Hand and Microsurgery
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Trigger ﬁnger/thumb is a condition affecting the gliding movement of the tendon as you bend or straighten the ﬁnger/thumb.
To understand the pathology behind trigger ﬁnger/thumb, let us look at how the tendon function normally in the ﬁnger/thumb. These tendons extend from the forearm to the end of the digit. When they pull, the ﬁngers and thumb will bend. Within the ﬁnger/thumb, they are held close to the bones by ﬁbrous tissue called pulleys which form a tunnel for the tendon passage.
The tendons are covered by a slippery coating called tenosynovium that reduces the friction during tendon gliding as the ﬁnger bends and extends. The pulley at the entrance of the tunnel located at the base of the ﬁnger is called the A1 pulley.
WHAT CAUSES TRIGGER FINGER?
It is the result of thickening of the tenosynovium or narrowing of the pulley. Constant irritation from the tendon sliding repeatedly through the pulley causes the tendon to swell and creates a nodule near the A1 pulley.
WHO GETS TRIGGER FINGER?
Anyone can get trigger ﬁnger. But it is commonly seen in women between the ages of 40-60.
Certain conditions such as rheumatoid arthritis and diabetes mellitus predispose the patients to trigger ﬁnger. Partial tendon laceration, repeated trauma or occupation requiring long hours of grasping can lead to trigger ﬁnger too.
Triggering is also observed in infants and young children. It commonly affects the thumb but other ﬁngers can be affected too.
HOW DO I KNOW IF I HAVE TRIGGER FINGER?
You will have ‘clicking’ and/or pain at the palm side of the base of ﬁnger/thumb as the ﬁnger/thumb is straightened or bent. These symptoms can be more pronounced in the morning. In later stage, there is more difficulty in straightening or bending the ﬁnger/thumb. Sometimes, a bent ﬁnger can only straighten with a gentle force, usually followed by a click and pain. In severe cases, the ﬁnger is locked in a bent position and cannot be straightened even with force.
The doctor will examine your hand to exclude other conditions that may present similar to trigger ﬁnger such as infection, arthritis, extensor tendon subluxation.
Treatment depends on the severity of triggering and how much it affects your daily function.
In mild early cases, you can treat them with ﬁnger exercise and stretching. You may need to change your activities to prevent triggering and give the inﬂamed tendon time to heal.
Steroid injection adjacent to the A1 pulley area can decrease the inﬂammation and swelling. It helps to relieve the triggering. It is very effective but may be short lived. There is a small risk of injuring the ﬁnger tendon, nerve and blood vessel.
Surgery is required if the triggering is troublesome and interferes with your work and activity or when the ﬁnger is difficult to straighten or locked. The A1 pulley which forms the entrance of the tunnel is released. If the tenosynovium is thickened, this may be excised too. This surgery is commonly performed under local anaesthesia in a Daycare surgery setting. This surgery is safe and very successful. There will be mild scar tenderness for few weeks. Nerve and blood vessels injury is uncommon.
DE QUERVAIN TENOSYNOVITIS
This is a condition that causes pain at the base of the thumb around the wrist. The pain arises from the inﬂammed and thickened tendons of the thumb.
The tendons that straighten the thumb arise from the forearm, pass through a tunnel at the back of the wrist and attached to the thumb. The ﬂoor of the tunnel is formed by the radius bone and a thick ﬁbrous tissue called extensor retinaculum forms the roof. The tendons are lined with a slippery coating called tenosynovium that allows the two tendons to glide easily within the tunnel. In de Quervain tenosynovitis, the tenosynovium is inﬂammed and thickened resulting in constriction of the two tendons within the tunnel.
WHAT CAUSES DE QUERVAIN TENOSYNOVITIS?
Majority may be due to repetitive thumb and wrist motion over a long period of time leading to chronic inﬂammation and thickening of the tenosynovium. These repetitive motion of grasping with the thumb can occur from activity such as carrying baby/child, manual scrubbing and wringing cloths, frequent and prolonged phone texting and console gaming.
Some may present after an episode of acute trauma such as a fall or a knock on the wrist.
This condition is also commonly seen in pregnancy and breastfeeding mother and is associated with the hormonal changes.
WHO GETS DE QUERVAIN TENOSYNOVITIS?
Anyone can get this condition. But it is commonly seen in women between the ages of 40-60. Pregnant women and breastfeeding mother have an increased risk of getting this tenosynovitis. Certain conditions such as rheumatoid arthritis predispose the patients to this condition.
WHAT ARE THE SYMPTOMS?
Commonly patient will have pain over wrist just below the base of the thumb. The pain is aggravated by thumb or wrist movement. Sometimes, a ‘click’ can be felt during thumb movement. Activities such as wringing, stirring, opening a tight jar cover, shaking hand and carrying baby/child can be painful.
HOW DOES THE DOCTOR MAKE THE DIAGNOSIS?
