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Home , Tendinopathy, Tenosynovitis

Review Article of the Hand and Wrist

Abstract Julie E. Adams, MD Tendinopathies involving the hand and wrist are common. Many are Rohan Habbu, MBBS diagnosed easily, and in many cases, the management is straightforward, provided the pathology and principles are understood. Common conditions involving the of the hand and wrist include , of the first through sixth dorsal extensor compartments, and flexor carpi radialis tendonitis. Management strategies include nonsurgical treatments, such as splinting, injection, or therapy, and surgical techniques such as release.

s its name suggests, tendinop- the conspicuous absence of inflamma- Aathy is an affliction of the ten- tory cells typically is noted. It has been don, occurring anywhere along its proposed that the prolonged repetitive course. Stenosing tenosynovitis, or stress of these conditions puts trigger finger, occurs when a size mechanical strain on the tendon, From the Mayo Clinic, Austin, MN discrepancy exists between the ten- causing microruptures.1-5 Because of (Dr. Adams) and Hand Surgery Associates, Mumbai, India don and the pulley or sheath through the lack of a robust intrinsic blood (Dr. Habbu). which the tendon passes. This con- supply and uneven strain, the healing Dr. Adams or an immediate family dition may occur because the sheath and remodeling responses are altered. member has received royalties from or pulley becomes narrowed or Changes in gene expression have Biomet; is a member of a speakers’ because of the increased size of the been noted in the tendons. may bureau or has made paid tendon secondary to degeneration or be mediated by neurochemical cyto- presentations on behalf of Arthrex; serves as a paid consultant to tendinosis. This distortion prevents kines and potentiated by vascular 1-7 Acumed and Articulinx; and serves as the easy and smooth gliding of the changes. a board member, owner, officer, or tendon. The pathophysiology can committee member of the American be varied, ranging from overuse to Association for Hand Surgery, the Stenosing Tenosynovitis American Shoulder and Elbow inflammatory pathology from such Surgeons, the American Society for disorders as rheumatoid Stenosing tenosynovitis at the A1 Surgery of the Hand, the Arthroscopy (RA) or crystalline disease (ie, ) Association of North America, and the pulley is by far the most common Minnesota Orthopaedic Society. to systemic disorders such as tendon pathology seen. Women are Neither Dr. Habbu nor any immediate mellitus (DM) or , affected six times more often than are family member has received anything which result in tendon adhesions or men, with a higher incidence in of value from or has stock or stock thickening. Common histologic options held in a commercial company patients with DM and RA. The or institution related directly or findings in the sheath include colla- prevalence of trigger digit is 2% to indirectly to the subject of this article. gen degradation, vascular ingrowth, 3%, but in patients with diabetes, the 8,9 J Am Acad Orthop Surg 2015;23: and fibrocartilage metaplasia, prevalence rises to 10% to 20%. 741-750 believed to be a response to com- Changes occur in the pulley, http://dx.doi.org/10.5435/ pression and shear during tendon including thickening of the A1 pulley, JAAOS-D-14-00216 gliding. and in the flexor tendons, primarily Tendinosis refers to chronic de- the flexor digitorum profundus (FDP) Copyright 2015 by the American Academy of Orthopaedic Surgeons. generative changes in the tendon. In but also the flexor digitorum super- stenosing tenosynovitis and tendinosis, ficialis (FDS) (Figure 1). The etiology

December 2015, Vol 23, No 12 741

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Tendinopathies of the Hand and Wrist

