DOCSLIB.ORG

Dupuytren's Disease

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Dupuytren's Disease ONLINE EXCLUSIVE Thomas Auld, MD; Joanne R. Werntz, MD Dupuytren’s disease: Department of Orthopedic Surgery, Rutgers New Jersey Medical School, Newark (Dr. How to recognize its early signs Auld); University of Central Florida School of Medicine, Palmar skin dimpling and nodule or cord formation Orlando (Dr. Werntz) signal advancing disease. Treatments vary in [email protected] The authors reported no potential conflict of interest effectiveness—in part, depending on condition severity. relevant to this article. CASE u A 52-year-old right-hand-dominant white man arrived PRACTICE at our clinic complaining that he was unable to straighten RECOMMENDATIONS his right ring finger. He had no associated pain or numbness, ❯ Evaluate patients with and had not injured his hand. The patient had type 2 diabetes suspected Dupuytren’s disease that was controlled with metformin. He had no history of sur- (DD) for coexisting conditions gery or drug allergies, did not smoke, and said he drank 2 to such as Ledderhose disease and Peyronie’s disease. C 3 alcoholic beverages per day. He was a car salesman and was self-conscious when shaking hands with customers. On physi- ❯ Use the Hueston cal examination, we noted that he held his right ring finger tabletop test to assess at roughly 45 degrees of flexion at the metacarpophalangeal severity of DD. C joint; a painless cord-like structure was palpable on the palmar ❯ Do not recommend surface of that joint. His left hand had no abnormalities. stretching exercises If this were your patient, how would you proceed? for DD; they can hasten disease progression. C upuytren’s disease (DD) is a disabling fibroprolif- Strength of recommendation (SOR) erative disorder of the hand for which there is no A Good-quality patient-oriented cure. While the exact cause of DD is unknown, it has evidence D been linked to a number of risk factors, including smoking, B Inconsistent or limited-quality patient-oriented evidence alcohol consumption, and diabetes. It affects about 5% of the C Consensus, usual practice, US population, and up to 70% of affected individuals may opinion, disease-oriented 1 evidence, case series initially seek treatment from a primary care physician. The disease is also referred to as Dupuytren’s contracture, which describes the flexion contractures of fingers at the end stage of the disease. Palmar fibromatosis is yet another name for the disorder. DD refers to a spectrum of presentations ranging from nodules to cords to discernible contractures, and it is not known which patients with early Dupuytren changes will prog- ress to severe contracture. With recognition of early changes, nonsurgical intervention is possible, such as collagenase injec- tion or percutaneous fasciotomy, and can slow the progression of DD, restore function, and avoid or delay surgical interven- tion. DD is a clinically challenging disorder. Treatment for an affected area may resolve symptoms, only to have them recur in that location or another. CONTINUED JFPONLINE.COM VOL 66, NO 3 | MARCH 2017 | THE JOURNAL OF FAMILY PRACTICE E5 FIGURE 1 The nodule, cord, and contracture seen in Dupuytren’s disease A B C PHOTOS COURTESY OF: JOANNE R. WERNTZ, MD PHOTOS COURTESY Skin dimpling and a palpable nodule are evident near the base of a patient’s ring finger (A). A well-defined cord associated with the little finger is causing minimal misalignment (B). Severe contracture at the proximal interphalangeal joint (C) can interfere with routine daily activities. How underlying pathology proximal interphalangeal (PIP) joints develop correlates with clinical findings flexion contractures. The distal interpha- DD affects the palmar fascia, a thick trian- langeal (DIP) joint, rarely involved, instead gular-shaped sheet of dense fibrous collag- exhibits a hyperextension contracture. Digi- enous connective tissue that lies deep to the tal flexion contractures are often disabling, dermis and superficial to the flexor tendons interfering with daily activities such as pick- of the hand with fibers extending both into ing up a glass, shaking hands, or putting the skin and into the deep tissue. The palmar one's hand in a pants pocket. Many patients fascia secures the skin during gripping and seek medical attention only after a palpable twisting motions, and it bifurcates into distal nodule, cord, or flexion contracture becomes extensions, called pretendinous bands, that apparent (FIGURE 1). overlay and mimic the flexor tendons. In a study of 326 patients who reported Clinical findings reflect the progression Dupuytren’s symptoms, the most common of underlying pathology. The earliest mani- symptoms that led them to seek treatment festation of DD is painless dimpling of the were, in descending order, a hard bump skin on the palmar surface of the hand.2 Over (48%), a ropelike growth (12%), dimpling time, the underlying fibrosis