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CURRENT CONCEPTS

Tendon Disorders of the Hand and Wrist
John A. McAuliffe, MD
The terminology used to describe most common tendon disorders in the hand and wrist
suggests that they are inflammatory in nature, although current evidence indicates that
mechanical and degenerative factors are more important. Corticosteroid injections provide
relief in 60% or more of cases; however, the duration of their effectiveness remains
uncertain. Surgical release of the stenotic pulley or sheath is curative in well over 90% of
cases; complications of surgery are rare, and relief is long-lasting. Enlightened management
of these common problems demands evidence-based guidelines defining indications for
surgery that will maximize outcomes and minimize costs. (J Hand Surg 2010;35A:846–853.
© 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the
Hand.)
Key words Tendonitis, tendinopathy, tendinosis, tenosynovitis, tendovaginitis.

HEN ALL THEIR various manifestations are
combined, disorders of the tendons in the
hand and wrist might constitute the most
common complaints evaluated by hand care professionals. Although some of the familiar tendon conditions
that are encountered regularly were first described well
over a century ago, our understanding of the pathophysiology of these processes has advanced surprisingly
little. These maladies are frequently (and carelessly)
labeled as tendonitis, tenosynovitis, or tendovaginitis,
despite the fact that those we treat most frequently are
not primarily inflammatory in nature.
A degree of uncertainty also surrounds the management of these disorders. It is essentially impossible to
determine the long-term success of the commonly used
nonsurgical treatments from the existing literature. Surgical treatment is generally quite successful; however,
there is little evidence to guide us in deciding when it is
most appropriate to abandon nonsurgical care and proceed to surgery. The importance of these questions will

W

Current Concepts

From Broward Health, Fort Lauderdale, FL.
Received for publication February 7, 2010; accepted March 1, 2010.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: John A. McAuliffe, MD, Broward Health, Orthopaedics, 300 SE 17th
Street, Fort Lauderdale, FL 33316; e-mail: jamca@bellsouth.net.
0363-5023/10/35A05-0030$36.00/0
doi:10.1016/j.jhsa.2010.03.001

846 䉬 ©  Published by Elsevier, Inc. on behalf of the ASSH.

continue to grow as the cost-effectiveness of medical
care comes under more intense scrutiny.
This brief review concentrates primarily on the recent literature, addressing the evaluation and management of common tendon disorders of the hand and
wrist, beginning with a discussion of basic concepts and
proceeding to a consideration of specific diagnoses.
ETIOLOGY
Most tendon disorders in the hand and wrist are idiopathic in nature. Symptoms usually begin spontaneously, without any antecedent trauma or change in
activity level. Patients will occasionally report that they
have performed unaccustomed manual activity or experienced mild local trauma in the days or weeks preceding the onset of symptoms. Individuals with diabetes
mellitus are predisposed to tendon disorders, trigger
finger in particular, although the biological basis for this
is unclear.1
The relationship between upper extremity tendon
disorders and workplace activity has been particularly
contentious, with obvious implications regarding causation and, ultimately, compensation. Diagnostic criteria for many work-related disorders remain controversial,2 and this issue continues to confound many studies
that suggest a relationship between force or, less consistently, repetition and possible tendonitis.3 A recent
systematic review of 18 papers focusing on evidence

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that might support compensation of workplace disorforceful motion. Hueston and Wilson elegantly deders has highlighted the relative lack of data to support
scribed the typical tendon damage as being akin to that
the attribution of work-relatedness to complaints of
seen when a large, braided thread is passed through the
tenosynovitis.4 Factors that have been found to have the
slightly smaller eye of a needle.10 In the aggregate, our
highest predictive value for identifying an individual
current knowledge seems to indicate that trigger finger
likely to develop upper extremity tendonitis include
and de Quervain’s disease are primarily degenerative or
mainly patient-related and few job-related factors, inreactive processes related to abnormal mechanical
cluding age greater than 40
stress on the sheath and tenyears, body mass index EDUCATIONAL OBJECTIVES
don within.

