Modified needle knife supplemented with manipulation for the treatment of stenosing tenosynovitis of the thumb has the advantages of simple and safe operation, low chance of bleeding and infection, small incision, no need for sutures, and definite efficacy, etc. It is a recommended method.
Stenosing tenosynovitis of the thumb is a common clinical condition in hand surgery, mostly seen in manual workers, also known clinically as “popping finger” or “trigger finger”. The main cause is frequent flexion and extension of the thumb, frequent friction between the flexor tendon and tendon sheath of the thumb, resulting in congestion and edema, thickening of the flexor tendon, which reduces the space for the flexor tendon to move, and gradually turning the flexor tendon into a gourd shape with a thin middle and thick sides, resulting in a popping sound. The main manifestation of the disease is a painful nodule on the palmar side of the metacarpophalangeal joint of the thumb and limited flexion and extension of the thumb, which brings a lot of inconvenience to life and work. For the treatment of this disease, in the past, the use of massage, topical drugs and local closure and other treatment means, the treatment course is long and easy to recur; needle knife is a very effective means of treatment of the disease; but many clinicians currently homemade knives for surgical treatment, such as hook knife, various types of push cutter but have such and such defects, the operation is difficult to form a unified standard. Some patients are treated by surgical incision, resection of the tendon sheath slide, and release of the narrow tendon sheath, but surgical treatment is more traumatic and prone to postoperative adhesions, which affects the efficacy and can easily lead to nerve injury during the operation. It is reported as follows.
1. Data and methods
1.1 Clinical data
All 80 cases were outpatients of our department, including 18 men and 62 women; age ranged from 36 to 65 years old; 13 cases were bilateral, 26 cases were left side and 41 cases were right side; the shortest duration of the disease was 2 months and the longest was 4 years. The clinical manifestations were pain, pressure pain and nodules at the metacarpophalangeal joint. Among them, there were 42 cases with flexion-extension popping and 28 cases with atresia. Forty-nine cases had received physiotherapy, closed therapy and oral medication in the past. All patients met the diagnostic criteria for stenosing tenosynovitis established by the State Administration of Traditional Chinese Medicine.
Sun Kang classified stenosing tenosynovitis according to its degree of severity as I.: limited pain on the palmar side of the metacarpophalangeal joint with pressure pain, but no popping sound and normal active flexion and extension activities. ii.: popping sound during flexion and extension of the affected finger, but diminished or disappeared after activity, and active flexion and extension activities could be completed. iii.: frequent popping sound during flexion and extension of the affected finger or reproduction of strangulation, and active flexion and extension activities were significantly limited. In this group, there were 54 cases of II. patients, accounting for 67.5%; 26 cases of Ill. patients, accounting for 32.5%.
1.2 Diagnostic criteria of “popping finger” patients, when the affected finger is bent, it suddenly stays in the semi-bending angle state, and if the finger is flexed with force, the affected finger can feel the phenomenon of sudden skipping after being blocked; the beating of the tendon can be palpated at the metacarpophalangeal side of the affected finger, and when the flexion and extension movements are completed, it is accompanied by the popping sound of the finger; in the late stage of the disease, due to If the tendon swelling is serious and the tendon sheath is hypertrophic, the active extension of the affected finger is inconvenient, and there can be obvious pressure points at the affected area of atresia.
1.3 Contraindications All episodes of serious visceral disease; those with hemophilia or other bleeding tendencies; those with particularly high or low blood pressure; diabetics; those with extreme physical weakness or extreme emotional stress without cooperation; those with local skin infection, muscle necrosis or deep abscesses.
1.4 Treatment method: Preoperatively, explain in detail with the patient the possible intraoperative and postoperative conditions and the corresponding treatment methods; explain the intraoperative operation method, the postoperative pain in the operated area and the importance of functional exercise. If the push cutter treatment is ineffective, open surgery may be used to treat the patient, and if infection occurs, it will be treated separately. Obtain the patient’s consent and sign the surgical consent form before proceeding. Confirm that there is no active infection in the operative area and that the patient has no acute cardiovascular or cerebrovascular disorders.
Operation steps of the one-incision method.
1. incision selection: the total length of the thumb tendon sheath slide is about 11 mm. the proximal end of the slide is 6 mm from the distal edge of the greater interosseous muscle, and the loop of the slide wraps around the tendon with a thickness of about 0.2 mm. the incision is selected in the longitudinal centerline of the thumb flexor tendon, 10 mm from the proximal end of the greater interosseous muscle, and the longitudinal incision is 2 mm long.