with increased (11%), and finger contractures (10%). Only collagen deposition can progress, leading 9% of patients seeking treatment for hand to development of nodules and eventually, symptoms associated with DD had received cords, which are sometimes mistaken for a diagnosis of DD from their initial medical flexor tendons. Dupuytren-like fibrotic tissue encounter, causing an unnecessary delay in can occur on the sole of the foot (Ledderhose treatment.1 disease) and penis (Peyronie’s disease).2,3 In patients with these coexisting condi- tions, prognosis is generally worse.4 With Who is at increased risk for DD? the hands, bilateral involvement is common, DD is most often seen in elderly white men although it is usually more severe in one of European descent.5 In the United States, hand. The ring finger is the digit most fre- the prevalence of the disease is roughly 5%,1 quently involved, followed by the little finger, compared with 4% to 39% in northwestern middle finger, and index finger. The thumb is Europe (eg, Iceland).6 The male-to-female rarely affected.3 ratio of DD ranges from 6:1 to 15:1.7 The prev- As the disease progresses and cords con- alence of DD appears to increase with age. tract, the metacarpophalangeal (MCP) and The prevalence in men and women is simi- E6 THE JOURNAL OF FAMILY PRACTICE | MARCH 2017 | VOL 66, NO 3 DUPUYTREN'S DISEASE lar up to age 45 years, after which the rate is FIGURE 2 much greater in males.7 Patient can’t flatten hand DD is associated with many risk factors including smoking, alcohol consumption, vascular insufficiency, epilepsy, hyperlip- idemia, manual labor, occupations with exposure to vibration, hand trauma, and even hand surgery such as carpal tunnel release or trigger finger release.8-11 It is also associated with diabetes; particularly type 1 insulin- dependent diabetes.12 There may also be an association with frozen shoulder.12,13 The need for surgical treatment of DD Presume Dupuytren’s disease when a patient with becomes more likely with a history of ciga- a hand nodule or cord is unable to flatten the palm rette smoking and heavy alcohol consump- of the hand against a table surface. tion. There seems to be an association with epilepsy, most likely from anti-epileptic drugs.14 Rheumatoid arthritis is the only con- dition that has been associated with a lower thumb, and is often associated with a waxy incidence of DD, possibly because of the appearance of the skin. Camptodactyly is It's not known use of anti-inflammatory drugs.15 There are an autosomal dominant disorder that more which patients genetic differences between patients with often presents in childhood and can be with early and without DD, although a “Dupuytren’s caused by a number of congenital syndromes. Dupuytren gene” has not been identified. Volkmann’s contracture can manifest as a changes will claw-like deformity of the hand caused by progress undiagnosed compartment syndrome of the to severe Rule out possible DD mimics forearm. contracture. The differential diagnosis for flexion con- tracture of the MCP or PIP joints seen in Dupuytren’s disease includes stenosing Assess the severity of DD flexor tenosynovitis, or trigger finger. Other In your evaluation, first identify palmar or conditions that can mimic DD are ulnar claw digital fibromatosis presenting as a nodule hand, trauma scars, intrinsic joint diseases or a cord. Second, estimate the degree of such as degenerative or rheumatoid arthritis MCP and PIP joint contractures. A common (RA), diabetic cheiroarthropathy, campto- measure of contracture is the Hueston table- dactyly, and Volkmann’s contracture. Trauma top test. Ask the patient to place the palm of scars—especially longitudinal scars—have the hand on a flat surface. If the patient is a tendency to contract and develop keloid unable to completely flatten the hand formation. against the surface, presume a positive result Stenosing flexor tenosynovitis and (FIGURE 2).16 ulnar claw hand are distinguishable from DD An accurate measure of the degree of by full or nearly full active or passive exten- flexion can be accomplished with a goniom- sion of the affected digit, whereas DD is a true eter. For a simple assessment of severity, have contracture of the joint that does not allow the patient place each affected finger along full extension. A careful history can rule out the convexity of a spoon. If adjoining sur- previous injury to the area. Although intrin- faces are flush, assume that the contracture sic joint disease, such as RA, can cause finger is at least 30 degrees (FIGURE 3). The severity contractures, the joints are usually enlarged, of DD can also be graded according to the painful, and associated with characteristic Tubiana classification system (TABLE17), radiologic findings. wherein the total deformity or contracture Unlike DD, diabetic cheiroarthropathy score is the sum of the angles of all 3 digital often involves all of the digits except for the joints of the finger.
