SNAPPING THUMB: TENDOVAGINITIS STENOSANS

OSCAR L. BELLE, M.D., F.A.C.S. AND KENNETH H. ~HNEPP, M.D.

Attending Surgeons, SpringfieId and St. John’s HospitaIs

SPRINGFIELD, ILL.

s NAPPING thumb, or tendovaginitis stenosans, is caused by a Iocahzed emargement of the tendon, usuahy

the Aexor poIIicis Iongus, as it passes onIy with effort through a partiaIIy stenosed tendon sheath; it is characterized cIinicaIIy by a typica snap or cIick upon both Aexion and extension of the distal phaIanx. There is a greater or less degree of pain at times and aIways considerabIe annoyance.

In 1933, Comperel reviewed the Iitera- ture and found but 38 cases reported, adding one of his own. It is beIieved that the present case report tends to verify the genera1 impression of the etioIogy.

CASE REPORT

A. M., a Frenchman, forty-five years of age, was seen for the first time on January IO, 1933. The past medica history was negative, even chiIdhood diseases couId not be recaIIed. Fifteen years ago the right index finger was fractured in a mine accident. The resuIt was exceIIent. He has never had anything simiIar to the present dif5cuIty. Three brothers and two sisters are Iiving and weI1. His mother died of “tumor of the breast” and the cause of his father’s death is unknown. The patient’s wife is Iiving and weI1, as are four chiIdren.

The patient is a machinist and at the time was operating a punch press. In the routine movements there was an aImost constant ffexion and extension of the right thumb. On November 24, 1934, while pushing a tank of oil on a truck, his right hand slipped, forcibIy abducting the thumb. This pained moderateIy and he returned to work after haIf-an-hour but it increasingIy became worse. On January IO, 1935, the doctor advised hot soaks, but with very IittIe benefit. About May I, a cIick or snap became noticeabIe on both ffexion and extension of the dista1 phaIanx. An x-ray picture reveaIed nothing abnormal. The cIick became more pronounced and rather

painfu1, so that it became impossibIe for the patient to work.

Physical Examination. The patient is a we11 deveIoped Iaborer of forty-five years. His temperature, pulse and respiration were normaI. The routine bIood count, urine anaIysis and blood Kahn were negative. His pupiIs react to Iight and accommodation and pateIIar reflexes are normaI. His teeth have recentIy been repaired and cIeaned. The throat is negative. The chest and abdomen are normaI. His extremities are norma with the exception of the right thumb. Upon both ffexion and extension, accompIished with both pain and effort, occurred a distinctIy audibIe snap. A tender noduIe in the region of the tendon near the metacarpophaIangea1 joint couId be paIpated and moved with the tendon, both abruptIy.

A diagnosis of IocaI traumatic enIargement of the tendon of the Aexor poIIicis Iongus was made and surgica1 measures urged. The patient was operated upon June 7, 1935, at SpringfieId HospitaI under nitrous oxide-oxygen anesthesia. The incision was made on the outer side of the thumb from the interphaIangea1 joint to the base of the first metacarpa1 bone. The media1 flap was reffected and the tendon sheath exposed by bIunt dissection. Just proxima1 to and incorporated with the transverse voIar ligament the sheath was surprisingIy thick and fibrous and seemed capabIe of causing an obstruction. Upon extension of the distal phaIanx of the thumb a firm fusiform sweIIing in the tendon snapped into view with an audible cIick. This enIargement was approximateIy twice the diameter of the tendon and about one cm. in length. After overcoming an initial resistance the noduIe, upon ffexion, again passed through the constricted portion of the sheath with an identica1 snap.

The transverse band was divided and the sheath opened IongitudinaIIy for about 3 cm. The tendon was spIit IongitudinaIIy and about haIf the fusiform sweIIing excised from within, thus forming a norma sized tendon with onIy a smooth gIistening surface presenting to

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322 American Journal of Surgery ZeIIe & Schnepp-Snapping Thumb AUGUST, rgv.5

the sheath. No attempt was made to cIose the tendon sheath. Hemostasis was obtained, the skin flaps were approximated with subcu- taneous catgut and cIosed with clips. The patient remained in the hospita1 three days and was discharged without evidence of wound infection.

EarIy passive motion was empIoyed by the patient for one week. FoIIowing this, active motion was encouraged and he returned to his origina work nine days after operation.

The patient was Iast seen October 12, 1935, having worked continuously since June 16, 1933. Function was perfect and there had been no pain for the past month. There was, how- ever, a smaI1 area of anesthesia on the medial aspect of the thumb, supposedIy the resuIt of division of sensory nerves at the time of operation.

COMMENT

In 1895, de Quervain2 first described the syndrome associated with stenosis of tendon sheaths with or without an enIargement of the tendon ahhough he limited the occurrence to the sheath of the abductor Iongus and extensor brevis poIIicis tendons in the region of the radia1 styIoid process. The Iast comprehensive review of the genera1 subject is that of Finkel- stein,3 in 1930, who recognized its appear- ance in other tendons. The article of Compere Iimits itseIf to Iesions of simiIar type occurring in the poIIicis Iongus tendon of the thumb. He apparentIy found 38 cases, 2 of which were biIatera1, and added his own case, aIso biIatera1.

It seems to be a genera1 impression that continuous chronic trauma is the most important singIe factor in the etioIogy of this condition. Most of the cases reported stress the occupation; among these are found pianists, typists, book- keepers, maids, factory workers, taiIors and cierks, a11 giving a positive history of proIonged, frequent and vigorous move- ments of the tendons in question.

Likevise with the present case, his work required continuous movement of the thumb and although the difhcuIty in question began with an undoubted

traumatic injury to the sheath or tendon or both, it is significant that the snapping began five months Iater and in a11 prob- abiIity wouId not have occurred in the absence of the continuous daiIy trauma.

The stenosis seems to be of primary importance since many of the tendons in reported cases showed no thickening. FinkeIstein’s experiments have demon- strated that with an intact skin it is possibIe to cause a stenosing tendovaginitis in rabbits by therma1, chemica1 or mechani- ca1 traumatization without visibIe pathoI- ogy in the tendon. Changes occur in the tendon onIy when injury is inflicted directIy to the tendon. This wouId indicate that the noduIes reported were caused by direct injury to the tendon. However, the occurrence of symptoms of a noduIe five months after the origina injury in our case wouId strongIy suggest that the noduIe was secondary to the sheath injury and represented an irritative Iocalized hyperpIasia of the tendon foIIowing onIy after the sheath presented a rough ede- matous inflammatory surface with con- sequent friction throughout a chronic proIonged course.

CONCLUSIONS

I. A case of snapping thumb is reported, caused by a stenosing tendovaginitis of the sheath, and with noduIe formation in the tendon of the Aexor poIIicis Iongus.

2. Conservative treatment was unsuc- cessfu1. SurgicaI division of the sheath and excision of the nodule resuIted in cure.

3. Judging by this case, the trauma to the sheath is the primary injury; it seems unIikeIy that such a condition wouId result, however, in the absence of repeated, prolonged, vigorous, occupationa trauma.

REFERENCES

I. COMPERE, EDWARD L. BilateraI snapping thumbs. Ann. Surg., 97: 773. 1933.

2. DE QUERVAIN, F. Uber eine Form von Chronischer Tendovaginitis. Cor. Bl. f. scbweiz. Aerzte, 25 : 389, 1895.

3. FINKELSTEIN, H. Stenosing tendovaginitis at the radial styloid process. Jour. Bone and Joint Surg., 12: gog, 1930.