Hand: Trigger Finger and Trigger Thumb Wrist: deQuervain's Disease
At the wrist and in the palm, tendons glide beneath a system of ligaments and pulleys in a tunnel that increases their mechanical efficiency. Where the tendons cross joints, they are sheathed in thin membranes known as synovium, which provide lubrication to decrease friction.
Inflammation of a synovial tendon sheath is called tenosynovitis (tendonitis). When the associated swelling of the sheath severely narrows the space normally required for a tendon to pass freely through its tunnel and beneath the pulleys and ligaments, the condition is known as stenosing tenosynovitis.
WHAT OCCURS IN STENOSING TENOSYNOVITIS?
The disease gradually narrows the tendon passageway beneath pulleys and ligaments and interferes with smooth gliding of the tendon. The resulting increase in friction is accompanied by increasing pain. Literally, the lubricating fluid can thicken or dry out around the tendon. Nodules or thickening of the tendon may appear near the entrance to the tunnel (pulley), much as thread may bunch with repeated attempts to pass it through a small eye of a needle. The enlarged tendon can cause more friction and the pain often worsens. As the disease progresses, the thickened tendon nodule may "pop" out of the tunnel. This is usually very painful and can be the source of apprehension when gripping and grasping with the fingers. At times, the finger "locks," and it is necessary to straighten the finger with the other hand. When the irregularity becomes too large to pass beneath the pulley or ligament, motion ceases, usually with a digit locked in a bent position. This can cause a contracture (inability to fully extend or straighten the finger) of the finger.
WHO GETS THIS DISEASE?
Like carpal tunnel syndrome, this disease is more common in women, typically over age 30. This disease is very common in diabetics. Repetitive bending of the fingers, thumb and wrist, gripping and grasping, often related to work, can aggravate or even cause stenosing tenosynovitis. Direct injury and a variety of medical diseases can increase vulnerability, and occasionally the disease is present from birth.
HOW TO DIAGNOSE A TRIGGER DIGIT:
Patients usually complain of pain over the palm, often over the ring finger. Many patients will point to the middle joint of the finger or the last joint of the thumb as the source of pain. However, the problem is almost invariably at the "A1" pulley at the base of the finger or thumb on the palm. Multiple fingers and/or the thumb can be involved. "Popping" sensations and pain frequently radiate to the digit, and the digit may lock in a bent position, particularly during sleep. The congenital form is diagnosed by an inability to straighten the digit(s) even with force. X-rays are usually not revealing but may indicate the presence or absence of arthritis, which may be a contributing factor.
HOW TO DIAGNOSE deQUERVAIN'S DISEASE:
Named after a Swiss surgeon who first described the disease, local tenderness, pain and swelling involve thumb tendons on the inside of the wrist. Popping sensations and locking are not common, but radiation of pain to the thumb and forearm are frequent. The wrist pain is made worse by grasping the thumb with the fingers and rocking the wrist toward the little finger (positive Finklestein test), and by "wringing" motions. This problem is frequent in those who do repetitive motion work and is common in new mothers (that are lifting their new bundle of joy). In the older patient, arthritis of the thumb must also be considered.
HOW IS STENOSING TENOSYNOVITIS TREATED?
Prolonged splinting, anti-inflammatory drugs and precise steroid injections are more helpful for deQuervain's disease than for trigger digits. One cortisone injection in the tendon sheath may be very useful in the early treatment of deQuervain's and may save time and money spent on prolonged therapy or splinting. No more than 1-3 cortisone injections should be considered to treat deQuervain's or trigger digits unless there are unusual circumstances. Numerous cortisone injections can lead to tendon and soft tissue damage. Surgical release, when necessary (~25%) can offer prompt and reliable relief when properly performed.
THIS MATERIAL DOES NOT CONSTITUTE MEDICAL ADVICE. IT IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. PLEASE CONSULT A PHYSICIAN FOR SPECIFIC TREATMENT RECOMMENDATIONS.
THE CENTER FOR ORTHOPAEDICS AND SPORTS MEDICINE
1211 Johnson Ferry Rd Marietta,
GA 30068 770-565-0011