26-28 Figure 1 and tendon rupture. Atransient elevation of blood glucose levels can occur, particularly in diabetic patients requiring insulin.20,28,29 In one study, the type of steroid— soluble triamcinolone versus insolu- ble dexamethasone—did not play a major role in the final long-term outcome. The insoluble steroid ten- ded to have a more rapid onset of Illustration demonstrating the flexor tendons and the pulley system of the digits. action, but results were less durable The A1 pulley is released during trigger finger release. A = annular pulleys, C = than those following injection of the cruciate pulleys, P = phalanges soluble steroid.24 If nonsurgical management fails, surgery is considered. Options include is varied, and an exact cause is be successful in 55% of cases. Com- open or percutaneous release of the unknown; it is likely multifactorial. pliance may be an issue because A1 pulley. Open release is the stan- Proposed contributing factors include patients may find the splints to be dard and is associated with a high rate genetic changes, systemic conditions cumbersome. of excellent results.30 Open release such as renal insufficiency, thyroid Supervised pro- can be achieved by a transverse, ob- disease, or DM, and occupational grams, often aimed at developing lique, or longitudinal incision. issues.7 differential gliding between the FDS Local anesthetic is preferred because Presenting symptoms often include and FDP tendons, tend to be less it allows the patient to move the pain at the level of the A1 pulley, effective than other modalities, such affected finger during surgery to con- which progresses to triggering or as steroid injection, in preventing firm the lack of triggering after release. locking. Patients may report a pain and triggering. One series re- If triggering persists despite A1 release, reduced grip, clicking, catching, or ported success rates of 69% for additional pathology such as an A0 locking. In most patients, a tender physical therapy programs versus pulley—a tight band of superficial nodule can be palpated at the site of 97% resolution for injection at 3 palmar aponeurosis proximal to the the A1 pulley. Patients also may have months, but patients who responded A1 pulley—or structural changes in a proximal interphalangeal (PIP) to physical therapy experienced no the FDS or FDP should be sought. In , which often fails to fully recurrence of pain or triggering at 6 certain patients, such as those with reverse even following successful months, indicating that physical long-standing DM, long-standing release. A high concordance with therapy was more effective than trigger digits, or RA, an element of concomitant carpal tunnel syndrome injection in preventing recurrence.18 FDP entrapment may be present at the is present, with .60% of patients injections into the A1 FDS decussation, or enlargement of with trigger digits demonstrating pulley region commonly are used as a the FDP may have led to entrapment at clinical or electrodiagnostic evidence first-line treatment of trigger digits. the A3 pulley. During the preoperative of median nerve compression at the They have shown an excellent evaluation in particular, the surgeon wrist.8,10-13 response rate of 60% to 90%.19 should have a heightened level of Initial management strategies may Recurrence rates are higher in the suspicion about patients with a pre- include a supervised therapy program setting of concomitant DM, multiple operative PIP contracture because or instruction in a home exercise pro- affected digits, and other associated these patients may have changes in the gram, rest with splints, and NSAIDs. tendinopathies;20-24 a diminishing tendons that could cause residual Orthoses are reported to provide relief likelihood of subsequent successful triggering after a complete A1 pulley in 40% to 87% of cases.14-16 These injection seems to exist following a release.31 Options in this setting aids typically immobilize the meta- recurrence of triggering after prior include reduction tenoplasty of the carpophalangeal (MCP) joint but injection.20 Alongerdurationof FDP tendon or, more commonly, allow PIP joint and distal interpha- symptoms has been associated with excision of a slip of the FDS.31 langeal joint motion, although one relatively poorer outcomes with Recurrence is rare following open splint described by Rodgers et al17 injections.25 Complications following release. Complications also are rare immobilized only the distal inter- corticosteroid injections are uncom- but include injury to the neuro- phalangeal joint and was reported to mon but can include fat atrophy vascular bundle and stiffness and

