MALLET FINGERDefinitionMallet finger is a condition of lost of extension at the distal interphalangeal

MALLET FINGERDefinitionMallet finger is a condition of lost of extension at the distal interphalangeal (DIP) joint of a digit due to a discruption of the extensor muscle. It is also known as dropped finger or baseball finger. Commonly it occurs at the third, fourth, and fifth digit of the dominant hand. Mallet finger can be classified as either acute or chronic. Acute is defined as when the injury is less than 4 weeks since the initial injury, while chronic is more than 4 weeks since the initial injury CITATION Kah18 l 1086 (Kahn & Xu, 2018).

Patient with mallet finger may present with the DIP joint maintained in flexion position and unable to bring the joint into full extension actively. On the other hand, swelling or ecchymosis may be noted over the dorsal aspect of the joint CITATION Mad18 l 1086 (Madden, Putukian , McCarty, & Young, 2018). Mallet finger is common in sport activities such as basketball, volleyball or rugby. This happen when the ball hits directly to the tip of the finger and causing a forced flexion ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISSN” : “1750-8460”, “PMID” : “21475106”, “abstract” : “Acute tendon injuries to the hand are common. In the UK, there are approximately 12000 inpatient admissions annually for injuries to the tendons and muscles of the hand and wrist (Dew, 2009). Hand injuries involving the dominant hand can cause long-term disability if not appropriately managed. Diagnosis of tendon injuries in the hand relies on careful clinical assessment, particularly if flexor and extensor tendon injuries are not to be missed. This article describes the tendon structure, explains the causes of tendon injury and discusses their assessment and management for a foundation level doctor who will face these injuries regularly whether in primary care or the emergency department.”, “author” : { “dropping-particle” : “”, “family” : “Sivaloganathan”, “given” : “Sivan S”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Kenward”, “given” : “Charlie”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Sarraf”, “given” : “Khaled M”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Jain”, “given” : “Abhilash”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “British journal of hospital medicine (London, England : 2005)”, “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2011” }, “page” : “M34-8”, “title” : “Acute tendon injuries in the hand and their management.”, “type” : “article-journal”, “volume” : “72” }, “uris” : “http://www.mendeley.com/documents/?uuid=3b4496b6-9cbe-487c-84bb-48089e26efbd” } , “mendeley” : { “formattedCitation” : “(Sivaloganathan, Kenward, Sarraf, & Jain, 2011)”, “plainTextFormattedCitation” : “(Sivaloganathan, Kenward, Sarraf, & Jain, 2011)”, “previouslyFormattedCitation” : “(Sivaloganathan, Kenward, Sarraf, & Jain, 2011)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Sivaloganathan, Kenward, Sarraf, & Jain, 2011).

Lin and Samora (2007) stated that mallet finger injuries are common tendon injuries in the finger. The extensor tendon of the distal interphalangeal (DIP) joint may sustain damage of varying degrees, from partial tear to complete rupture, as characterized by Doyle’s classification system (Table 1.1, Figure 1.1.1).

Type Characteristics
I Closed injury with or without avulsion fracture
II Open injury (laceration at or around DIP joint)
III Open injury with loss of skin and substance of the extensor tensor
IV A: Growth plate fracture (paediatric)
B: Fracture fragment involves 20% to 50%of articular surface (adult)
C: Fracture fragment involves more than 50% of articular surface (adult)
Table 1.1: Doyle’s classification

Figure 1.1.1
Source: https://www.orthobullets.com/hand/6014/mallet-finger
AetiologyDirect hit to the DIP joint
The most common injury mechanism is hyperflexion of the extensor digitorum tendon which often occurs when a ball hits an outstretched finger and jams it (Chang, 2013).
The direct and sudden forced flexion of an extended distal interphalangeal joint causes interruption to the finger extensor mechanism, hence, causes fracture to the dorsal lip at the base of the distal phalange (Lee, Kim, Yang, Moon, & Choy, 2010).

PrevalenceMallet finger injuries usually occur in work environment of during sports participation. It is common in young and middle aged male patients. The mean age for males is 34 years old while for females is 41 years old. Seventy-four percent of bonny mallet finger injuries involve the dominant hand and more than 90% of injuries were found in the long, ring or small finger ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1177/1558944716642763”, “ISBN” : “1558944716642”, “author” : { “dropping-particle” : “”, “family” : “Lamaris”, “given” : “Gregory A”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Matthew”, “given” : “Michael K”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2017” }, “title” : “The Diagnosis and Management of Mallet Finger Injuries”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=b44a83ed-8fd1-4be9-90c9-d4fad44f5404” }, { “id” : “ITEM-2”, “itemData” : { “DOI” : “10.1007/s11552-014-9609-y”, “author” : { “dropping-particle” : “”, “family” : “Alla”, “given” : “Sreenivasa R”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Deal”, “given” : “Nicole D”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Dempsey”, “given” : “Ian J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-2”, “issued” : { “date-parts” : “2014” }, “page” : “138-144”, “title” : “Current concepts : mallet finger”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=8e063657-cb10-4202-9d67-8b5c8162664e” } , “mendeley” : { “formattedCitation” : “(Alla, Deal, & Dempsey, 2014; Lamaris & Matthew, 2017)”, “plainTextFormattedCitation” : “(Alla, Deal, & Dempsey, 2014; Lamaris & Matthew, 2017)”, “previouslyFormattedCitation” : “(Alla, Deal, & Dempsey, 2014; Lamaris & Matthew, 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Alla, Deal, & Dempsey, 2014; Lamaris & Matthew, 2017)
Anatomy of mallet finger
Figure 1.4.1: Extensor Digitorum Communis Tendons
Source:http://www.assh.org/handcare/Anatomy/Muscles
These tendons are functioning in straightening all fingers except the thumb. The origin of these tendons is lateral epicondyle of humerus and insertion at extensor expansions of medial four digits. It is innervate by posterior interosseous nerve. Retinaculum are a bundle of tissue around tendons that holds it in it places but the tendons still can move in their own action CITATION Ten18 l 1033 (American Society for Surgery of the Hand, 2018).

-755657157085The terminal extensor tendons are located at the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. Lumbrical and interosseous muscles controls the movement of these tendons CITATION Mea17 l 1033 (Meals, 2017).

Figure 1.4.2: Extensor tendons
PathophysiologyMallet finger occurs when there is a disruption of extensor tendon function (Figure 1.5.1). A sudden flexion force on the extended fingertip force DIP joint into flexion. Consequently, the extensor tendon may be stretched or tear. In more severe cases, mallet finger is caused by the avulsion of the tendon inserted on the distal phalanx. In addition, laceration, abrasion or forced hyperextension of DIP joint that result in fracture of base of distal phalanx also cause mallet finger. As DIP joint lost active extension power due to disruption of extensor tendon function, DIP joint rest in abnormally flexed position or known as mallet appearance CITATION Jes17 l 17417 (Yee & Waseem, 2017).
If this condition left untreated, it may lead to swan neck deformity (the DIP joint rests in an abnormally flexed position and the PIP joint rests in a hyper-extended position) as the volar plate is lax and concentrated extension force that shifts to PIP joint cause the PIP joint to hyperextension (Figure 1.5.2). Therefore, mallet finger need to be treated to prevent the development of swan neck deformity that cause functional deficit CITATION Mau05 l 17417 (Mauffrey, 2005).

