, Radial styloid tenosynovitis, de Quervain disease, de Quervain'stenosynovitis,mother's wrist

DeQuervain's syndrome

From Wikipedia, the free encyclopedia

de Quervain Syndrome
Classification and external resources
Finkelstein's test for DeQuervain's tenosynovitis
ICD-10	M65.4
ICD-9	727.04
eMedicine	pmr/36

de Quervain syndrome (also known as washerwoman's sprain, Radial styloid tenosynovitis, de Quervain disease, de Quervain'stenosynovitis, de Quervain's stenosing tenosynovitis or mother's wrist), is an inflammation or a tendinosis of the sheath or tunnel that surrounds two tendons that control movement of the thumb. ^[1]

Contents [hide] 1 Eponym 2 Pathology 3 Cause 4 Symptoms 5 Treatment 6 References 7 External links

[edit]Eponym

It is named after the Swiss surgeon Fritz de Quervain who first identified it in 1895.^[2] It should not be confused with "de Quervain's thyroiditis", another condition named for the same person.

[edit]Pathology

The mucous sheaths of the tendons on the back of the wrist.

The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles, which run side by side, have almost the same function: the movement of the thumb away from the hand in the plane of the hand--so called radial abduction (as opposed to movement of the thumb away from the hand, out of the plane of the hand (palmar abduction)). The tendons run, as do all of the tendons passing the wrist, in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. While de Quervain syndrome is commonly believed to be an inflammatory condition or tendosynovitis, evaluation of histological specimens shows no inflammatory changes--rather a thickening and myxoid degeneration consistent with a chronic degenerative process are seen. ^[3] The pathology is identical in de Quervain seen in new mothers. ^[4]

de Quervain syndrome is more common in women. A speculative rationale for this is that women have a greater styloid process angle of the radius, but scientific support for this theory is lacking.

[edit]Cause

The cause of de Quervain's disease is not known. In medical terms, it remains idiopathic.

Some claim that this diagnosis should be included among overuse injuries and that repetitive movements of the thumb are a contributing factor. More specifically, repetitive eccentric lowering of the wrist into ulnar deviation especially with a load in the hand such as a child or even a stack of dishes. ^[5][6].

de Quervain's syndrome was also referred to as mother's wrist due to the fact that it can be caused by over-extending the wrist into the awkward positions that parents use to hold and handle infants. It was also nicknamed washerwoman's sprain as it can be caused by wringing motions, such as wringing out a washrag or similarly, removing the lid from a jar.

Recently cases have surfaced linked to the use of video game controlers with a so called "Analog-stick".

[edit]Symptoms

This article may contain original research or unverified claims. Please improve the article by adding references. See the talk pagefor details. (October 2008)

Symptoms are pain, tenderness, and swelling over the thumb side of the wrist, and difficulty gripping.

Finkelstein's test is used to diagnose de Quervain syndrome in people who have wrist pain. To perform the test, the thumb is placed in the closed fist and the hand is tilted towards the little finger - ulna deviation (as in the picture) in order to test for pain at the wrist below the thumb. Pain can occur in the normal individual, but if severe, DeQuervain's syndrome is likely. Pain will be located on the thumb side of the forearm about an in inch below the wrist.

Differential diagnosis includes ruling out:

1. Osteoarthritis of the first carpo-metacarpal joint
2. Intersection syndrome - pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist
3. Wartenberg's syndrome

[edit]Treatment

The management of De Quervain’s disease is determined more by convention than scientific data. From the original description of the illness in 1895 until the first description of corticosteroid injection by Christie in 1955^[7], it appears that the only treatment offered was surgery.^{[8] [9][10]} Since approximately 1972 the prevailing opinion has been that of McKenzie (1972) who suggested that corticosteroid injection was the first line of treatment and surgery should be reserved for unsuccessful injections.^[11] However, data regarding the efficacy of corticosteroid injection is sparse and uncontrolled (Oxford Level of Evidence 4) and it is not clear that there is a benefit over the natural history of the illness. A structured review published in 2003 identified only 35 publications that addressed De Quervain’s on Medline, only 7 of which presented data regarding corticosteroid injection, and none of which were controlled studies.^[12]

Retrospective studies all report success rates for corticosteroid injection greater than 70%, but the one prospective cohort study noted a success rate of only 58% and many of those patients took 12 to 18 months until symptom resolution.^[13] While the authors of that study ascribed the failure of corticosteroid injection to anatomical variations, it has not been clearly established that corticosteroid injection is better than placebo or that a symptom course of 12 to 18 months is any better than the natural course of the illness.

