Extensor digitorum and extensor digiti minimi both insert into the extensor hoods of digits 2-5 (or just 5 in the case of e. digiti minimi). In every source that I can find, extensor pollicis longus & brevis insert directly into the base of the distal and proximal phalanxes respectively.
Does this indicate that the thumb does not have an extensor sheath as the remainder of the digits do?
From $n=2$ textbooks, the results are equivocal.
Moore et al. (2013)
- There is no mention of an extensor expansion associated with the pollex.
- EPL and EPB are listed as inserting on the distal and proximal phalanges, respectively.
Rohen et al. (2010) (p. 394)
- "Extensor expansion of extensor of thumb" The label points to the middle of the diaphysis of the proximal phalanx. It's odd that extensor is singular here, given that there are two extensors.
However, Abdel-Hamid et al. (2013) present data from dissection of 95 limbs.
Extensor pollicis longus:
"EPL tendon was attached to both proximal (PP) and distal (DP) phalanx through the extensor expansion in 94.7% of specimens (Figs. 1A, B; 2A). In 5.3% of upper limbs, the EPL tendon was attached to the DP through its extensor expansion (Fig. 2B; Table 2)."
Extensor pollicis brevis:
In 55.8% of upper limbs, [EPB] was attached distally to the base of the [proximal phalanx] of the thumb (Fig. 1B). While in 41%, EPB tendon was attached to the extensor expansion of the thumb at the level of the base of [proximal phalanx] (Fig. 2A). However, in 3.2% of specimens its tendon was inserted into the extensor expansion of the thumb at the level of the base of [distal phalanx]."
And the answer appears to still be equivocal.
Abdel-Hamid GA, El-Beshbishy RA, Abdel Aal IH. 2013. Anatomical variations of the hand extensors. Folia Morphol 72:249-257.
On thoracic limb of horses, the common digital extensor tendon (dorsal digital extensor tendon) is the continuation of the common digital extensor muscle. The tendon passes over the dorsolateral aspect of the carpus, continuing distally over the dorsal metacarpus and joined by the branches
of the interosseous muscle (suspensory ligament) before its insertion on the extensor process of the distal phalanx.
A minor branch of the common digital extensor tendon inserts on the middle phalanx and some fibres insert on the hoof cartilages.
- Origin: Common digital extensor muscle on the lateral humeral epicondyle
- Insertion: Extensor process of distal phalanx
- Action: Extends carpus and digit
- The common digital extensor tendon is surrounded by the extensor retinaculum and a protective synovial sheath. The tendon sheath begins approximately 10cm proximal to the carpus, extending distally to the level of the metacarpus.
Text by Antoine Micheau, MD - Copyright IMAIOS
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Cartilage tumors of the soft tissues particularly in the hand and foot
Tenosynovial chondromatosis—an unusual case
Br J Surg
Synovial chondromatosis of the hand
Plast Reconstr Surg
Trigger finger due to a tenosynovial osteochondroma. A case report
J Bone Joint Surg [Am]
Tenosynovial chondromatosis in the hand
J Bone Joint Surg [Am]
Tenosynovial osteochondroma in the hand
J Bone Joint Surg [Am]
Cartilaginous tumors of the soft tissues of the hands and feet
Mayo Clin Proc
Most ruptures of the anterior tibial tendon occur in patients over the age of 50, with a male preponderance. Patients often present with gait abnormality and foot drop. On physical examination, a palpable mass may be present over the anterior ankle corresponding to the retracted tendon, with no palpable tendon distal to the mass. Initial symptoms are often mild, which can result in delayed presentation and missed diagnoses. 1,2,3
Ankle extensor tendon disorders are less commonly reported in the medical literature than other ankle tendon pathology. The incidence of extensor tendon abnormalities is uncertain. Complete rupture of the anterior tibial tendon is described as “rare” by some authors 1,4 , but also has been reported as the third most common tendon rupture in the lower extremity, behind Achilles and patellar tendon tears. 5
Review of Radsource cases over the past 10 years utilizing keyword database search found 31 cases of complete anterior tibial tendon rupture, and a total of 447 cases of ankle extensor tendinopathy (342 involving the anterior tibial tendon, 67 involving the extensor hallucis longus, and 38 involving the extensor digitorum longus or peroneus tertius). Most of these patients had additional coexisting ankle or hindfoot pathology.
Finger and hand infections
The hand is susceptible to infection by virtue of its intimate contact with the outside world, its great surface area and its propensity for injury. That is, the hand is exposed frequently to infectious organisms, and these organisms are frequently given a point of entry.