Figure 1.5.1: Disruption of extensor tendon. Figure 1.5.2: Swan neck deformity and mallet finger.

Figure 1.5.3: Pathophysiology of Mallet finger
Sign and SymptomSign and symptoms of mallet finger is distal interphalangeal joint is unable to fully extend. This deformity is present when common extensor tendon is avulsed (Figure 1.6.1) CITATION And03 l 17417 (Anderson, 2003).A pop or rip felt in the finger at the times of injury. Other than that, pain when moving the affected finger. Next, tenderness, swelling and warmth of the injured finger especially on the back of injured finger or joint. Besides, bruising will appear after 48 hours if the mallet deformity is due to fracture phalanges CITATION Saf11 l 17417 (Safran, Zachazewski, & Stone, 2011). In addition, if there is concomitant injury to digital nerve, diminished sensation may present (Figure 1.6.2) CITATION Fro14 l 17417 (Frontera, Silver, & Rizzo, 2014).

Source : http://austinspineandsport.typepad.com/dr_bockmann/2008/03/mallet-finger-f-1.html
Source : http://printer-friendly.adam.com/content.aspx?productId=117&pid=1&gid=002967&c_custid=815
Figure 1.6.1 Extensor tendon avulsion Figure 1.6.2 Digital nerve injury
AssessmentFirst of all, therapists need to ask about the history including past and current to find out the cause of the condition. The patient may inform the history of recent trauma of the affected finger. Then, pain assessment should be carried out to identify the area of pain, quality of pain, intensity of pain using Numeric Pain Rating Scale (NPRS), aggravating factor, easing factor and also twenty-four hours behaviour of symptom CITATION Dio11 l 17417 (Ryder, 2011). Other information such as family history, social history such as hobby, hand dominance, general health and underlying disease such as diabetes mellitus, inflammatory arthritis and cardiovascular disease will be helpful in determining the most efficient treatmentCITATION Dio11 l 17417 (Ryder, 2011).The objective assessment starts with observation of the affected site. The observation may figure that the affected digit locked in flexion. Palpation at the affected DIP joint will find localized swelling and tenderness. After that, range of motion of the finger is carried out and may be result in reduced motion especially in active extension of DIP joint due to pain. The range of motion for cervical movement, shoulder, elbow and forearm also need to be check to rule out their involvement with the condition. Next, manual muscle testing is carried on to determine the grip strength and also pinch strength using hand-held dynamometer and pinch gauge. Finger extension strength also needs to carry out. The strength may be decrease due to pain. CITATION Tur17 l 17417 (Turner & Cooper, 2017).Besides, sensation test should be carried out to rule out any nerve involvement and to ensure the effectiveness of the treatment. Sensation test such as light touch, pinprick and two-point discrimination should be normal for patient with mallet finger CITATION Bra15 l 17417 (Brault, 2015).

Management1.8.1Doctor ManagementMost mallet finger lesion can be treated through splinting. In acute mallet finger, the doctor will immobilize the finger for 6-8 weeks with splint i.e.; stack splint (Figure 1.8.1a), dorsal aluminium (Figure 1.8.1b) and custom thermoplastic (Figure 1.8.1c). The effectiveness between the three splint is quite similar ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.apmr.2010.10.035”, “ISBN” : “0003-9993”, “ISSN” : “00039993”, “PMID” : “21272714”, “abstract” : “Objective To compare Stack, dorsal, and custom splinting techniques in people with acute type 1a or b mallet finger. Design Multi-center randomized controlled trial. Setting Outpatient hand therapy clinics (2 public hospitals and 1 private clinic). Participants Patients (N=64) with acute type 1a or b mallet finger. Interventions Prefabricated Stack splint (control), dorsal padded aluminum splint, or custom-made thermoplastic thimble splint. All were worn for 8 weeks continuously, with a 4 week graduated withdrawal and exercise program. Main Outcome Measures The primary outcome was extensor lag at 12 and 20 weeks. Secondary outcomes were incidence of treatment failure, complications, range of motion of the distal interphalangeal joint, pain (visual analog scale) patient compliance, and patient satisfaction. Results There was no difference in the primary outcome between groups at 12 or 20 weeks; however, the Stack and dorsal splints had significant rates of treatment failure (23.8% in both groups, compared to none in the thermoplastic group; P=.04). There was a medium negative correlation between patient compliance and degree of extensor lag. No significant differences between groups were observed for patient satisfaction or pain. Conclusions As splints for mallet finger must be worn continuously for 6 to 8 weeks, and compliance correlates with favorable outcomes, treating practitioners must ensure the splint provided is robust enough for daily living requirements and does not cause complications, which are intolerable to the patient. In this study, no extensor lag difference was found between the 3 splint types, but custom-made thermoplastic splints were significantly less likely to result in treatment failure. u00a9 2011 American Congress of Rehabilitation Medicine.”, “author” : { “dropping-particle” : “”, “family” : “O’Brien”, “given” : “Lisa J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bailey”, “given” : “Michael J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Archives of Physical Medicine and Rehabilitation”, “id” : “ITEM-1”, “issue” : “2”, “issued” : { “date-parts” : “2011” }, “page” : “191-198”, “publisher” : “Elsevier Inc.”, “title” : “Single blind, prospective, randomized controlled trial comparing Dorsal aluminum and custom thermoplastic splints to stack splint for acute mallet finger”, “type” : “article-journal”, “volume” : “92” }, “uris” : “http://www.mendeley.com/documents/?uuid=3f402938-05d1-43bd-83e7-6cb7546e2fd9”, “http://www.mendeley.com/documents/?uuid=2f2f09ef-f8d0-4080-bd3a-e8ad4c9a2b18” } , “mendeley” : { “formattedCitation” : “(Ou2019Brien ; Bailey, 2011)”, “plainTextFormattedCitation” : “(Ou2019Brien ; Bailey, 2011)”, “previouslyFormattedCitation” : “(Ou2019Brien ; Bailey, 2011)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(O’Brien & Bailey, 2011).

