Hand Soft Tissue

Flexor and extensor tendon disorders

Tendon clinical testing, extensor tendon disorders of the hand and trigger finger

17 questions 3 source pages 1 fact-check flags

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Q1What is this test and how is it performed?▸

Eichhoff test (often misnamed Finkelstein's): ulnar deviation of the wrist with the thumb in the palm reproduces symptoms
Finkelstein's test: examiner pulls the thumb into ulnar deviation
Used for the diagnosis of de Quervain disease

Q2What is de Quervain disease?▸

Stenosing tenosynovitis of the first dorsal wrist compartment (APL and EPB)
Not truly inflammatory: mucopolysaccharide accumulation and a thickened retinaculum
Caused by attrition and degeneration
Common in racquet sports and golfers, more common in women (postpartum mothers)

Q3What are the clinical features of de Quervain disease?▸

Dorsoradial wrist tenderness
Swelling
Crepitus

Q4What is the non-operative treatment of de Quervain disease?▸

Activity modification and splinting
Local corticosteroid injection (steroid successful in >80%)
Concomitant splint/NSAID after injection does not improve outcome

Q5What are the operative steps and complications of de Quervain release?▸

Oblique incision proximal to the wrist: longitudinal better cosmesis, transverse more complicated
Release the dorsal side of the 1st compartment to prevent volar tendon subluxation
Beware anatomic variation: APL multiple slips (2-4), EPB may have its own separate compartment
Complications: injury to the superficial sensory radial nerve, tendon subluxation, CRPS, recurrence from incomplete release

Q6List the six extensor compartments and a condition associated with each.▸

1: de Quervain (APL/EPB)
2: Intersection syndrome (ECRL/ECRB with APL/EPB)
3: EPL rupture / drummer wrist
4: EDC tenosynovitis
5: Vaughan-Jackson
6: Snapping ECU

Q7What is intersection syndrome and how is it managed?▸

Inflammatory condition at the crossing of the 1st (APL/EPB) and 2nd (ECRL/ECRB) dorsal compartments
Conservative: rest, wrist splinting, steroid injection to the 2nd compartment
Rarely surgery: release of the 2nd dorsal compartment ~6cm proximal to the radial styloid

Q8What is drummer wrist?▸

Tenosynovitis of the 3rd dorsal compartment containing EPL
Classically in drummers who play for long periods without rest

Q9What is snapping ECU syndrome and what is its mechanism?▸

Secondary to attenuation or rupture of the ECU subsheath (6th compartment); attenuation gives subluxation, rupture gives dislocation
Ulnar-sided tears: ECU subluxates on supination and reduces on pronation
Radial-sided tears: ECU subluxates on supination and lies on top of the torn subsheath on pronation
Flexion and supination elicit a painful snap; subluxation can cause ECU tendonitis

Q10What is the differential for snapping ECU and how is it managed?▸

DDx: TFCC tear, hook of hamate fracture, ulnar styloid fracture, ulnar styloid impaction syndrome, ulnar tunnel syndrome, pisotriquetral arthritis
Non-operative: wrist splint or long arm cast immobilised in pronation and slight radial deviation
Operative: ECU subsheath reconstruction +/- wrist arthroscopy; direct repair in acute cases, extensor retinaculum flap for chronic
Wrist arthroscopy shows concurrent TFCC tears in 50%

Q11What is Wartenburg syndrome?▸

Compression of the superficial radial nerve (SPN) by the brachioradialis (BR) and ECRL
Not related to the extensor compartment diseases above

Q12What is trigger finger and what is its pathology?▸

Stenosing tenosynovitis at the A1 pulley
Fibrocartilaginous metaplasia of tendon and/or pulley: chondrocyte proliferation, increased type III collagen
Chronic hyperglycaemia creates collagen cross-links and impairs collagen degradation
Usually involves FDP and spares FDS
Trigger thumb associated with a 4th (variable annular) pulley in up to 75%

Q13What conditions are associated with trigger finger?▸

Associated conditions: RA, calcific tendinitis, septic tenosynovitis, carpal tunnel syndrome, congenital trigger thumb
Medical diseases: diabetes, amyloidosis, hypothyroidism, sarcoidosis, gout/pseudogout

Q14What is the Green classification of trigger finger?▸

Type 1: pain on A1 pulley
Type 2: spontaneously corrects
Type 3: passively corrects
Type 4: rigid

Q15What are the success rates of non-operative and operative treatment?▸

Splinting, activity modification, NSAIDs: 40-97% effective
Corticosteroid injection: 60-90% effective
Percutaneous A1 release: success >90%, earlier return to work than open
Open release: satisfactory in >90%; higher recurrence in diabetic patients

Q16When is FDS slip release performed?▸

Release of A1 pulley and 1 slip of FDS (usually ulnar slip) for RA or recurrent/persistent trigger finger
In RA, FDS slip excision without A1 release may prevent exacerbation of ulnar drift at the MCPJ/volar subluxation

Q17How is paediatric trigger finger managed?▸

Notta's node (proximal to A1 pulley), flexion contracture and triggering
Surgery at 2-4 years of age to prevent interphalangeal joint contracture
May need release of remaining FDS slip and A3 pulley
Success rate >90%

Fact check

The thumb-in-palm with ulnar deviation manoeuvre is Finkelstein's test — naming conflation — The thumb-in-palm then ulnar deviation manoeuvre is the **Eichhoff test**, commonly misnamed Finkelstein's test; the true Finkelstein test has the examiner grasp the thumb and ulnar-deviate the wrist and is more specific with fewer false positives — source

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Flexor and extensor tendon disorders

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