Load more

Recommended publications
  • Multiple Pulley Rupture Following Corticosteroid Injection for Trigger Digit: Case Report
    SCIENTIFIC ARTICLE Multiple Pulley Rupture Following Corticosteroid Injection for Trigger Digit: Case Report Cassie Gyuricza, MD, Eva Umoh, BA, Scott W. Wolfe, MD We report a case of pulley rupture following repeated local corticosteroid injections for trigger digit. The treatment involved exploration, tenolysis, and reconstruction using the palmaris longus tendon. (J Hand Surg 2009;34A:1444–1448. © 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Corticosteroid, pulley rupture, trigger digit. RIGGER DIGIT, OR stenosing tenosynovitis,isa local corticosteroid injection through a lateral approach condition characterized by painful locking or at the proximal phalanx10 (0.5 mL local anesthetic and Tsnapping of a digit caused by mechanical im- 0.5 mL triamcinolone acetonide 40 mg/mL [Kenalog- pingement of the flexor tendon passing through a hy- 40, Bristol-Meyers Squibb Co, Princeton, NJ]). Her pertrophic A1 pulley. Initial conservative management symptoms of pain temporarily improved, but 4 months of trigger digits with various corticosteroid preparations later, the patient returned with recurrent pain and a is well described.1–4 Side effects, including subcutane- second local corticosteroid injection was administered, ous fat atrophy, pain, depigmentation of the skin, and again using the lateral approach. During the ensuing 8 transient elevation of urine and blood glucose levels in months, the patient had persistent pain and tenderness patients with diabetes, are generally mild and self- over the A2 pulley. The patient also developed pain at limiting.5,6 We are aware of 2 previously reported cases the A1 pulley, and a third injection (0.5 mL local of delayed flexor tendon rupture following corticoste- anesthetic and 0.5 mL triamcinolone acetonide 40 mg/ 7,8 roid injections for trigger digit thought to be the result mL) was given into the palmar surface overlying the A1 of intratendinous injection.
    [Show full text]
  • Top Hand, and Wrist Problems
    12/10/2016 TOP HAND, AND WRIST Disclosures PROBLEMS: HOW TO • None SPOT THEM IN CLINIC Nicolas H. Lee, MS MD [email protected] UCSF Dept of Orthopaedic Surgery Assistant Clinical Professor Hand, Upper Extremity and Microvascular Surgery Dec. 10 th , 2016 Outline Outline • Carpal Tunnel Syndrome •Carpal Tunnel Syndrome • Trigger Finger • • Basal Joint arthritis Trigger Finger • Basal Joint arthritis • De Quervain tenosynovitis • De Quervain tenosynovitis • Mallet Finger • Mallet Finger • Ganglion cyst • Ganglion cyst 1 12/10/2016 Carpal Tunnel Syndrome • Compression of median nerve in carpal tunnel • Irritation of the nerve presents as numbness/pain 10 structures 9 flexor tendons Median nerve https://www.pinterest.com/pin/429812358163325007/ Anatomy (motor) Etiology 1. Idiopathic – most common 2. Anatomic – rare • Thenar Muscle (OAF) 3. Systemic – DM, hypothyroidism • Opponens Pollicis (deep) 4. **** Occupational Exposure • Abductor Pollicis Brevis (superficial) **** “A direct relationship between repetitive work • Flexor Pollicis Brevis activity (eg, keyboarding) and CTS has never been (superficial 1/2) objectively demonstrated.” 1 http://teachmeanatomy.info/upper-limb/muscles/hand/ 2 12/10/2016 Rare anatomic causes Carpal Tunnel Syndrome ● HPI – systemic risk factors Tenosynovitis CMC arthritis ◦ More common in: Ganglion Fracture 1) Diabetics 2) Hypothyroidism 3) Pregnancy (20-45%) Persistent Median artery Acromegaly Abnormal muscle Tumor Carpal Tunnel Syndrome ● CC: ◦ “I wake up at night and my hands are asleep” ◦ “I have to shake them to get the blood flowing again” ◦ “I have to run them under warm water and then I can go back to sleep” ◦ “Fingers go numb when I drive” ◦ “My hand goes numb when I use my cell phone” ◦ “I am always dropping things” Carpal Tunnel Syndrome Cranford, C.S.