Discuss the etiology of tendon disorders in the wrist and hand.
greater than 30, baseline
Histologic findings at
complaints of shoulder or ● Describe the pathophysiology of trigger digits.
other anatomic locations
neck discomfort, a history of ● List changes in the extensor retinaculum associated with de Quervain’s have been reported much
carpal tunnel syndrome, and
less frequently. Eleven padisease.
finally, jobs with higher ● State the conditions associated with true tenosynovitis.
tients with what was termed
shoulder posture ratings.5 It ●
proliferative tenosynovitis in
Discuss the role of corticosteroid injection in the treatment of trigger finseems increasingly clear that
the fourth extensor compartger.
work-related upper extremity
ment demonstrated reactive
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perplasia, and little to no inical attributes of the worker
flammatory reaction.11 No
and the workplace itself. The intricate details of these
signs of synovial invasion of the tendons were visible
inter-relationships require much more study.
under loupe magnification, another major difference
compared to cases of true inflammatory tenosynovitis.
Another recent report described the histopathologic
PATHOPHYSIOLOGY
findings in 6 patients who failed conservative treatment
The one consistent finding in the histopathologic studfor flexor carpi ulnaris (FCU) symptoms as being simies of patients with both trigger finger and de Quer6 –9
ilar to the angiofibroplastic hyperplasia that is seen in
vain’s disease is the absence of inflammation. There
other extrasynovial degenerative tendinopathies such as
is disagreement as to whether the A1 pulley is comepicondylitis.12 Acute inflammatory cells were not enposed of 2 or 3 layers, but most studies agree that there
countered, and macrophages and lymphocytes were abis increasing disorganization or breakdown of the inner
6–8
sent or seen only rarely.
gliding layer of the pulley in the pathologic state.
Other, less-common tendon disorders have not been
Chondroid metaplasia of the inner layer is frequently,
7– 8
subjected
to the same rigorous histologic evaluation as
but not universally, reported.
In long-standing trigtrigger
finger
and de Quervain’s disease. The presence
ger finger, the fibrocartilaginous gliding surface of the
of acute and chronic inflammation has been reported in
sheath is invaded by the hyperplastic outer vascular
cases of tendon disorders in other anatomic areas, inlayer, ultimately replacing it with fibrotic tissue in se6
cluding the second and sixth dorsal compartments,
vere cases.
without any detailed description of the findings or disThe extensor retinaculum in patients with de Quercussion of the involvement of specific tissues (synovain’s disease also demonstrated increased vascularity
vium, tendon, or sheath). In light of our current underand deposition of dense fibrous tissue that resulted in
9
standing of the pathology of trigger finger and de
thickening of up to 5 times that seen in controls. This
Quervain’s disease, more critical histologic appraisal of
recent study also noted marked accumulation of mucothese other tendon disorders is required to evaluate the
polysaccharide, an indicator of myxoid degeneration,
9
presence of inflammatory and degenerative etiologies.
but not inflammation.
The question remains: Are some of these tendon disorHistologic examination of the affected tendons is
ders primary inflammatory processes, or is inflammararely performed; however, tendon nodularity and fraytion, when present, secondary to stenosis and mechaning appear to be secondary to impingement on the
ical stress on the tendon?
degenerated and stenotic sheath. The edges of the pulTrue tenosynovitis does exist in the hand and wrist,
leys or small-diameter retinacular sheaths through
and is usually associated with a specific underlying
which many tendons pass act as fulcrums. Considerable
diagnosis such as inflammatory arthritis (rheumatoid
angulation about these fixed points can occur during
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TENDON DISORDERS OF THE HAND AND WRIST

disease), metabolic processes (gout or pseudogout), or
atypical infection (Mycobacterium). These lesscommon inflammatory tendon disorders are usually
suggested by the clinical setting and should not be
neglected when forming a differential diagnosis.
NOMENCLATURE
The available histologic evidence calls into question the
appropriateness of the terms tendonitis, tendovaginitis,
and tenosynovitis in most commonly encountered clinical settings; however, these terms are firmly entrenched in the literature and are not likely to be abandoned. Tendinopathy has come to be strongly
associated with intrasubstance degeneration of extrasynovial tendons, usually at or near their entheses, as seen
in epicondylitis or rotator cuff disease. Although the
dictionary definition of the term tendinopathy would
describe any tendon disorder, common usage seems to
have narrowed its scope. The suffix -osis also describes
any abnormal state or condition, although some authors
have appropriated it to describe primarily degenerative
conditions;12 this usage does not seem to have gained
widespread acceptance. Tendovaginosis might be the
most accurate and least misunderstood description for
the process commonly seen in cases of trigger finger
and de Quervain’s disease. Continued use of the adjective stenosing also seems appropriate, based on our
current understanding.