In severe cases, surgical is required. The most commonly described surgical techniques included trans-DIP joint K-wire fixation, open reduction internal fixation with K-wire, and open suture repair of the tendon plus trans-DIP joint K- wire fixation (tenodermodesis) ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jhsa.2017.10.004”, “ISSN” : “15316564”, “PMID” : “29174096”, “abstract” : “Purpose: The current literature describes multiple surgical and nonsurgical techniques for the management of mallet finger injuries, and there is no consensus on the indications for surgical treatment. The objective of this study was to determine, through a literature review, if any conclusions can be drawn concerning the indications for surgery in mallet finger injuries; the treatment outcomes of surgical versus nonsurgical management; the most effective methods of surgical and nonsurgical treatment; and the most common treatment complications of mallet finger injuries. Methods: A systematic review of multiple databases was performed. English language clinical studies evaluating therapeutic interventions for mallet fingers that reported objective, standardized outcome measures were included. Basic science studies, cadaveric studies, conference abstracts, level V evidence studies, studies lacking statistical data, and tendinous injuries other than mallet fingers were excluded. Salvage procedures and studies evaluating exclusively chronic lesions were also excluded. Results: Forty-four studies that reported clinical outcomes for the treatment of mallet finger injuries, 22 evaluating surgical treatments and 17 studies investigating nonsurgical treatments were included. The average distal interphalangeal joint extensor lag was 5.7u00b0 after surgical treatment and 7.6u00b0 after nonsurgical treatment. Complication rates of surgical and nonsurgical interventions were comparable (14.5% and 12.8%, respectively). Five studies directly compared the outcomes of surgical with nonsurgical management, with mixed results and recommendations. Conclusions: Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. Insufficient evidence is available to determine when surgical intervention is indicated. Based on our literature review, it appears that these treatments are equivalent and should be individualized to the patient. Type of study/level of evidence: Therapeutic IV.”, “author” : { “dropping-particle” : “”, “family” : “Lin”, “given” : “James S.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Samora”, “given” : “Julie Balch”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Surgery”, “id” : “ITEM-1”, “issue” : “2”, “issued” : { “date-parts” : “2017” }, “page” : “146-163.e2”, “publisher” : “Elsevier”, “title” : “Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review”, “type” : “article-journal”, “volume” : “43” }, “uris” : “http://www.mendeley.com/documents/?uuid=734446c6-c0b0-45be-a945-6e62f73f5954”, “http://www.mendeley.com/documents/?uuid=fbc35074-7241-4dcf-922d-f79aef66e88c” } , “mendeley” : { “formattedCitation” : “(Lin ; Samora, 2017)”, “plainTextFormattedCitation” : “(Lin ; Samora, 2017)”, “previouslyFormattedCitation” : “(Lin ; Samora, 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Lin & Samora, 2017).

If surgery is required, orthopaedics will perform k-wires fixation as the treatment usually successful, simple and reliable surgical technique ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.otsr.2017.08.018”, “ISSN” : “18770568”, “abstract” : “Introduction: Extension-block pinning represents a simple and reliable surgical technique. Although this procedure is commonly performed successfully, some patients develop postoperative extension loss. To date, the relationship between extension-block Kirschner wire (K-wire) insertion angle and postoperative extension loss in mallet finger fracture remains unclear. Hypothesis: We aimed to clarify this relationship and further evaluate how various operative and non-operative factors affect postoperative extension loss after extension-block pinning for mallet finger fracture. Materials and method: A retrospective study was conducted to investigate a relationship between extension block K-wire insertion angle and postoperative extension loss. The inclusion criteria were: (1) a dorsal intra-articular fracture fragment involving 30% of the base of the distal phalanx with or without volar subluxation of the distal phalanx; and (2) ; 3 weeks delay from the injury without treatment. Extension-block K-wire insertion angle and fixation angle of the distal interphalangeal (DIP) joint were assessed using lateral radiograph at immediate postoperative time. Postoperative extension loss was assessed by using lateral radiograph at latest follow-up. Extension-block K-wire insertion angle was defined as the acute angle between extension block K-wire and longitudinal axis of middle phalangeal head. DIP joint fixation angle was defined as the acute angle between the distal phalanx and middle phalanx longitudinal axes. Results: Seventy-five patients were included. The correlation analysis revealed that extension-block K-wire insertion angle had a negative correlation with postoperative extension loss, whereas fracture size and time to operation had a positive correlation (correlation coefficient for extension block K-wire angle: u22120.66, facture size: +0.67, time to operation: +0.60). When stratifying patients in terms of negative and positive fixation angle of the DIP joint, the independent t-test showed that mean postoperative extension loss is u22123.67u00b0 and +4.54u00b0 (DIP joint fixation angles of ; 0u00b0 and u2265 0u00b0 respectively, P = 0.024). When stratifying patients in terms of extension-block K-wire insertion angle (30u00b0 30u00b0u201340u00b0 ; 40u00b0), ANOVA showed significantly less postoperative extension loss for higher insertion angles (; 40u00b0) than for medium insertion angles (30u00b0u201340u00b0). Mean postoperative extension loss difference between higher insertion angle (; 40u00b0) and medium insertion anglu2026”, “author” : { “dropping-particle” : “”, “family” : “Lee”, “given” : “S. K.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Kim”, “given” : “Y. H.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Moon”, “given” : “K. H.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Choy”, “given” : “W. S.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Orthopaedics and Traumatology: Surgery and Research”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2018” }, “page” : “127-132”, “publisher” : “Elsevier Masson SAS”, “title” : “Correlation between extension-block K-wire insertion angle and postoperative extension loss in mallet finger fracture”, “type” : “article-journal”, “volume” : “104” }, “uris” : “http://www.mendeley.com/documents/?uuid=9cb6b196-6cfc-4217-8fb6-bb7599940801”, “http://www.mendeley.com/documents/?uuid=9fd6de7a-64ce-464d-9218-c045f1281f01” } , “mendeley” : { “formattedCitation” : “(Lee, Kim, Moon, ; Choy, 2018)”, “plainTextFormattedCitation” : “(Lee, Kim, Moon, ; Choy, 2018)”, “previouslyFormattedCitation” : “(Lee, Kim, Moon, ; Choy, 2018)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Lee, Kim, Moon, & Choy, 2018).

Figure 1.8.1 a: Stack splint Figure 1.8.1 b: Dorsal aluminium splint

Figure 1.8.1 c: Custom thermoplastic splint
1.8.2Physiotherapy ManagementFor mallet finger rehabilitation, physiotherapy commonly choose stretching and strengthening exercise and exercises that mimic to patient’s activity daily living (ADL).