    [Show full text]
  • Your Guide to Trigger Finger Surgery Brian J
    Your Guide to Trigger Finger Surgery Brian J. Bear, MD OrthoIllinois Hand, Wrist, and Elbow Center of Excellence Care Team and Contact Numbers: Brian J. Bear, MD Main Phone line . 815-398-9491 OrthoIllinois Kailey - Lead Nurse . .815-398-9491 324 Roxbury Road Ronda - Surgery Scheduler . 815-484-6969 Rockford, IL Sadie - Office Scheduler . .815-484-6996 TABLE OF CONTENTS Learn about Dr. Bear . 2 What is Trigger Finger/Trigger Thumb?. 3 Surgical Treatment v Description of Trigger Finger Release . 3 The Surgical Experience v Information to Keep in Mind Prior to Surgery . 4 v Pre-Admission Guide for Surgery . 5 v Pre-operative Phase . 6 v Intra-operative Phase . 7 v Post-operative Phase . 8 After Surgery v While You Recover at Home . 9 Commonly Asked Questions . 10-11 What Can I Do After Surgery? . 13 1 Learn More About Dr. Bear I would like to take this opportunity to tell you more about myself and my experience in health care. Originally from Winnetka, Illinois, I attended Northwestern University graduating in 1987, cum laude, president of Mortar Board Senior Honor Society and a member of Phi Betta Kappa. I continued my studies at Northwestern University School of Medicine, receiving my medical degree in 1991 as a member of Alpha Omega Alpha honor society. Following my graduation, I pursued advanced orthopedic training at Cornell Hospital for Special Surgery, which is ranked as the top orthopedic hospital in the United States. In addition, I completed a specialized training fellowship program in elbow and hand surgery at the Mayo Clinic. My practice is focused on shoulder, elbow, hand, microvascular, traumatic, and reconstructive surgery.
    [Show full text]
  • Trigger Finger
    PATIENT EDUCATION Trigger Finger Trigger Finger "Trigger finger" sounds like a malady that might affect gunslingers or hunters. In fact, this common condition results in a finger bent as if to pull a trigger. People over 40 years of age with a history of diabetes or rheumatoid arthritis are especially at risk to develop this condition. How it develops Although the exact cause of trigger finger is unknown, the progression of the condition is well documented. Trigger finger involves the tendons and pulleys in the hand that bend the finger. The tendons connect the muscles of the forearm with the bones of the fingers. Each tendon is covered by a slick lining or sheath. When you bend your fingers, the tendons glide back and forth, guided by a restraining pulley or yoke. When the tendon sheath becomes inflamed, it swells and may develop a knot or thickening in the tendon. The knot passes through the pulley as the finger bends, but gets stuck as the finger straightens. This causes further irritation and results in a vicious circle of irritation, swelling, catching and more irritation until finally, the finger locks in a bent position. Diagnosis No X­rays are needed to diagnose trigger finger. Your doctor will examine your hand and fingers, and use the findings to make the diagnosis. The finger may be swollen and there may be a bump, or nodule, over the joint in the palm of the hand. The finger may be stiff and painful. Although it may seem that the problem is in the knuckles, it is actually at the joint nearest the palm of the hand.
