Trigger Finger and Ganglion Cyct . Seminar Ortho Year 5

TRIGGER FINGER&

GANGLION CYSTPREPARED by:PUWANISWARI

ROHINIE MAZLINA

AINUL FARHANA ANUSHAH

Anatomy of trigger fingers

• Tendon sheaths of the long flexors run from the level of metacarpal heads ( distal palmar crease, superficial; volar plate, deep)to distal phalanges

• They are attached to the underlying bones and volar plates, which prevent the tendons from bowstringing

• Predictable and efficient thickenings in the fibrous flexor sheath act as pulleys, directing the sliding movements of the fingers.

• The 2types of pulleys are annular (A) and cruciate ( C).

• Annular pulleys are composed of single fibrous bands, while cruciate pulleys have 2 crossing fibrous bands.

The order of the pulleys from proximal to distal :

• The A1 pulley overlies the meatcarpophalangeal joint

• Flexor tendons pass within the tendon sheath and beneath the A1pulley at approximately the metacarpal head, beyond which they travel into the digit.

• The A2 pulley overlies the proximal end of the proximal phalanx

• The C1 pulley overlies the middle of the proximal phalanx

• The A3 pulley lies over the proximal interphalangeal joint

• The C2pulley lies over the proximal end of the middle phalanx

• The A4 pulley lies over middle of the middle phalanx

• The C3 pulley lies over the distal end of the middle phalanx

• The A5 pulley lies over the proximal end of the distal phalanx

Definition

• Stenosing tenosynovitis

• Painful condition in which a finger or thumb locks when it is flexed or extended.

• Caused by inflammation of the flexor tendon sheath.

PathophysiologyFibrosis can occur and bumps (nodules) can form with prolonged inflammation.

PathophysiologyInflammed nodule

Flexor tendon trapped by thickening at the entrance to its sheath.

Affected tendon is caught at the edge of the first annular (A1) pulley.

Infantile Trigger Finger

• Abnormal flexion at interphalangeal joint.• Can be bilateral.• Flexor pollcis longus tendon thickened – Abnormal collagen degeneration and synovial

proliferation– Incr. FPL tendon diameter compared to A1– Disruption in tendon gliding

• Fix thumb flexion (interphalangeal joint)• Painless• Notta node

Trigger FingerDemographicsCommon form: Primary type.Found predominanty in otherwise healthy

middle-aged women with frequency 2 to 6 times higher than men.

Most commonly affected digit is the thumb, followed by ring, long, little and index finger.

Secondary trigger finger

Seen in patients with diabetes, gout, renal disease, rheumatoid arthritis and other rheumatic diseases. Associated with worse prognosis after conservative or surgical management.

A locked trigger digit can lead to an incorrect diagnosis of dislocation, Dupuytren’s disease, focal dystonia or hysteria.

Classification Trigger Digits• Grade 1(Prettriggering)Pain: History of catching, but

not demonstrable on physical examination, tenderness over the A1 pulley

• Grade 11(Active)Demonstrable catching but

the patient can actively extend the digit.

• Grade 111(Pasive)- Demonstrable catching requiring passive extension(111A) or inability to actively flex(grade 111B)

• Grade 1V(contracture)- Demonstrable catching with a fixed flexion contracture of the PIP joint.

GANGLIONS of the HAND&WRIST

Ganglion cyst

Definition :• A tumor or swelling on top of a joint or the

covering of a tendon

Etiology • Outpouching of synovium, as an irritation of

articular tissue

• Degeenerative of connectiontissue and cystic space formation

• Degeneration of the connective tissue is caused by an irritation or chronic damage causing the mesenchymal cells or fibroblasts to produce mucin

Pathophysiology • Most commonly appears multilobulated but

can still appear unilobulated.• With septa made from connective tissue

separating the lobes or cavities• A ganglion cyst is not a true cyst and because

of this histologic observation, the theories of synovial herniation or synovial tumor formation may be disputed

