Review Article Tendinopathies 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 tendons of the hand and wrist include trigger finger, tenosynovitis 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 tendon 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. Pain 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 arthritis Stenosing tenosynovitis at the A1 Surgery of the Hand, the Arthroscopy (RA) or crystalline disease (ie, gout) Association of North America, and the pulley is by far the most common Minnesota Orthopaedic Society. to systemic disorders such as diabetes tendon pathology seen. Women are Neither Dr. Habbu nor any immediate mellitus (DM) or thyroid disease, 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 physical therapy 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 contracture, 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 Corticosteroid 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 joint 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 de Quervain syndrome (blue