The most common disorders of the hand associated with carpal tunnel syndrome in adults

Carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies caused by chronic compression of the median nerve in the area of the carpal tunnel and its etiology is multifactorial. Trigger fingers and de Quervain’s disease are common disorders of the hand related to CTS in adults.Theaim of this study was to present the most common disorders of the hand such as stenosing tenosynovitis in adults with surgically treated CTS and to evaluate their demographic data.Material and methods: A total of 116 surgically treated patients with established diagnosis of CTS (clinically and by electrophysiological examination) were included in this prospective study, which was conducted at the University Clinic for Orthopedic Diseases in Skopje. Demographic data, findings of history of the disease and clinical examination were recorded and analyzed.Results: Participants with CTS included in the study were with a mean age of 55.41±10.7 years (age range 29-75). 75% of them were female. 63.8% of participants suffered from one or more comorbid chronic diseases. On admission to hospital, disorders such as trigger fingers and de Quervain’s disease were concomitantly diagnosed in 15.51% on ipsilateral hand with CTS. All disorders were surgically treated following open carpal tunnel release, as “one stage procedure”, under local anesthesia.Conclusion: Our findings have determined concomitant existence of CTS and stenosing tenosynovitis (trigger fingers and de Quervain’s disease) on ipsilateral hand, which suggests common etiological factors. Female gender and age range 40-60 years are major common factors related to these three disorders.

Features of minimally invasive ligamentotomy of the thumb A1 pulley (our experience)

Objective. Stenosing tenosynovitis (Nott’s disease, "trigger finger") is one of the most common pathologies of the hand which hand surgeons and orthopedic surgeons have to deal with. A variety of conservative methods are used to treat “trigger finger", including individual splinting and corticosteroid injections. Surgical treatment consists of dissection of the A1 pulley. Traditionally, the operation starts with a small incision. However, in recent years, a number of articles have appeared that report that percutaneous ligamentotomy on II-V fingers is a safe and effective alternative to an open surgery. Due to anatomical features, some authors do not recommend performing a percutaneous ligamentotomy on the thumb, fearing the damage it can cause to the digital nerves.The purpose of this research is to show that the minimally invasive needle ligamentotomy of the thumb A1 pulley is a safe procedure and to conduct the approbation of the offered method.Material and methods. The research consisted of two parts - anatomical and clinical. In the anatomical part of the research (8 upper extremities of 4 unfixed corpses), we proposed the safe accesses in order to conduct percutaneous ligamentotomy of the thumb A1 pulley.In the clinical part of the study we tested a minimally invasive ligamentotomy and analysed the results of treatment in 109 patients with stenosing tenosynovitis of the thumb II-IV stage by Green aged from 28 to 80. All patients received minimally invasive ligamentotomy of the A1 pulley with 18g needle under local anaesthesia (120 surgeries). Average length of the operation was several minutes. All procedures were performed outpatiently. Evaluation of the results of treatment was performed using the Visual Analog Scale (VAS) and Gilberts questionnaire. The observation period was from 12 months up to 24 months.The results. In most cases both clinical and esthetical results were excellent. It was possible to eliminate the “trigger” of the finger intraoperatively for all patients. However, 6 (5.5%) patients complained about the presence of residual clicks due to incomplete dissection of the ligament at the control examination a week later. Percutaneous ligamentotomy was conducted again on all patients with successful outcomes. No recurrence of the disease was noted. 17% of patients tend to complain about pain in the A1 pulley localization during the first week after the operation.Conclusion. The empirical findings prove the efficiency and safety of percutaneous ligamentotomy of the thumb A1 pulley. One of the merits of this technique is a lower risk of postoperative complications and lower treatment expenses. This technique can be successfully used in the practice of hand surgeons in the outpatient setting that have the experience with the conduction of open operations.