The specialized anatomy of the hand, particularly the tendon sheaths and deep fascial spaces, create distinct pathways for infection to spread. In addition, even fully cleared infections of the hand can result in significant morbidity, including stiffness and weakness. For these reasons, early and aggressive treatment of hand infections is imperative.
In this section, specific hand infections will be considered:
- paronychia: infection of the folds of skin surrounding a fingernail
- felon: a purulent collection on the palmar surface of the distal phalanx
- flexor tenosynovitis: purulent material resides within the flexor tendon sheath.
- septic arthritis: infection in the joint space, often related to bite wounds
The paronychium is a small band of epithelium that covers the medial and lateral borders of the nail. The eponychium is a small band of epithelium that covers the proximal aspect of the nail.
A paronychia is an infection of the paronychium or eponychium. It is caused by minor trauma such as nail biting, aggressive manicuring, hangnail picking or applying artificial nails. Immunodeficiency, poor glycemic control, and occupations involving repeated hand exposure to water (e.g. dishwasher) are risk factors for the development of paronychia.
Tenderness and erythema of the nail fold at the site of infection will become evident within a few days of the inciting trauma. Progression to abscess formation is common.
Turkman et al described the "digital pressure test for paronychia": A paronychia will appear as a blanched area when light pressure is applied to the volar aspect of the affected digit.
If left untreated, the paronychia can spread along the nail fold from one side of the finger to the other, or to beneath the nail plate.
Treatment for early cases includes warm water soaks and antibiotics. However, once a purulent collection has formed, treatment requires opening the junction of the paronychial fold and the nail plate. This is normally done with the bevel of an 18 gauge needle.
Figure The bevel of an 18 gauge needle is passed between the nail plate below and the nail fold above to allow for drainage of the pus.
Acute paronychiae are usually caused by Staphylococcus aureus and are treated with a first-generation cephalosporin or anti-staphylococcal penicillin. Broader coverage is indicated if other pathogens are suspected. Chronic paronychiae may be caused by Candida albicans or by exposure to irritants and allergens.
Paronychiae may be prevented by avoiding behaviors such as nail biting, finger sucking, and cuticle trimming. Patients with chronic paronychia should be advised to keep their nails short and to use gloves when exposed to known irritants.
A felon is an abscess on the palmar surface of the fingertip. Bacteria are normally introduced via minimal penetrating trauma, such as a splinter.
The palmar aspect of the fingertip contains many osteocutaneous ligaments that connect the palmar skin of the fingertip to the distal phalanx. These ligaments prevent excessive mobility of the skin during pinch they also maintain position of the cutaneous sensory endings and receptors to allow for identification of objects during grasp. The organization of these osteocutaneous ligaments form a relatively non-compliant compartment in the distal phalanx thus, rather than expanding when pus is introduced, the compartment will simply increase in pressure.
Elevated compartment pressure results in significant pain relative to the (small) amount of pus. In addition, the gradient between capillary pressure and tissue pressure is decreased the resulting decrease in perfusion can lead to tissue necrosis. Furthermore, because the osteocutaneous ligaments attach to the distal phalanx itself, osteomyelitis (infection of the bone) can occur.
Treatment involves surgical drainage and antibiotics. Incision and drainage is performed at the most fluctuant point. The incision should not cross the distal interphalangeal joint flexion crease (to prevent formation of a flexion contracture from scar formation) or penetrate too deeply (to prevent spread of infection from violating the flexor tendon sheath). Potential complications of excessive dissection to drain a felon include an anesthetic fingertip or unstable finger pad.
Antibiotic treatment should cover staphylococcal and streptococcal organisms. X-rays may be helpful to ensure that there is no retained foreign body.
In the fingers, a series of pulleys hold the tendons in close apposition to the bone, preventing bowstringing during flexion. There are a total of 8 pulleys overlying the finger flexor tendons and 3 pulleys overlying the thumb flexor tendon these pulleys together are called the flexor tendon sheath.
In flexor tenosynovitis, the infection is within the flexor tendon sheath. This infection is particularly harmful because bacterial exotoxins can destroy the paratenon (fatty tissue within the tendon sheath) and in turn damage the gliding surface of the tendon. In addition, inflammation can lead to adhesions and scarring, and infection can lead to overt necrosis of the tendon or the sheath.
Although patients may not recall a specific history of trauma, flexor tenosynovitis is usually the product of penetrating trauma. Flexor tenosynovitis may be caused by inoculation and introduction of native skin flora (eg, Staphylococcus and Streptococcus) or by more unusual organisms (eg, Pasteurella and Eikenella) when there is a bite wound.