2 The patient was placed in a supine position with the affected limb abducted, palm up, five fingers separated, and placed on the operating table with a soft pillow at the wrist. The patient was asked to flex and extend the affected finger several times, and the operator reconfirmed the most obvious pressure point of the metacarpophalangeal joint of the affected finger and the subcutaneous hard nodes embedded in it, and there was a bouncing sensation under the hand, that is, the thickened tendon passed through the stenosis, and the bouncing was located at the distal end of the incision. Mark with a Maker pen. Routinely disinfect, spread the towel and wear sterile gloves. Take a 5ml syringe with 2% lidocaine about 1.5ml, saline 2.5ml in the localization point puncture to do local anesthesia, after anesthesia passive movement of the affected finger, if the affected finger has been adhesion without popping, to restore the popping, the nodal position will be placed in the distal end of the narrow tendon sheath after using a sterile surgical tip blade in the direction of the tendon travel to make a 2-3mm incision at the incision point, the operator’s left hand holds sterile gauze, swabbing the bleeding after The surgeon’s left hand holds sterile gauze, after wiping the bleeding, the right hand holds the push cutter, from the incision and skin at an angle of 3O degrees stabbing, followed by a feeling of falling, this part indicates that the needle knife has reached the subcutaneous tissue. Continue to stab people needle knife, so that the ventral side of the push cutter against the palmar side of the tendon slide, rather than stabbing into the tendon, the direction can not deviate from the longitudinal middle line of the finger flexor tendon, to avoid nerve damage. This site indicates that the needle knife has reached the superficial layer of the tendon sheath. Keep this direction to the distal end of the test, can push the cutter blunt head into the narrow carriage after feeling a sense of resistance under the hand, keep the position of the push cutter, gently and forcefully to the distal end of the push test, can feel a sense of elasticity under the hand, lightly push the loose force can feel the push cutter is bounced back by the carriage. At this time, it can be determined that the push cutter is stuck on the narrow carriage against the finger flexor tendon, along the direction of tendon alignment from the proximal to the distal end is still close to the tendon to keep sliding to cut open the thickened tendon sheath tissue, at this time can be heard to cut the tendon sheath “chatter” sound, the operator’s hand has a clear sense of resistance to cut the tough tissue, can feel the cut length of about 10mm. After cutting until the resistance disappears, the patient is asked to flex and extend the affected finger, and there is no restriction of movement or popping sound, then the needle knife is withdrawn. The wound length is about 2-3 mm and no suture is needed. Intraoperative bleeding is less than 5 ml, and local sterile gauze is applied with pressure. The specific operation steps can be summarized as, one probe, two trial, three push cut. First, probe whether the ventral side of the push-cutting knife is close to the tendon; second, try whether the blade of the push-cutting knife is stuck in the narrow carriage; third, push the cut longitudinally along the center line of the tendon toward the distal end.
1.5 Postoperative treatment and follow-up: After the operation, the patient was instructed to press the wound by himself for 1O minutes, and the operator assisted the patient to complete the hyperextension and extreme flexion of the affected finger several times, and the patient was instructed to adhere to the daily flexion and extension exercises of the affected finger. The patient was informed that there would be obvious pain after the anesthesia wore off, and that he could take oral anti-inflammatory and pain-relieving drugs and continue to exercise. On the first day after surgery, the wound was changed and the thin dressing was replaced to facilitate the functional exercise of the patient. The wound should not be washed for 5 days. The third and seventh postoperative days were reviewed at the outpatient clinic to observe whether the wound recovery and functional exercise were satisfactory, and the patient should not engage in the original disease-causing work for 1 month. Among them, 76 cases were followed up for more than 15 days, in line with the diagnostic efficacy criteria for TCM diseases established by the State Administration of Traditional Chinese Medicine
2.Efficacy standards
According to the unified standard set by the State Administration of Traditional Chinese Medicine, the affected finger was cured if there was no swelling and pain on the palm side, no pressure pain, and normal movement of independent extension and flexion, without popping sound and strangulation; the affected finger was cured if the local swelling and pain was reduced, and the affected finger had slight pain when moving, or slight popping sound, but no strangulation; the affected finger was improved if there was no improvement in clinical symptoms; the affected finger was invalid if there was no improvement in clinical symptoms.