Current Concepts

CORTICOSTEROID INJECTIONS
Corticosteroid injections have been used as a mainstay
of nonsurgical treatment for both trigger finger and de
Quervain’s disease for many years with reasonable success, although the absence of histologically documented
inflammation in both of these disorders makes their
mechanism of action uncertain.
A recent review of level 1 and 2 prospective, randomized trials of adults treated with corticosteroid injection for trigger finger analyzed 4 studies including a
total of 297 digits.13 The outcome measures used to
determine resolution of trigger finger symptoms were
not standardized and highly variable, and the maximum
follow-up was 27 months, with 2 of the studies reporting follow-up of 4 months or less. The combined results
demonstrated relief of triggering in 115 of 201 (57%)
patients. The authors of this review note that previous
case series of patients treated with corticosteroid injections have reported success rates that in some series
exceeded 90% (63 of 68); the reason for this discrepancy is unclear. In a consecutive series that included
124 trigger digits, Rozental and coauthors found recurrence of symptoms in 70 of 124 (56%) patients one year

after injection.14 Younger age, insulin-dependent diabetes mellitus, involvement of multiple digits, and a
history of other tendinopathies of the upper extremity
(not clearly defined) were associated with a higher rate
of treatment failure.
A prospective, randomized study of 35 digits in
patients with diabetes and 29 digits in patients without
diabetes found that corticosteroid injections were significantly (p ⫽ .03) more effective in the digits of
patients without diabetes.15 In the patients with diabetes, corticosteroid injections did not decrease the surgery rate or improve symptom relief when compared to
placebo. Wang and Hutchinson followed morning
blood glucose levels in 18 patients with diabetes who
were receiving methylprednisolone injections for a single trigger finger.16 On the first morning after injection,
blood glucose was an average of 73% higher than
preinjection levels, and by the fifth morning after injection, blood glucose levels were still increased by an
average of 26%. This effect was particularly pronounced in patients with type I diabetes whose average
blood glucose level was increased by 145% on the first
morning after injection. Although no adverse effects
were noted in this study, it emphasizes the importance
of warning patients with diabetes that changes in their
management might be necessary in the days after injection.
A prospective, randomized trial comparing injection
with either soluble (dexamethasone) or insoluble (triamcinolone) corticosteroid found significantly improved satisfaction (p ⬍ .01) and absence of triggering
(p ⬍ .05) in the triamcinolone cohort at 6-week followup; the 2 groups were indistinguishable at 3 months.17
After the close of this study at 3 months after injection,
the authors noted 8 (of 41) recurrences in the triamcinolone cohort and one (of 31) in the dexamethasone
cohort. These data suggest that triamcinolone might
have a more rapid but less durable effect on trigger
finger than does dexamethasone. Although it has been
suggested that soluble corticosteroids might have a better safety profile than insoluble preparations with respect to fat atrophy, skin depigmentation, and tendon
injury, there is no evidence to clearly support this claim.
Extrasynovial steroid injection has also been touted as
effective and possibly safer for the tendons.18 Despite
repeatedly voiced concerns in the literature regarding
the possibility of direct tendon injury, I am aware of
only 2 reports of tendon rupture following corticosteroid injection for trigger finger in the English language
literature, one of which is recent.19
Corticosteroid injection of the first dorsal compartment for treatment of de Quervain’s disease is at least as

