Flexor tendon tenosynovitis. Flexor tendon tenosynovitis is a chronic aseptic inflammatory change in the tendon sheath of the flexor tendon of the finger caused by mechanical friction, also known as “snapping finger” and “trigger finger”. The disease can occur at different ages, mostly in women and manual workers, and is more common in the thumb, middle finger, and ring finger, and in a few patients, multiple fingers can develop simultaneously. Stenosing tenosynovitis is also common in children due to congenital causes.
I. Diagnosis
1.Diagnostic points
(1) Medical history
There is a history of hand strain. Most often seen in women and manual workers, most often in the thumb, middle finger and ring finger.
(2) Symptoms and signs
The disease starts slowly, with limited pain on the palmar side of the metacarpophalangeal joint in the early stage, aggravated in the morning or after work exertion, or after using cold water, and relieved after activity or hot compress, with slightly restricted activity, then the pain may spread to the distal side of the wrist and fingers. With the development of tendon sheath stenosis and tendon degeneration and thickening, tendon sliding becomes more and more difficult, the palmar side of the metacarpophalangeal joint is painful, and hard nodules can be found, and the nodules can be felt to slide and bounce when the finger is flexed and extended, producing trigger-like movements and popping. There may be acute attacks, and in severe cases, the fingers cannot be actively flexed or interlocked in the flexed position and cannot be straightened.
(3) Imaging
X-ray orthopantomographs can clarify the location, nature and ligament-bone tunnel of tendinitis of the finger flexor tendon, but there is no bone or
There is no structural change of bone and bone joint.
(4) Other examinations
High-frequency ultrasonography can be used for the diagnosis of tenosynovitis.
II. Treatment
1.Treatment principles
There are many treatment methods for tenosynovitis of finger flexor tendons, and non-surgical treatment is the main one. The common methods of non-surgical treatment are manipulation, acupuncture, Chinese herbal medicine, external fixation, local injection of drugs and percutaneous release treatment such as small needle knife. Also, there is surgical incisional release treatment. The clinical choice of non-surgical or surgical treatment should be made according to the patient’s specific situation, in order to restore function.
2.Non-surgical treatment (Recommended grade: A)
(1) Manual treatment (Recommended grade: E)
The operator’s left hand holds the affected wrist, the right hand thumb in the nodal part of the action such as press and rub, horizontal push, longitudinal pluck tendons, and finally hold the end of the patient to the distal end of the rapid pull away, if the sound is better, the operation, moderate force, from light to heavy, once a day, 15-20min each time. 10 days for a course of treatment.
(2) Acupuncture treatment (Recommended grade: B)
(3) External treatment with Chinese medicine (Recommended grade: E)
(4) External fixation treatment (Recommended grade: B)
Splint external fixation method Use thermoplastic material to fix the metacarpophalangeal joint of the affected finger from the middle of the palm to the root of the affected finger, and change to a circular splint at the root of the finger, and fix it in a straight position without exceeding the proximal interphalangeal joint. After confirming that the splint is securely fixed and the affected finger is free of pressure and discomfort, fix the affected finger for as long as possible after more than 24 hours until the splinting fails.
(5) Local injection of drugs (Recommended grade: A)
①Injection method (Recommended grade: A)
Disinfect the skin around the nodule, inject 0,5~1ml of cortisol drug mixed with 1~1,5ml of 1% lidocaine in the direction of parallel tendon at the nodule, withdraw a little when the needle meets the bone, and inject the drug with immediate local distension and increased tension. Once a week, generally inject 1 to 2 times, not more than 3 times.
②Key points of technique
There is no significant difference in the efficacy, complication rate and recurrence rate of percutaneous tendon sheath internal and external injection . (Recommended grade: B ) Blind percutaneous injection is comparable to ultrasound-guided injection, but more economical . (Recommended grade: A ) Intrathecal cortisol combined with lidocaine injection has better short-term effects than lidocaine injection alone, with no significant side effects or adverse reactions (Recommended grade: B ) Tretinoin injection for trigger finger is safe and effective, with faster efficacy than dexamethasone injection. Parallel tendon direction injection (medial injection technique) is less painful than vertical injection of the metacarpal head (traditional injection technique), and there are no complications using this technique. (Recommended grade: B )
(6) Percutaneous release treatment such as small needle knife (Recommended grade: A)
(1) Small needle knife treatment (Recommended grade: A)
After satisfactory local anesthesia, use a small needle knife to pierce the nodule parallel to the direction of the tendon, and make an up-and-down prick along the direction of the tendon, do not deflect to both sides, otherwise the tendon, nerves and blood vessels can be damaged. If the ringing has disappeared and the finger activity has returned to normal, it means that the tendon sheath has been cut. If the incision is small, it can be left unsutured and wrapped with sterile gauze with pressure for 2-3 days [21-25].
②Percutaneous release
After satisfactory local anesthesia, a syringe needle or blade is used to pierce the nodule parallel to the direction of the tendon, moving in the direction of the tendon’s course without deflecting to either side, otherwise the tendon, nerves, and blood vessels may be damaged. If the ringing has disappeared and the finger activity has returned to normal, then the tendon sheath has been cut. If the incision is small, do not suture, with sterile gauze pressure bandage 2 to 3 days.
3.Surgical incision and release treatment
The surgery should be performed under a tourniquet, with the affected finger lying flat and in an external booth. After satisfactory local anesthesia, a transverse incision of about 2 cm in length is made along the distal transverse palmar line, and after cutting the skin, the subcutaneous tissues and the palmar tendon membrane are cut longitudinally. The finger nerve and finger artery of the thumb are located subcutaneously on the palmar side and are superficially located. After cutting the skin, the subcutaneous tissue is bluntly separated to reach the tendon sheath, and the skin and neurovascular vessels are gently retracted on both sides to reveal the tendon sheath. Under direct vision, a small incision was made longitudinally on the lateral side of the tendon sheath, and the thickened tendon sheath was incised longitudinally with small scissors to completely release the narrowed part of the tendon sheath. Immediately afterwards, the finger is checked for flexion and movement, and the swollen portion of the tendon is seen to slide unimpeded. A tourniquet is loosened to stop bleeding, the wound is irrigated, and the skin is closed with fine silk sutures without suturing the incised tendon sheath. After surgery, the affected limb was suspended and active activities were started the next day. The stitches should be removed 10-12 days after surgery.
4.Functional exercise
The flexion and extension activities of the fingers can be started on the same day or the next day after the treatment, and the amplitude of the activities should not be too large; gradually increase the degree and amplitude of the exercises until the normal function of the fingers is restored.