Stenosing tenosynovitis

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Stenosing tenosynovitis
Classification and external resources
ICD-10M65.3-M65.4
ICD-9727.03-727.04
 
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Stenosing tenosynovitis
Classification and external resources
ICD-10M65.3-M65.4
ICD-9727.03-727.04

Stenosing tenosynovitis (often called trigger finger, trigger thumb, stenosing tenovaginitis) is a painful condition caused by the inflammation (tenosynovitis) and progressive restriction of the superficial and deep flexors fibrous tendon sheath adjacent to A1 pulley at a metacarpal head. Repetitive forceful compression, tensile stress, and resistive flexion, causes inflammation, swelling, and microtrauma, that results in thickening and stenosis (commonly a nodular formation) of the tendon distal to the pulley leading to a painful digital base, limitation of finger movements, triggering, snapping, locking, and deformity progressively.

Patients report a popping sound (at the PIP joint), morning stiffness with/without triggering, delayed and sometimes painful extension of the digit, and when more advanced, a locking position that requires manipulation to extends the affected finger. This condition more commonly affects the middle and ring fingers (occasionally the thumb), and the flexor rather than extensor tendons in the hand.[1]

In rheumatic trigger finger (or in diabetes), more than one finger may be involved. Cases of stenosing peroneal tenosynovitis, have been reported where the patient presents with pain over the lateral malleolus, both with active and passive range of motion and no physical of radiographic evidence of instability.[2][3]

Two common diagnoses fall into this category[edit]

Causes[edit]

Most common cause is overuse from chronic repetitive activities using the hand or the involved finger. Examples include work activities (e.g., computer use, materials handling, hand surgeons) or recreational activities (e.g., knitting, golf, racket sports). Recently notable, the repetitive movements while using the controller of video games, has coned the name "Game-Boy Thumb" or from texting "texting tendonitis" when the thumb if affected.[citation needed] Carpenters who use hammers suffer from this as well as those who continuously grip wood or other materials when cutting them due to having to use your hands as a clamp to hold things in place.

Primary stenosing tenosynovitis can be idiopathic, occurring in middle age women more frequently than in men, but can present also in infancy.

Secondary stenosing tenosynovitis, can be caused by disease or entities that causes connective tissue disorders such as:

Others:

Clinical presentation[edit]

Differential Diagnosis[edit]

Work up[edit]

No specific work up is defined. Stenosing tenosynovitis is a clinical diagnosis. However, if rheumatoid arthritis is suspected, laboratory evaluation of is granted (e.g. rheumatoid factor).

Imaging[edit]

As a rule, no imaging studies are needed to diagnose the condition. However, they can be valuable adjuvants to achieve a diagnosis. An ultrasound or MRI (most reliable study) can show increase thickness of the tendons involved. Thickening and hyper-vascularization of the pulley are the hallmarks of trigger fingers on sonography[7]

Management[edit]

Occupational therapy is based on relieving the symptoms and reducing the inflammation. Overall cure rate, for dutifully applied non-operative treatment, is over 95%. Several modalities of treatment exists, depending on the chronicity and severity of the condition.

For symptoms that has been persistent or recurrent more than 6 months and/or unresponsive to conservative treatment, surgical release of the pulley may be indicated. Two approaches exists, open and percutaneous. The precutaneous approach, is preferred in some centers due to its reported shorter time of recuperation of motor function, less complications, and less painful.[11] Complication of the surgical management include, persistent trigger finger, bowstringing, digital nerve injury, and continued triggering.[12]

Of note, diabetes seems to be poor prognostic indicator for nonoperative treatment and may develop stiffness after surgical release.

There has been some anecdotal reports the use of tinctures containing cannabis extract results in anti-inflammatory relief, allowing the digits to extend in a normal fashion with minimal pain.[13]

See also[edit]

References[edit]

  1. ^ Foye, MD, Patrick M. "Physical Medicine and Rehabilitation for Trigger Finger Clinical Presentation". WebMD, LLC. 
  2. ^ Andersen, MD, Erik (1987). "Stenosing Peroneal Tenosynovitis Symptomaticall Simulating Ankle Instability". The American Journal of Sports Medicine 15 (3): 258–259. doi:10.1177/036354658701500313. 
  3. ^ Gunn, D.R. (March 14, 1959). "Stenosing Tenosynovitis of the Common Peroneal Tendon Sheath". Br Med J. 1 (5123): 691–692. PMC 1993081. PMID 13629094. 
  4. ^ "De Quervain Tenosynovitis: eMedicine Physical Medicine and Rehabilitation". Retrieved 2010-08-03. 
  5. ^ Oxford Textbook of Rheumatology. NY, USA: Oxford University Press, Inc. 1993. p. 951. 
  6. ^ John H Kippel, Paul A Deppe (1998). Rheumatology, 2nd edition. Mosby. 
  7. ^ Guerini H, Pessis; E, Theumann N, Le Quintrec JS, Campagna R, Chevrot A, Feydy A, Drapé JL. (Oct 2008). "Sonographic appearance of trigger fingers.". J Ultrasound Med. 27(10) (10): 1407–13. PMID 18809950. 
  8. ^ Tarbhai, K; Hannah S, von Schroeder HP. (Feb 2012). "custom metacarpophalangeal (MCP) joint blocking splint and a distal interphalangeal (DIP) joint blocking splint". J Hand Surg Am. 37(2) (2): 243–249. doi:10.1016/j.jhsa.2011.10.038. PMID 22189188. 
  9. ^ Newport, ML; Lane LB, Stuchin SA (Sep 1990). "Treatment of trigger finger by steroid injection". J Hand Surg Am. 15(5) (5): 748–750. PMID 2229972. 
  10. ^ Wheeless, III,, Clifford R. "Trigger Finger / Tenosynovitis". Duke Orthopaedics. 
  11. ^ Pavlicný, R (Feb 2010). "Percutaneous release in the treatment of trigger digits". Acta Chir Orthop Traumatol Cech. 77(1) (1): 46–51. PMID 20214861. 
  12. ^ Ryzewicz M, Wolf JM. (Jan 2006). "Trigger digits: principles, management, and complications.". J Hand Surg Am. 31(1) (1): 135–46. doi:10.1016/j.jhsa.2005.10.013. PMID 16443118. 
  13. ^ http://medicalmarijuana.com/medical-marijuana-treatments/Carpal-Tunnel-Syndrome