Another commonly used criterion for failure of non-operative treatment is election of operative treatment, but the decision to operate is complex and biased by the beliefs and emotions of the surgeon and the patient. Use of an elective event such as surgery to define success makes data regarding nonoperative treatment difficult to interpret. For instance, in one of the two investigations in which a substantial number of patients were treated without injection (splints and anti-inflammatory medication alone were used), a remarkable 45 of 93 (48%) of patients in all non-operative treatment groups had surgery. ^[14] This may simply reflect frustration on the part of both the patient and the surgeon with the prolonged symptom course associated with the disease. It may appear to both patient and surgeon that, after many months of symptoms, the illness will never resolve. The data of Lane and colleagues ^[15] indicating that non-operative treatment is successful only in mild cases is similarly marred by the lack of patients randomly assigned to alternative treatments and the use in many patients of a decision for surgery as a failure criterion.

Most tendinoses are self-limiting and the same is likely to be true of de Quervain's although further study is needed.

Palliative treatments include a splint that immobilized the wrist and the thumb to the interphalangeal joint and anti-inflammatory medication or acetaminophen.

Surgery (in which the sheath of the first dorsal compartment is opened longitudinally) is documented to provide relief in most patients.^[16] The most important risk is to the radial sensory nerve.

[edit]References

1. ^ Ilyas A, Ast M, Schaffer AA, Thoder J (2007). "De quervain tenosynovitis of the wrist". J Am Acad Orthop Surg 15 (12): 757–64. PMID 18063716.
2. ^ Ahuja NK, Chung KC (2004). "Fritz de Quervain, MD (1868-1940): stenosing tendovaginitis at the radial styloid process". J Hand Surg [Am] 29 (6): 1164–70. doi:10.1016/j.jhsa.2004.05.019. PMID 15576233.
3. ^ Clarke MT, Lyall HA, Grant JW, Matthewson MH (December 1998). "The histopathology of de Quervain's disease". J Hand Surg [Br] 23 (6): 732–4. PMID 9888670.
4. ^ Read HS, Hooper G, Davie R (February 2000). "Histological appearances in post-partum de Quervain's disease". J Hand Surg [Br] 25 (1): 70–2. doi:10.1054/jhsb.1999.0308. PMID 10763729.
5. ^ "Weiss Orthopaedics - Common Injuries - Wrist/Hand - de Quervain Stenosing Tenosynovitis".
6. ^ "OSH Answers: De Quervain's Disease".
7. ^ Christie BG. Local hydrocortisone in de Quervain's disease. Br Med J 1955 Jun 25;1(4929):1501-3.
8. ^ Christie BG. Local hydrocortisone in de Quervain's disease. Br Med J 1955 Jun 25;1(4929):1501-3.
9. ^ Piver JD, Raney RB. De Quervain's tendovaginitis. Am J Surg 1952 Mar;83(5):691-4.
10. ^ Lamphier TA, Long NG, Dennehy T. De Quervain's disease: an analysis of 52 cases. Ann Surg 1953 Dec;138(6):832-41.
11. ^ McKenzie JM. Conservative treatment of de Quervain's disease. Br Med J 1972 Dec 16;4(5841):659-60.
12. ^ Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract 2003 Mar-Apr;16(2):102-6.
13. ^ Witt J, Pess G, Gelberman RH. Treatment of de Quervain tenosynovitis. A prospective study of the results of injection of steroids and immobilization in a splint. J Bone Joint Surg Am. 1991 Feb;73(2):219-22.
14. ^ Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. J Hand Surg [Am] 1994 Jul;19(4):595-8.
15. ^ Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain's disease:role of conservative management. J Hand Surg [Br] 2001 Jun;26(3):258-60.
16. ^ Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. J Hand Surg [Am] 1994 Jul;19(4):595-8.