    [Show full text]
  • CONSTRUCTION WORK and CUMULATIVE TRAUMA DISORDERS What Are Cumulative Trauma Disorders?
    Connecticut Department of Public Health Environmental and Occupational Health Assessment Program 410 Capitol Avenue MS # 11OSP, PO Box 340308 Hartford, CT 06134-0308 (860) 509-7740 http://www.ct.gov/dph CONSTRUCTION WORK and CUMULATIVE TRAUMA DISORDERS What are Cumulative Trauma Disorders? Cumulative trauma disorders (CTDs) also known as repetitive strain injuries, repetitive motion disorders, overuse syndrome, and work-related musculoskeletal disorders are the largest cause of occupational disease in the United States and the most frequently reported type of occupational disease in Connecticut. CTDs are injuries of the musculoskeletal system (joints, muscles, tendons, ligaments, nerves, and blood vessels) which are caused by over use as a result of stressful work over a period of time. CTDs are usually caused by a combination of the following risk factors common to construction work: • repetitive motions • forceful exertions - pulling, pushing, lifting, and gripping • awkward postures - body positions that are not the natural resting position • static postures - body positions held without moving • mechanical compression of soft tissues in the hand against edges or ridges, such as using tools or objects which press against the palm • fast movement of body parts • vibration, especially in the presence of cold conditions • lack of sufficient recovery time (rest breaks, days off), which will increase the risk of developing a CTD by any of the above factors. Cumulative trauma disorders most often occur in the upper body. Common symptoms of CTDs include pain and swelling of the body parts that are performing work duties involving the above risk factors. Although back injuries are excluded from the definition of CTDs, back injuries are often caused by similar risk factors and occur quite frequently in construction workers.
    [Show full text]
  • De Quervain's Release Standard of Care PT
    BRIGHAM & WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. Case Type/Diagnosis: (diagnosis specific, impairment/dysfunction specific) 11 Since the first description of “washerwoman’s sprain” tenosynovitis of the first dorsal compartment has become a commonly recognized inflammatory disorder. The most radial of the extensor compartments on the dorsum of the wrist is occupied by the tendons of the extensor pollicis brevis and abductor pollicis longus. The tendons are enveloped in an osseofibrous canal lined by synovium, which, when subjected to excessive or repetitive mechanical stresses, responds in a characteristic fashion distinguished by pain, swelling, and limitation of motion of the thumb. In 1895,Fritz de Quervain, a Swiss surgeon, 1 was first credited with the recognition of this disease and so it bore his name. More accurately, Tillaux 2 and Gray 3 referred to this disorder before de Quervain. Anatomy: Twenty-four extrinsic tendons cross the wrist and provide power and dexterity in the hand. Each tendon passes through a series of tight fibrous -osseous canals designed to optimize the balance between motion and force production by maintaining the tendon in close approximation to the joint or joints it controls. There are six separate compartments under the dorsal carpal ligament each lined with a separate synovial sheath membrane. The first one is over the radial styloid and it contains the abductor pollicis longus and the extensor pollicis brevis tendons. These tendons pass through an unyielding osteoligamentous tunnel formed by a shallow groove in the radial styloid process and a tough overlying roof composed by the transverse fibers of the dorsal ligament.