Flexor tenosynovitis can also have noninfectious causes such as chronic inflammation from diabetes mellitus, rheumatoid arthritis or other rheumatic conditions (eg, psoriatic arthritis, systemic lupus erythematosus, and sarcoidosis).
Kanavel described four classic signs of flexor tenosynovitis, as follows:
- Flexed posture of the digit.
- Fusiform (sausage-shaped, or tapering) swelling.
- Tenderness to palpation over the flexor tendon sheath.
- Pain over the flexor tendon sheath with passive extension of the finger
Figure This patient’s fourth digit exhibits erythema, fusiform swelling, and mild flexion compared to the adjacent digits.
Anatomic relationships of flexor sheaths to deep fasical spaces should be kept in mind. Contiguous spread can result in a “horseshoe abscess”: from small finger flexor sheath to the thumb flexor sheath via connection between the radial and ulnar bursae.
If the diagnosis of flexor tenosynovitis is not clear, the patient may be admitted to the hospital for antibiotics, elevation of the affected hand, and serial examination. Non-operative treatment should be reserved for normal hosts. In patients with diabetes or any disease that may compromise the immune system, early surgical drainage is indicated even for suspected cases.
If the diagnosis of flexor tenosynovitis is established definitively, or if a suspected case in a normal host does not respond to antibiotics, surgical drainage is indicated. During this surgery, it is important to open the flexor sheath proximally and distally to adequately flush out the infection with saline irrigation. The distal incision is made very close to the digital nerve and artery as well as the underlying distal interphalangeal joint it is important to avoid damage to these structures during surgery. Some surgeons will leave a small indwelling catheter in the flexor sheath to allow for continuous irrigation after surgery, but there is no conclusive evidence that this ultimately improves results.
Figure Proximal and distal incisions have been made, allowing adequate drainage of the flexor tendon sheath.
Post-operative active and passive ROM exercises are recommended. Intravenous antibiotics should continue for an additional two or three days. (The duration of IV antibiotic administration as well as the need for oral antibiotics thereafter is determined by the intraoperative cultures and clinical response.)
Post-operative adhesions damage gliding surfaces and decrease active range of motion, and thus require tenolysis. Soft tissue necrosis and flexor tendon rupture are other relatively common complications.
The metacarpophalangeal and interphalangeal joints are closed, relatively avascular spaces. Infection can reach the joint space via direct penetration or hematogenous spread.
Small (and ring) finger metacarpophalangeal joint infections in particular may result from a “fight bite,” where the patient strikes and an opponent in the mouth with a closed fist and the opponent’s tooth penetrates the joint and seeds it with oral flora. As with flexor tenosynovitis, a major risk of joint space infection is destruction of the gliding surface by bacterial exotoxins, which can compromise recovery of motion after the infection resolves.
A fight bite is at particularly high risk for complications, for the following reasons:
- the puncher may underestimate the severity of the wound
- the puncher may have been intoxicated (and sufficiently "medicated" to not feel pain)
- the puncher may attribute initial symptoms to bone pain from punch and not present for care until cellulitis is rampant
- the initial examiner may underestimate the severity of the wound, as it is usually small (the size of an incisor tooth or smaller, eg 3mm) with clean edges
- the human mouth has a high concentration of nearly 200 species of bacteria, many "unusual" anaerobes
- motion of the MCP joint to "shake off the pain" may drive saliva deeper into the tissue
- the extensor tendon and joint capsule are fairly superficial and may be violated with seemingly shallow wounds
- the extensor tendon and joint capsule are fairly avascular and thus unable to fight infection
Fight bites should be meticulously irrigated, preferably with a formal debridement by a hand surgeon in the operating room. The laceration must not be closed in the ED.
Figure: a punch to the tooth may inadvertently lacerate the skin over the MCP joint and introduce oral flora into the joint
Diagnosis of an established joint infection is often made by clinical examination. Patients will have swelling and erythema centered on the affected joint. Motion or axial loading of the joint will increase pain. Assessment of joint fluid for cell count, gram stain, and crystals (acute crystalline arthropathy such as gout can mimic a joint infection) can aid in the diagnosis, but it is often quite difficult to pass a needle into the narrow joint space and obtain an adequate sample. Serum markers of inflammation (such as white blood cell count, erythrocyte sedimentation rate, and C - reactive protein) are not typically elevated with an infection of a small joint of the hand. Xrays should be obtained to ensure that there is no fracture or retained tooth fragment.