742 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Julie E. Adams, MD and Rohan Habbu, MBBS bowstringing if the pulley is cut. Will Figure 2 and Lubahn32 reported a 28% rate of minor complications, including stiffness and wound complications, and a major complication rate of 3% in a study of 78 open trigger releases. Recent studies document the precise surface anatomy of the A1 pulley, and percutaneous release of the A1 pulley also has been described. Cadaver studies have shown a high rate of divi- sion of the A1 pulley and a low com- plication rate with percutaneous trigger release.33-38 Clinical studies also have Illustration demonstrating the anatomy of the first (blue arrow) and second supported the early recovery from (yellow arrow) dorsal extensor compartments, differentiating the locations of (blue arrow) and intersection syndrome (black arrow). and the benefits of the percutaneous procedure.39,40 Concerns remain, however, about tendon scoring or is withdrawn until it is just out of the may coexist and may or may not be laceration and neurovascular injury, tendon. The needle is then advanced symptomatic. Other diagnostic stud- especially in the border digits and the longitudinally, producing a tactile ies rarely are required or useful. On thumb.33 grating sensation as the pulley is cut. radiographs, soft-tissue calcifications The specific instruments and tech- When the surgeon believes that at the first dorsal compartment may niques used for percutaneous release release is complete, the needle is be visualized occasionally, but more vary but include hypodermic needles, withdrawn, and an attempt to elicit commonly, radiographs are com- knife blades, or purpose-made triggering is made.41 pletely unremarkable.47 devices or blades deployed under Patients typically present with pain tactile feel or with guid- and swelling over the dorsoradial side ance. In general, however, some De Quervain Stenosing of the wrist. These symptoms are common features exist across all Tenosynovitis aggravated by resisted motion of the techniques. An injection of local thumb. Radial deviation and exten- anesthesia over the intended surgical De Quervain tenosynovitis affects the sion also can worsen the pain. site is used. In general, percutaneous tendons within the first dorsal com- Examination shows tenderness over release is easiest in the setting of active partment, the abductor pollicis lon- the first compartment. Often a full- triggering because adequate release gus (APL), and the extensor pollicis ness or swelling is present that rep- can be confirmed immediately. To brevis (EPB) (Figure 2). A septum resents a thickening of the first dorsal extend or hyperextend the MCP may separate the EPB and APL ten- compartment retinaculum, and a joint, the patient rests the dorsum of dons in the first compartment itself small retinacular may the hand on a stack of towels, al- in about 40% of the population. be present in the area. Typically, lowing the digital neurovascular Additionally, multiple tendon slips and history structures to drop more dorsally and of the APL typically are present.42-46 alone are diagnostic. The assessment away from the surgical site. The De Quervain tenosynovitis is asso- commonly described as the Finkel- patient may be asked to flex and ciated with pregnancy, the post- stein test (ie, ulnar deviation of the extend the digit, and the region of the partum period, and lactation, and wrist when the patient grasps the A1 pulley is palpated over the volar with activities involving repeated thumb in the palm with the other area of the MCP joint. The blade or radioulnar deviation, such as ham- digits) was in fact described by Eich- needle is introduced at the proximal mering, cross country skiing, or off and referenced by Finkelstein48 in edge of the A1 pulley and is used to cut lifting a child or pet. his report. A staged series of testing distally. If a needle is used, it is typi- The diagnosis is based on the clini- described by Dawson and Mudgal49 cally 18- to 19-gauge, and the bevel is cal examination and history. Radio- may be superior because patients oriented parallel to the tendon. It may graphs of the wrist may be obtained may find the Finkelstein test exces- be placed into the flexor tendon; to exclude alternative pathology in sively painful. During this testing, the location may be confirmed by the distal radius or carpus; thumb the patient places the wrist in neutral movement of the digit; and the needle carpometacarpal (CMC) arthritis pronosupination on a table, with the

