Wrist & Hand
Trigger Finger
Trigger finger is a condition that affects the tendons in your hand.
When patients flex a finger, the flexor tendon passes through a series of sheaths called annular and
cruciform pulleys.
These sheaths encapsulate the tendon, preventing it from separating from the bone when the finger
is flexed, and it also allows the tendon gliding smoothly back and forth during flexion and extension.
There are five annular pulleys (A1-A5) and three cruciform pulleys (C1-C3).
Trigger finger is caused by inflammation and narrowing of the A1 pulley of the affected digit, typically
the third or fourth.
Sometimes you can feel the flexor tendon nodule as the tendon is trapped in the tendon sheath.
Causes
▪ Trauma such as repetitive use or compression forces can cause tendon hypertrophy and
sheath narrowing that prevent the tendon from sliding smoothly in the sheath and result in a
catching or locking sensation.
▪ Trigger finger is thought to be idiopathic, although there is a correlation with repetitive use
of the affected hand as well as history of diabetes, particularly type 1 diabetes (Harvard
Women's Health Watch, 2010).
▪ Repetitive hand and wrist movements
▪ Activities that require prolonged gripping at work
▪ Likely to develop in the fifth or sixth decade of life and women are up to six times more likely
to develop trigger finger than men
Symptoms
▪ Pain & Stiffness
▪ Locking & catching when you flex and extend the finger
▪ Feel the flexor tendon nodule (A1 Pulley)
Assessment/Diagnosis
▪ Subjective & Objective Assessment
▪ Loss of motion, particularly in extension
▪ Ultrasound: Using ultrasound to measure the thickening of the affected sheath compared
with unaffected sheaths on the same hand. The degree of thickening seen on ultrasound is
correlated with symptom severity.
Treatment Pathway:
▪ Rule out Dupuytrens contracture first
▪ CSI: Directly into the inflamed tendon sheath. For many patients, a single injection provides
relief for up to 10 years. A second and occasionally third corticosteroid injection may be
given 4 to 6 months apart - The goal of the injection is to reduce the inflammation and
pressure on the tendon for better gliding through the flexor pulleys.
▪ Splinting
, ▪ Surgery: Surgery for trigger finger is done to increase the space for your flexor tendon to
move.
1. Open - They cut about a 1/2-inch incision in your palm, in line with the affected finger or
thumb. They cut the tendon sheath. The sheath can impede movement if it becomes too
thick. They then move your finger around to check that the movement is smooth.
2. Percutaneous – mostly done for the middle and ring fingers. Percutaneous means through
the skin, needle is used to break up constricting tissue around the tendon sheath. Because
no incision is made, no stitches are needed after the procedure.
Research
Ninety digits were investigated with at least a year follow up. The study mainly
focused on the efficacy of the injections, as well as co-morbidities, presence of a
nodule and actual digit injected.
There was a 34% success rate with the first injection (31/90). This rose to 63%
(57/90) with the second injection and 66% (59/90) with the third injection.
The study found that steroid injections are an effective first-line intervention for
the treatment of trigger digit.
It also found an increased efficacy for treating the thumb compared to other digits.
Both the severity of the condition at presentation and the presence of a nodule
had no significant impact on the efficacy of the injections.
Dala-Ali et al. 2012
Radial Sided Wrist Pain
De Quervain’s Tenosynovitis
Pain and inflammation of the tendons at the base of the thumb (Extensor pollicis brevis and
abductor pollicis longus tendons)
Extensor pollicis brevis - Thumb: extension
Abductor pollicis longus - Thumb: abduction
Causes
▪ The most common cause is chronic overuse.
▪ Mothers of newborns who are repeatedly lifting their baby.
▪ Repetitive gripping, grasping, or wringing.
Symptoms
▪ Radial side wrist pain, radiating up the forearm with grasping or extension of the thumb
, ▪ Pain & reduced ulnar deviation & abduction.
