1. Tendinopathies in the Hand

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

4. Terminology and Pathology

5. 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

6. “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

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

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

9. 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

10. Flexor Tendons Annular and Cruciate Pulleys
Essentials of Hand Surgery 2002

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

12. Common conditions

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

14. 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

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

16. 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

17. 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

18. 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

19. 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

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

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

22. Trigger finger “Stenosing tendovaginitis”

23. “Extensor tenovaginitis”
Dequervains
Intersection syndrome
ECU tenosynovitis

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

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

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

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

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

29. “EPL/EDC tenosynovitis”
Rare

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

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

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

33. Thank you