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Tendinopathies of the Hand and Wrist ulnar aspect of the forearm resting on improve the success rate of treatment discomfort is more proximal than the table and the wrist and distal over steroid injection alone.51,53,54 that seen in de Quervain syndrome aspect hanging over the edge of the The success rate is poorer if an and is exacerbated by wrist motion, table unsupported. Simple active associated septum is present within particularly resisted wrist extension. gravity-assisted ulnar deviation is the first dorsal compartment44 or if Palpable or audible may be performed. A painful result indicates triggering of the first dorsal extensor noted. The diagnosis is based on first dorsal extensor pathology. If the compartment tendons occurs.55 The the history, clinical symptoms, and result is negative, further passive ulnar risks of corticosteroid injection examination findings. Differential deviation performed by the examiner include skin depigmentation and skin local anesthetic injections may help in may elicit pain to secure the diagnosis. and subcutaneous tissue atrophy, in supporting the diagnosis or in differ- Finally, if de Quervain syndrome is addition to the transient elevation of entiating between intersection syn- suspected but the previous tests are blood glucose levels.51,53,54 drome and de Quervain syndrome. not suggestive, the examiner may add Surgery involves the release of the The initial treatment is nonsurgi- passive thumb flexion into the palm sheath covering the first dorsal com- cal and includes a trial of anti- with concomitant wrist ulnar devia- partment. This release can be inflammatory medications, rest, tion to assess for pain.49 achieved by a transverse or longitu- activity modification, and forearm- Factors associated with a relatively dinal incision. Care should be taken based wrist splinting at about 15° poorer response to nonsurgical treat- to identify and protect the superficial of wrist extension. Corticosteroid ment include the presence of separate branch of the radial nerve. After the injection also may be useful. Many compartments for the APL and EPB or sheath is released, a separate sub- patients will respond to these mea- the triggering of the tendons with compartment for the two tendons sures, but if nonsurgical manage- thumb motion.50 Alexander et al44 should be sought. If present, this ment fails, surgical release of the described an EPB entrapment test to subcompartment also should be second dorsal extensor compartment assess for the presence of a separate released. Missing this step is the most is an option. It is important to release compartment for the EPB. The common cause of recurrence or any over the tendons about the patient is asked to extend the MCP residual symptoms. Most surgeons area of pathology.56 joint of the thumb against resistance advocate release of the compartment and then to palmar abduct the thumb on the dorsal side, thus leaving a against resistance. If the first maneu- volar portion of the retinaculum to Extensor Pollicis Longus ver is more painful, the presence of a act as a buttress against volar sub- Tenosynovitis separate compartment is indicated. luxation of the tendons. The test is highly sensitive (81%) but Complications are minor and rare. Tendinitis or tendinosis of the third moderately specific (50%) for a sep- They include volar subluxation of the dorsal extensor compartment is rare arate EPB compartment. first compartment tendons over the and is even rarer in the patient with- Treatment options include oral radial styloid, superficial radial nerve out RA. Triggering or snapping of the NSAIDs or , splinting, neuritis or neuroma, residual symp- extensor pollicis longus (EPL) result- physical therapy, and surgery. Splint- toms, or a painful or bothersome scar. ing from a size discrepancy between ing alone is successful in about 14% to the tendon and the compartment has 18% of patients.51,52 been described and may progress to Typically, a forearm-based thumb Intersection Syndrome attenuation and rupture of the ten- spica splint is used to enforce a period don. A high rate of rupture is seen; of rest or prevent motions that exac- Irritation of the tendons of the second thus, surgery is preferred over non- erbate symptoms. Physical therapy dorsal compartment, or intersection surgical treatment.57-60 may include education about and syndrome, is relatively rare.56 It is The disorder is believed to be more modification of activity, modality associated with the frequent and common in drummers or following treatments, and tendon-gliding exer- repetitive use of the wrist and typi- trauma to the wrist, particularly a fall cises. Cortisone injection is the most cally occurs in athletes such as on the extended wrist. The proposed successful nonsurgical treatment mo- rowers. Pain is located at the inter- mechanism involves impingement of dality reported in the literature by far, section of the first and second dorsal the EPL between the dorsal radius with a 62% to 100% success rate extensor compartments and is spec- and the third metacarpal.61 suggested by prior studies. The addi- ulated to be related to rubbing of Impending or completed rupture tion of physical therapy and/or splint- the EPB/APL against the radial of the EPL classically is described in ing to steroid injection does not seem to wrist extensors (Figure 2). The wrist the setting of a minimally displaced

