Trigger finger
Inflammation of the tendon sheath prevents you from extending your finger easily. Symptoms of a trigger finger are: Difficult to extend the finger, painful thickening in the palm or at the base of the thumb, and a finger that is as if it were ‘locked’.
Triggerfinger also called tenosynovitis stenosis or hock finger is a common condition. You have a trigger finger if the finger can only be stretched with difficulty and then straightens with a jerk. Sometimes there is a painful bulge in the palm or at the base of the thumb. Triggerfinger is a swelling due to inflammation in one of the flexor tendons of the fingers. Trigger finger occurs mainly in women in the age category of 45 to 65 years. The most commonly affected fingers are the ring finger and thumb. The index finger and little finger are rarely affected. Trigger finger often occurs in combination with Carpal Tunnel Syndrome (CTS) and vice versa.
Cause
Before the trigger finger symptoms, there has always been inflammation of the tendon sheath. As a result, the flexor tendon can no longer move smoothly, so you cannot easily stretch your finger.
Usually, there exists a swelling of the tendon far from the tendon sheath, the imbalance between the size of the tendon and the volume of the tendon sheath (fibro-osseous tunnel) prevents the tendon from sliding smoothly. This creates the so-called ‘triggering’. The tendon hangs, making bending and stretching difficult. In severe cases, the finger is in a flexed position and extension is only possible passively.
A trigger finger can arise after strenuous exercise, but in many cases, the cause cannot be determined. It is often the case that you do not report to the clinic at the time of the inflammation. By sparing the finger, the inflammation has often calmed down and you have a relatively painless trigger finger. In some cases, the inflammation and mechanical ‘triggering’ are so intense that your finger is in a fixed flexion position. It is also established that a trigger finger is more common in people with rheumatism and diabetes (diabetes).
Diagnosis
The diagnosis is made based on the consultation and the physical examination. There is talk of ‘locking’ the finger. When you are asked to open and close the hand, this is not possible. The easy and painless movement of the affected finger precludes the presence of a trigger finger. The doctor also feels the flexor tendons and looks for pain and swelling.
The pain may be exacerbated by stretching the tendon in extension or with isometric bending. There may also be snapping or sticking of the finger. This depends on the time of day and how long the symptoms have been present.
Therapy
Trigger fingers can be treated in several ways. We always choose the least intrusive way. If it turns out that the Triggerfinger is related to a certain action, then the action will be avoided. Anti-inflammatories or a splint can also offer a solution. However, if the complaints persist for more than six months, a splint is not sufficient to make the complaints disappear.
The most commonly used treatment method is an injection of a long-acting corticosteroid. This happens immediately at the first clinic visit. This injection is somewhat sensitive, but you usually get rid of the complaints within a few days.
Injection into the affected tendon sheath provides long-term healing in 60 to 92% after a maximum of three injections. Betamethasone sodium phosphate is the most commonly used injection as it is water-soluble and leaves no residue in the tendon sheath.
If an injection does not help or is insufficient, the band of the tendon sheath can be surgically cut. This procedure is only necessary in 10% of cases. If you have diabetes or diabetes, the chance of recovery is less great after an injection. For that reason, in some cases, an operation can be chosen earlier. In general, the results of surgery are excellent.
Risks
If you have diabetes, you should check your sugar level more often after the injection. There is a minimal risk of infection after an injection.
Recovery
The effect after injection can be felt after a few days, but it takes about six weeks before the maximum result is reached.
After surgery, you will be given a bandage that you can remove after three days. In the meantime, you can use your hand as far as it goes. The hand should be kept as high as possible during this period. After removing the bandage, the wound may become wet, but not soak. You can then put a plaster on it. The stitches are removed after ten to fourteen days. If at that moment it appears that the recovery is lagging, hand therapy is started.
Hand therapy
OrthoDirect works closely with hand therapy partners. That is a great advantage because an operation alone is not enough. After that, a period of intensive therapy is sometimes necessary to be able to use your hand or wrist properly again. Our tailor-made and specialist aftercare benefits your recovery.