According to ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jhsa.2007.08.008”, “ISBN” : “0363-5023 (Print)\r0363-5023 (Linking)”, “ISSN” : “03635023”, “PMID” : “17996780”, “abstract” : “Purpose: To compare the efficacy of therapeutic activities that mimick the activities of daily living with that of traditionally used therapeutic exercises in the management of injured hands in young adult patients. Methods: Thirty-six patients having functional loss due to hand injury were enrolled. Patients were allocated randomly into 2 groups. The study group included 20 patients, and the control group included 16 patients. For the control group, according to their impairments, an exercise program including passive, active assistive, and active range of motion and strengthening exercises in addition to physical modalities was applied for 2 sessions a day. For the study group, in addition to 1 session of the same program, a program composed of 25 activities that mimick activities of daily living (ADL) was applied for 1 session. Treatment continued for 3 weeks, 5 days a week. Then the patients were given a home program. After 2 months, patients were reevaluated. Results: Mean age for the patients was 23 years u00b1 3. The time span from injury to surgery was a mean of 7 days u00b1 5, and the mean period between the injury and the physical therapy was a mean of 102 days u00b1 68. Grip strength, pinch strength, finger pulp-distal palmar crease distance, total active movement, range of opposition, range of abduction, Jebsen hand function test, and Disabilities of Arm, Shoulder, and Hand scores were obtained before treatment, after treatment, and 2 months after treatment. At final assessment, differences in improvements of all parameters were found to be statistically significant between the groups in favor of the study group. Conclusions: Because of the complex anatomy, determination of the most appropriate treatment may not be easy in an injured hand. Our results showed that the therapeutic activities that mimick the ADL improve the functions of the hand more effectively. We suggest that the therapeutic activities that mimick the ADL may be more beneficial than the standard rehabilitation activities in the management of an injured hand. Type of study/level of evidence: Therapeutic I. u00a9 2007 American Society for Surgery of the Hand.”, “author” : { “dropping-particle” : “”, “family” : “Guzelkucuk”, “given” : “Umut”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Duman”, “given” : “Iltekin”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Taskaynatan”, “given” : “Mehmet Ali”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Dincer”, “given” : “Kemal”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Surgery”, “id” : “ITEM-1”, “issue” : “9”, “issued” : { “date-parts” : “2007” }, “page” : “1429-1435”, “title” : “Comparison of Therapeutic Activities With Therapeutic Exercises in the Rehabilitation of Young Adult Patients With Hand Injuries”, “type” : “article-journal”, “volume” : “32” }, “uris” : “http://www.mendeley.com/documents/?uuid=775fbb03-6e8d-42bc-9703-29df352fcd6f”, “http://www.mendeley.com/documents/?uuid=456f9404-f24b-4b0a-ad19-1ed33988c91c” } , “mendeley” : { “formattedCitation” : “(Guzelkucuk, Duman, Taskaynatan, ; Dincer, 2007)”, “plainTextFormattedCitation” : “(Guzelkucuk, Duman, Taskaynatan, ; Dincer, 2007)”, “previouslyFormattedCitation” : “(Guzelkucuk, Duman, Taskaynatan, ; Dincer, 2007)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Guzelkucuk, Duman, Taskaynatan, & Dincer, 2007), therapeutic activities that mimic the ADL may be more beneficial than the standard rehabilitation activities in the management of an injured hand. The study had shown the group which perform therapeutic exercises i.e ; passive, active assisted and active range of motion and strengthening exercise that mimic to their ADL regain their functional activities compared to the group which perform basic therapeutic exercises.
In addition, self-regulated intermittent power pinch exercises (Figure 1.8.2a) can be a helpful modality in the management of old soft-tissue mallet deformity with tendency toward stiffness of the DIP joint. To compensate for the deficit of extension at the DIP joint, the patient is advised to develop a habit of holding the involved finger and the thumb in the power tip-to-tip pinch position for up to 5-min intervals with less than 1-min rest periods as frequently as possible ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jht.2015.02.002”, “ISBN” : “0894-1130”, “ISSN” : “1545004X”, “PMID” : “26190029”, “abstract” : “The utilization of an orthotic device to treat a mallet finger injury is common practice. This author describes a different approach to treating patients with an old mallet finger injury. The incorporation of frequent, self-regulated exercises without the use of an orthosis is described. – Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor”, “author” : { “dropping-particle” : “”, “family” : “Macionis”, “given” : “Valdas”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Therapy”, “id” : “ITEM-1”, “issue” : “4”, “issued” : { “date-parts” : “2015” }, “page” : “433-436”, “publisher” : “Hanley ; Belfus”, “title” : “Self-regulated frequent power pinch exercises: A non-orthotic technique for the treatment of old mallet deformity”, “type” : “article-journal”, “volume” : “28” }, “uris” : “http://www.mendeley.com/documents/?uuid=c9089e0a-815f-46c4-8150-6eb3aec5686e”, “http://www.mendeley.com/documents/?uuid=bdd284d5-bbf1-4351-9f68-d54f6642d2d7” } , “mendeley” : { “formattedCitation” : “(Macionis, 2015)”, “plainTextFormattedCitation” : “(Macionis, 2015)”, “previouslyFormattedCitation” : “(Macionis, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Macionis, 2015).

Figure 1.8.2a: Self-regulated intermittent power pinch exercises
ComplicationComplications that may occur due to mallet finger are permanent deformity and inability to straighten the finger. People with mallet finger will have pain in gripping. Other than that, affected finger will become stiff due reduce activity of hand as the patient feel pain with movement of affected finger. Next, untreated and hyperextended middle finger joint with last joint bent will causing a swan neck deformity (Figure 1.9.1). Swan neck deformities also may occur due to dorsal subluxation of lateral bands and contracture of triangular ligament that will maintains the deformity. Usually mallet finger will be healing with splinting but if the splint is too tight it will cause death of the skin and pressure sore (Figure 1.9.2). Arthritis of the finger can occur especially when the mallet finger associated with fracture (Figure 1.9.3). In surgical intervention there will be risks of infection, injury to nerves, bleeding and stiffness CITATION Saf11 l 17417 (Safran, Zachazewski, & Stone, 2011).Source : https://patient.info/forums/discuss/swan-neck-deformity-after-mallet-finger-623714

Figure 1.9.1 Swan neck deformity

Source : https://www.ebay.co.uk/itm/Plastic-Mallet-Finger-Splint-DIP-Joint-Support-Brace-Protection-Fracture-Pain-/251250817750
Figure 1.9.2 Finger splintFigure 1.9.3Arthritis of finger
Source : https://theprpdoctor.com/services/hands/

TRIGGER FINGERDefinition Trigger finger is the snapping, triggering, or locking of a finger as the finger flexed or extended. The thumb and the ring finger is usually affected in adults, while in paediatric, triggered finger occured at the thumb CITATION Fro15 l 1086 (Frontera , Silver, & Rizzo, 2015). Based on Ferri (2018), trigger finger is one of the most common causes of hand pain in adults, with prevalence of 2.6% in the general population. According to Frazier & Drzymkowski (2016), trigger finger is also called as stenosing tenosynovitis.

In patient with trigger finger, the digital flexor tendon sheath become inflamed and causes formation of nodule at the flexor tendon. Therefore, the flexor tendon unable to glide through the A1 pulley (Figure 2.1.1) and causes the patient has difficulty in extending the finger actively.The cellular characteristics of the pulley are well characterized as a process of chondroid metaplasia, although it is unclear if the diameter of the pulley is reduced ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.bjps.2017.05.037”, “ISSN” : “18780539”, “PMID” : “28709917”, “abstract” : “To define the role of the flexor tendons in trigger finger, a high-resolution ultrasound examination was performed in 20 trigger fingers and 20 normal contralateral digits in three digital postures: full extension, mid-flexion and near-full flexion. Precise measurements of diameter and cross-sectional area of the combined tendon mass were recorded at five clearly defined locations: summit of the metacarpal head, proximal lip of the proximal phalanx (PP) and at 1/8, 1/4 and 1/2 length of the PP. In the normal tendons, there was an anatomical thickening, not previously appreciated at 1/4 length PP, in the region of the FDS bifurcation. This anatomical region moved proximally on finger flexion to the A1 pulley. In trigger fingers, the flexor tendons had greater diameter (sagittal view) and cross-sectional area than the normal side at all locations (p ; 0.01, p ; 0.001), with an even greater increase in diameter in the FDS bifurcation area (p ; 0.001). Trigger fingers also had thicker A1 pulleys (p ; 0.001). Triggering occurs on flexing the finger when the enlarged combined flexor tendon mass at the specific anatomical region of the FDS bifurcation impacts on the thickened A1 pulley, resisting its excursion.”, “author” : { “dropping-particle” : “”, “family” : “Chuang”, “given” : “X. L.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ooi”, “given” : “C. C.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Chin”, “given” : “S. T.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Png”, “given” : “M. A.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Wong”, “given” : “S. K.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Tay”, “given” : “S. C.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “McGrouther”, “given” : “D. A.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Plastic, Reconstructive and Aesthetic Surgery”, “id” : “ITEM-1”, “issue” : “10”, “issued” : { “date-parts” : “2017” }, “page” : “1411-1419”, “publisher” : “Elsevieru00a0Ltd”, “title” : “What triggers in trigger finger? The flexor tendons at the flexor digitorum superficialis bifurcation”, “type” : “article-journal”, “volume” : “70” }, “uris” : “http://www.mendeley.com/documents/?uuid=0a0429b9-b83f-4678-92ef-89c7d0f4a02f” } , “mendeley” : { “formattedCitation” : “(Chuang et al., 2017)”, “plainTextFormattedCitation” : “(Chuang et al., 2017)”, “previouslyFormattedCitation” : “(Chuang et al., 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Chuang et al., 2017).