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effective and might provide longer duration of relief
than injection for trigger finger. A case series including
249 patients with moderate to severe symptoms
achieved complete resolution of symptoms in 189 of
249 patients (76%) and improvement in 17 of 249
patients (7%), with follow-up of one to 6 years.20 Injections have been demonstrated to be superior to
splinting alone, and concomitant splinting does not
seem to add to the success of injection alone. A recent
randomized, double-blind trial including 160 patients
did not demonstrate any additional benefit to the supplemental administration of an oral nonsteroidal antiinflammatory agent.21 Failure to release a separate subsheath within the first dorsal compartment has been
shown to negatively affect surgical outcome; it would
seem that efforts to reposition the needle in order to specifically infiltrate the space surrounding both abductor pollicis longus (APL) and extensor pollicis brevis
(EPB) tendons might be associated with higher success
rates following injection for de Quervain’s disease.22
Despite our familiarity with corticosteroid injections
in the treatment of these tendon disorders and their
generally good results, several pieces of this puzzle are
still missing. We have no knowledge whatsoever regarding the intermediate- or long-term results of corticosteroid injections. Patients in the vast majority of
studies were rarely followed up for as long as 2 years,
and sometimes as briefly as one month. How many
patients ultimately return with symptoms and have surgery? In what percentage of patients are injections simply delaying the inevitable? It would also be helpful to
have better information regarding the safety, efficacy,
and timing of repeat injections. In many studies, physicians provided second and sometimes even third injections at the patient’s request. Is there an optimal time
frame during which a second injection should be performed? Several case series have suggested that a third
injection is almost never successful, and a recent study
examining the direct cost of trigger finger care from the
payer’s perspective concluded that 2 injections before
surgery is the least costly treatment strategy.23 More
quality data of this type are needed to help us make
better informed treatment decisions.
TRIGGER FINGER
Trigger finger has been aptly described as a pathologic
disproportion between the volume of the flexor tendon
sheath and its contents.24 Although pain is the most
common presenting symptom for other tendon disorders and can certainly be present in cases of trigger
finger, patients mainly complain of the digit snapping,
catching, or locking. Flexion deformities of the proxi-

849

mal interphalangeal (PIP) joint and an inability to fully
flex the finger into the palm can be seen. Trigger finger
has a prevalence of roughly 2% in the general population and approximately 20% in multiple studies of patients with diabetes.1 Splint immobilization of the metacarpophalangeal joint in a position approaching neutral
extension for 6 weeks provided complete resolution of
symptoms in only 10 of 28 patients (36%).25 I am
unaware of any report that suggests that nonsteroidal
anti-inflammatory drugs alter the course of symptomatic trigger finger, although they might provide temporary pain relief.
Surgical treatment of trigger finger has been shown
to be safe and effective. A recent study evaluated 234 of
276 consecutive patients who had surgery for trigger
finger at an average 14.3-year (minimum 10.0-y) follow-up.26 All 254 affected digits had complete resolution of triggering, and all but 5 digits had regained full
range of motion. Nine perioperative complications (including 5 instances of transient neurapraxia of the radial
digital nerve of the thumb) had been treated nonsurgically and resolved uneventfully. There were no instances of bowstringing of the flexor tendons, and all
scars were painless.
Percutaneous trigger finger release was first described more than 50 years ago, but it has gained
increased popularity more recently. Potential benefits of
the percutaneous procedure include shorter procedure
time and quicker recovery of function. Initial concerns
regarding the safety of the digital nerves when attempting this procedure, particularly in the border digits and
thumb, have largely been laid to rest. Precise knowledge of surface anatomy and attention to detail is imperative. Most authors use a beveled needle to accomplish the release, although small hooked knives and
flat-bladed devices have also been used;27 there is no
evidence that these devices improve safety or efficacy.
Some element of scoring of the tendon seems unavoidable, and most authors deposit a small amount of corticosteroid through the needle used to accomplish the
release at the conclusion of the procedure in order to
prevent postoperative symptoms and facilitate early recovery.
A recent case series of 240 trigger digits treated by
percutaneous release reported fairly typical results, with
226 of 240 patients (94%) rated excellent or good.28
Ten patients experienced recurrent symptoms and required subsequent open release. Although most authors
have proceeded to open surgical release of the A1
pulley when percutaneous release has been ineffective,
Fu and coauthors recently reported success in 28 of 31
digits following repeat percutaneous release.29 In an-