Hand therapy is a relatively young profession; special training for hand therapists has only been in place for a few years now. The hand therapists OrthoDirect works with already have a lot of experience in this field. They work very closely with hand surgeons and continue to develop professionally through regular refresher courses at home and abroad. Hand therapists use modern research and treatment equipment and work according to the most recent insights. Thanks to a targeted approach and specific knowledge, you will receive optimal treatment and guidance. This way we make your recovery time as short as possible and we strive for the best possible result.
Practice is important!
Depending on the severity of the condition, the duration of hand therapy may also vary. It may be that you can move forward with an overloaded wrist after three treatments and the right advice. But after surgery for extensive injuries, the follow-up treatment can sometimes take up to a year. Whether the therapy is long or short: it is very important that you carefully follow the prescribed exercises and advice! The frequency of treatment is sometimes very high, especially in the first weeks after surgery. Because it is during that period that the most profit can be made. The hand therapists go for an efficient and optimal approach, but your motivation to work at home on your recovery is just as important!
Dupuytren
In this disease, the multiplication of connective tissue under the skin causes strands and nodules. Symptoms of Dupuytren’s disease are: the curvature of the finger due to an increase in connective tissue, hard lumps in the palm, and decreased sensation in the fingers.
Cause
Genetic predisposition plays a role in Dupuytren’s disease. In a quarter of the cases, there is a member in the family with the same condition. It is much more common in men than women and usually starts in middle age (40+), although in some cases it can occur much younger. Because Dupuytren’s disease always comes back, you may need treatment several times in your life.
Therapy
Three treatments are possible:
- Needle fasciotomy
If you have a cord in your palm that does not have a twisted finger (PIP joint), you may be a candidate for a needle fasciotomy. This is a simple treatment under local anesthetic. With a needle or a knife, the strand is cut through a small opening of a few millimeters in the palm. With inexperienced hands, this is no more dangerous than open surgery. It works less for a long time than the normal extensive surgery but is also a lot less stressful. Usually, your hand is fully recovered within a few days.
- Partial fasciectomy
In this operation, the strands are removed as extensively as possible, so that the fingers can be stretched again. For this, a zigzag incision is made over the fingers and hand.
- Dermo fasciectomy
If you have had surgery for Dupuytren before, it is sometimes necessary to remove not only the strands but also the associated skin. A piece of donor skin from, for example, your forearm is placed over the wound in your hand. In reoperations, it takes longer for the disease to return to that site if a skin graft is performed.
Risks
Complications can occur with any operation, such as bleeding, wound infection, tissue necrosis, anesthesia problems, thrombosis, or pneumonia. These complications are rare and can almost always be treated well.
During a hand operation, the sensory nerves of the fingers can be damaged and cause a partial sensory disturbance. Dystrophy is a very rare complication that causes pain, swelling, discoloration, and stiffness of the fingers. To prevent functional disorders, this abnormality must be treated in time.
Recovery
It is wise to keep the hand high for the first few days in a sling or on a pillow. This prevents swelling of the hand as much as possible.
When you can go back to work depends on the work you are doing and the wound healing. The doctor will discuss this with you.
Usually, the follow-up treatment will be combined with physiotherapy and/or occupational therapy (splinting).
Carpal tunnel syndrome
Carpal Tunnel Syndrome (CTS) is caused by compression of the metacarpal nerve in the wrist. Symptoms of Carpal Tunnel Syndrome are stinging and painful feeling in the palm and fingers, swollen, thick feeling in the hand, radiating pain to the forearm, elbow, and shoulders, and reduction in hand strength.
Symptoms
With CTS, the symptoms can vary or be experienced differently. For example, you can suffer from
- A stinging and painful sensation in the palm and fingers
- A swollen thick feeling in the hand
- Radiating pain in the forearm, elbow, and shoulders
- Reduction in hand strength
Therapy
Wearing a wrist brace (splint) during the night often has a beneficial effect on the symptoms. A corticosteroid injection can cure early CTS.
