Finkelstein test

환자의 Thumb(무지)를 flexion한 위치에서 Wrist을 강하게 Ulna(척측)으로 internal rotation(내전)하면 Radius의 원위 외측에 pain 유발 --> most pathognomic but no diagnostic

Trigger finger

Introduction
Stenosing tenosynovitis caused by inflammation of the flexor tendon sheath Epidemiology more common in diabetics ring finger most commonly involved Mechanism caused by entrapment of the flexor tendons at the level of the A1 pulley fibrocartilaginous metaplasia of tendon and pully found in pathology Associated conditions diabetes mellitus rheumatoid arthritis amyloidosis
Anatomy
Flexor pulleys of finger A1 overlie the MP joints Muscles FDP FDS
Classification
Green Classification Grade I Palm pain and tenderness at A-1 pulley Grade II Catching of digit Grade III Locking of digit, passively correctable Grade IV Fixed, locked digit
Imaging
Radiographs not required in diagnosis and treatment
Presentation
Symptoms finger clicking pain at distal palm near A1 pulley finger becoming "locked in flexed position Physical exam tenderness to palpation over A1 pulley a palpable bump may be present near the same location
Treatment
Nonoperative night splinting, activity modification, NSAIDS indications first line of treatment steroid injections indications best initial treatment for fingers, not for thumb technique give 1 to 3 injections in flexor tendon sheath diabetics do not respond as well as non-diabetics Operative surgical debridement and release of the A-1 pulley indications in cases that fail nonoperative treatment
Techniques
Surgical debridement and release of the A-1 pulley approach longitudinal or transverse incision release technique in children, in addition to A-1 pulley release, may also need to release one or both limbs of the sublimus tendon A-2 pulley A-3 pulley postoperative early passive and active ROM 4 times a day if patient does not have FROM at first post-op visit then send to PT
Complications
Radial digital nerve injury

** 정형외과학 561

수술적 치료: 수술적 치료 방법으로는 전통적 개방술을 통한 감압술, 내시경을 이용한 감압술 및 최소 절개를 통한 감압술이 있다. 전통적 개방술을 통한 감압술은 큰 절개를 통해 수근 관 내외의 해부학적 구조물을 직접 확인할 수 있고 류마토이드 관절염이나 통풍 등의 증식성 건막염(proliferative tenosynovitis)의 경우, 감압술과 동시에 건막 절제술을 용이하게 할 수 있다. 또한 이전에 감압술을 받은 환자의 재수술이나 손목이 고정된 환자의 경우에도 적응증이 된다. 요즈음은 특발성 수근 관 증후군에서 예전에 많이 행해졌던 내부 신경 박리술(internal neurolysis)이나 신경 외막 절개술(epineurotomy) 또는 굴근 건막 절제술(flexor tenosynovectomy)등은 여러 연구에 의해 수술 성적의 통계학적 의의가 없는 것으로 밝혀져 거의 행해지지 않는다. 전통적 개방술의 단점으로는 큰 절개로 인해 정중신경의 수장측 수근 분지(palmar carpal branch)의 종말 분지(terminal cutaneous branch)가 손상되어 반흔 압통(scar tenderness)이 생길 수 있다는 것과 술 후 악력의 회복이 더디다는 것이 있다.

근래에 정형외과 영역에서 내시경적 수술법의 사용이 확대되면서 수근 관 증후군의 수술에도 내시경적 수술법이 도입되었다. Agee, chow 그리고 Okutsu등의 여러 방법이 사용되고 있으며, 손바닥 통증 등 술 후 이환율이 낮고, 강력 파악력과 정밀 파악력의 회복이 빨라 정상 생활이나 일로 빨리 복귀할 수 있다는 장점이 있다. 단점으로는 기술적인 합병증의 빈도가 높은 것이 지적될 수 있으며 술 후 신경 진탕(neuropraxia), 정중 신경 손상, 표재 수장궁(superficial palmar arch)의 손상 등이 있을 수 있다. 또한 횡 수근 인대의 불완전한 절개로 인해 재발률이 높다는 것을 지적하는 연구도 있다.

Figure 55-1

Trigger finger is caused by repetitive microtrauma from repeated clenching of the hand.

Figure 55-2

The catching tendon sign for trigger finger.

(From Waldman SD: Physical diagnosis of pain: an atlas of signs and symptoms, Philadelphia, 2006, Saunders, p 195.)