744 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Julie E. Adams, MD and Rohan Habbu, MBBS distal radius fracture and has an Figure 3 Figure 4 estimated 5% incidence.62 Although rupture could be related etiologi- cally to rubbing of the tendon over a sharp bony prominence (ie, attri- tional rupture), it is believed to be related most commonly to a nutritional phenomenon, in which swelling increases the pressure within the compartment and alters Clinical photograph demonstrating the blood supply to the mesotendon dorsal tenosynovitis of the fourth in this relative watershed zone, extensor compartment, with soft-tissue causing ischemic changes in the swelling that tracks with the tendons tendon.63 This phenomenon likely is Magnetic resonance image as they move and bunches or tucks at demonstrating extensor pollicis longus the edge of the retinaculum, producing related to the unique anatomy at the “tuck sign.” (Reproduced with this area, in which the EPL tendon (EPL) tenosynovitis in the setting of a nondisplaced distal radius fracture, permission from Huang HW, Strauch takes a sharp turn just distal to the suggestive of impending EPL rupture. RJ: Extensor pollicis longus Lister and is encased in The arrow indicates the EPL tendon. tenosynovitis: A case report and (Reproduced with permission from review of the literature. J Hand Surg the tight fibrous sheath of the 2000;25A:577-579.) third compartment, which does not Hasham S, Burke FD: Diagnosis and treatment of swellings in the hand. allow for expansion. Thus, swelling Postgrad Med J 2007;83-296-300.) digital extension (Figure 4). Secretan increases the pressure in the non- disease can present in a similar way, compliant compartment, altering the with dorsal . This disorder is blood supply and leading to ischemic Fourth Compartment self-inflicted for secondary gain or changes. This theory is supported Tenosynovitis appears as the result of a conversion by findings of —which disorder. Surgery for this condition is precedes rupture57—on MRI, ultra- Extensor tenosynovitis, or extensor avoided.66 sonography, or visual inspection dur- digitorum communis tenosynovitis of Initial treatment of fourth com- ing surgical exploration64 (Figure 3). the entire fourth compartment, can partment tenosynovitis includes rest Presenting symptoms include pain present in the setting of RA or other with splints, ice, and NSAIDs. Steroid and swelling at the distal radius in the inflammatory etiologies. It also may injections can be used if the symp- area of the Lister tubercle; pain is begin after trauma or a nondisplaced toms persist. Failure of nonsurgical exacerbated by active or passive distal radius fracture. It has been pro- management to relieve pain suggests thumb motion. Occasionally, palpa- posed that, because of wrist stiffness, a physical etiology of increased pres- ble crepitus is present. Some patients an increase in the moment arm of the sure within the compartment, namely demonstrate snapping or triggering. extensors occurs as they course toward an accessory tendon or anomalous Radiography may be helpful in their target digits and insertion sites. muscle, and may lead to surgical excluding any distal radius fracture or Cooper et al65 have described extensor release or tenosynovectomy.67 Cooper possible bony prominence. digitorum communis tenosynovitis in et al65 described 11 patients with Treatment is typically surgical a nonrheumatoid setting, in which the proliferative tenosynovitis who pre- because a high risk of tendon rupture histopathologic evidence was consis- sented with a limitation of wrist is present. The third dorsal compart- tent with traumatic tenosynovitis. extension. These patients had no ment is approached via a dorsal inci- Fourth compartment tenosynovitis improvement with nonsurgical treat- sion centered over the Lister tubercle, presents with pain over the fourth ment. They required tenosynovec- and the compartment is released. The compartment, along with localized tomy, which improved their wrist EPL is moved to the radial sub- tenderness and swelling. Forced extension and grip strength. cutaneous tissues, and the compart- extension of the wrist may impinge the ment is inspected for any bony tendons and exacerbate the pain. The prominences. The tendon itself is in- “tuck sign,” in which a mass or Fifth Compartment spected for attritional changes, and synovial thickening tracks with the Tenosynovitis the surgeon should be prepared to tendons as the tendons move, com- graft or perform a tendon transfer if monly is present and bunches or tucks The fifth compartment, containing the indicated.57 at the edge of the retinaculum during extensor digiti minimi, also may be