• Hyaluronic acid predominates the mucopolysaccharides that make up the fluid within the cyst’s cavity, while collagen fibers and fibrocytes make up the wall lining

• The development of these cysts is histologically observable beginning with swollen collagen fibers and fibrocytes, followed by a degeneration and liquefaction of these elements, a termination of degeneration, and a proliferation of the connective tissue, resulting in a border that is dense in texture

Management • Imaging :- Plain xray : visualization of the cysts, identify bony

abnormaloities that can be causing the symptoms.- Confirmation of clinical diagnosis : MRI,

ultrasonography and arthroscopic imaging• Others : - Allen test performed when the cyst is located near

the radial artery, including most volar wrist ganglia.

Ganglion cyst

Medical therapy

• Early stage: manually compressed until it bursts, and fluid is absorbed (least invasive treatment)

• Slightly more invasive approach when a minimum of 3 aspiration

Corticosteroids injection with aspiration ( yet has been contraindicated in some cases) : can cause thinning of the overlying skin.

• Another moderately invasive procedure is cyst puncture.

• In this procedure, a suture is passed through the skin perpendicularly through the cyst and is left there for 3 weeks, increasing the risk of infection ( not commonly used even it has 95% cure rate)

Surgical therapy• Open removal with arthroscopy, including a

reduction in intraoperative risks and postoperative complications. (40% recurrence is seen)

• Remove a portion of capsule to reduce the recurrence rate (4%)

• Brief splinting of 3-7 days is recommended for both open and arthrospcopic ganglionectomy, but it seems that wrist motion within 3-5 days post operation can prevent stiffness.

• Compared to open ganglionectomy, arthroscopy uses smaller incisions and therefore leaves smaller scars.

• Arthroscopy allows better visualization

Dorsal Wrist Ganglion• Most common : 60-70%

• Arise from scapholunate ligament.

• Can occur anywhere else between extensor tendons and connected to ligament through a long pedicle.

• Extend and direction-palpation with digital compression.

• Transillumination and aspiration confirms the diagnosis.

Occult Dorsal Carpal Ganglion

Smaller, occult dorsal ganglions are easily overlooked and can be often only be palpated with the involved wrist in marked volar flexion.

Comparison with opposite normal wrist is helpful.

Clinical Features

Clinical Features

Unexplained wrist pain and disproportionately tender.

Differential Diagnosis

Chronic tenosynovitis of the extensor tendons

Dorsiflexion injuries of the wrist- pain and sprains of the scapholunate ligament and other intercarpal ligaments

Investigations

Radiographic

For further diagnostic studies: MRT, CT, ultrasonography

TreatmentConservative(best initially)• Immobilization and steroid injections directly into

the dorsal capsule

Operative:• Excision of the posterior interosseous nerve at the

level of the radiocarpal joint - alleviate the pain and postoperative comfort.

Volar Retinacular(Flexor Tendon

Sheath)Ganglion

Prepared by:ANUSHAH THIAGARAJAN

• The third most common ganglion,about 10%-12%,which arises from the proximal annular ligament(A1 pulley) to the flexor tendon sheath.

• This ganglion is invariably small(3mm-8mm)

• Firm,tender mass palpable under the MP flexion crease.

• The cyst is attached to the tendon sheath and does not move with the tendon.

• Needle rupture followed by a steroid injection and digital massage disperse the cyst’s contents can frequently delay or obviate the need for surgery.

• Several attempts at conservative treatment are recommended before surgery with patient’s understandings that reccurences might happen.

• The proximity of digital nerves must be appreciated.

• The incision must allow identification and mobilization of radial and ulnar neurovascular bundles.

• The ganglion can then be traced to the tendon sheath and excised to a small portion of the sheath.

OPERATIVE TECHNIQUE

• The ganglion is approached through an oblique incision over the mass.

• Transverse incisions are more popular but don’t allow adequate exposure with undue skin traction and are not easily incorporated into an extensile incision.

• The synovial side of the specimen usually reveals a defect in its smooth,white homogenous surface suggestive of a communication between a tendon space and cyst.