Treatment consists of incision and drainage of the joint space. For the metacarpophalangeal joints of the fingers, the approach is normally dorsal through the long extensor tendon. In “fight bite” situations, there may be an indentation of the head of the metacarpal where it struck the tooth. For the interphalangeal joint, the approach is normally dorsolateral between the extensor mechanism dorsally and the collateral ligament laterally. Arthroscopic approaches have been described for the wrist and even the metacarpophalangeal joint, but an open approach is more commonly used.
- Open wounds must be irrigated to remove debris.
- Closed abscesses must be incised and drained
- Devitalized tissue should be debrided.
- Penetrating wounds require consideration of tetanus status
- Splinting the hand may enhance healing
Patients with diabetes mellitus have more gram-negative infections and require broader antibiotic coverage
Patients in an immunocompromised state may develop a hand infection from hematogenous spread from another site.
Unusual exposures lead to unusual bacteria: eg tropical fish aquarium workers, butchers, farmers.
Patients suspected of having a hand infection will often undergo plain x-rays. The bony structures will typically appear normal except in very advanced infections involving the bone. Ultrasound can show loculated fluid collections, but is heavily dependent on the skill of the person performing the study. Magnetic resonance imaging, with or without gadolinium contrast, may show occult deep space infections if the clinical picture is not clear. Use of MRI is limited by cost as well as availability depending on when and where the patient is being evaluated.
For most cases, the diagnosis of infection is made by history and physical exam. X-rays are a rapid and cost effective way to identify bony changes and radiopaque foreign bodies. More complex imaging studies should be reserved for situations where the diagnosis remains unclear despite adequate examination and initial treatment, or if the patient does not respond to appropriate management.
Collateral ligament injuries
MCP collateral ligament injuries range from mild sprain (grade 1) to complete tears (grade 3). Complete tears lead to instability (Figures 10-11). The most common collateral ligament injury in the hand involves the ulnar collateral ligament of the thumb, usually due to a violent hyperabduction mechanism and commonly referred to as “gamekeepers” or “skiers” thumb (Figure 12). Low grade partial or nondisplaced UCL injuries are successfully treated with conservative measures in most cases. However, if the thumb UCL ligament is torn and retracted it may become displaced superficial to the adductor aponeurosis (known as a Stener lesion), which will inhibit healing (Figure 13). Stener lesions require surgical fixation to prevent chronic instability and reduced pinch/grip strength. 5, 9 Collateral ligament injuries of the lesser digit MCP joints are much less common. As with thumb UCL injuries, good outcomes are usually achieved with conservative treatment, although isolated high grade ligament tears may require surgical repair. 10
De Quervain's Tenosynovitis
De Quervain's Tenosynovitis is a painful inflammation of tendons on the side of the wrist at the base of the thumb.
These tendons include the extensor pollicis brevis (EPB) and the abductor pollicis longus (APL). These muscles are located on the dorsal side of the forearm and go to the lateral side of the thumb through a fibrous-osseous tunnel made of the processus styloideus radii and the extensor retinaculum.   The pain, which is the main complaint, gets worse with the abduction of the thumb, grasping action of the hand, and an ulnar deviation of the wrist. Thickening and swelling can also be present.    
Relevant Clinical Anatomy [ edit | edit source ]
The tendon sheaths around the abductor pollicis longus and extensor pollicis brevis pass through the fibro-osseous tunnel located along the radial styloid at the distal wrist.
M. extensor pollicis brevis (EPB)
- Origin: ½ dorsal side of the radius, the membrana interossea
- Insertion: base of the proximal phalanx of the thumb
- wrist joint: radial abduction
- thumb: extension
M. abductor pollicis longus (APL)
- Origin: dorsal side of the radius and the ulna, the membrana interossea
- Insertion: base of ossis metacarpi
- wrist joint: radial abduction
- thumb: abduction
Aetiology [ edit | edit source ]
De Quervain tenosynovitis
- Has been attributed to myxoid degeneration (the process in which the connective tissues are replaced by a gelatinous substance) with fibrous tissue deposits and increased vascularity rather than acute inflammation of the synovial lining. This deposition results in thickening of the tendon sheath, painfully entrapping the abductor pollicis longus and extensor pollicis brevis tendons.
- It is associated with repetitive wrist motion, specifically motion requiring thumb radial abduction and simultaneous extension and radial wrist deviation.
- The classic patient population is mothers of newborns who are repeatedly lifting a newborn with thumbs radially abducted and wrists going from ulnar to radial deviation.
- The most common cause is chronic overuse.
- Activities such as golfing, playing the piano, fly fishing, carpentry, office workers and musicians can lead to chronic overuse injuries.