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Tendinopathies of the Hand and Wrist

Figure 5 when the forearm is supinated increases discomfort. Rolling the tendon under the examiner’s finger may elicit crepitus because of an edematous sheath. Altered sensation may be seen over the distribution of the dorsal sensory branch of the ulnar nerve because it travels in close approximation to the sheath. The ECU synergy test is helpful in dif- ferentiating between ECU pathology and intra-articular (ie, TFCC) prob- lems.72 The patient rests the elbow of the supinated forearm on a table, with the digits extended. The ex- aminer grasps the patient’s thumb and long finger and asks the patient Illustration demonstrating a subluxating extensor carpi ulnaris (ECU) tendon that to deviate the thumb radially against may be stabilized by creating a flap of extensor retinaculum and securing it about resistance. The examiner’s other the ECU tendon and to itself. The smaller image is a cross-sectional view. hand gently palpates the ECU and flexor carpi ulnaris. The presence of affected in isolation.68,69 This occur- and overlap in pathology between the pain suggests pathology in the ECU rence is rare. The pain is localized ECU and the TFCC, it may be difficult rather than intra-articular pathol- over the fifth compartment, and the to isolate the source of ulnar side wrist ogy. Patients are assessed for sub- tenderness and swelling are present pain clinically and to differentiate luxation of the ECU tendon. The over the extensor digiti minimi ten- between TFCC pathology and ECU examiner moves the patient’s wrist don. This condition is investigated problems, or both. When examining from a position of supination and and managed similarly to other the ECU, it is important to differen- extension to one of flexion and ulnar tendinopathies. tiate between ECU tendinitis and ECU deviation. This maneuver allows the pain secondary to subluxation. ECU tendon to move out of the Although ECU subluxation may groove of the sixth compartment. Extensor Carpi Ulnaris begin with an injury to the wrist joint The test is positive when visible Tenosynovitis with or without any underlying frac- subluxation is present or an audible tures, ECU tendinitis typically occurs snap is heard. Extensor carpi ulnaris (ECU) teno- following overuse or occurs in an Diagnostic studies may include plain is included in the differential idiopathic fashion. Pain is localized radiographs, including PA grip views to diagnosis for ulnar side wrist pain over the ulnar side of the wrist and evaluate for ulnar positive variance and and is a very common source of such worsens with gripping and other possible ulnar impaction as an alter- pain.70,71 The diagnosis may be heavy activities. Unlike ECU sub- native source of ulnar side wrist pain. challenging because the ECU is luxation, which may occur in athletes Occasionally, ultrasonography or MRI apposed closely to other ulnar side following an injury, tendinitis is seen may be used to confirm tendinopathy, wrist structures, including the tri- more often in nonathletes. The document subluxation, or exclude angular fibrocartilaginous complex patient may be unable to localize the other sources of pathology. Differential (TFCC). The ECU is a wrist ulnar site of pain easily; hence, it is impor- diagnostic and therapeutic injections deviator when the forearm is in pro- tant to differentiate the pathology may be considered. The diagnostic cri- nation and a wrist extensor when the from other causes of ulnar side wrist teria can be improved by injecting local forearm is supinated. It has been pain. In the setting of ECU tendinitis, anesthetic into the ECU sheath. The shown to provide a static as well as a careful palpation reveals point ten- elimination of symptoms and signs can dynamic support to the wrist. The derness over the ECU tendon, with differentiate this condition from other volar ECU sheath is adjacent to the some fullness. Range of motion may causes of ulnar side wrist pain. TFCC, and ECU injury may coexist not be restricted, but resisted ulnar The initial treatment is non- with concomitant TFCC injury. deviation when the forearm is in surgical and may include rest, Because of the close anatomic location pronation or resisted wrist extension activity modification, therapy, ice,