Figure 2.1.1
Source : https://www.orthobullets.com/hand/6004/flexor-pulley-systemADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Niyazi”, “given” : “Mohd Saif”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2017” }, “page” : “19-21”, “title” : “Triggering and patient satisfaction following percutaneous trigger finger release”, “type” : “article-journal”, “volume” : “1” }, “uris” : “http://www.mendeley.com/documents/?uuid=f1d3df15-b520-4e95-9e0e-7322c94d00a5” } , “mendeley” : { “formattedCitation” : “(Niyazi, 2017)”, “manualFormatting” : “Niyazi (2017)”, “plainTextFormattedCitation” : “(Niyazi, 2017)”, “previouslyFormattedCitation” : “(Niyazi, 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }Niyazi (2017) stated that triggered finger can be classified into 5 grades by using Eastwood classification (Table 2.1)
Grade Characteristics
Grade 0 Mild crepitus in a non triggering digit
Grade 1 Uneven movement of the digit
Grade2 Clicking without locking
Grade 3 Locking of the digit but passively correctable
Grade 4 Locked digit
Table 2.1
AetiologyMedical conditions
Triggered finger commonly occur in patients with medical conditions sucah as rheumatod arthritis, diabetes and gout. Diabetics have almost 10% lifetime risk of developing a trigger finger CITATION Fer18 l 1086 (Ferri, 2018).

Repititive task
Repetitive movement causes the tendon to be excessively used , thus, contributed to the inflammation and scarring of the tendon that provides flexion movement of the finger CITATION Fra16 l 1086 (Frazier & Drzymkowski, 2016)PrevalenceTrigger finger is commonly attack women in their fifth to sixth decade of life compare to men and nearly six times more frequently. 28 per 100 000 population has reported yearly. The chance of getting trigger finger is 2-3%, but for diabetic patients the percentage will increase up to 10%. This is because due to period and progression of the disease. Risk factors of trigger finger are patients who had Carpal tunnel syndrome, DeQuervain’s disease, Hypothyroidism, Rheumatoid arthritis, renal disease and Amyloidosis. The ring finger is a usually affected site compare to the other fingers ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1007/s12178-007-9012-1”, “author” : { “dropping-particle” : “”, “family” : “Swigart”, “given” : “Carrie R”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Dodds”, “given” : “u00c6 Seth D”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2008” }, “page” : “92-96”, “title” : “Trigger finger : etiology , evaluation , and treatment”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=74650509-45c2-484e-bf01-d7b0c7a20317” }, { “id” : “ITEM-2”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Akhtar”, “given” : “Sohail”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bradley”, “given” : “Mary J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Quinton”, “given” : “David N”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Burke”, “given” : “Frank D”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-2”, “issue” : “July”, “issued” : { “date-parts” : “2005” }, “page” : “30-33”, “title” : “Clinical review Management and referral for trigger finger / thumb”, “type” : “article-journal”, “volume” : “331” }, “uris” : “http://www.mendeley.com/documents/?uuid=3047231e-e240-4a6d-a741-96c2552e6657” } , “mendeley” : { “formattedCitation” : “(Akhtar, Bradley, Quinton, ; Burke, 2005; Swigart ; Dodds, 2008)”, “plainTextFormattedCitation” : “(Akhtar, Bradley, Quinton, ; Burke, 2005; Swigart ; Dodds, 2008)”, “previouslyFormattedCitation” : “(Akhtar, Bradley, Quinton, ; Burke, 2005; Swigart ; Dodds, 2008)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Akhtar, Bradley, Quinton, & Burke, 2005; Swigart & Dodds, 2008).

Anatomy of Trigger Finger
Figure 2.4.1 Figure 2.4.2
Source: HYPERLINK “https://orthoinfo.aaos.org/en/diseases–conditions/trigger-finger/” https://orthoinfo.aaos.org/en/diseases–conditions/trigger-finger/
Flexor tendon is surrounded by tendon sheath (membranous structure). Annular pulleys are the thick sheath over the bones while the cruciform pulleys are the thin sheath over the joints. During the digital flexion the annular pulley loose and the cruciform pulley is compress ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Akhtar”, “given” : “Sohail”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bradley”, “given” : “Mary J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Quinton”, “given” : “David N”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Burke”, “given” : “Frank D”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “July”, “issued” : { “date-parts” : “2005” }, “page” : “30-33”, “title” : “Clinical review Management and referral for trigger finger / thumb”, “type” : “article-journal”, “volume” : “331” }, “uris” : “http://www.mendeley.com/documents/?uuid=3047231e-e240-4a6d-a741-96c2552e6657” } , “mendeley” : { “formattedCitation” : “(Akhtar et al., 2005)”, “plainTextFormattedCitation” : “(Akhtar et al., 2005)”, “previouslyFormattedCitation” : “(Akhtar et al., 2005)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Akhtar et al., 2005).
It start from A1 pulley, A2 pulley at the proximal end of the proximal phalanx, C1 pulley at middle of proximal phalanx, A3 pulley at the proximal end of the middle phalanx, C2 pulley at the proximal end of the middle phalanx, A4 at the middle of the middle phalanx, C3 at the distal end of the middle phalanx and lastly is A5 at the proximal end of distal phalanx. At the proximal border of the tendon sheath A1 pulley (annular pulley), the thickened nodule on the flexor tendon hit the A1 pulley, and this cause the finger cannot be straightened CITATION Kal17 l 1033 (Kale, 2017).

PathophysiologyTrigger finger is also known as stenosing flexor tenosynovitis. In a normal movement mechanism, the tendon of finger flexor glides back and forth under a restraining pulley system consists of a series of annular and cruciform pulley and produced flexion or extension movement CITATION Mak08 l 17417 (Makkouk, Oetgen, Swigart, ; Dodds, 2008). However, in trigger finger cases, patient having difficulties in flexes or extends their finger due to pain or locking of finger in certain position.
Trigger finger caused by microtrauma due to repetitive friction or compression forces between flexor tendon and corresponding inner layer of the retinacular sheath (A1 pulley). These will lead to inflammation and injury of the flexor tendon-sheath complex CITATION Jea17 l 17417 (Jeanmonod ; Waseem, 2017).

Over time, the inflammation resulted in hypertrophy of the sheath (fibrocartilaginous metaplasia) and nodule developed. The nodule blocks the tendon from passing smoothly under the A1 pulley. Thus, patient unable to smoothly flexes or extends finger as the tendon get stuck due to the narrowing of the sheath. Forced extension or flexion of the finger causing pain and catching of the finger CITATION Ten10 l 17417 (Tendon trouble in the hands: de Quervain’s tenosynovitis and trigger finger, 2010).