Figure 55-3

Giant cell tumor of the tendon sheath. A, In this 55-year-old woman with a 2-year history of pain and gradual swelling of the fingers, a soft tissue mass (arrow) can be identified at one distal interphalangeal joint. Underlying inflammatory osteoarthritis of the articulations is evident, and this combination of findings would suggest that the mass is a mucous cyst. However, biopsy of the affected joint demonstrated a giant cell tumor of the tendon sheath. B, Photomicrograph (×86) in a different patient reveals a tendon capsule tumor (arrowhead) associated with moderately vascularized stroma, plump spindle-shaped or ovoid cells, and multinucleated giant cells.

(From Resnick D: Diagnosis of bone and joint disorders, ed 4, Philadelphia, 2002, Saunders, p 4248.)

reference)

Atlas of Common Pain Syndromes , Third Edition Steven D. Waldman, Chapter 55, 178-180

www. orthobullet.com

정형외과학 6판 P 561

De Quervain's Tenosynovitis

De Quervain's Tenosynovitis

Definition

- 드 꾀르벵병은 신전 지대의 제 1구획의 APL 및 EPB의 협착성 건막염

  : De Quervain's tenosynovitis refers to a painful inflammatory process of the first dorsal retinacular compartment containing the tendons of the abductor pollicis longus and extensor pollicis brevis.

Synonyms

• Stenosing tenosynovitis of the radial styloid process
• Stenosing tenovaginitis of the first dorsal compartment
• De Quervain's disease
• De Quervain's tendonitis
• De Quervain's stenosinig tenosynovitis
• Tendinosis

ICD-9CM CODES

727.04 Radial styloid tenosynovitis, de Quervain disease727.0 Synovitis and tenosynovitis727.05 Other tenosynovitis of hand and wrist

Epidemiology & Demographics

- 30~50대 사이의 여성에서 호발, 특히 임신 말기나 수유기에 흔함.

• More common in women than in men (10:1)
• Usually occurs between the ages of 30 and 50
• Associated with rheumatoid arthritis (RA)
• Can be seen in new mothers or daycare providers due to holding the babies with an outstretched thumb
• Seen more frequently in certain occupations involving repetitive wrist motion (e.g., clerical, assembly, and manual labor)

Physical Findings & Clinical Presentation

• Pain over the styloid process of the radius with grasping and isometric thumb abduction
• Swelling on the radial styloid
• Tenderness in the anatomic snuffbox
• Positive Finkelstein's test ( Fig. 1-271 )

FIGURE 1-271  : Finkelstein's test is positive in de Quervain's stenosing synovitis.  Ulnar flexion of the wrist produces pain over the dorsal compartment containing the extensor pollicis brevis and abductor pollicis longus. (From Noble J [ed]: Textbook of primary care medicine, ed 2, St Louis, 1996, Mosby.)

• Crepitance
• Numbness of the dorsum of the thumb is rarely noticed.
• Absence of local heat on examination

Etiology

- 대개 수부나 수근 관절을 과도하게 사용하는 반복적인 활동에 의해 발생

- 2차적으로 신전 지대의 섬유화가 진행

- 해부학적 변이(APL의 이상 분지, 이상 건 부착, 비정상적인 중격)

• The cause is usually repetitive use or overuse of the hand and thumb involving pinching with the thumb while moving wrist in radial and ulnar directions causing thickening of the fibrous tendon sheath (e.g., typing, writing, nailing, golfing, fly-fishing, etc.).
• Acute trauma to the first extensor dorsal compartment can also lead to tenosynovitis.
• It can also occur in inflammatory joint conditions like RA and conditions causing calcium apatite deposition.

Diagnosis

• The diagnosis of de Quervain's tenosynovitis is based on the clinical triad of:

1. Tenderness over the radial styloid

               2. Swelling over the first dorsal retinacular compartment

3. Pain on ulnar movement of the wrist with the thumb adducted and flexed (Finkelstein's test; see Fig. 1-271).

• Consideration can be given to injecting 1.5 ml of 1% Xylocaine into the tenosynovial sac, and if all three physical signs resolve, the diagnosis is confirmed, allowing for differentiation from carpometacarpal (CMC) osteoarthritis (OA).
• Finkelstein maneuver can also be present in first CMC joint OA; therefore it should also be evaluated if this test is positive.