- Repetitive gripping, grasping, clenching, pinching, or wringing of objects can cause inflammation of the tendons and tendon sheaths and narrows the first dorsal compartment and causes limitation of motion of the tendons. If left untreated, the inflammation and progressive narrowing (stenosis) can lead to scarring that further limits thumb motion. 
Epidemiology [ edit | edit source ]
- The estimated prevalence of de Quervain tenosynovitis is about 0.5% in men and 1.3% in women with peak prevalence among those in their forties and fifties.
- It may be seen more commonly in individuals with a history of medial or lateral epicondylitis.
- Bilateral involvement is often reported in new mothers or child care providers in whom spontaneous resolution typically occurs once lifting of the child is less frequent 
- In industrial settings, studies have shown a point prevalence of 8% when wrist pain and a positive Finkelstein’s test is present. 
Characteristics/Clinical Presentation [ edit | edit source ]
The primary complaint is radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb. The pain has been described as a “constant aching, burning, pulling sensation."  Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand.  Swelling in the anatomical snuff box, tenderness at the radial styloid process, decreased CMC abduction ROM of the 1st digit, palpable thickening of the extensor sheaths of the 1st dorsal compartment and crepitus of the tendons moving from the extensor sheath may be found upon examination.  Other possible findings include weakness and paresthesia in the hand.  Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms.
Examination [ edit | edit source ]
The evaluation of a patient with signs and symptoms of De Quervain’s Tenosynovitis begins with a thorough history followed by a physical examination:
History [ edit | edit source ]
- Overuse injury vs acute trauma
- Prior history of symptoms
- Repetitive movements of the upper extremity with work or activities of daily living (ADL)
- Pain localized over the base of the thumb and dorsolateral aspect of the wrist near the radial styloid process
- Hand dominance
- Pregnant or currently in the post-partum stage
Physical Exam [ edit | edit source ]
- Patients present with radial-sided wrist pain which is typically worsened by thumb and wrist motion.
- The condition may be associated with pain or difficulty with tasks such as opening a jar lid.
- Tenderness overlying the radial styloid is usually present, and fusiform swelling in this region may also be appreciated.
- On palpation, some key, significant findings will be tenderness over the base of the thumb and/or 1st dorsal compartment extensor tendons on the thumb side of wrist particularly over the radial styloid process 
- The provocative Finkelstein test, in which the thumb is flexed and held inside a fist, and the patient actively clearly deviates the wrist, causes sharp pain along the radial wrist at the first dorsal compartment. 
Medical Management [ edit | edit source ]
De Quervain tendinopathy can be self-limited and may resolve without intervention.
- For those individuals with persistent symptoms, splinting, systemic anti-inflammatories, and corticosteroid injection are the most frequently utilized non-surgical treatment options.
- Splinting with a thumb spica brace may offer patients temporary relief, but failure and recurrence are often high and compliance low
Non-Surgical Treatment [ edit | edit source ]
The aim of non-surgical management is to reduce pain and swelling initial treatment of de Quervain's tenosynovitis may include:
- Immobilizing your thumb and wrist with a splint or brace to help rest your tendons. Clinicians do not agree on the frequency and duration of the splint some think it should be worn continually for four to six weeks others recommend wearing it only as needed for pain. 
- Avoiding repetitive or aggravating movements
- Applying ice to the affected area
- Nonsteroidal anti-inflammatory drugs (NSAIDS)
- Physical Therapy
Patients may also be prescribed for immobilization for up to 6 weeks. A splint for thumb immobilization can do this. When used a 19% improvement was observed but when they combined it with NSAID’s they found an even bigger improvement of 57%. 
Ultrasound is thought to improve the treatment outcome and can be used as a diagnostic tool in the management of de Quervain’s disease.  Success with ultrasound-guided injections was better than it was reported in the literature and without adverse reactions.  Ultrasound-guided injections targeting the M. Extensor Pollicis Brevis with septation is more effective than manual injection. 
Surgical Treatment [ edit | edit source ]
The 1-minute video shows the simple surgery performed.
- Surgery is rare and is usually for those when non-surgical treatment has failed and the patient experiences persistent inflammation affecting his or her function. The goal of surgery is to open the dorsal compartment covering to make more room for the irritated tendons. The opening allows pressure relief of the tendons, to ultimately restore free tendon gliding.
Physical Therapy Management [ edit | edit source ]
This video shows the technique, used a lot in practice, by R McKenzie
Ice/Heat Packs - Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath.
Massage - Deep tissue massage at the thenar eminence can help relax tight musculature that causes pain. (See video). Graston Technique of manual soft tissue mobilization along with the eccentric exercise is also helpful. Graston technique includes breaking down fascia restriction, stretching connective tissue, and promoting a better healing environment. 