    [Show full text]
  • Rotator Cuff Tendinitis Shoulder Joint Replacement Mallet Finger Low
    We would like to thank you for choosing Campbell Clinic to care for you or your family member during this time. We believe that one of the best ways to ensure quality care and minimize reoccurrences is through educating our patients on their injuries or diseases. Based on the information obtained from today's visit and the course of treatment your physician has discussed with you, the following educational materials are recommended for additional information: Shoulder, Arm, & Elbow Hand & Wrist Spine & Neck Fractures Tears & Injuries Fractures Diseases & Syndromes Fractures & Other Injuries Diseases & Syndromes Adult Forearm Biceps Tear Distal Radius Carpal Tunnel Syndrome Cervical Fracture Chordoma Children Forearm Rotator Cuff Tear Finger Compartment Syndrome Thoracic & Lumbar Spine Lumbar Spine Stenosis Clavicle Shoulder Joint Tear Hand Arthritis of Hand Osteoporosis & Spinal Fx Congenital Scoliosis Distal Humerus Burners & Stingers Scaphoid Fx of Wrist Dupuytren's Comtracture Spondylolysis Congenital Torticollis Shoulder Blade Elbow Dislocation Thumb Arthritis of Wrist Spondylolisthesis Kyphosis of the Spine Adult Elbow Erb's Palsy Sprains, Strains & Other Injuries Kienböck's Disease Lumbar Disk Herniation Scoliosis Children Elbow Shoulder Dislocation Sprained Thumb Ganglion Cyst of the Wrist Neck Sprain Scoliosis in Children Diseases & Syndromes Surgical Treatments Wrist Sprains Arthritis of Thumb Herniated Disk Pack Pain in Children Compartment Syndrome Total Shoulder Replacement Fingertip Injuries Boutonnière Deformity Treatment
    [Show full text]
  • Trigger Finger: an Overview of the Treatment Options
    CME Trigger finger: An overview of the treatment options Amber Matthews, PA-C, MPAM; Kristen Smith, PA-C, MPAM; Laura Read, PA-C; Joyce Nicholas, PhD; Eric Schmidt, PhD ABSTRACT Stenosing flexor tenosynovitis, more commonly known as trigger finger, is one of the most common causes of hand pain and dysfunction. Clinicians must be able to identify the disorder, know the broad range of treatment options, and counsel patients on the treatment best suited for their condi- tion. Awareness of the economic burden each option entails is central to optimizing treatment outcomes and patient satisfaction. Keywords: trigger finger, stenosing flexor tenosynovitis, A1 pulley, audible snap, flexion contracture, flexor tendon nodule Learning objectives Describe the typical presentation of a patient with trigger finger. List the commonly used treatments to manage symptoms of trigger finger. Describe the economic effect of the various treatment options with regards to therapeutic decision-making. 53-year-old woman presents to her primary care provider with a 1-week history of pain and tender- Aness at the base of her right ring finger that has worsened in the past 2 days. She describes the pain as a cramping sensation that radiates from her ring finger to her palm and occurs with flexion and extension of the digit. When the symptoms started 1 week ago, she only experienced a painless clicking when bending her fingers. But over the past 2 days, her finger has locked in the bent position, forcing her to use her other hand to straighten it. The patient says that her symptoms seem to be worse At the time this article was written, Amber Matthews and Kristen Smith in the morning and get progressively better throughout the were students in the PA program at the University of Lynchburg in day.
    [Show full text]
  • Trigger Finger
    Trigger Finger What is it? Figure 1: Normal anatomy flexor sheath showing pulley, Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger tendon, and tenosynovium. thumb”, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys (see Figure 1). Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon Tendon develops a nodule (knot) or swelling of its lining. Because of the increased Pulley resistance to the gliding of the tendon through the pulley, one may feel Tenosynovium pain, popping, or a catching feeling in the finger or thumb (see Figure 2). When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend. What causes it? Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and Figure 2: Abnormal anatomy showing tendon catching thick, diabetes.
