PRESENTER: Dr. ANKUR MITTAL

INTRODUCTION

ANATOMIC CONSIDERATION

ANATOMY OF THE TENDON SHEATH:

Tendon nutrition is derived from: • Synovial fluid from tenosynovial sheath• Vincular blood supply

After injury healing occurs by

•Extrinsic – peripheral fibroblast •Intrinsic – fibroblast from tendon itself

Flexor synovial sheath for index, middle and ring finger begins at the level of metacarpal neck 1 cm proximal to the proximal border of deep transverse metacarpal ligament.

It is doubled walled hollow tube sealed at both hand.

FUNCTION: Gliding and bathing the tendon with synovial fluid

Retinacular portion of flexor tendon sheath overlies these synovial layers

Retinacular portion include 5 annular pulleys and 3 cruciform pulleys and also palmar aponeurosis pulley

A1 At MCP JointA2 Proximal phalanxA3 Proximal IP jointA4 Middle phalanxA5 Distal IP joint

C1 Near head of proximal phalanxC2 Base of middle phalanxC3 Distal end of middle phalanx

Function: Annular pulley prevent bowstringing during finger flexion and cruciate pulley make tendon sheath able to conform to the position of flexion by allowing annular pulley to approximate each other.

A2 and A4 pulleys are most functionally important so must be prevented or reconstructed in flexor tendon surgery to prevent bowstringing.

Flexor synovial sheath for thumb starts proximal to carpal canal and its retinacular portion has 2 annular pulleys and an oblique pulley

A1 – At MCP jointA2 – At IP jointOblique – Middle of proximal phalanx

DEFINATION:

What Is STENOSING TENOSYNOVITIS?

It is a group of conditions in which there is mismatch between the size of the tendon sheath and tendon which passes through it.

It may result from enlargement of tendon as seen in Trigger FINGEROrFrom narrowing and fibrosis of tendon sheath as seen in DE QUERVAIN’S TENOSYNOVITIS.

TRIGGER FINGER or stenosing tenosynovitis is caused by a nodule or thickening of flexor tendon which catches on the proximal edge of A1 pulley when the finger is actively flexed.

Most common in1. Ring finger2. Thumb3. long4. index5. small finger

More common in women than men

AETIOLOGY:

•Congenital

•Repetitive trauma

•Medical conditions of rheumatoid arthritis, gout, diabetes, hypothyroidism, amyloidosis and certain infections — including tuberculosis and sporotrichosis, a fungal infection.

•Other rare causes are: -Collateral ligament may catch on a bony prominence on the side of metacarpal head.

-Rarely abnormal seasmoid may catch on the metacarpal head

-Capsule may become interposed when it is split transversely by trauma

-Extensor tendon may slip off the head of metacarpal and displace ulnarward over the interdigital cleft.

When the tenosynovium becomes inflamed from repetitive strain injury or overuse or due to inflammatory conditions such as rheumatoid arthritis,

the space within the tendon sheath become narrow and constricting.

The tendon can't glide through the sheath easily, at times catching the finger in a bent position before popping straight.

With each catch, the tendon itself becomes irritated and inflamed, worsening the problem.

PATHOPHISIOLOGY

With prolonged inflammation, fibrosis can occur and bumps (nodules) can form

SIGNS AND SYMPTOMS

•Pain at the root of finger

•Swelling

•Tenderness

•Palpable nodule

•When hand is opened up from a clenched position then affected finger remain in flexion

With more forceful effort or passively opening by other hand it may extend with jerky release or often a palpable or audible click.

More symptomatic in morning improving through the day

EAST WOOD CLASSIFICATION

Grade 0 : mild crepitus in a non triggering digit

Grade 1 : uneven movement of the digit

Grade 2 : clicking without locking

Grade 3 : locking of the digit that is either actively or

passively correctable

Grade 4 : locked digit

Treatment

It depends on etiology:

Initial treatment of the condition can include:

Rest. To prevent the overuse of affected finger.

Splinting. To keep the affected finger in an extended position for several weeks. The splint helps to rest the joint. Splinting also helps prevent you from curling your fingers into a fist while sleeping, which can make it painful to move your fingers in the morning.

Finger exercises. Perform gentle exercises with the affected finger. This help you to maintain mobility in finger.

Soaking in water. Placing the affected hand in warm water for five to 10 minutes, especially in the morning, may reduce the severity of the catching sensation during the day. If this helps, it can be repeated throughout the day.