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TENDON DISORDERS OF THE HAND AND WRIST

other recent study, 44 of 46 trigger thumbs treated by
percutaneous release were reported to have satisfactory
results, as compared to 12 of 47 treated with a single
corticosteroid injection, at 12-month follow-up.27
Large-scale studies that examine the cost-effectiveness
of open versus percutaneous release are needed.
Atypical cases of triggering at the distal A2 or A3
pulleys have been described.30 Although this finding is
quite rare, it is important to attempt to clinically determine the site of triggering during preoperative evaluation by examining the entire length of the flexor sheath.
Fusiform enlargement of the profundus tendon beneath the A2 pulley and fraying and degeneration of the
superficialis tendon have both been associated with
continued triggering, limitation of digital motion, and
PIP flexion deformity following A1 pulley release. Isolated tendon nodules seem to be a less common cause of
this problem and have been successfully treated by
removing a central core of tissue from an enlarged
tendon in a procedure termed reduction tenoplasty.31
Decreased tendon volume can also be achieved by
excising one slip of the flexor digitorum superficialis.
LeViet and coauthors performed this procedure in 228
digits with persistent flexion deformity of the PIP joint
at the time of A1 pulley release.32 Motion was improved in all but 8 patients, with an average gain of 26°
in passive PIP extension. Precise indications for these
more involved procedures remain to be defined; many
patients with residual PIP flexion deformity at the time
of A1 pulley release will improve with postoperative
therapy and tincture of time.

Current Concepts

DE QUERVAIN’S DISEASE
Evaluation of the incidence of de Quervain’s disease
among United States military personnel from 1998
through 2006 demonstrated that women had a significantly (p ⬍ .0001) higher rate of this disorder (2.8 cases
per 1000 person-years) compared to men (0.6 cases per
1000 person-years).33 Other risk factors for de Quervain’s disease in this population included age greater
than 40 and black race. Kutsumi and co-workers examined the biomechanical basis for Finkelstein’s test in a
sample of 15 cadavers.26 They found that the EPB
tendon was significantly (p ⬍ .05) more distal and had
significantly (p ⬍ .05) greater bulk and tethering effect
when the thumb was flexed and adducted and the wrist
ulnarly deviated compared with other wrist positions.
These results suggest that an abnormal Finkelstein’s test
reflects symptoms related to the EPB tendon more than
to the APL.
A successful outcome, defined as the absence of
triggering and pain both subjectively and on examina-

tion, was achieved in all 94 patients treated by surgical
release for de Quervain’s disease at an average 15.7year follow-up.34 Six perioperative complications, including 4 transient lesions of the radial sensory nerve,
resolved spontaneously. Studies continue to find that a
separate subcompartment for the EPB tendon is much
more common in patients treated surgically for de
Quervain’s disease (102 of 143 patients, 71%), than in
a random sample of cadavers (18 of 90 patients,
20%).35 Diligent exploration and release of all subcompartments within the first dorsal compartment is critical
to successful surgery.
INTERSECTION SYNDROME
The outcropping muscle bellies of the APL and EPB
intersect with the long radial wrist extensors on the
dorsal radial aspect of the distal forearm. Symptoms of
pain, swelling, and occasional crepitance in this area
have come to be known by the term intersection syndrome. Other than a few reports describing the magnetic resonance imaging findings in patients with these
symptoms, little new clinical information regarding this
disorder has appeared in the literature in more than 20
years. Grundberg and Reagan’s 1985 report on the
surgical treatment of 13 patients concluded that the
basic pathologic anatomy was stenosing tenosynovitis
of the sheath of the common radial wrist extensors.36
This description suggests that space constraints within
the second compartment result in an accumulation of
reactive tissue proximal to its boundaries, in the area
beneath the APL and EPB tendons. Surgical decompression of the second compartment seems to be curative, indicating that this is the source of the pathology,
although patient numbers are small and follow-up is
limited.
EXTENSOR POLLICIS LONGUS AND EXTENSOR
DIGITI MINIMI
Rare cases of pain and triggering related to the tendons
occupying the third and fifth dorsal compartments have
been reported. It has been suggested that surgical release be considered early in the course of thirdcompartment disease.37 This is a known watershed area
of limited vascularity within the extensor pollicis longus tendon, and a common site of posttraumatic tendon
rupture. It has been proposed that early surgical decompression and avoidance of injections into this region of
compromised vascularity will diminish the risk of tendon rupture, although evidence for this conjecture is
scant.