Differential Diagnosis

• Carpal tunnel syndrome
• Arthritis (e.g., degenerative OA or RA)
• Gout
• Infiltrative tenosynovitis
• Radiculopathy
• Compression neuropathy (e.g., superficial branch of the radial nerve "bracelet syndrome")
• Ganglia
• Infection (e.g., tuberculosis, bacterial)
• Scaphoid fracture
• Intersection syndrome

Laboratory Tests

• ESR is usually normal in patients with de Quervain's tenosynovitis.
• Arthrocentesis can be used to rule out gout (crystals) and infection (Gram stain and culture of aspirate).

Imaging Studies

• Imaging of the wrist and thumb is not necessary unless a fracture or arthritis is suspected.

Treatment

Nonpharmacologic Therapy

• Rest
• Avoiding repetitive movements of the hand or thumb
• Splinting (thumb spica)
• Icing (4-6 times day for 15 minutes)
• Physiotherapy

Acute General Rx

• Corticosteroid injection using 20 to 40 mg triamcinolone acetonide and 1% Xylocaine is effective in relieving pain.
• NSAIDs (ibuprofen 800 mg tid or naproxen 500 mg bid)
• Topical hydrocortisone on the radial styloid for mild conditions

Chronic Rx

• Once signs of active inflammation have resolved after 3-4 wk, gentle stretching exercises involving abductor and extensor tendons usually help recovery.
• Surgical release is generally reserved for patients not responding to NSAIDs and corticosteroid injection therapy.

Disposition

• ∼90% of patients have relief of symptoms with either single or multiple steroid injections.
• Rarely, steroid injection use can cause infection and tendon rupture.
• If left untreated, can lead to fibrosis and decrease in mobility (stenosing tenosynovitis).
• Surgical control of symptoms achieved in 90% of referred cases
• Complications of surgery include:

                  - 수술 후 합병증으로

                      1. 건의 탈구(신전 지대의 지나친 절제, 건막 절개시에 가능한 배측에서 시행),

                      2. 표재 요골 신경 분지의 손상(신경통)

• Radial nerve damage
• Paresthesia (∼10%)
• Neuroma
• Scarring

                       

                    Campbell P.4300

                         failure to obtain relief after surgery may result from

                          - formation of neuroma in a branch of ther superficial radial nerves

                          - volar subluxation of the tendon when too much of ther sheath is removed

                          - failure to find and release a seperate aberrant tendon within a seoerate compartment

                          - hypertrophy of scar from a longuitudinal skin incision

• Recovery rates are higher with early treatment to ∼80% after 6 wk but >40% after 4 yr.

Pearls & Considerations

• Steroid injection is generally recommended after failure of conservative treatment for 2-6 wk.
• Pain relief is usually noted within 48 hr with patient becoming asymptomatic by the first or second week after corticosteroid injection.
• If there is no improvement by 6 wk post second corticosteroid injection, referral to an orthopedic hand surgeon is recommended.
• Without treatment it will not improve and can get worse.
• Condition can recur if triggering activity continues.

Suggested Readings

available at INTER REF www.expertconsult.com

Related Content

• De Quervain's Tenosynovitis (Patient Information)

AUTHOR: SYEDA M. SAYEED, M.D.

Suggested Readings

Asif et al., 2009Asif M., Ilyas A.M.: Surgical treatment for de Quervain's tenosynovitis. J Hand Surg 2009; 34: 928-929

Bouras et al., 2010Bouras Y.: Surgical treatment in de Quervain's tenosynovitis. Ann Chir Plast Esthet 2010; 55: 42-45

Capasso et al., 2002Capasso G., Testa V., Maffulli N.,

et al

: Surgical release of de Quervain's stenosing tenosynovitis postpartum: can it wait?. Int Orthop 2002; 26: 23

Graham et al., 2007Graham J.B., Hulkower S.D., Bosworth M.,

et al

: Are steroid injections effective for tenosynovitis of the hand?. J Fam Pract 2007; 56: 1045-1047

Ilyas et al., 2007Ilyas A.M.: De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg 2007; 15: 757-764

Jirarttanphochai et al., 2004Jirarttanphochai K.: Treatment of de Quervain disease with triamcinolone injection with or without nimesulide A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am 2004; 86-A: 2700

Richie and Briner, 2003Richie C.A., Briner W.W.: Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract 2003; 16: 102

Reference

Ferri's Clinical Advisor 2014 Fred F. Ferri , 327-327.e1 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.