The Management of Trigger Finger: A 5-Year Retrospective Review

Stenosing tenosynovitis, generally known as Trigger Finger (TF), is a common hand disorder characterized by pain and locking of the affected digit, which is often found on the dominant hand [1- 3]. This locking occurs when swelling or thickening of the flexor tendon restricts its ability to glide through the A1 pulley during flexion or extension [4, 5]. The general population has a two percent lifetime risk of developing trigger finger, with an average age of onset of 50 years [6, 7]. Women are affected up to six times more than men and diabetics have an increased risk of 10% [8, 9]. Although all digits are susceptible, evidence has shown the ring finger and thumb to be the most affected [10].

Snapping thumb: a rare case of stenosing tenosynovitis of the extensor pollicis longus tendon

Tenosynovitis of the extensor pollicis longus (EPL) is rarely reported in patients without rheumatoid arthritis but may lead to thumb snapping as a consequence of EPL stenosing tenosynovitis.This case presents painful thumb snapping that developed after a wrist trauma and repetitive loading. Ultrasound and MRI were used as diagnostic tools, before surgical release of the EPL in the third extensor compartment was performed. Neither EPL tenosynovitis nor thumb snapping were found at follow-up.

Posterior Ankle Arthroscopy for Flexor Hallucis Longus Entrapment: A Case Report

Introduction: Stenosing tenosynovitis is a chronic disorder frequently observed in finger triggering of a digit. Regarding the toes, although entrapment of the flexor hallucis longus (FHL) has already been reported in a few cases among sports players, the clinical condition is uncommon. Besides, the case without any specific causes is particularly rare. Case Report: We report the case of a 26-year-old male with FHL entrapment. Even though he was unaware of any cause, he felt tenderness on the posteromedial side of his left ankle, and his great toe was locked in the flex position. Magnetic resonance imaging indicated effusion in the tendon sheath of the FHL and the possibility of a partial tear of the FHL. We hypothesized that the scar tissue secondary to the partial tear of the FHL may have been irritated at the retrotalar pulley below the sustentaculum tali, where the FHL glides. Therefore, posterior ankle arthroscopy was performed for the treatment of the FHL entrapment. Conclusion: Orthopedic surgeons should list this pathology as a differential diagnosis of posterior ankle pain, even in non-athletes. Keywords: ankle arthroscopy, flexor hallucis longus, stenosing tenosynovitis.

A case of bilateral “double/multiple crush” entrapment syndrome of the upper limbs in a violinist

Entrapment syndromes of the upper limb are common neuro-muscular-skeletal pathology in musician instrumentists. From this group of morbid entities, the most prevalent worldwide is carpal tunnel syndrome closely followed by the cubital tunnel syndrome and de Quervain stenosing tenosynovitis. Due to their distinctive etiopathogenic correlation with exposure to specific occupational factors linked to instrument interpretation and professional environment, these diseases raise a medical challenge and constitute a socioeconomic and professional burden with legal branchings and implications for individuals and society. These syndromes develop isolated or more often in various associations with each other in a clinical pattern that has been described under the model of “double crush” syndrome by Upton and McComas. From its inception in 1973 until the present time, this clinical model has been a point of interesting debate between various specialists worldwide. This model underlines an already lesioned neuron’s susceptibility and vulnerability for further neural damage at a different level from the initial lesion. The sophisticated clinical presentation of this “double or multiple crush” syndrome is due not only to overlapping symptomatology from each contributing neuro-muscular-skeletal pathology or lesional site but also to other local or systemic conditions such as trauma, diabetes, osteoarthritis, thyroid disease, obesity, etc. The occupational factors such as repetitive movements, strain and overload, vibrations, ergonomics, and others all contribute to the creation and progression of the morbid process. We cannot overstate the implications of understanding these complex relations and interdependencies between the factors mentioned above as they are essential not only for the diagnosis of these neuropathies but also for the treatment, rehabilitation, and occupational reinsertion of the patients. The studies support the fact that both lesional sites need to be medically addressed for an optimal outcome and resolution. We present the case of a female violinist with bilateral multiple neuro-muscular-skeletal pathologies of the upper limb treated previously invasively and conservatively over several years by various specialists without a satisfactory clinical resolution of the symptomatology or any professional and legal measures taken.