By Ray



This is one of a number of Medical Checkpoints giving information about common conditions and what you can do about it. Your opinion and reaction to these Medical Checkpoints would be valued and appreciated. Medical Checkpoints are published periodically by STARTHealthcare and are provided as a free service.


from Campbell's Operative Orthopaedics, 8th edition, edited by A. H. Crenshaw, page 3438 (Stenosing Tenosynovitis):


Stenosing tenosynovitis occurs more often in the hand and wrist than anywhere else in the body. When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is sometimes called de Quervain's disease. When the long flexor tendons are involved, trigger thumb, trigger finger, or snapping finger occurs.


What is going on:

Pain, swelling, local crepitus, and clicking or catching with painful release are what is experienced with trigger thumb or finger or sometimes with tendons around the wrist. These conditions have a similar inflammation of the delicate covering of the tendon called "tenosynovium". The tolerances inside the tendon sheaths of the fingers and wrist are quite close. With swelling associated with the inflammation, the space between the tendon and its sheath or pulleys may become too small, and the rubbing or catching of the tendon as it moves through the tendon pulleys or channels that hold the tendons in place, cause pain and irritation. This inflammation of the tendon sheath and tendon covering called "synovium" (the same name for the same structure inside of joints), is called in medical terms "tenosynovitis". The "stenosing" word means that the space is too small for the tendon to move freely and so it gets stuck and jerks and rubs and causes more inflammation and more pain.


What to do:

1. The first thing to do is to get rid of pain and inflammation. Rest will usually accomplish this quite well. There are a number of ways to rest a part. The best way is to encase it in plaster of Paris or a fiberglass cast. This will usually work for the wrist and thumb but is not practical for the fingers. Less rigid ways to rest the wrist and thumb is to use a splint that can be taken on and off. Being able to take a splint off is a great advantage for personal hygiene and for comfort. This also allows for water treatments which also helps decrease the inflammation. However these advantages need to be weighed against the added movement and irritation of the tendon and its sheath that results from being out of the splint.


2. A powerful way to decrease the inflammation is to do alternate hot and cold soaks in water. Local heat will have the effect of making it feel better while promoting healing. Alternate hot and cold applied locally will increase the blood flow to the part and have the effect of "washing out" the collection of pain chemicals while bringing in the needed repair substances. Heat will ease the pain and help reduce swelling, allowing for more normal local blood flow. The best way to apply hot and cold to the foot (e.g. 3 min. hot and 1/2 min. cold) is with two basins or buckets of water. Use a thermometer to measure the heat of the hot water. Start the hot water about 100F (37.7C) and increase the temperature by adding more hot water (without burning yourself) to a maximum temperature of 110F (43C). Add ice to thecold water to keep it cold and end the treatment with cold (at least three hots and three colds). If you have diabetes, peripheral neuritis, or other disease that makes your body part insensitive to temperature, consult your professional medical providers before attempting to use hot and cold on yourself. Local treatment with hot and cold and rest will usually take care of the inflammation with no risk of any side effects - as long as you do not burn yourself with the hot water!


3. It may be necessary to seek professional medical advice if simple rest and anti-inflammatory hot and cold treatments do not bring relief. Your doctor may advise a local cortisone injection into the inflamed tendon sheath. This will many times help resolve the condition and avoid surgery. It is necessary to make sure that gout or infection is not present that may be worsened by steroid injections. A blood test to measure the uric acid level of the blood and other markers for infection or arthritis may be indicated.


4. Surgery: Should your doctor suggest that surgery may help, what does the surgery do? While surgery does not affect the conditions that led to the development of the inflamed tendon sheath, it does remove the condition that keeps it going - the tight tendon sheath. What surgery does is open up the tendon sheath so that the tendon has more room to move and function normally. The sheath is not put together at surgery but simply opened up and left open. The body rapidly heals the sheath and the end result is a larger diameter sheath with no more tightness. The risks of the surgery (apart from allergic reaction to any anaesthetic agents used and having a scar) are related to potential damage to surrounding structures such as nerves. Sometimes the tendon is not all together in one cord, but has several slips, each with its own sheath. Where this is the case, all of the slips must be released from their conduits or the painful condition will likely continue from the unreleased segments of the tendon. With trigger finger it is important to release all of the pulleys that are tight. Under local anaesthetic with the patient able to move the finger, it can be checked at the time of surgery to see whether the tendon moves freely after a pulley or tight segment of the tendon sheath is released.


After surgical release of a trigger finger, the patient is encouraged to use the finger for light usage normally. In the case of wrist tendon releases, normal hand usage is encouraged with limited wrist movement until healed.


5. Prevention: There is no generally agreed methods of preventing trigger fingers. Because of the nature of the condition, it would appear reasonable that the following suggestions would be helpful:

a) Avoid chilling your fingers. Wear gloves or mittens in cold weather and protective gloves for heavy work.

b) Avoid repetitive activities that are unfamiliar to you. At the first evidence of pain over a tendon, rest or accomplish the work in some other way than using exactly the same movement that is beginning to cause pain.

c) If early, intermittent sticking of a finger is experienced, hot and cold treatments along with avoidance of movements that cause the finger to trigger may be helpful. High fiber diet, a balance of rest and exercise, several glasses of pure water a day, good posture promoting full deep breathing will all aid in good health and the avoidance of painful inflammations of tendons and joints.

Often surgery is the best treatment. The risks when surgery is done by a skilled surgeon, is minimal. The benefits are immediate and complete relief in the vast majority of trigger fingers.