If the complaints do not diminish as a result of the above treatments or if they persist for more than three months, you will need surgery. If this is not done, the nerve can suffer permanent damage. Experience has shown that surgical treatment of CTS is successful in more than 90% of cases.
The operation
The procedure is performed in a supine position with the arm to the side. The nurse will put a band (tourniquet) around your lower or upper arm. You will receive a local anesthetic using an injection at the site of the cut in the skin. When the anesthetic has taken effect, the band around your upper arm will be inflated. This prevents blood from flowing to the hand for a short period of surgery (about ten minutes). This gives better visibility to the surgeon.
The transverse wrist band is exposed through a short, approximately three centimeters long, cut in the skin and then cut lengthwise. This widens the tunnel and gives the nerve more space. The nurse will then deflate the band around your upper arm again. This restores circulation and is often accompanied by a short period (several minutes) of tingling in the hand. The skin is closed with a few stitches. The wound is then covered with a pressure bandage. You can move your fingers freely. The total duration of the procedure is approximately 15 minutes.
Risks
Complications can occur with any surgery, such as bleeding, pillar pain (an altered feeling around the scar), or wound infection. These complications are rare and can almost always be treated well.
The nerve can be damaged during the procedure, but this is extremely rare. Occasionally the hand is painful and swollen and it is difficult to start the movement of the fingers after the operation. In such cases follow-up treatment using hand therapy is necessary.
It is important to report these complaints during your check-up visits to the outpatient clinic. The chance that the condition will come back is very low (<0.5%). In about 5% of patients, the scar remains sensitive during the first months.
Recovery
You will wear a sling during the day for the first three days after the operation. It is important that you move (extend and bend) your fingers regularly during this time to prevent your hand from becoming stiff. At night you do not have to wear the sling, you can then put your arm on a pillow. You can take off the sling while taking a shower, but make sure that the bandage remains dry.
You can remove the pressure bandage yourself after three days. You put a bandage on the wound. After that, you can carefully use the hand and wrist again with increasing amounts of load.
In principle, you can use the hand normally again after two weeks. You can discuss whether this also applies to your work with the doctor during the consultation after the operation. Seven to twelve days after the operation you will be expected back for a wound check and removal of the sutures if they are not soluble.
After the operation, you may experience an unpleasant stinging sensation (especially at night). In most cases, this disappears quickly (within a few days). You may suffer from a reduced sense of touch at your fingertips. It can take three to six months for the feeling to fully return. There is also a temporary loss of (squeeze) strength after the operation. Recovery from this usually takes two to three months.
Thumb-bases osteoarthritis
In thumb-based osteoarthritis, the thumb assumes an abnormal position. The mouse pointer moves inward and the rest of the thumb goes overstretched. Often, we see a swelling of the thumb base. The abnormality is usually well visible on X-rays of the base of the thumb. If in doubt, a bone scan can be made.
Therapy
If there is mild wear and tear, the treatment consists of rest, splints, pain relief, and possibly anti-inflammatory injections. Our hand therapists will guide you through this process, they will develop a splint for you so that the thumb is supported.
If the above means ultimately do not (any longer) offer sufficient relief, surgery can be opted for. With the thumb base osteoarthritis, one-half of the joint can be removed (the wrist bone, trapezium, is completely or partially removed), after which the resulting cavity may or may not be filled with a roll of tendon tissue. This procedure is also called the ‘anchovy’ or ‘Sardella’ plastic. If no tendon roll is placed, this is known as the Gervis method. In addition, a so-called ‘suspension plastic’ can be performed to try to make the thumb stronger and to keep it longer. An example of this is the Burton-Pellegrini technique (see drawing below). In a few cases, it is decided to fix the joint (arthrodesis).
Risks
Complications can occur with any operation, such as bleeding, wound infection, tissue necrosis, anesthesia problems, thrombosis, or pneumonia. These complications are rare and can almost always be treated well.