▪ Swelling anatomical snuff box
▪ Tender over the APL, EPB & Radial Styloid Process
Assessment/Diagnosis
▪ Subjective Assessment
▪ Finkelstein test
▪ Ax: Resisted Thumb Extension
▪ On palpation - tenderness over the base of the thumb, radial styloid process
▪ Thickening of the extensor sheaths of the first dorsal compartment
Treatment Pathway
▪ Conservative management: Splinting (Spica), Activity Modification, Ice Cube Massage, Hand
& Ulna Deviation Stretch, Isometric
▪ CSI - up to 2 attempts - if no success after 2 attempts - consider referral to hand surgeon
▪ Surgery: Open the compartment that encases the tendons to make more room for the
irritated tendons. The opening allows pressure relief of the tendons, to ultimately allow the
tendons to more freely.
Research: Surgical Treatment Outcome of de Quervain’s Disease – Bosman et al. 2022
➢ 21 studies with a total of 939 patients - Some patients underwent bilateral surgery.
➢ 12 studies reported on pain reduction and residual pain. The surgical release of the first
extensor compartment resulted in a significant reduction of pain (95%) but also has a
substantial complication rate of 11%.
➢ However, 5% of the patients still experienced pain at follow-up.
➢ A total of 160 complications were reported in the studies (superficial radial nerve injuries,
vein injuries, subluxations, scar problems, and residual pain).
➢ No difference in outcome between different types of surgery or incisions was seen.
Central Wrist Pain
Carpal Tunnel Syndrome (CTS)
CTS is a neuropathy caused by compression/pressure on the median
nerve which travels through the carpal tunnel.
Carpal tunnel pressure is 3-7mmHg but with CTS it is >30mmHg.
The median nerve is the most common accounting for 90% of
all neuropathies.
Causes
▪ Genetics
▪ Repetitive Wrist Movements (e.g. typing)
▪ RA
▪ Pregnancy (Having more fluid in the body during pregnancy and this then results in a build-
up of pressure on the nerves)
Symptoms
▪ Pain, numbness, and paraesthesia into hands and fingers (median nerve distribution)
▪ Reduced sensation
Trigger Finger
Trigger finger is a condition that affects the tendons in your hand.
When patients flex a finger, the flexor tendon passes through a series of sheaths called annular and
cruciform pulleys.
These sheaths encapsulate the tendon, preventing it from separating from the bone when the finger
is flexed, and it also allows the tendon gliding smoothly back and forth during flexion and extension.
There are five annular pulleys (A1-A5) and three cruciform pulleys (C1-C3).
Trigger finger is caused by inflammation and narrowing of the A1 pulley of the affected digit, typically
the third or fourth.
Sometimes you can feel the flexor tendon nodule as the tendon is trapped in the tendon sheath.
Causes
▪ Trauma such as repetitive use or compression forces can cause tendon hypertrophy and
sheath narrowing that prevent the tendon from sliding smoothly in the sheath and result in a
catching or locking sensation.
▪ Trigger finger is thought to be idiopathic, although there is a correlation with repetitive use
of the affected hand as well as history of diabetes, particularly type 1 diabetes (Harvard
Women's Health Watch, 2010).
▪ Repetitive hand and wrist movements
▪ Activities that require prolonged gripping at work
▪ Likely to develop in the fifth or sixth decade of life and women are up to six times more likely
to develop trigger finger than men
Symptoms
▪ Pain & Stiffness
▪ Locking & catching when you flex and extend the finger
▪ Feel the flexor tendon nodule (A1 Pulley)
Assessment/Diagnosis
▪ Subjective & Objective Assessment
▪ Loss of motion, particularly in extension
▪ Ultrasound: Using ultrasound to measure the thickening of the affected sheath compared
with unaffected sheaths on the same hand. The degree of thickening seen on ultrasound is
correlated with symptom severity.
Treatment Pathway:
▪ Rule out Dupuytrens contracture first
▪ CSI: Directly into the inflamed tendon sheath. For many patients, a single injection provides
relief for up to 10 years. A second and occasionally third corticosteroid injection may be
given 4 to 6 months apart - The goal of the injection is to reduce the inflammation and
pressure on the tendon for better gliding through the flexor pulleys.