[edit]External links

• Hand University: A Patient's Guide to de Quervain Tenosynovitis
• DeQuervain's Syndrome: Medical Imagery - Medical Art and Illustration
• -1744437193 at GPnotebook
• Computer related diseases and prevention methods

[hide] v • d • e Soft tissue disorders (M65-M79, 725-727) Connective tissue, articular (arthropathy) Tendinopathy Enthesopathy Enthesitis: upper limb (Adhesive capsulitis of shoulder, Rotator cuff tear, Golfer's elbow, Tennis elbow) · lower limb (Iliotibial band syndrome,Patellar tendinitis, Achilles tendinitis, Calcaneal spur, Metatarsalgia) · Bone spur Other/general Tendinitis · Tendinosis Synoviopathy Synovitis/Tenosynovitis (Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome) · Transient synovitis · Ganglion cyst osteochondromatosis (Synovial osteochondromatosis) · Plica syndrome villonodular synovitis (Giant cell tumor of the tendon sheath) Bursopathy Bursitis (Olecranon, Prepatellar, Trochanteric, Subacromial) · Baker's cyst Connective tissue, nonarticular Fasciopathy Fasciitis: Plantar · Nodular · Necrotizing · Eosinophilic Fibromatosis/contracture Dupuytren's contracture · Peyronie's disease · Plantar fibromatosis · Aggressive fibromatosis Adiposopathy Panniculitis/Erythema (Erythema induratum, Erythema nodosum) Other Neuropathy Neuralgia/Neuritis Undefined Rheumatism · Fibromyalgia see also neoplasia, systemic connective tissue disorders