Recovery
Burton Pellegrini Technique
After the operation, your thumb and forearm will be in a cast. This plaster remains in place for about two weeks. During this time, it is important to keep your hand elevated to reduce the chance of swelling. The fingers are not in the plaster, you can just move them.
After about two weeks, the cast is removed and the hand therapist makes a removable splint that supports and protects your thumb. After the splint has been made, you will start with exercises under the supervision of the hand therapist. You start with exercises that make the thumb joints flexible, after six to eight weeks you will also do exercises that make your thumb and hand stronger. You must wear the splint for up to eight weeks after the operation, outside of practice. Driving is not allowed during this period for insurance reasons.
After these eight weeks, wearing the splint will be reduced and you only need to wear the splint when you do heavier things by hand. You should not put a heavy load on your hand, for example during sports activities, until three to four months after the operation.
After the operation, the result is usually disappointing at first. It takes a lot of time to get back to the old level and eventually get better than before the surgery. In general, this takes about three to six months after a trapezoidal excision. The strength then increases measurably over a period of five years after surgery.
Arthrodesis
With arthrodesis, the recovery is generally faster. The original pain from the wear is usually gone immediately after surgery. It usually takes up to three months for the pain from the surgery itself to completely disappear. A small number of patients continue to have pain at the base of the thumb after surgery.
To get a good impression of the result of the operation, the measurements taken before the operation are repeated after six months and after a year.
De Quervain
De Quervain’s condition is an inflammation of the tendons and/or tendon sheath on the thumb side of the wrist. Initially, there is pain on the thumb side of the forearm. If left untreated, the pain can spread to the thumb and the top of the forearm. If you apply force with your hand, the tendons can crack. In severe cases, swelling develops around the area of the tendon sheath. Lifting, holding, and moving the thumb then becomes increasingly difficult and painful.
Cause
At the end of the radius on the thumb side, the tendons run through a narrow tunnel (tendon sheath). The inner lining of the tunnel consists of a mucous membrane layer. The tendons of the thumb normally glide smoothly along with this layer through the tendon sheath, but when the mucous membrane layer is inflamed, this is no longer possible.
De Quervain’s tendonitis is caused by irritation, often by repetitive movement movements such as grasping, lifting, squeezing, and wringing. Rheumatism and diabetes can also be associated with De Quervain’s disease.
Diagnosis
The doctor makes the diagnosis through a physical examination. No complicated tests or X-rays are needed. Usually, Finkelstein’s test is done: place the thumb in the palm and make a fist, then bend the wrist sideways toward the little finger. If this hurts the tendon sheath on the thumb side, you may have De Quervain’s condition.
Therapy
Without surgery
Try to avoid the movements and activities that cause the pain. For example, take breaks more often with repeated actions and work behind the computer and try to lift underhand. The hand therapist can give you posture and lifting advice and can also look at how you can adjust your workplace, for example.
The doctor will prescribe a splint for six weeks to give the irritated tendons a rest. Anti-inflammatory drugs such as ibuprofen and diclofenac help with the pain and swelling of the irritated mucous membrane of the tendon sheath.
If all this does not help enough, an injection of hydrocortisone can be given. This medication is then injected into or around the tendon sheath.
With surgery
If the above approach does not help and the symptoms persist for more than three months, surgery can be considered in some cases. The roof of the tendon sheath is examined under a local anesthetic. This gives both tendons more space in the sheath.
Recovery
After the operation, you should let the tendons move immediately, even if this sometimes hurts at first. If you keep your hand and thumb still, scarring sometimes occurs between the tendons and the tendon sheath, making it less possible for you to move the thumb.
You should avoid lifting and repetitive movements for three to four weeks. It can sometimes take a few months for the pain to disappear completely
Risks
Complications can occur with any operation, such as bleeding, wound infection, tissue necrosis, anesthesia problems, thrombosis, or pneumonia. These complications are rare and can almost always be treated well.
Injections with hydrocortisone can sometimes discolor and thin the skin.
During an operation, a sensory nerve may be hit because it is kept aside. This can cause a temporary sensory disturbance. In very exceptional cases, the nerve can start to hurt.
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