▪ Splinting
, ▪ Surgery: Surgery for trigger finger is done to increase the space for your flexor tendon to
move.
1. Open - They cut about a 1/2-inch incision in your palm, in line with the affected finger or
thumb. They cut the tendon sheath. The sheath can impede movement if it becomes too
thick. They then move your finger around to check that the movement is smooth.
2. Percutaneous – mostly done for the middle and ring fingers. Percutaneous means through
the skin, needle is used to break up constricting tissue around the tendon sheath. Because
no incision is made, no stitches are needed after the procedure.
Research
Ninety digits were investigated with at least a year follow up. The study mainly
focused on the efficacy of the injections, as well as co-morbidities, presence of a
nodule and actual digit injected.
There was a 34% success rate with the first injection (31/90). This rose to 63%
(57/90) with the second injection and 66% (59/90) with the third injection.
The study found that steroid injections are an effective first-line intervention for
the treatment of trigger digit.
It also found an increased efficacy for treating the thumb compared to other digits.
Both the severity of the condition at presentation and the presence of a nodule
had no significant impact on the efficacy of the injections.
Dala-Ali et al. 2012
Radial Sided Wrist Pain
De Quervain’s Tenosynovitis
Pain and inflammation of the tendons at the base of the thumb (Extensor pollicis brevis and
abductor pollicis longus tendons)
Extensor pollicis brevis - Thumb: extension
Abductor pollicis longus - Thumb: abduction
Causes
▪ The most common cause is chronic overuse.
▪ Mothers of newborns who are repeatedly lifting their baby.
▪ Repetitive gripping, grasping, or wringing.
Symptoms
▪ Radial side wrist pain, radiating up the forearm with grasping or extension of the thumb
, ▪ Pain & reduced ulnar deviation & abduction.
▪ Swelling anatomical snuff box
▪ Tender over the APL, EPB & Radial Styloid Process
Assessment/Diagnosis
▪ Subjective Assessment
▪ Finkelstein test
▪ Ax: Resisted Thumb Extension
▪ On palpation - tenderness over the base of the thumb, radial styloid process
▪ Thickening of the extensor sheaths of the first dorsal compartment
Treatment Pathway
▪ Conservative management: Splinting (Spica), Activity Modification, Ice Cube Massage, Hand
& Ulna Deviation Stretch, Isometric
▪ CSI - up to 2 attempts - if no success after 2 attempts - consider referral to hand surgeon
▪ Surgery: Open the compartment that encases the tendons to make more room for the
irritated tendons. The opening allows pressure relief of the tendons, to ultimately allow the
tendons to more freely.
Research: Surgical Treatment Outcome of de Quervain’s Disease – Bosman et al. 2022
➢ 21 studies with a total of 939 patients - Some patients underwent bilateral surgery.
➢ 12 studies reported on pain reduction and residual pain. The surgical release of the first
extensor compartment resulted in a significant reduction of pain (95%) but also has a
substantial complication rate of 11%.
➢ However, 5% of the patients still experienced pain at follow-up.
➢ A total of 160 complications were reported in the studies (superficial radial nerve injuries,
vein injuries, subluxations, scar problems, and residual pain).
➢ No difference in outcome between different types of surgery or incisions was seen.
Central Wrist Pain
Carpal Tunnel Syndrome (CTS)
CTS is a neuropathy caused by compression/pressure on the median
nerve which travels through the carpal tunnel.
Carpal tunnel pressure is 3-7mmHg but with CTS it is >30mmHg.
The median nerve is the most common accounting for 90% of
all neuropathies.
Causes
▪ Genetics
▪ Repetitive Wrist Movements (e.g. typing)
▪ RA
▪ Pregnancy (Having more fluid in the body during pregnancy and this then results in a build-
up of pressure on the nerves)
Symptoms
▪ Pain, numbness, and paraesthesia into hands and fingers (median nerve distribution)
▪ Reduced sensation