Stretching - Stretching the thenar eminence muscles into thumb extension and abduction can relax and lengthen this tight musculature that causes pain.  (See video )
- Resisted finger and thumb extension
- Palm up position - for thumb extension and abduction strength
- Thumb up position - for thumb extension and abduction strength
- Resisted radial deviation
- In thumb up position
- Resisted supination
- In thumb up position
- Resisted thumb opposition
- In thumb up position
Improving Range of Motion Stretching as explained above can be used to improve range of motion. Ice/Heat packs can relax tight musculature so that you can attain a bigger range of motion.
Mobilization with movement has shown effectiveness in decreasing the pain, improving range of motion, and improving the function of a patient with De-Quervain tenosynovitis. The therapist provides a manual radial glide of the proximal row of carpals, then asked the patient to move her thumb into radial abduction-adduction.  Mobilization with movement performed for 3 sets of 10 repetitions and followed by eccentric hammer curl exercise with theraband and high voltage electrical stimulation has shown effective result after 6 months followup, 
Kinesio-taping Technique can also be used to decrease pain and improve function. 
Therapeutic Ultrasound has also better outcomes in pain reduction and healing. 
Decreasing Swelling To decrease swelling you can use:
- Thumb splinting
- Corticosteroid injections
- Ice/heat packs
Home Management Programme [ edit | edit source ]
Any of the above stretching and strengthening exercises can be done as a home exercise program (HEP). Patients can also use ice and heat packs at home. After education, patients can perform self-massage techniques at home, and if chosen as the preferred intervention.
Evidence for Management [ edit | edit source ]
Conflicting, the below is a summary
- Corticosteroid injection is superior to splinting in relieving pain 
- An Impairment-based approach using manual interventions (specifically grade IV radiocarpal, intercarpal, and 1st CMC joint mobilization) relieves pain and dysfunction in radial wrist pain. 
Oral anti-inflammatory medication coupled with night splinting and relative rest is of use (relative rest approach, in which a patient avoids aggravating activities while remaining otherwise active). 
- Splinting is the most important component of treatment for tenosynovitis. It was found that a splint that allowed for some movement was superior to complete immobilization of the thumb with respect to duration of the disability. 
- Time off from work was neither necessary nor desirable.
Differential Diagnosis [ edit | edit source ]
- Intercarpal Instabilities. 
- Superficial Radial Neuritis (Wartenberg’s Syndrome) 
- C6 Cervical Radiculopathy (CMC). 
- Intersection Syndrome
Outcome Measures [ edit | edit source ]
Clinical Bottom Line [ edit | edit source ]
Effective management of DeQuervain’s tenosynovitis will involve a highly individualized, impairment driven approach for the patient in question. Early splinting during the acute phase will prevent aggravation of the tissues, and allow the patient to perform activities essential to self-care and employment. The patient will need to be educated on the tissue healing timetables, as well as why it is important to avoid activities that are aggravating to their symptoms. Once symptoms have decreased to the point that a splint is no longer necessary, the therapist will need to perform a thorough examination and evaluation to determine the residual effects from immobilization. Some losses in ROM may occur, and grade III-IV mobilizations of the radiocarpal, scapholunate, and 1st CMC joint would then be warranted. As the patient nears discharge, education should include a component on the importance of avoiding repetitive motions that could play an aggravating role, or potentially lead to a relapse of the condition.
Hand contains 20 muscles as follows.
- Abductor pollicis brevis
- Flexor pollicis brevis
- Opponens pollicis
- Abductor pollicis
- Plamaris brevis
- Abductor digit minimi
- Flexor digit minimi
- Oppenens digit minimi
Tendon Sheath and Insertion Injections
Tendons are impressively strong structures that link muscles to bone. They function to transmit the force of muscular contraction to a bone, thereby moving a joint or helping to immobilize a body part. Their microscopic organization is thoroughly described elsewhere.
The organizational unit in a tendon is the collagen fibril, which collectively forms fascicles, which as a group compose the tendon itself. Some tendons, especially long ones, are guided and lubricated along their paths by sheaths ( Fig. 12-1 ) (e.g., biceps brachii, ( Fig. 12-2 ) extensor pollicis brevis, and abductor pollicis longus).
A prototypical muscle consists of the muscle belly centrally, two musculotendinous junctions, and tendinous insertions into bone at the points of anatomic origin and insertion. Some muscles, such as the extensor carpi radialis longus and brevis at the elbow, attach directly into bone ( Figs. 12-3 ), an arrangement that may be more susceptible to injury.