3.Results
The postoperative incisions were all healed at stage I. There were no complications such as infection and finger nerve injury; the operation time was 5-8 minutes; the intraoperative bleeding was less than 5 ml. 76 cases were followed up for an average of 15 days, and 2 cases were lost. 2 cases refused functional exercise after the operation because they could not tolerate the pain, resulting in significant limitation of finger flexion and extension. 72 cases were cured, 4 cases were improved, 2 cases were not cured, 2 cases were lost, the total effective rate was 95%.
4. Discussion
4.1 Anatomy of the flexor tendon sheath of the thumb. The tendon sheath of the thumb consists of the synovial sheath that surrounds the tendon and the fibrous sheath that is wrapped around the synovial sheath. The synovial sheath of the tendon of the thumb is a double-layered cylinder, with the inner layer adhering to the surface of the tendon and the outer layer adhering to the inner surface of the fibrous sheath, with a small amount of synovial fluid in the cavity between the two layers to reduce the friction of the tendon during movement, and a double-layered membranous tether formed at the palmar surface of the finger bone, where the inner and outer layers of the synovial sheath migrate from each other, with the blood vessels supplying the tendon passing through, and a tubular tendon fibrous sheath formed at the periphery of the synovial sheath by the thickening of the deep fascia, with the fibrous sheath attached At the periphery of the tendon synovial sheath, the deep fascia thickens to form a tubular tendon fibrous sheath, and the fibrous sheath is attached to the periosteum of the finger bone and the sides of the joint capsule of the finger, forming a bony fibrous canal to restrain the tendon synovial sheath.
4.2 Etiology of stenosing tenosynovitis of the flexor tendon of the thumb. Thumb flexor tendon stenosis tendinitis, the onset of the site in the beginning of the finger flexor tendon fiber sheath tube, where the thicker ring-shaped fibers and palm bone constitute a relatively narrow fiber bone tube, the finger flexor tendon through mechanical stimulation, and increased friction, coupled with the palm bone bulge, easy to form a ring-shaped stenosis, the occurrence of tendon and muscle sheath injury inflammation, easy to form nodules over time. Qi and blood stagnation, blood does not glory tendon, the affected finger discomfort, inconvenience, morning stiffness. Due to inflammatory edema, exudation, soft tissue hyperplasia, adhesions, etc., the surrounding nerves are stimulated, causing muscle vascular spasm, ischemia and hypoxia of the lesioned tissue, and an increase in pain-causing substances, resulting in persistent pain in the affected finger in the lesioned area. The disease is caused by the formation of a pike or gourd shaped enlargement and difficulty in passing.
4.3 Treatment of stenosing tenosynovitis of the flexor tendon of the thumb The treatment of stenosing tenosynovitis of the flexor tendon of the thumb can mostly be relieved by non-surgical treatment, and surgical treatment is feasible when non-surgical treatment is ineffective or recurrent.
The thumb stenosing tenosynovitis is treated by cutting through the thickened annular ligament (tendon sheath slide) at the metacarpophalangeal joint of the affected finger to make the narrow bony fiber canal spacious and allow the flexor tendon and its tendon sheath to flex and extend freely.
Since the push cutter is performed under relatively “blind” vision, there is a risk of undesirable complications if one is unfamiliar with the relevant anatomy and does not perform the procedure properly. In the literature, it has been reported that needle knife treatment may result in serious complications such as flexor tendon rupture, severe postoperative tendon adhesions, recurrence of dirty sheath infection and peripheral nerve damage, and infection. For example, five patients who developed injuries after acupuncture treatment were reported to have been found to have ruptured the long flexor thumb tendon during surgical exploration; three cases had loss of sensation on one side of the thumb, and finger nerve injury was found during exploration.
The following points should be noted during clinical treatment (1) strict aseptic operation to prevent local infection and septicemia; (2) familiarity with anatomical levels and accurate positioning to avoid injury to the flexor tendon, nerves and blood vessels; (3) the knife blade must be sharp and the cut must be thorough to completely cut the narrow tendon sheath so that the affected finger can move freely without obstruction; (4) early postoperative functional exercise to prevent adhesions. Manual treatment should be gentle and appropriate. (5) Postoperative pressure bandaging to reduce bleeding.
In conclusion, the push-cut knife one-stroke method for the treatment of thumb stenosing tenosynovitis has the advantages of simple operation, safety, reproducibility with standardization, less chance of bleeding and infection, small incision, no sutures, and exact efficacy, which is a recommended method.