Stenosing Tenosynovitis

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

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

• Hand table and basic hand set

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.

• 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.

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.

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.