In severe cases, finger locked in flexion (if the nodule proximal to A1 pulley) or extension (if the nodule distal to A1 pulley) cause functional deficit.

centerbottom
Sign and SymptomThe main symptom of trigger finger is pain. Pain will become worst with active gripping motions of hand. Thus the range of motion of the finger limited due to painCITATION Wal18 l 17417 (Waldman, 2018). Next, inflammation at affected tendon will cause tenderness in the palm at the base of affected finger (Figure 2.6.1). Other than that, finger stiffness and locking finger tend to be worse after periods on inactivity, usually after wake up in the morning CITATION Tri18 l 17417 (Trigger Finger: Surgery & Treatment, Symptoms, and Causes). Clicking and popping sound will produce when the finger is moving due to joint unable to glide smoothly CITATION Tri17 l 17417 (Trigger finger – Symptoms and causes – Mayo Clinic, 2017).

Source: http://samimimd.com/services/handwrist/trigger-finger/Figure 2.6.1Inflammation of tendon
AssessmentThe subjective assessment starts with the history of condition and symptoms including past and current to find out the cause of the conditionCITATION Dio11 l 17417 (Ryder, 2011). The patient may explain the history of recent trauma, job related repetitive movement, locking or snapping while flexing or extending the affected digit, radiating pain to the palm or digits. Then, pain assessment should be carried out to identify the area of pain, quality of pain, intensity of pain using Numeric Pain Rating Scale (NPRS), aggravating factor, easing factor and also twenty-four hours behaviour of symptom CITATION Dio11 l 17417 (Ryder, 2011). Other information such as family history, social history such as hobby, hand dominance, general health and underlying disease such as diabetes mellitus, inflammatory arthritis and gout will be helpful in diagnosing trigger finger CITATION Col08 l 17417 (Colbourn, Heath, Manary, & Pacifico, 2008).

Observation on the affected site may find a digit locked in flexion and swelling. Tenderness may exist during palpation. A painful nodule in the palmar metacarpophalangeal secondary to intratendinous swelling may present in patient with trigger fingerCITATION Con17
l 17417 (Trigger finger, 2017). Range of motion of the digit as well as cervical, shoulder, elbow, forearm and wrist to rule out any involvement. The affected digit may loss of motion, particularly in extension. It is important to determine whether there is normal passive range of motion in metacarpophalangeal and interphalangeal to detect any interphalangeal joint flexion contractures. The grip strength is also assessed using hand held dynamometer and the strength is usually decreased due to pain CITATION Lan17 l 17417 (Langer, Maeir, Michailevich, & Luria, 2017). Neurologic examination findings, including sensation, and reflexes, should be normal, with the exception of severe cases associated with disuse weakness or atrophy CITATION Ben15 l 17417 (Bengston & Silver, 2015).

The special test performed on patient with trigger finger is open and close hand x10. In this test, patient is asked to make ten fists actively. The number of triggering events in ten active full fists is then scored out of 10. If patient’s finger remains locked at any time, the test is completed and an automatic score of 10/10 is recorded. This test is also one of the outcome measures for trigger finger CITATION Col08 l 17417 (Colbourn, Heath, Manary, ;Pacifico, 2008).

Management2.8.1Doctor ManagementDoctor management for trigger finger involved conservative treatments ( the uses of non-steroidal anti-inflammatory medications (NSAIDs), corticosteroid injections, and immobilization utilizing varying orthoses) and non-conservative treatments ( percutaneous TF release, and surgery) ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jht.2017.10.016”, “ISSN” : “1545004X”, “abstract” : “Study Design: Systematic review. Introduction: Trigger finger (TF) is a common condition in the hand. The primary purpose of this systematic review was to evaluate the current evidence to determine the efficacy of orthotic management of TF. A secondary purpose was to identify the characteristics of the orthotic management. The tertiary purpose of this study was to ascertain if the studies used a patient-reported outcome to assess gains from the patient’s perspective. Methods: All studies including randomized controlled trials, prospective, and retrospective cohort studies were included in this review due to limited high-level evidence. Results: Four authors demonstrated moderate to large effect sizes ranging from 0.49 to 1.99 for pain reduction after wearing an orthotic device. Two authors demonstrated a change in the stages of stenosing tenosynovitis scale scores showing a clinically important change with a large effect size ranging from 0.97 to 1.63. Seven authors immobilized a single joint of the affected digit using a variety of orthoses. Conclusion: All authors reported similar results regardless of the joint immobilized; therefore for orthotic management of the TF, we recommend a sole joint be immobilized for 6-10 weeks. In assessing TF, most authors focused on body structures and functions including pain and triggering symptoms, 2 authors used a validated functional outcome measure. In the future therapists should use a validated patient report outcome to assess patient function that is sensitive to change in patients with TF. Furthermore, more randomized controlled trials are needed.”, “author” : { “dropping-particle” : “”, “family” : “Lunsford”, “given” : “Dianna”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Valdes”, “given” : “Kristin”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hengy”, “given” : “Selena”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Therapy”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2018” }, “publisher” : “Elsevier Inc”, “title” : “Conservative management of trigger finger: A systematic review”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=ab309ff2-bd3a-4daa-bc49-c5fa1b45372f”, “http://www.mendeley.com/documents/?uuid=94f01407-ae96-4f5f-8284-284ebdb79542” } , “mendeley” : { “formattedCitation” : “(Lunsford, Valdes, & Hengy, 2018)”, “plainTextFormattedCitation” : “(Lunsford, Valdes, & Hengy, 2018)”, “previouslyFormattedCitation” : “(Lunsford, Valdes, & Hengy, 2018)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Lunsford, Valdes, ; Hengy, 2018).

For minor case of trigger finger, doctor would recommend patient with splint and injection. Splint wear is advised for 3-9 weeks but usually splinting is focusing on the metacarpophalangeal to allow the full movement of interphalangeal ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1177/1753193416682917”, “ISBN” : “1753193416682”, “ISSN” : “20436289”, “PMID” : “28488453”, “abstract” : “The aim of this systematic review was to develop an evidence-based guideline to assist clinicians in the treatment of adult trigger digits. There is moderate evidence to suggest that local corticosteroid injection is a safe and effective short-term treatment and it may, therefore, be recommended as an initial treatment for this condition. However, when compared with surgery, there is strong evidence that corticosteroid injection is associated with increased rates of ongoing or recurrent symptoms at 6 months after intervention. There is strong evidence suggesting that trigger digit can be managed safely by surgical release. There is weak evidence to support the use of splinting or other non-operative modalities. Hence a single corticosteroid injection may be offered as the first line in treatment of adult trigger digits, but percutaneous release is a safe alternative. Surgery should be the next line if the injection fails, symptoms recur or the patient chooses.”, “author” : { “dropping-particle” : “”, “family” : “Amirfeyz”, “given” : “R.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “McNinch”, “given” : “R.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Watts”, “given” : “A.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Rodrigues”, “given” : “J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Davis”, “given” : “T. R.C.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Glassey”, “given” : “N.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bullock”, “given” : “J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Surgery: European Volume”, “id” : “ITEM-1”, “issue” : “5”, “issued” : { “date-parts” : “2017” }, “page” : “473-480”, “title” : “Evidence-based management of adult trigger digits”, “type” : “article-journal”, “volume” : “42” }, “uris” : “http://www.mendeley.com/documents/?uuid=72ff244f-92e8-43bd-bcac-5316a0ea8d5b”, “http://www.mendeley.com/documents/?uuid=f159cf2e-76ec-4edd-b55b-652f5cc6cd0f” } , “mendeley” : { “formattedCitation” : “(Amirfeyz et al., 2017)”, “plainTextFormattedCitation” : “(Amirfeyz et al., 2017)”, “previouslyFormattedCitation” : “(Amirfeyz et al., 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Amirfeyz et al., 2017).

