Tendinopathies in the Hand

Goal To review common tendinopathies in the hand Terminology Pathology Specific conditions and treatments

Terminology and Pathology

Tendinopathy Painful conditions affecting the tendons of the wrist hand Most common reason for hand surgeon visit Entrapment/stenosis vs. Inflammation Trigger finger De Quervains vs. Rheumatoid associated tenosynovitis

“Tendinosis” Histology: Accumulation of micro-ruptures Associated pain collagen degradations, absence of inflammatory cells vascular ingrowth Accumulation of micro-ruptures Associated pain possibly from neurochemical cytokines (substance P, glutamate, others) potentiated by vascular ingrowth

“Tendon entrapment/Tendovaginitis/ Stenosing tendovaginitis” Thickening of tendon sheath Fibrocartilagenous metaplasia Tendinosis

“Tenosynovitis” Inflammation of synovial lining of tendon sheath Typically assocat4d with inflammatory arthropahies (RA) Deposition diseases Amyloid, calcific tendonitis/gout, septic

Tendon anatomy Enter a fibro-osseous tunnel (flexor sheath) at the level of the MCP joint Sheath thickened to produce strong annular pulleys that position the tendons close to the underlying bone A2 and A4 pulleys are essential to prevent bowstringing

Flexor Tendons Annular and Cruciate Pulleys Essentials of Hand Surgery 2002

Extensor tendons Compartments 1st- APL & EPB 2nd- ECRL & ECRB 3rd- EPL 4th- EIP & EDC 5th- EDQ 6th- ECU Essentials of Hand Surgery 2002

Common conditions

Trigger finger “Stenosing tendovaginitis” Often called “stenosing tenosynovitis: A1 pulley entrapment by enlarged tendons Fibrous metaplasia of A1 pulley Tendinosis like changes in tendon

Trigger finger “Stenosing tendovaginitis” Women 6:1 3% lifetime risk 10-20% diabetics Higher risks hypothyroid, renal dz, rheumatological, gout Pain, clicking, catching, limited grip Concordant with CTS

Trigger finger “Stenosing tendovaginitis” Treatment NSAIDs Splinting/Therapy Injections Surgery

Trigger finger “Stenosing tendovaginitis” Splinting/Therapy Some have shown it works 44% improvement 55% resolution DIP splinting If respond to therapy have less recurrence at 6mo

Trigger finger “Stenosing tendovaginitis” Injection Location of injection/technique No difference in effectiveness Possible worse side effects if subq Atrophy, pulley rupture, tendon ruputre Cure in 57-97% (1-2 injections) ~ 80% cure Less success with more injections Recurrence higher with multiple digits, younger, diabetes

Trigger finger “Stenosing tendovaginitis” Injection Diabetic 57-86% cure Less effective if poor glucose Elevate serum glucose Type of steroid Insoluble (triamcinolone) *more rapid Soluble (dexamethasone) *more durable

Trigger finger “Stenosing tenosynovitis” Splinting/Therapy Some have shown it works 44% improvement 55% resolution DIP splinting If respond to therapy have less recurrence at 6mo

Trigger finger “Stenosing tendovaginitis” Surgery Percutaneous release ? Equal efficacy Injury to neurovascular bundle, A2 pulley, incomplete release Usually ok middle ring

Trigger finger “Stenosing tendovaginitis” Surgery Open release A1 pulley release *Not in rheumatoid arthritis Low threshold for FDS tenectom

Trigger finger “Stenosing tendovaginitis”

“Extensor tenovaginitis” Dequervains Intersection syndrome ECU tenosynovitis

Extensor tendon anatomy Compartments 1st- APL & EPB 2nd- ECRL & ECRB 3rd- EPL 4th- EIP & EDC 5th- EDQ 6th- ECU Essentials of Hand Surgery 2002

“Dequervains” Dequervains Impaired gliding of APL EPB Myxoid degeneration, muco-polysaccharide deposition, fibrocartilage metaplasia 1.3% women, 0.% men

“Dequervains” Dequervain’s Associated Finklestein Ulnar deviation Pregnancy Postpartum Lactation Finklestein Ulnar deviation Treatment NSAIDs Splinting (14%) Injection (60%) Surgery

“Dequervains” Dequervains Steroid atrophy Superficial radial sensory nerve branch Subluxaition of tendons

“Intersection syndrome” Where 1st and 2nd cross (more proximal) Rowers and gymnasts

“EPL/EDC tenosynovitis” Rare

“ECU tenosynovitis” Usually twisting injury Concomitant injury with TFCC injury ECU subluxation Dynamic ultrasound Treatment RICE Therapy Occasional operations For tenoysynovectomy or subluxation

“ECU tenosynovitis” Usually twisting injury Concomitant injury with TFCC injury ECU subluxation Dynamic ultrasound Treatment RICE Therapy Occasional operations For tenoysynovectomy or subluxation

“FCU/FCR tenosynovitis” These are repetitive injury Can be calcific FCR with STT arthritis NSAIDS, RICE, steroids ?rupture/ rare surgical release

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