Much is known about a tendon’s response to laceration and operative repair, although this clinical situation is not frequently encountered. Less is understood about the more common and clinically relevant overuse tendinitis. A tendon and its sheath (if present) will undergo a typical inflammatory response to acute or chronic overuse injury, followed by a regenerative repair process. The distinction between an overload type of acute injury and a chronic overuse mechanism will aid in successful rehabilitation of tendinitis.
Cortisone and its derivatives are known to reduce or prevent inflammation. Numerous corticosteroid preparations are available for local injection (see Chapter 2 on medications). The injectable corticosteroids are suspensions of insoluble particles, and therefore, the antiinflammatory effect is profound only where the material is deposited. The ability of corticosteroids to control inflammation makes them a valuable adjunct in treating tendon injuries because they do not alter the underlying process that leads to inflammation.
As with many other physical medicine treatment modalities, well-designed scientific studies regarding the usefulness of corticosteroid injections are rare. These injections should be considered when, in the practitioner’s judgment, the recognized antiinflammatory effect of local corticosteroid placement may be beneficial for the conditions of tendinitis, enthesitis, or tenosynovitis, and no harm will likely result.
McWhorter and colleagues injected hydrocortisone acetate into rat Achilles peritenons that had been previously injured. There were no deleterious effects of one, three, or even five injections, measured biomechanically (tension to failure) or histologically (light microscopy), compared to controls. This finding should reassure physicians that they are not doing harm with properly placed steroid injections. A 30-year literature review identified eight prospective, placebo-controlled studies of steroid injection treatment for sports-related tendinitis. Three of the studies showed beneficial effects of injections at clinical follow-up. A meta-analysis of properly designed investigations of steroid injection for Achilles tendinitis found no beneficial effects, although very few studies qualified as rigorous. Adverse side effects occurred with a 1% incidence. No “proof” of the usefulness or uselessness of this treatment modality exists.
Contraindications, Complications, and Side Effects
The lack of a specific diagnosis is the single largest contraindication to a local corticosteroid injection. If the diagnosis is clear and the antiinflammatory effect of a corticosteroid may facilitate the rehabilitation process, injection can be considered.
Repeated injections to the same area must be avoided, particularly into joints. Alterations in articular cartilage have been documented with repeated administration, possibly resulting in joint damage and weakened ligaments. A widely recognized complication of steroid injection is tendon rupture, a negative outcome that appears to be decreasing in frequency because it is now well understood. Achilles and other tendon ruptures have been reported, and deposition of injected material directly into any tendon substance is contraindicated. One report links the effect of repeated steroid injections to rupture of the plantar fascia.
Some experimental findings have suggested that corticosteroid administration led to smaller, weaker tendons as a side effect. A more common side effect is subcutaneous atrophy, especially at the knee and lateral elbow and more frequently with the use of triamcinolone. Theoretically, atrophy of the specialized fat pads of the heel following steroid injection for plantar fasciitis may lead to a significant disability in an athlete, due to the loss of cushioning effect.
Alternatives to Corticosteroids
In recent years alternatives to corticosteroids have emerged for the treatment of chronic localized musculotendinous pain. These treatments include percutaneous tenotomies and platelet rich plasma (PRP) injections.
Percutaneous tenotomies have been described for treatment of chronic lateral epicondylitis and plantar fasciitis. These injections are performed with large bore needles (18 or 20 gauge) under ultrasound guidance. The needle tip is used to repeatedly fenestrate the affected tissue under local anesthetic. The bony surface (i.e., epicondyle) can be abraded and calcifications may be fragmented. This technique is thought to be a safe and effective alternative to corticosteroid injections.
Platelet rich plasma injections use concentrated platelets from autologous blood to stimulate a healing response in damaged tissue. Blood is drawn from the patient and placed in a centrifuge. The concentrated platelets are removed and reinjected directly into the patient’s abnormal musculotendinous tissue or ligament usually under ultrasound guidance. These concentrated platelets produce growth factors that include platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and transforming growth factor-beta (TGF-β). These compounds are instrumental in attracting cells that promote healing by stimulating neovascularization and cellular reproduction. The efficacy of PRP injections and appropriate clinical indications (when and where it should be used) are currently being researched and yet to be definitively determined. Initial results of clinical studies appear promising.
Methods of Injection
Tendon and tendon sheath injections are office procedures, typically performed under clean or sterile conditions. The corticosteroid of choice is often combined with a local anesthetic, the latter helping to confirm the proper location of the deposited material. Diagnostic ultrasound has been advocated to guide injections near the heel when guidance by palpation alone fails.