Diagnosis is usually made based on patient’s symptoms and physical examination.
Imaging is usually not needed. Occasionally X-ray of the wrist is taken to exclude any arthritis of the wrist or base of thumb which may mimic the pain of de Quervain tenosynovitis. Occasionally a cystic swelling develops over the tunnel and this can be visualized with an ultrasound.
Non-operative treatment is commonly the initial treatment. It includes resting the wrist and thumb in a splint to allow the inﬂammation of the tendons to resolve. Avoidance of any activities of the thumb and wrist that cause pain helps. Some anti-inﬂammatory medication can help to control the inﬂammation and swelling of the tenosynovium and also ease the pain.
Steroid injection into the tight tunnel will effectively reduces the swelling and inﬂammation of the tenosynovium and relieves the symptoms. However, following full recovery, recurrence may occur after months later. Steroid injection may also result in transient whitening of the skin at the site of injection which can resolve after few months.
If all non-operative treatments fail or the symptoms are severe, surgery is indicated. In this surgery, the roof of the tunnel is divided to relieve the constriction. Thickened tenosynovium of the tendons may need to be excised. Relieve of pain after the surgery occurs early. Complications of surgery are uncommon. Infection is rare. Injury to the nearby superﬁcial radial nerve is uncommon and can be avoided with careful dissection under loupe magniﬁcations. Tendon subluxation may occur after surgery.
CARPAL TUNNEL SYNDROME
This is a common condition caused by an increased pressure within a tunnel in the wrist which squeezes the median nerve that runs through the tunnel. Pressure on median nerve causes numbness, tingling (‘pin and needle’) sensation, and pain in the hand, ﬁngers and thumbs.
The roof of this tunnel is made of a thick tough band of ligament while the ﬂoor and walls of the tunnel are made up of carpal bones of the wrist, hence the name, carpal tunnel. It allows the passage of all the tendons that bend the ﬁngers and thumb as well as the median nerve. All these structures are in close contact which one another and any increase in the volume or additional swelling will result in an increased pressure within the tunnel.
WHO GETS CARPAL TUNNEL SYNDROME?
It can affect people of all ages but more commonly affect female between 40 to 60 years old. It is common in pregnant ladies. Patients with diabetes, chronic renal failure, rheumatoid arthritis and gout may have higher risk of getting this condition.
Both hands can be affected at the same time.
WHAT ARE THE CAUSES OF CARPAL TUNNEL SYNDROME?
In most cases, there is no obvious cause. Generally, an increased pressure in the carpal tunnel can occur because of swelling of the lining of the ﬂexor tendons that traverses the tunnel (called tenosynovitis); fracture, dislocation or arthritis of the wrist which narrow the tunnel. Fluid retention during pregnancy can also cause swelling within the tunnel and compress the nerve. Thyroid conditions, rheumatoid arthritis, diabetes, gout and chronic renal failure can be associated with carpal tunnel syndrome. Certain occupation requiring strenuous repetitive wrist motion and a use of vibrating tools may predispose to carpal tunnel syndrome. Familial or genetic factors may play a role as some patients have small narrow tunnel. In some cases, there may be a combination of causes.
WHAT ARE THE SYMPTOMS?
Patients will have numbness, tingling (‘pin and needles’) sensation or burning pain over the hand. Some patients may be able to localise the numbness to the thumb, index, middle and half of the ring ﬁngers. This pain may also radiates to the forearm, arm and shoulder. These symptoms commonly occur at night or early morning but as it worsens they become more persistent and severe throughout the day. Patients ﬁnd it difficult to drive, hold the handphone or type for a long period of time. In early cases, the symptoms may be relieved by shaking the hand rapidly. In prolonged cases, the muscles of the thumb can be wasted and weak.
Early and intermittent symptoms of numbness and night pain can be treated with non-operative treatment. Avoid strenuous repetitive wrist motion Wearing night wrist splint keeps the wrist in neutral position to ensure an optimum carpal tunnel space and may help with the night symptoms. Drugs such as anti-inﬂammatory drugs to relief pain, vitamin supplements such as B6 and B12 to improve and restore nerve function may also help.
Steroid injection into the carpal tunnel may be successful in relieving symptoms but risk of recurrence is high.
Surgery is indicated when the above treatment has failed. When the symptoms worsen from intermittent to more frequent episodes or constant numbness or pain, surgery becomes necessary. The surgical aim is to relieve the pressure of median nerve by cutting the transverse carpal ligament which forms the roof of the tunnel. The surgery can be performed through a mini-open technique or arthroscopically (key-hole surgery). This operation is safe with excellence results. Complications are minimal. Scar tenderness and pillar pain may occur. Wound infection is uncommon. Injury to the motor branch to the thumb muscle is rare. Recurrence is uncommon and can happen if transverse carpal ligament is incompletely cut or ﬁbrosis develops around the nerve after surgery.