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EXTENSOR CARPI ULNARIS
A broad spectrum of pathology involving the extensor
carpi ulnaris (ECU) tendon has been described, including stenosing tenosynovitis, tendinosis and fraying,
bony erosion of the floor of the sixth compartment,
tendon subluxation, and even rupture.42– 44 Athletes
who use a club or racquet seem to have a particular
predilection to develop symptoms related to the ECU.
Associated ulnar-sided wrist or distal radioulnar joint
injury can also be present, making diagnosis challenging.44
The ECU synergy test has recently been described in
an attempt to separate tendon and joint pathology on
examination.45 With the elbow flexed to 90° and the
forearm in full supination, the examiner resists radial
abduction of the thumb with counter pressure on the
long finger. Recreation of the patient’s typical pain is
considered to be a positive test. The authors note that
the standard maneuver of resisting extension and ulnar
deviation of the wrist also loads the triangular fibrocartilage and lunotriquetral joints and might yield confusing results. All 21 patients in their study with a negative
ECU synergy test were found to have intra-articular

pathology on magnetic resonance imaging or arthroscopy, and all 33 with a positive test had symptomatic
relief after injection of the ECU sheath. These results
seem promising, but as the authors point out, prospective data are needed to determine the true sensitivity and
specificity of this maneuver.
The ECU tendon resides in its own fibro-osseous
tunnel deep to and distinct from the extensor retinaculum.46 Reports of surgical decompression of the tendon
often do not clearly describe anatomic detail; however,
it seems that release of the radial border of the fibroosseous tunnel followed by repair of the overlying
retinaculum is unlikely to lead to tendon instability.
Anomalous tendon slips between ECU and the extensor
digiti minimi were found in 7 of 28 patients who had
surgery for sixth compartment pathology; it is recommended that these be excised.44 Tendon subluxation
can indicate the accompanying loss of secondary restraints, and reconstruction of the fibro-osseous tunnel
is recommended in this setting, using either a retinacular graft attached directly to the ulna or the retinacular
flap described by Spinner and Kaplan.46 The latter
method has the added advantage of resurfacing the floor
of the sixth compartment in the presence of bony erosion. There is no high-level evidence to guide us in
choosing among these available procedures.
FLEXOR CARPI RADIALIS
Little has appeared in the literature to add to our understanding of flexor carpi radialis (FCR) tendinitis
since the seminal work published by Bishop and coauthors in 1994.47– 48 Given the tight confines of this
tendon and the unyielding nature of its fibro-osseous
sheath (the trapezium forms an average of 68% of the
circumference of the tunnel at the level of the trapezial
crest), it is only surprising that stenosing tendovaginosis
of the FCR is not more commonly encountered clinically. In the absence of a response to conservative
treatment measures, surgical release of the tendon
sheath generally provides good relief. Scaphotrapeziotrapezoidal arthritis can be associated with pain and
swelling of the FCR sheath.49 Selective injections into
the tendon sheath and joint might help to isolate the
symptoms and determine the most appropriate course
of treatment when radiographic evidence of arthritis
accompanies FCR symptomatology.
FLEXOR CARPI ULNARIS
The FCU and palmaris longus are the only tendons in
the hand and wrist that do not pass through an enclosed
sheath at some point in their course. These tendons do
not display the typical symptoms associated with ste-