A study from University Malaya ( UM ) proved that NSAIDs injection is more effective than steroid injection ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jhsa.2012.03.040”, “ISBN” : “0363-5023”, “ISSN” : “03635023”, “PMID” : “22721455”, “abstract” : “Purpose: Stenosing tenosynovitis of the flexor tendon sheath of the digits of the hand results from a discrepancy between the diameter of the flexor tendon and its sheath at the A1 pulley. The treatment options for trigger digits include oral nonsteroidal anti-inflammatory drugs (NSAIDs) and local NSAID applications, splintage, steroid injection, and percutaneous and open release of the A1 pulley. Injectable NSAID is used intramuscularly and locally in other sites. The hypothesis is that an injectable NSAID is as effective as the traditionally used steroid injection in the treatment of trigger digit, based on Quinnell grading, and that the treatment works as well in patients with diabetes as in those without diabetes. Methods: In this prospective, randomized, double-blinded controlled study for trigger digits, we injected diclofenac sodium locally in one group (NSAID group) and triamcinolone acetonide in another (corticosteroid group). A total of 100 patients (50 patients in each group) were followed up and assessed 3 weeks and 3 months after the injection. Results: At the end of the follow-up, 35 patients (70%) in the corticosteroid group and 28 patients (53%) in the NSAID group had complete symptomatic resolution. There was no difference between the response of patients with and without diabetes. There was no significant difference found in Quinnell score between treatments at 3 months, although at 3 weeks, the patients who received steroid had significantly better Quinnell scores. Conclusions: We concluded that, although steroids gave quicker relief, NSAID injections are equally effective at 3 months in the treatment of trigger digits. We were unable to detect a statistically significant difference in the response of patients with and without diabetes to either treatment. Therapeutic I. u00a9 2012 American Society for Surgery of the Hand. All rights reserved.”, “author” : { “dropping-particle” : “”, “family” : “Shakeel”, “given” : “Hussain”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ahmad”, “given” : “T. Sara”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Surgery”, “id” : “ITEM-1”, “issue” : “7”, “issued” : { “date-parts” : “2012” }, “page” : “1319-1323”, “publisher” : “Elsevier Inc.”, “title” : “Steroid injection versus NSAID injection for trigger finger: A comparative study of early outcomes”, “type” : “article-journal”, “volume” : “37” }, “uris” : “http://www.mendeley.com/documents/?uuid=2ca36158-3ba4-4053-9c50-8fa960d7bf50”, “http://www.mendeley.com/documents/?uuid=10c73a0c-5155-4b63-a3a1-7f6154d27393” } , “mendeley” : { “formattedCitation” : “(Shakeel & Ahmad, 2012)”, “plainTextFormattedCitation” : “(Shakeel & Ahmad, 2012)”, “previouslyFormattedCitation” : “(Shakeel & Ahmad, 2012)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Shakeel ; Ahmad, 2012). The effect NSAIDs injection (dilcofenac sodium) last 3 month longer than steroid injection (triamcinolone acetoide).For a severe cases, a surgery is needed., The percutaneous and open surgery methods (Figure 2.8.1a and 2.8.1b) displayed similar effectiveness and proved superior to the conservative corticosteroid method regarding the trigger cure and relapse rates ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1093/rheumatology/ker315”, “ISBN” : “1462-0332”, “ISSN” : “14620324”, “PMID” : “22039269”, “abstract” : “Objective. The aim of this study is to evaluate the effectiveness of CS injection, percutaneous pulley release and conventional open surgery for treating trigger finger in terms of cure, relapse and complication rates.\nMethods. One hundred and thirty-seven patients with a total of 150 fingers were randomly assigned and allocated into one of the treatment groups, with treatments allocated into 150 opaque and sealed envelopes. We included patients >15 years of age with a trigger on any finger of the hand (Types IIu2013IV) and used a minimum follow-up time of 6 months. The primary outcome measures were cures, relapses and failures.\nResults. Forty-nine patients were assigned to the conservative group to undergo CS injections, whereas 45 and 56 were assigned to undergo percutaneous release and outpatient open surgery, respectively. The trigger cure rate for patients in the injection method group was 57%, and wherever necessary, two injections were administered, which increased the cure rate to 86%. For the percutaneous and open release methods, remission of the trigger was achieved in all cases.\nConclusions. The percutaneous and open surgery methods displayed similar effectiveness and proved superior to the conservative CS method regarding the trigger cure and relapse rates.\nTrial registration. Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926.”, “author” : { “dropping-particle” : “”, “family” : “Sato”, “given” : “Edson S.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Gomes dos santos”, “given” : “Jou00e3o B.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Belloti”, “given” : “Jou00e3o C.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Albertoni”, “given” : “Walter M.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Faloppa”, “given” : “Flavio”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Rheumatology”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2012” }, “page” : “93-99”, “title” : “Treatment of trigger finger: Randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery”, “type” : “article-journal”, “volume” : “51” }, “uris” : “http://www.mendeley.com/documents/?uuid=68c70791-14d0-4539-9c1a-4fecea64a5b2”, “http://www.mendeley.com/documents/?uuid=9fad98f7-3463-41d9-a8a5-2cf482e395fd” } , “mendeley” : { “formattedCitation” : “(Sato, Gomes dos santos, Belloti, Albertoni, & Faloppa, 2012)”, “plainTextFormattedCitation” : “(Sato, Gomes dos santos, Belloti, Albertoni, & Faloppa, 2012)”, “previouslyFormattedCitation” : “(Sato, Gomes dos santos, Belloti, Albertoni, & Faloppa, 2012)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Sato, Gomes dos santos, Belloti, Albertoni, ; Faloppa, 2012).

Figure 2.8.1a Percutaneous release surgery Figure 2.8.1b Open release surgery
2.8.2Physiotherapy ManagementPhysiotherapy management for trigger fingers are hot and cold therapy (paraffin wax and ice) soft tissue mobilization and hand exercise.

