Stenosing Tenosynovitis

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PRE-PROCEDURE
INDICATIONS
  • The indications for surgery in both de Quervain's disease and trigger finger are largely similar.
    • Failure of conservative management
    • Delayed presentation
    • Severe symptoms
CONTRAINDICATIONS

Rheumatoid arthritis is a relative contraindication for A1 pulley release, because the release increases the tendency for ulnar drift.

EQUIPMENT
  • Hand table and basic hand set
ANATOMY

De Quervain's tenosynovitis

  • Tendons from extensor pollicis brevis and abductor pollicis longus are involved in de Quervain's tenosynovitis.
    • Both lie in the same synovial sheath below the extensor retinaculum in the first dorsal tendon compartment.
    • Extensor pollicis brevis (EPB)
      • Extends carpometacarpal and metacarpophalangeal joints of thumb
      • Supplied by posterior interosseous branch of radial nerve (C7 and C8)
    • Abductor pollicis longus (APL)
      • Partially abducts and extends thumb
      • Supplied by posterior interosseous branch of radial nerve (C7 and C8)

Flexor tenosynovitis

  • Annular ligaments and cruciform ligaments bind the tendon sheaths of the palmar surface of the phalanx.
    • This prevents volar displacement of the tendon sheaths during flexion of the phalanx.
      • Thus they are termed the annular digital pulleys.
    • Annular ligament locations
      • A1: metacarpophalangeal joint
      • A2: shaft of proximal phalanx
      • A3: proximal interphalangeal joint
      • A4: shaft of medial phalanx
      • A5: distal interphalangeal joint
    • The A2 and A4 pulleys are most important biomechanically.
      • Excision of the A2 pulley results in a 44% increase in work of finger flexion.
      • Excision of the A1 pulley results in a 10% increase in work of finger flexion.
    • A1 and A2 are typically separated by 0.4-4.1 mm.
      • However, there is almost a 50% incidence of continuity between A1 and A2.
      • When found in continuity, there is typically a thinned layer of retinacular tissue.
    • Cruciform ligaments are highly variable in their location.

PROCEDURE
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The full content of this section includes:
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  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: De Quervain's Disease
  • Post-Procedure: Trigger Finger and Thumb
  • Post-Procedure: Percutaneous Release of Trigger Finger

Post-Procedure: De Quervain's Disease

POST-PROCEDURE CARE
  • The small pressure dressing is removed after 48 hours and a patch dressing is then applied.
  • Motion of the thumb and hand is immediately encouraged and is increased as tolerated.
COMPLICATIONS
  • Failure to obtain complete relief after surgery is the most common complication.
  • This may result from
    • Formation of a neuroma in a severed branch of the superficial radial nerve
    • Volar subluxation of the tendon when too much of the sheath is removed
    • Failure to find and release a separate aberrant tendon within a separate compartment
    • Hypertrophy of scar from a longitudinal skin incision
ANALYSIS OF RESULTS
  • Conservative management is the initial treatment of choice.
  • Approximately 80% of patients respond well to nonoperative management.
OUTCOMES AND EVIDENCE
  • Conservative treatment
    • Harvey et al: 63 wrists initially treated with injections of steroids and local anesthetic into the tendon sheath
      • Pain relief complete after 1 injection: 45 (71.4%)
      • Pain relief complete after 2 injections: 7 (11.1%)
      • Required operative management: 11 (17.4% )
        • Of note, in 10 of these 11 patients, the extensor pollicis brevis was found in a separate compartment.
    • Christie (1955), Lapidus (1972), and Weiss et al (1994) reported similar results.
Procedure: De Quervain's Disease

Post-Procedure: Trigger Finger and Thumb

POST-PROCEDURE CARE
  • The compression dressing is removed after 48 hours, and a patch dressing is applied.
  • Sutures are removed at 10 to 14 days.
  • Normal use of the finger or thumb is advised after wound healing.
COMPLICATIONS
  • A2 pulley injury
  • Digital nerve injury
ANALYSIS OF RESULTS
  • Conservative management is successful in 60% to 70% of patients.
  • In those patients requiring surgery, 97% have complete resolution of symptoms postoperatively.
OUTCOMES AND EVIDENCE
  • Conservative treatment
    • Benson and Ptaszek
      • 60% of patients had symptoms resolved after one injection
    • Patients with diabetes mellitus may be more refractory to nonoperative management according to Griggs and associates.
    • Surgical release reliably relieves the problem for most patients.
      • Turowski, Zdankiewicz, and Thomson
        • 97% of patients had complete resolution after operative treatment.
      • Finsen and Hagen
        • Recurrence in 2 of 84 operated digits
        • Two patients had transient neurapraxias.
Procedure: Trigger Finger and Thumb

Post-Procedure: Percutaneous Release of Trigger Finger

POST-PROCEDURE CARE
  • Encourage active use of the finger with stretching exercises.
COMPLICATIONS
  • Failure to release, A2 pulley injury, digital nerve injury
ANALYSIS OF RESULTS
  • A prospective randomized trial has demonstrated no significant difference between percutaneous release and open release.
OUTCOMES AND EVIDENCE
  • Gilberts et al (2001): prospective randomized trial of 100 trigger digits
    • 98% success rate in open release
    • 100% success rate in percutaneous release
    • Mean operative time was significantly longer for open release.
    • Postoperative pain duration and time to recovery were shorter in percutaneous release.
Procedure: Percutaneous Release of Trigger Finger
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