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Current Concepts

FOURTH EXTENSOR COMPARTMENT
A recent retrospective case series reviewed 11 patients
with proliferative tenosynovitis of the fourth extensor
compartment.11 Patients reported pain, swelling, and
limited active wrist extension caused by a mechanical
block to tendon excursion. None of these patients had
any evidence of underlying rheumatoid or inflammatory disorder, and none reported a history of strenuous
or repetitive activity. Wrist splint immobilization, oral
nonsteroidal anti-inflammatory agents, and at least one
corticosteroid injection proved ineffective, and all patients were ultimately treated with tenosynovectomy.
One patient experienced a recurrence 30 months after
surgery; the remaining 10 patients were asymptomatic
and demonstrated improved, but not normal, wrist motion.
Extensor tendon triggering seems to be more common in the index and little fingers.38 These tendons are
subjected to the greatest angulation in their course at the
distal extent of the retinaculum, and they are therefore
subject to the greatest mechanical stress. Other uncommon tendon pathologies are described in the tendons of
the fourth dorsal compartment, including intratendinous
ganglions39 and multiple tendon duplication.40 The extensor digitorum brevis manus muscle is found in approximately 2% to 3%of the population and might be
another cause of swelling, pain, and mechanical symptoms in the fourth compartment.41

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nosing tendon disorders, and they are incapable of
triggering. Pain and tenderness often occur 2 to 3 cm
proximal to the FCU insertion on the pisiform. Intrasubstance tendon degeneration was found in 6 patients
who failed conservative treatment of FCU symptoms,
similar to that seen in other extrasynovial tendon disorders such as epicondylitis.12 This finding has not been
described in other anatomic locations about the wrist
and hand where the tendons are confined in tunnels and
synovial sheaths. The authors suggest this type of degenerative tendinopathy might be better treated by
strengthening and stretching than by modalities aimed
at inflammation.

Current Concepts

CALCIFIC PERITENDINITIS OR PERIARTHRITIS
Calcific peritendinitis or periarthritis is a poorly understood phenomenon that results in acute pain, swelling,
and inflammation; it has been described in the vicinity
of almost every tendon and joint in the hand and
wrist.50 It is seen most commonly at or near the insertion of the FCU. Signs and symptoms are of rapid onset
and so severe that they are often confused with acute
infection. This disorder has been labeled calcific tendinitis, but because involvement of tendon substance has
never been demonstrated and it occurs in pericapsular
locations not in immediate proximity to any tendon,
peritendinitis or periarthritis would seem to be the
preferred terms.
Approximately one third of patients will describe
some type of antecedent trauma, but the symptoms are
most often spontaneous in origin. Infection can usually
be ruled out on clinical grounds and by the absence of
systemic toxicity, although aspiration and culture might
be necessary. A recent study found the calcium deposits
to be composed of carbonate apatite,51 although their
etiology is unclear and the process is not associated
with underlying rheumatologic or metabolic disorders.
Radiographs will demonstrate fluffy calcification in the
area of acute inflammation, but this finding might not
be apparent until a few days after the inflammatory
symptoms have begun. Conservative treatment, including immobilization and the administration of nonsteroidal anti-inflammatory drugs, is curative within days;
local corticosteroid injection can provide almost immediate relief.
The terminology used to describe most common
tendon disorders in the hand and wrist suggests that
they are inflammatory in nature, although current evidence indicates that mechanical and degenerative factors are more important. Corticosteroid injections provide relief in 60% or more of cases; however, the
duration of their effectiveness remains uncertain. Sur-

gical release of the stenotic pulley or sheath is curative
in well over 90% of cases; complications of surgery are
rare and relief is long-lasting. Enlightened management
of these common problems demands evidence-based
guidelines defining indications for surgery that will
maximize outcomes and minimize costs.
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3. Thomsen JF, Mikkelsen S, Andersen JH, Fallentin N, Loft IP, Frost
P, et al. Risk factors for hand-wrist disorders in repetitive work.
Occup Environ Med 2007;64:527–533.
4. Palmer KT, Harris EC, Coggon D. Compensating occupationally
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Tendon Disorders of the Hand and Wrist
What is the etiology of the majority of tendon
disorders in the wrist and hand?
a. Idiopathic
b. Trauma
c. Inflammatory
d. Diabetic
e. Work related

What is the effect of corticosteroid injection in
the treatment of trigger finger?
a. Better in diabetic then nondiabetic patients
b. Minimal elevation of blood glucose in diabetic
patients
c. Effective relief of triggering about 60% of the time
d. Effective relief of triggering about 20% of the time
e. Ineffective relief of triggering compared to
surgery

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