• After skin closure,a simple dressing is applied and early motion allowed.

COMPLICATIONS

• Rare,although injuries to the digital nerves have been reported

MUCOUS CYST

• Ganglion of the DIP joint that occurs between 5th and 7th decades.

• The earliest sign maybe longitudinal grooving of the nail,without a visible mass,caused by pressure on the nail matrix.

• Usually,the patient is seen after the cyst has enlarged and attenuated the overlying skin.

• The cyst,3mm to 5mm,typically lies on one side of the extensor tendon and between the dorsal distal joint crease and eponychium.

• The patient often has Herbeden’s nodes and radiographic evidence of osteoarthritis changes in the joint.

• The cyst and osteophytes should be treated to ensure satisfactory result.

OPERATIVE TECHNIQUE

• The cyst has historically been approached through ‘L’-shaped or curved incision and any attenuated or involved skin that cannot be easily separated from the cyst wall,is excised elliptically.

• The cyst is immobilized,traced to the joint capsule and excised with the joint capsule.

• All soft tissue,between the retracted extensor tendon and adjacent collateral ligament is excised and the DIP joint is left exposed.

• Care is taken to not disturb the incision of the extensor tendon or nail matrix.

• With the joint extended and tendon retracted dorsally,the opposite site is explored and occult cyst or hypertrophied synovial tissue is excised.

• Osteophytes can be excised with a rongeur or a fine powder bur

• Skin closure may require rotation and advancement of dorsal skin flap or a full-thickness skin graft.

• An alternative and current prefered approach is to make a transverse incision centred over the DIP joint

• The base of mucous cyst is identified and excised while leaving the distal and superficial portion of the cyst intact.

• Osteophytes and the joint capsule are excised while leaving the skin closed.

• The remaining portion of the cyst will involute over several weeks.

POST-OPERATIVE CARE

• If a skin graft was used,the distal joint is supported with a cast or splint for 2 weeks.

• Earlier motion is permitted if a local rotation flap was used.

• Motion and theraphy can then be undertaken until full painless motion has been achieved.

COMPLICATIONS

• Recurrences maybe due to inadequate excision of the capsular attachment of the ganglion and failure to recognize extension of the ganglion under the extensor tendon to the opposite site.

• The underlying arthritic process persist and may result in new ganglion formation.

• Relief of pressure on the nail matrix by decompression or excision of ganglion usually restores the nail to its normal appearance

• Stiffness is a rarely functional problem

OTHER GANGLION CYST

• Dorsal,volar retinacular and DIP constitutes more than 90% of ganglions of hand

GANGLIONS of the PROXIMAL INTERPHALANGEAL JOINT

• Dorsally over the PIP joint on the other side of the extensor tendon.

• They arise from the joint capsule and pierce the oblique fibres between the central slip and lateral band.

• These cysts are small(3mm-5mm),tender and may interfere with joint motion.

OPERATIVE TECHNIQUE

• A curve incision over the PIP joint exposes the ganglion.

• The lateral margin of the lateral band is released from the transverse retaining ligament and retracted dorsally to expose the PIP joint.

• The pedicle from the main cyst can usually be followed through the extensor system into the joint capsule.

• A small elliptical incision through the oblique extensor fibres mobilize the cyst and pedicle.

• The entire joint capsule and synovial lining are excised between the collateral ligament and extensor insertion on the middle phalanx.

POST-OPERATIVE CARE

• A simple skin closure and early motion

GANGLION EXTENSOR TENDONS

• Typically occur over the metarcarpals and are distinguished by their proximal motion with their fingers in extension.

• Tenderness,aching or snapping of the tendon with motion

OPERATIVE TECHNIQUE

• The ganglion is approached through a transverse incision and the intimate broad attachment to the extensor tendon is readily appreciated.

• The ganglion is dissected off the extensor tendon with all the synovial tissue surrounding the involved tendon

• Rupture of the tendon is difficult to avoid but recurrence are rare.