Immobilization of the treated structure usually is not needed following injection, although vigorous use of weight-bearing tendons (Achilles, patellar) should be avoided for 48 hours. Ice application may help when the local anesthesia fades, along with other physical medicine modalities as indicated by the particular condition present, usually starting after 48 hours.
If an initial corticosteroid injection proves useful, one or two repeat injections separated by a few weeks or more may be considered. Numerous injections over time should not be considered the sole or primary treatment.
Corticosteroid or local anesthetic injections should not be used routinely to arrive at diagnoses pertinent to the musculoskeletal system. The range of physical examination techniques used by the physician is described elsewhere and, in most cases, will suffice at pinpointing the specific cause of pain. The distinction between the conditions of subacromial bursitis and rotator cuff tendinitis can be clarified with injection, but even in this case the physical examination and subsequent rehabilitation program deservedly receive most of the attention.
In most instances, the literature supports an adjunctive, not primary, role for injections in the treatment of tendon and tendon sheath injuries. When the doctor and patient decide to proceed with injection, the control of inflammation that is obtained should be used to facilitate the prescribed rehabilitation program, rather than being the only treatment. The area of exception to this generalization is the wrist and hand (to be discussed in detail later).
Upper Extremity Injections
The literature supports the use of corticosteroid injections as a primary treatment for stenosing flexor tenosynovitis in the hand, known as trigger thumb or trigger digit. In this setting, injection has been shown to be as effective as operative release of the tendon sheath and to have fewer complications. Injection has been employed successfully into the hands of patients with diabetes mellitus and trigger digit, but the success rate may be reduced. Instillation of the material directly into the tendon sheath has no apparent benefit over subcutaneous placement. Multiple pulley rupture and flexor digitorum profundus and superficialis tendon rupture has been reported as a complication from this injection. As with other soft tissue injections, a physician treating trigger finger with instillation of corticosteroid needs to maintain expertise by performing this procedure at least several times yearly.
Stenosing tenosynovitis of the first dorsal wrist compartment also is known as de Quervain syndrome. This compartment typically transmits the tendons of both the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). However, anatomic studies have demonstrated that multiple APL slips are common, as are two subcompartments. Interestingly, although one or more injections are usually successful in treating de Quervain syndrome nonoperatively, patients requiring subsequent operative release have been found to have two subcompartments in greater than expected frequency. Trigger digit and de Quervain syndrome, therefore, are usually treated successfully nonoperatively, and corticosteroid injection is the primary component of the management ( Fig. 12-4 ).
1: Examination of the Hand and Wrist
The human hand consists of a broad palm with five digits, attached to the forearm at the wrist joint. The five digits include the thumb and the four fingers, namely the index (IF), long (LF), ring (RF), and small finger (SF) (Fig. 1-1). The long and small fingers are often called the middle and little fingers, respectively. We believe that the term long finger is more appropriate to avoid the ambiguity as to what constitutes the middle finger. The use of little finger and long finger confuses their acronyms (LF) hence, small finger is preferred.
The hand has two surfaces—dorsal and palmar. The use of the term palmar should be restricted to the area limited by the glabrous skin, and the term volar should be used for areas proximal to it (see Fig. 1-1). Radial is used to describe direction toward the thumb and ulnar to describe direction toward the small finger, rather than lateral and medial (see Fig. 1-1). The palm has two eminences: the thenar eminence, which contains the intrinsic muscles of the thumb and the hypothenar eminence, which contains the intrinsic muscles of the small finger (see Fig. 1-1). The connotation of the word intrinsic is to describe muscles that originate and insert in the hand, whereas extrinsic indicates muscles that originate outside the hand, such as the extrinsic finger flexors. The three well-defined creases of the hand are the thenar crease (forms the boundary of the thenar eminence), the proximal and distal palmar creases, and the distal wrist crease (forms the boundary of the glabrous skin) (see Fig. 1-1).
There are eight carpal bones arranged in roughly two rows. From radial to ulnar, the proximal row has the scaphoid, lunate, triquetrum, and pisiform, and the distal row has the trapezium, trapezoid, capitate, and hamate (Fig. 1-3). The bones of the distal row form the CMC joint with the base of the metacarpals and the midcarpal joint with the carpal bones of the proximal row. The proximal row articulates with the radius and the ulna. The palpable bony landmarks of the hand and wrist and their relation to the surrounding structures are depicted in Figure 1-4. The correct terminology to use when describing motion at the different joints of the hand is illustrated in Figure 1-5.