746 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Julie E. Adams, MD and Rohan Habbu, MBBS

70,73,74 and NSAIDs. Corticosteroid Figure 6 injection may be considered, but care is taken not to inject into the tendon substance. In addition to the risk of elevated blood glucose levels, steroid atrophy, or skin changes, a risk of tendon rupture also exists following injection.75 Surgery is reserved for patients with ECU tendinitis in whom nonsurgical treatment has failed to relieve the pain. The surgical approach is made via a longitudinal incision centered over the sixth extensor compartment. The dorsal ulnar sensory branch should be identified and protected. The com- partment is released via a longitudinal incision or by creating a retinacular flap for later repair. Any projecting fibro-osseous structures can be removed. Although concerns exist about subsequent subluxation of the ECU if the retinaculum is not repaired, several series have reported no insta- bility or subluxation, even when the sheath or the retinaculum was not re- paired.71,73 In the setting of surgery for a subluxating ECU, the tendon is stabilized by creating a pulley from the retinaculum after the ECU has been released from its sheath. A variety of techniques have been described, but one method involves creating an ulnarly based flap of the extensor retinaculum elevated from over the fourth extensor compart- ment. The flap is routed under (volar to) the ECU tendon and then directed dorsally, where it is sutured to the adjacent radial side of the ECU sheath and to itself76 (Figure 5). A through C, Cross-sectional illustrations demonstrating the anatomy of the flexor carpi radialis (FCR) tendon in the fibro-osseous groove. At the level of the Flexor Carpi Radialis distal trapezium (A), the FCR occupies approximately 90% of the available Tendinitis space, whereas more proximally at the proximal trapezial level (B) and at the scaphoid tuberosity level (C), the FCR occupies less of the available space. At the tuberosity level, the FCR occupies approximately 60% of the available The flexor carpi radialis (FCR) ten- space. don has a unique anatomic path and insertion. It angles across the tra- pezial ridge and enters a fibro- some cases, the trapezium may enclose and fraying from and osseous tunnel adjacent to the the tendon77 (Figure 6). This narrow degenerative changes in the adjoining trapezium before inserting into the fibro-osseous tunnel makes the FCR , including thumb CMC and base of the second metacarpal; in tendon vulnerable to impingement scaphotrapezial degeneration.78,79

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Tendinopathies of the Hand and Wrist