    [Show full text]
  • De Quervain's Tenosynovitis
    de Quervain’s Tenosynovitis What is it? de Quervain’s tenosynovitis refers to inflammation of the soft tissues surrounding the tendons that move the thumb – it is an overuse injury. de Quervain’s tenosynovitis affects two thumb tendons. These tendons are responsible for extending the thumb backwards and for moving the thumb away from the palm of the hand. These tendons connect their respective muscles in the forearm to the thumb. On their way to the thumb, the tendons slide through a thick fibrous sheath that forms a tunnel. Normally the tendons glide easily back and forth within this tunnel but in de Quervain’s tenosynovitis the tunnel is tight and irritates the tendons. See figure 1. Figure 1 What are the symptoms? How did I get it? What should I do? de Quervain’s tenosynovitis results Repetitive or unaccustomed use of Left untreated, this friction-induced in pain and tenderness over the the thumb that involves pinching tenosynovitis can progress to fibrosis thumb tendons as they cross the top with the thumb while moving the and lack of flexibility of the thumb. wrist (e.g., gripping and grasping) of the wrist joint. Here the tendons It generally does not get better leads to thickening of the fibrous may also be swollen. Pinch grasping without medical intervention. tendon sheath. Thickening results in and when the thumb and wrist are You should avoid activities which inflammation and tightening as the moved causes pain. Crepitus or aggravate or provoke your pain. tendon sheath passes over the wrist creaking of the tendons may also be These may lead to further rubbing of bone.
    [Show full text]
  • Q & a Trigger Finger
    Q & A Trigger Finger What is trigger finger? A trigger finger is characterized by intermittent locking or snapping of the finger joints. The affected finger is slowly flexed and snaps or triggers into a flexed position. Once the finger triggers, extending it is difficult. Occasionally, the trigger digit must be extended manually using the unaffected hand. In adults, this condition affects the ring and middle finger most commonly. In children, the thumb is most commonly affected and when it occurs in children, it is most likely a congenital problem. What causes the finger to trigger? In trigger fingers, a nodule or a swelling usually develops on the flexor tendon, most likely in response to irritation of the tendon in the tendon sheath. This swelling or nodule then impinges on one of the fibrous tissues encircling the tendon known as the A1 pulley, and the result is triggering when the digitis extended. This is a self perpetuating problem; the irritation from the triggering prevents the swelling from going down. In children less than two years old, a congenital narrowing of the tendon sheath known as the pulley may be present, resulting in congenital trigger digit, most commonly the thumb. What are the causes of trigger finger? There are various fractures that can lead to trigger finger. Repetitive activity such as typing can lead to swelling in the tendon resulting in trigger finger. Other conditions such as diabetes, gout, and rheumatoid arthritis are associated with the development of this condition. What are the treatment options for trigger finger? In adults, trigger fingers can be treated with injection of lidocaine and cortisone into the tendon sheath.
    [Show full text]
  • Evaluation and Diagnosis of Trigger Finger with Current Management Strategies
    Clinical Evaluation and Diagnosis of Trigger Finger with Current Management Strategies Urgent message: Appropriate treatment of “trigger finger” in the urgent care setting starts with differentiating that diagnoses from other disorders of the hand. This is relatively straightforward if one finger is involved, but can become more complex with multiple digits. ALEXANDER M. STOCK, MD and SHAILENDRA K. SAXENA, MD, PHD Introduction rigger finger, also known as stenosing flexor teno- Tsynovitis, is a common hand disorder that affects approximately 2.6% of the general population dur- ing their lifetime.1 For diabetics, the risk of developing trigger finger approaches 4% to 10%, with more com- plicated presentations involving multiple fingers.1 In the urgent care setting, differentiating trigger finger from other disorders of the hand and evaluating its severity is crucial to making treatment decisions. The pathological process required to create trigger finger involves thickening of the first digital, annular (A1) retinaculum that serves as a pulley sheath along the metacarpophalangeal (MCP) joint. With annular narrowing, the digital flexor tendon loses the ability to relax following flexion, resulting in a “triggered fin- ger.” Possible etiologies responsible for fibrosis of the the A1 retinaculum include diabetes mellitus (DM), amyloidosis, repetitive hand motions, and carpal tun- nel release (CTR); however, in most patients the cause 2-4 is often idiopathic. ©AdobeStock.com A recent review has postulated that viewing CTR as a cause of trigger finger may actually be the result of Urgent Care Evaluation a publication bias.4 It is also important to note that Establishing a diagnosis of trigger finger can be relatively stenosing flexor tenosynovitis is not an inflammatory simple if one digit is involved, but may require some process, despite the misnomer.2,5 thought if it involves more than one digit (see Figure 1 on the next page).
    [Show full text]