Categories: Overuse injuries | Inflammations

A Patient's Guide to de Quervain's Tenosynovitis Introduction de Quervain's tenosynovitis is a condition that causes pain on the inside of the wrist and forearm just above the thumb. It is a common problem affecting the wrist and is usually easy to diagnose. This document will help you understand • how this condition starts • how to recognize the symptoms • what can be done to stop the pain Anatomy What part of my thumb and wrist is causing problems? de Quervain's tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus(APL) and the extensor pollicis brevis (EPB). Tendons connect muscle to bone. Muscles pull on tendons for movement. The muscles connected to the APL and EPB tendons are on the back of the forearm. The muscles angle toward the thumb. View close-up of anatomy. On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole. View tunnel image. This tunnel is lined with a slippery coating called tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis. In de Quervain's tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel. Causes How did this condition develop? Repeatedly performing hand and thumb motions such as grasping, pinching, squeezing, or wringing may lead to the inflammation of tenosynovitis. This inflammation can lead to swelling, which hampers the smooth gliding action of the tendons within the tunnel. Arthritic diseases that affect the whole body, such as rheumatoid arthritis, can also cause tenosynovitis in the thumb. In other cases, scar tissue from an injury can make it difficult for the tendons to slide easily through the tunnel. Symptoms What problems does this condition cause? At first, the only sign of trouble may be soreness on the thumb side of the forearm, near the wrist. If the problem isn't treated, pain may spread up the forearm or further down into the wrist and thumb. As the friction increases, the two tendons may actually begin to squeak as they move through the constricted tunnel. This noise is called crepitus. If the condition is especially bad, there may be swelling along the tunnel near the edge of the wrist. Grasping objects with the thumb and hand may become increasingly painful. Diagnosis What tests will my doctor want to do? Doctors usually diagnose de Quervain's tenosynovitis easily through a physical examination. Most of the time no fancy tests are required. The major problem can be distinguishing de Quervain's tenosynovitis from intersection syndrome, which is a very similar condition. Document Link: A Patient's Guide to Intersection Syndrome Careful attention must be paid to where the pain is located--over de Quervain's tunnel near the end of the radius bone, or over the intersection point on the wrist. The intersection point is about three inches up the forearm. The Finklestein test is one of the best ways to make the diagnosis. You can do this test yourself. Bend your thumb into the palm and grasp the thumb with your fingers making a fist with the thumb inside. Now bend your wrist away from your thumb in a side to side motion. If you feel pain over the tendons to the thumb, your problem may be de Quervain's tenosynovitis. Treatment How can I make the pain go away? Conservative Treatment If at all possible, you must change or stop all activities that cause your symptoms. Take frequent breaks when doing repeated hand and thumb actions. Avoid repetitive hand motions, such as heavy grasping, wringing, or turning and twisting movements of the wrist. Keep the wrist in a neutral alignment. In other words, keep it in a straight line with your arm, without bending it forward or backward. Your doctor may want you to wear a special forearm and thumb splint called a thumb-spica splint. This splint keeps the wrist and lower joints of the thumb from moving. The splint allows the APL and EPB tendons to rest, giving them a chance to begin to heal. Anti-inflammatory medications may also help control the swelling of the tenosynovium and ease symptoms. These medications include common over-the-counter medications such as ibuprofen and aspirin. If these simple measures fail to control your symptoms, your doctor may suggest an injection ofcortisone into the irritated tunnel. Cortisone reduces the swelling of the tenosynovium and may temporarily relieve your symptoms. Cortisone injections will usually control the inflammation in the early stages of the problem. Your doctor may have you work with a physical or occupational therapist. The main focus of therapy is to reduce or eliminate the cause of irritation of the thumb tendons. Your therapist may check your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems. Surgical Treatment If all else fails, your doctor may recommend surgery. The goal of surgery is to give the tendons more space so they no longer rub on the inside of the tunnel. To do this, the surgeon performs a surgical release of the roof of the tunnel. This surgery can usually be done as an outpatient, which means that you won't have to spend the night in the hospital. It can be done using a general anesthetic, which puts you to sleep, or a regional anesthetic. A regional anesthetic blocks the nerves going to only a certain part of the body. Injection of medications similar to novocaine can block the nerves for several hours. In surgery for de Quervain's tenosynovitis, you may get an axillary block, which puts the arm to sleep, or a wrist block, which puts only the hand to sleep. It is even possible to perform the surgery by simply injecting novocaine around the area of the incision. Once you have anesthesia, your surgeon will make sure the skin of your forearm and wrist is free of infection by cleaning the skin with a germ-killing solution. The first step in the surgical release is to make a small incision along the thumb side of the wrist. View steps of surgery: 1. Incision site. The surgeon moves aside other tissues and locates the tendons and the tunnel. An incision is made to split the roof, or top, of the tunnel. This allows the tunnel to open up, creating more space for the tendons. The tunnel will eventually heal closed, but it will be larger than before. Scar tissue will fill the gap where the tunnel was cut. 2. Tunnel opened The skin is then stitched together, and your hand is wrapped in a bulky dressing. Rehabilitation What can I expect after treatment? If conservative treatment is successful, you may see improvement in four to six weeks. You may need to continue wearing your thumb splint to control symptoms. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions of the wrist and thumb. View splint. Rehabilitation is more involved after surgery. Full recovery could take several months. Pain and symptoms generally begin to improve after surgery, but you may have tenderness in the area of the incision for several months. Take time during the day to support your arm with your hand elevated above the level of your heart. You should move your fingers and thumb occasionally during the day. Keep the dressing on your hand until you return to the doctor. Avoid getting the stitches wet. Your stitches will be removed ten to fourteen days after surgery. You will probably need to attend occupational or physical therapy sessions for six to eight weeks. You'll begin doing active hand movements and range-of-motion exercises. Therapists also use ice packs, soft-tissue massage, and hands-on stretching to help with the range of motion. When the stitches are removed, you may start carefully strengthening your hand and thumb by squeezing and stretching putty. Therapists also use a series of gentle stretches to encourage the thumb tendons to glide easily within tunnel. As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand and thumb. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you'll do are designed get your hand working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your thumb and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.
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