Massage. Massaging the affected fingers may feel good and help relieve pain, but it won't affect the inflammation

For more serious symptoms,

Nonsteroial anti-inflammatory drugs (NSAIDs). Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve the inflammation and swelling that led to the constriction of the tendon sheath and trapping of the tendon.

IN NON-RHEUMATOID PATIENTS

Non operative treatment in form of STERIOD INJECTION

Betamethasone is commonly used

Inject 0.25–0.50 ml in 1 ml of lidocaine

SITE: around the A1 pulley.

PRECAUTIONS: -Use small needle less than 21G-Should be given in flexor tendon sheath.-Should not be intertendinous as it may lead to tendon rupture.- Warn the patient that it will take a few weeks to see whether the injection is successful.-A second steroid injection can be given 6 weeks after the initialinjection if no improvement has been noted. Sometimes the second injection is successful even if the first resulted in little improvement

IMPORTANCE:

Steroid injection around the A1 pulley may provide symptomatic relief,which can delay the need for surgery for many month

Anderson and kyle (1991) from a prospective study found that:

61% - respond to single steroid injection.

27% - recurred

12% - Required surgical release

6% - Subcutaneous fat atrophy

0% - Infected or tendon rupture

so it should be explained to patient before hand

Operative Treatment

Operative treatment should be considered when two steroid injections are unsuccessful in alleviating symptoms or when symptoms argue against waiting 4–6 weeks for improvement.

A patient whose finger is locked in flexion also should undergo surgical treatment. Waiting for a steroid injection to work is impractical because of concerns about subsequent joint stiffness due to inability to move the finger for so long a period

SURGERY OF CHOICE:

PERCUTANEOUS RELEASE:

PROBE BLADE

Metacarpophalangeal joint hyperextended and 19-gauge needle inserted just distal to the flexor crease. Bevel of needle oriented longitudinally with tendon.

Needle stabilized and pulley released from proximal to distal. Loss of grating sensation as pulley is cut indicates completion of release.

OPEN SURGERY

IMPORTANT CONSIDERATION BEFORE SURGERY

Best performed under wrist block so that patient can actively flex and extend the affected digit once the release is performed

Tourniquet should be used on the forearm or upper arm. It is important to have a bloodless field to prevent injury to the nearby neurovascular bundles

Do not cut anything until you are certain that the neurovascular bundles are protected.

A2 pulley must be preserved

OPEN SURGERY

SITE OF INCISION

Postoperative Care

1. Acetaminophen or nonsteroidal anti-inflammatory agents shouldbe adequate for postoperative pain control.

2. Keep the hand elevated to decrease swelling and decrease pain.

3. The patient should be encouraged to use the hand for light activitieswithin 1–2 days after surgery.

4. Remove the dressing the day after surgery, and clean with gentlesoap and water daily.

5. Apply antibiotic ointment to the suture line daily for the first fewdays. Cover with dry gauze as needed.

6. After 10–14 days, remove the sutures. Instruct the patient to increase gradually the activities performed with the hand until the patient has resumed regular activities

COMPLICATIONS OF SURGERY

Percutaneous release associated with incomplete release

Surgical release includes

•Digital nerve transection

•A2 pulley injury with subsequent bowstringing of tendons

•Bothersome scars

•Recurrent symptoms

•Stiffness

•Sympathetic dystrophy

IN RHEUMATOID PATIENTS.

•Underlying problem is synovitis with in flexor tendon sheath

•And it weakens both tendons and surrounding synovial sheath

•Therefore first control synovitis along with programme of active assisted exercises and splinting

•STERIOD INJECTION SHOULD NOT BE GIVEN AS THERE IS A REAL RISK OF TENDON RUPTURE.

•If synovitis and triggering persist despite above therapy

•Then SURGICAL SYNOVECTOMY should be performed without releasing the annular pulleys.

IN TRIGGER THUMB:

•Flexor sheath is much tighter than in the fingers

•So it is difficult to inject tendon sheath without injecting into tendon

•Therefore surgeon directly proceed to operative intervention if single injection is ineffective..

•IMPORTANT NOTE: Surgical release require retraction of radial digital nerve which crosses directly over A1 pulley

CONGENITAL TRIGGER FINGER:

•Present with digits in a position of flexion

•Present at birth but not appreciated until months later

•Anomaly is secondary to either sheath stenosis or tendon nodule or both

•Period of observation with or without splinting is recommended if child is less than 6 months of age

•Condition is less likely to resolve in older child so surgery is recommended

•If left untreated older child may develop fixed flexion deformity and joint contractures

•So older child if comes like this trigger finger as well as secondary joint contractures must be treated.

THANK YOU