Patients with FCR tendinitis may fascia over the tendon is decom- degenerative tendons disease. Scand J Med present with pain in the region of the pressed from the volar wrist crease Sci Sports 2005;15(4):211-222. radial volar forearm at the wrist distal to the trapezium. It is common 7. Lundin AC, Eliasson P, Aspenberg P: Trigger finger and tendinosis. J Hand Surg level. The pain worsens with resisted to find fraying of the tendon, which Eur Vol 2012;37(3):233-236. wrist flexion and radial deviation. should be débrided, and any bony 8. Koh S, Nakamura S, Hattori T, Hirata H: An associated swelling may be pre- impingement in the tunnel should be Trigger digits in diabetes: Their incidence sent over the palpable area of excised. A high rate of symptomatic and characteristics. J Hand Surg Eur Vol tenderness at the FCR. The differ- improvement and a low rate of 2010;35(4):302-305. ential diagnosis for FCR tendinitis recurrence are seen following surgi- 9. Chammas M, Bousquet P, Renard E, ’ 80 Poirier JL, Jaffiol C, Allieu Y: Dupuytren s includes ganglions and scaphoid cal release. disease, carpal tunnel syndrome, trigger injuries. Thumb CMC or scaphoid- finger, and diabetes mellitus. J Hand Surg trapezium-trapezoid arthritis also Am 1995;20(1):109-114. are included in the differential diag- Summary 10. Wessel LE, Fufa DT, Boyer MI, Calfee RP: nosis but may coexist. Plain radio- Epidemiology of carpal tunnel syndrome in Common conditions involving the patients with single versus multiple trigger graphs are obtained to delineate digits. J Hand Surg Am 2013;38(1):49-55. tendons of the hand and wrist arthritic changes and osteophytes. 11. Gancarczyk SM, Strauch RJ: Carpal tunnel MRI may show signal changes or include trigger finger, tenosynovitis syndrome and trigger digit: Common “ ” edema at the FCR sheath. of the first through sixth dorsal diagnoses that occur hand in hand . J Hand Surg Am 2013;38(8):1635-1637. Injection of local anesthetic with or extensor compartments, and FCR without corticosteroid medication tendonitis. Management of tendi- 12. Garti A, Velan GJ, Moshe W, Hendel D: nopathies of the hand and wrist is Increased median nerve latency at the alleviates pain and can differentiate carpal tunnel of patients with “trigger FCR tendinitis from other patholo- typically straightforward. Strategies finger”: Comparison of 62 patients and 13 include nonsurgical treatments, such controls. Acta Orthop Scand 2001;72(3): gies. Care must be taken when in- 279-281. jecting because the radial artery or its as splinting, injection, or therapy, and surgical techniques, such as 13. Rottgers SA, Lewis D, Wollstein RA: branches lie in close proximity to the Concomitant presentation of carpal tunnel tendon. In addition, injection can tendon release. syndrome and trigger finger. J Brachial Plex precipitate tendon rupture, although Peripher Nerve Inj 2009;4:13. tendon rupture typically results in 14. Valdes K: A retrospective review to References determine the long-term efficacy of orthotic resolution of symptoms with little devices for trigger finger. J Hand Ther functional deficit. Left untreated, the References printed in bold type are 2012;25(1):89-95, quiz 96. FCR tendon also may rupture. those published within the past 5 15. Evans RB, Hunter JM, Burkhalter WE: Nonsurgical treatment is the first- Conservative management of trigger finger: years. A new approach. J Hand Ther 1988;1: line approach and begins with symp- 59-68. tomatic care, including NSAIDs, 1. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M: Histopathology of common 16. Colbourn J, Heath N, Manary S, splinting for rest, and ice. Occasion- tendinopathies: Update and implications Pacifico D: Effectiveness of splinting for the ally, physical therapy is added. Corti- for clinical management. Sports Med 1999; treatment of trigger finger. J Hand Ther sone injection may be considered. 27(6):393-408. 2008;21(4):336-343. Intractable symptoms may require 2. Xu Y, Murrell GA: The basic science of 17. Rodgers JA, McCarthy JA, Tiedeman JJ: tendinopathy. Clin Orthop Relat Res 2008; Functional distal interphalangeal joint surgery. If the radiographs suggest 466(7):1528-1538. splinting for trigger finger in laborers: A substantial bony impingement of the review and cadaver investigation. canal, early release may be consid- 3. Sharma P, Maffulli N: Tendon injury and Orthopedics 1998;21(3):305-309, tendinopathy: Healing and repair. J Bone discussion 309-310. ered before the tendon ruptures. Joint Surg Am 2005;87(1):187-202. Release is achieved through a volar 18. Salim N, Abdullah S, Sapuan J, Haflah NH: 4. Fedorczyk JM, Barr AE, Rani S, et al: Outcome of corticosteroid injection versus incision centered over the FCR at the Exposure-dependent increases in IL-1beta, physiotherapy in the treatment of mild wrist. Blunt dissection should be used substance P, CTGF, and tendinosis in flexor trigger fingers. 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