Common Hand Tendon Disorders
This is an extremely broad topic which includes many conditions. Hand pain can be the result of trauma, arthritis, nerve compression, infections, tumors, and skin/circulatory disorders. There are two common causes of hand pain which are seen on a frequent basis. The first is trigger finger/trigger thumb (stenosing tenosynovitis), and the second is De Quervain’s disease, or extensor tenosynovitis.
What is trigger finger/trigger thumb or stenosing tenosynovitis?
The muscles on the palmar side of the forearm are connected to the fingers by long tendons or ropes. When these tendons pass out into the thumb and fingers, they run through a tendon sheath or tube. Think of it as a rope going through a hose. The thumb has one flexor tendon, and each finger has two flexor tendons. The tendon sheath holds the tendons against the bone and adds mechanical advantage for the flexion of the thumb and fingers. In stenosing tenosynovitis, the tendon sheath thickens, there may be inflammation of the tendon, and the tendons fail to glide through the tendon sheath in a smooth and painless fashion. This may lead to pain, catching or triggering, or the thumb or finger becoming stuck in a flexed or extended position. Some medical conditions such as rheumatoid arthritis and diabetes can be associated with an increased risk of trigger finger/thumb, and local trauma may be a precipitating cause, but often the etiology is unclear.
The patients often have pain on the palmar aspect of the thumb and fingers. This may be intermittent, and the patients may develop snapping or catching. Often this is worse in the morning, and symptoms can worsen during the day with repetitious use of the hands. The diagnosis is made with a careful history of the patient’s symptoms, a physical exam of the hand and upper extremity which may demonstrate tenderness, triggering, or a locked digit. X-rays are often necessary to rule out underlying arthritis or traumatic conditions, and occasional laboratory studies will be ordered to rule out underlying systemic disease.
Treatment of trigger finger/trigger thumb:
Treatment includes non-operative and operative modalities. Nonsurgical treatment includes rest, splinting, NSAIDs, work modification where appropriate, and occasional corticosteroid injections into the tendon sheath. The majority of patients will respond to non-operative measures. Those patients who have persistent symptoms despite nonsurgical treatment may be indicated for a trigger finger/thumb release. This type of surgery is carried out in an outpatient facility, often under local anesthesia through a small incision. The neurovascular structures can be protected, and the proximal portion of the tendon sheath can be released. This generally allows the tendon to glide smoothly and restores the function of the hand. The outcomes are usually quite positive with complications being unusual.
De Quervain’s stenosing tenosynovitis is tendinitis of the first extensor compartment. The muscles on the back of the forearm are connected to the wrist and fingers by long ropes (tendons). These tendons pass through six compartments on the dorsum or back of the wrist. Any of the compartments can be involved in stenosis tenosynovitis; however, the first extensor compartment containing two tendons to the thumb is by far the most commonly involved extensor tendon compartment. The name De Quervain’s tenosynovitis is attributed to the Swiss surgeon who first described the condition approximately one century ago. Just as the etiology for trigger finger/thumb is often unclear, the etiology for De Quervain’s tenosynovitis is also often unclear. It is generally felt that repetitious type activities contribute to the development of extensor tenosynovitis. This may be seen with awkward positioning of the hand and wrist, and can sometimes develop after a wrist trauma such as a fracture. Some patients are also predisposed to this condition by having duplicate tendons to the thumb.
Symptoms and diagnosis:
Symptoms generally include pain on the radial or thumb side of the wrist. There may be some associated swelling, and occasionally there is an associated ganglion or small cyst. Thumb and wrist motion can cause pain localized to the first extensor compartment, and extending the thumb against resistance increases the pain that the patient is experiencing. The diagnosis is made by careful history and a physical that demonstrates tenderness, crepitus, and sometimes catching and locking. X-rays are generally indicated to rule out any underlying pathology, and occasionally laboratory studies are ordered to rule out systemic conditions.
Treatment of De Quervain’s stenosing tendinitis:
Treatment can be non-operative or operative. Non-operative treatment consists of a splint which would include the thumb, nonsteroidal anti-inflammatories, NSAIDs, work and activity modification where appropriate, and occasional corticosteroid injections into the extensor compartment. Surgical treatment may be indicated if the patient fails to respond to the above modalities. The surgical treatment is carried out through a small incision taking care to protect the sensory nerves located in the subcutaneous tissue and release of the compartment which frees up the tendons to glide smoothly, has a high degree of success, and generally very favorable outcomes. Occasionally, hand therapy is required after surgery. However many patients are able to achieve a favorable outcome with exercise and work modification.