Tendon Sheath Organization
-fibrotic or retinacular outer sheath
-internal or synovial sheath (includes visceral that releases synovial fluid and nutrition, and parietal)
reason for wrist and hand tendinopathies
occur in fibroosseus tunnels
thickening of sheath and tendon
pain and impaired tendon gliding occur
stenosing tendovaginitis or tendon entrapment
systemic disorders may contribute
infection may lead to tenosynovitis
pregnancy may increase P
female > male
Most common tendinopathy @ the wrist
DeQuervain involves wich muscle?
Thumb Ext: EPB/APL
Location of DeQuervain
Radial side wrist pain at the 1st dorsal compartment and radial styloid
APL often has 2 or more tendinous slips
Clinical Sx of DeQuervain
Localized Edema in the tendon sheath at the level of radial styloid or ext retinaculum
forceful, repetitive thumb ABD and simultaneous wrist UD, e.g. opening jars, hand wringing, cutting with scissors, and needlework
Test for DeQuervain + explanation
-Finkelstein Test: UD and thumb flexion. + test = pain
-Resisted CMC ext and ABD: Inc. pain if true tendinopathy
What to r/o if DeQuervain
Irritability of Dorsal Radial Sensory Nerve
STT Arthritis (Scaphoid, trapezium, trapezoid)
How to r/o EPL tenosynovitis?
resisted motion with pt hand pronate and raise thumb off.
+ test: pain tenderness
Who gets Intersection Syndrome?
power lifter and rower
Location of intersection syndrome?
fascial syndrome bw mm in 1st/2nd compartment
r/o Intersection syndrome
Active wrist ext with active thumb circumduction
+ test = pain, crepitus, and squeaking sound
How to palpate ECU?
in the gap between ulnar styloid and base of 5th MC in pronation and during UD.
ECU lies on ulnar aspect of wrist in pronation and moves dorsally over the ulnar head during supination
Purpose of ECU Sheath
part of TFCC which helps to stabilize the DRUJ
Reasons for ECU tendinopathy
Repetitive snapping motions of wrist
abrupt twisting motion; hypersupination with flexion
diffuse ulnar sided wrist pain with active or resisted wrist motion UD or passive stretch into RD
ECU instability observed when ext, supinated wrist is moved into flexion and UD; visual or audible snap
Location of pain for FCR?
Pain over proximal volar wrist crease and scaphoid tubercle.
tenderness, bogginess, crepitus may indicate inflammatory or degenerative changes
How is pain provoked with FCR?
resisted wrist flexion and RD or passive stretch into wrist ext.
FCR pain may occur secondary to.....
trauma, arthritis of scaphotrapezial joint, or with repetitive wrist motion
What to r/o if suspecting of FCR pathology
ganglion cysts, cmc and/or scaphotrapezial arthritis, scaphoid fx, Dequervain's
How is FCU pain provoked?
ulnar side of wrist, worst with UD and wrist flx
passive wrist ext and RD
tenderness, bogginess, crepitus may indication inflammatory or degenerative changes
Causes of FCU pathology?
repetitive wrist motion
sx localized to the FCU about 3cm pros to insertion of pisiform
may be associated with pisotriquetral arthritis
lexor tenosynovitis or tendovaginitis of digits
Acute or chronic inflammatory condition (overuse, RA, DM)
Acute infection (pyogenic or purulent flexor tenosynovitis
May result in acute CTS
Kanavel's 4 cardinal signs
intense pain with attempt to extend finger
percussion tenderness along tendon sheath
What is Trigger finger
stenosis within the flexor tendon sheath at the level of A1 pulley
incidence greater in thumb, ring and long
Insidious onset, overuse -forceful repetitive finger flexion
comorbidities -RA and DM
Sx of Trigger finger
Clicking, popping and triggering finger posture; pain over volar MP
ECRL/B at the base of 2-3MC
Associated with sudden forceful gripping
pain with resisted ext radial to lister's tubercle
degenerative changes at bases of 2-3MC > development of CMC loss
Congenital trigger finger
misnomer - not really trigger finger, but PIP flexion contracture deformity
treated with surgical release
General Conservative management
Reduce sx (pain)
promote tendon healing/gliding
How to reduce pain/inflammation?
Rest (active modification, splinting)
Corticosteroids can be used for __________ and __________ and its best with duration of sx ________
DeQuervain & Trigger finger
Assessment of trigger finger
Pain Assessment (VRS, VAS)
Palpate for nodule
SST grading scale
# of triggering events in 10 active fists
Therapeutic management of trigger finger
splint should block MP motion of the involved digits (<15)
Hand or finger based splint
hook fists - differential gliding bw FDP/FDS
Pain free A/PROM of digits
Avoid aggravating activities
Therapeutic management of DeQuervain Tendinopathy
Thumb Spica Splinting
Pain free A/PROM of digits
Avoid aggravating activities
Radial Sided Thumb Spica
Not effective for DeQuervain b/c Allows awkward mov of thumb and wrist. Radial side of wrist may hit dorsiradial side of splint
Ulnar sided thumb spica
eliminated use of thumb and UD with no pressure over dorsiradial aspect of wrist
can't use thumb... so what? we want it to rest anyway!
Splinting for FCR, FCU, ECU, ECRL/B Tendinopathies
flexor tendon problem => dorsal splint
due to RA - flair up, and infection (puncture wound) pyogenic from thorn.
Management of tenosynovitis
Anti biotic therapy if related to infection (24 hours)
emphasis on differential tendon gliding as sx resolve.
scarring likely along with tendon tightness & intrinsic tightness
Indications for surgery?
failed conservative management
too many recurrences
patient wants it
General idea is to open tunnel to allow improve tendon mobility and dec. pain
in DeQuervain might remove anomalous slip of tendon in APL
General post op management
Following 1 week in post op bandages/plaster slab, pt referred to therapy
-wound management to promote healing
-Progressive return to activity and strengthening @ 2-3 weeks post op
-Return to work activities 6-12 weeks post op
Dequervain's may lead to injury irritation to DSRN
pain unresolved in long term