According to ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.5958/j.0973-5674.8.1.033”, “ISSN” : “0973-5666”, “author” : { “dropping-particle” : “”, “family” : “Malty”, “given” : “Abul-Majeed”, “non-dropping-particle” : “Al”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Jebril”, “given” : “Mohammad”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “AbuTariah”, “given” : “Hashem”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Albostanji”, “given” : “Shaden”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Indian Journal of Physiotherapy and Occupational Therapy – An International Journal”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “0” }, “page” : “170”, “title” : “The Effect of Paraffin Wax and Exercise vs. Exercise Treatment on Keyboard User’s Hands Pain and Strength”, “type” : “article-journal”, “volume” : “8” }, “uris” : “http://www.mendeley.com/documents/?uuid=783526b7-11ba-43df-9112-030e62c27e93”, “http://www.mendeley.com/documents/?uuid=b46070ea-552e-4f2f-b895-66973e366ec7” } , “mendeley” : { “formattedCitation” : “(Al Malty, Jebril, AbuTariah, & Albostanji, n.d.)”, “manualFormatting” : “(Al Malty, Jebril, AbuTariah, & Albostanji, 2014)”, “plainTextFormattedCitation” : “(Al Malty, Jebril, AbuTariah, & Albostanji, n.d.)”, “previouslyFormattedCitation” : “(Al Malty, Jebril, AbuTariah, & Albostanji, n.d.)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Al Malty, Jebril, AbuTariah, ; Albostanji, 2014), paraffin bath or paraffin wax combining with hand exercise will relieve the pain much faster rather than exercise alone. The single blinded study chooses 33 secretary typewriters to participate in the study and they were divided into two groups: paraffin bath with exercise and exercise alone. The result shown the group which get both treatment relieve pain and build strength faster than the other group.
For soft tissue mobilization, active release technique (ART) and Graston technique (Figure 2.8.2a) are used help patient achieve full range of motion (ROM) and reduce pain ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “0008-3194 (Print)\n0008-3194 (Linking)”, “ISSN” : “0008-3194”, “PMID” : “17549185”, “abstract” : “OBJECTIVE To detail the progress of a patient with unresolved symptoms of Trigger thumb who underwent a treatment plan featuring Active Release Technique (ART) and Graston Technique. CLINICAL FEATURES The most important feature is painful snapping or restriction of movement, most notably in actively extending or flexing the digit. The cause of this flexor tendinopathy is believed to be multi-factorial including anatomical variations of the pulley system and biomechanical etiologies such as exposure to shear forces and unaccustomed activity. Conventional treatment aims at decreasing inflammation through corticosteroid injection or surgically removing imposing tissue. INTERVENTION AND OUTCOME The conservative treatment approach utilized in this case involved Active Release Technique (ART) and Graston Technique (GT). An activity specific rehabilitation protocol was employed to re-establish thumb extensor strength and ice was used to control pain and any residual inflammation. Outcome measures included subjective pain ratings with range of motion and motion palpation of the first right phalangeal joint. Objective measures were made by assessing range of motion. CONCLUSION A patient with trigger thumb appeared to be relieved of his pain and disability after a treatment plan of GT and ART.”, “author” : { “dropping-particle” : “”, “family” : “Howitt”, “given” : “Scott”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Wong”, “given” : “Jerome”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Zabukovec”, “given” : “Sonja”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “The Journal of the Canadian Chiropractic Association”, “id” : “ITEM-1”, “issue” : “4”, “issued” : { “date-parts” : “2006” }, “page” : “249-54”, “title” : “The conservative treatment of Trigger thumb using Graston Techniques and Active Release Techniques.”, “type” : “article-journal”, “volume” : “50” }, “uris” : “http://www.mendeley.com/documents/?uuid=56899c56-fe16-4faf-85c2-5249eb62f309”, “http://www.mendeley.com/documents/?uuid=32c59b57-e6e7-4322-94b7-e3b281ba1683” } , “mendeley” : { “formattedCitation” : “(Howitt, Wong, & Zabukovec, 2006)”, “plainTextFormattedCitation” : “(Howitt, Wong, & Zabukovec, 2006)”, “previouslyFormattedCitation” : “(Howitt, Wong, & Zabukovec, 2006)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Howitt, Wong, ; Zabukovec, 2006). The result shown the patient achieves full ROM and reduce pain on his 8th treatment. The case report informed they used ice as a pre and post treatment to control pain on patient thumb. So, they use the combination of soft tissue mobilization and ice to increase the effectiveness in their treatment.
Basically, the combination of certain treatment can improve patient’s hand performance and reduce their recovery time.

.

Figure 2.8.2a: Graston technique
ComplicationComplication of trigger finger is rare and most of them occur following the surgical intervention. The most common complication of trigger finger is stiffness of the affected finger. Next, temporary soreness and swelling at the site of surgery due to incision. Patient with surgery will have inability to straighten the affected finger if the finger is not straightened completely before the surgery. Other than that, the less common complications may include persistent locking and clicking which indicate more pulleys needs to be released. Bowstringing occur when one or more important pulleys are released and tendon bow away from the bone resulting reduced in range of motion. In other words, bowstringing mean tendon is in wrong position (Figure 2.9.1). Besides, digital nerve injury can happened and cause numbness or tingling sensation along the part of finger. Infection is also common complication during surgery but rare in trigger finger surgery. CITATION Tri181 l 17417 (Trigger Finger – Trigger Thumb – OrthoInfo – AAOS, 2018)
Source: http://boneandspine.com/trigger-finger-presentation-and-treatment/
Figure 2.9.1
DE QUERVAIN’S TENOSYNOVITISDefinitionDe quervain disease or also called as de quervain tendinosis is a condition of inflammation of the first extensor compartment of the wrist ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.main.2013.09.002”, “ISSN” : “12973203”, “PMID” : “24139754”, “abstract” : “The purpose of this study was to describe the technique and usefulness of ultrasound-guided intrasheath injection of triamcinolone in the treatment of de Quervain’s disease (dQD). Our study was retrospective in design. Seventy-one wrists of 62 patients who were treated with an ultrasound-guided triamcinolone injection for dQD were included. A literature search was performed to compare our results. In the literature we found supportive evidence that accurate injection of triamcinolone in the first dorsal compartment of the wrist is important for a good outcome. In this retrospective study we found that treatment with ultrasound-guided injections of triamcinolone is both safe and effective. After two injections, 91% of the patients had good long-term results, which is a higher cure rate than found in most other studies. Furthermore, we found that Finkelstein’s test can give a false positive result. Therefore, ultrasound should not only be considered to improve the treatment outcome, but can also be useful as a diagnostic tool in the management of de Quervain’s disease. u00a9 2013 .”, “author” : { “dropping-particle” : “”, “family” : “Hajder”, “given” : “E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Jonge”, “given” : “M. C.”, “non-dropping-particle” : “de”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Horst”, “given” : “C. M A M”, “non-dropping-particle” : “van der”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Obdeijn”, “given” : “M. C.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Chirurgie de la Main”, “id” : “ITEM-1”, “issue” : “6”, “issued” : { “date-parts” : “2013” }, “page” : “403-407”, “publisher” : “Elsevier Masson SAS”, “title” : “The role of ultrasound-guided triamcinolone injection in the treatment of De Quervain’s disease: Treatment and a diagnostic tool?”, “type” : “article-journal”, “volume” : “32” }, “uris” : “http://www.mendeley.com/documents/?uuid=e755edc7-ca48-4605-8f28-41a8ed5326d7” } , “mendeley” : { “formattedCitation” : “(Hajder, de Jonge, van der Horst, & Obdeijn, 2013)”, “plainTextFormattedCitation” : “(Hajder, de Jonge, van der Horst, & Obdeijn, 2013)”, “previouslyFormattedCitation” : “(Hajder, de Jonge, van der Horst, & Obdeijn, 2013)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Hajder, de Jonge, van der Horst, ; Obdeijn, 2013). (Figure 3.1.1). The swelling of the tendon and the tendon sheath may cause pain at the base of the thumb when they rub each other. It is commonly noticeable when the patient is gripping an object or forming a fist.

Figure 3.1.1
Source : http://www.georgia-clinic.com/blog/2014/10/treatment-for-de-quervain-tenosynovitis-in-augusta-ga/
According to Forget et al (2008), de Quervain’s disease is caused by a stenosis of the first dorsal compartment of the wrist that contains the tendons and synovial sheaths of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles. The APL acts at the base of the first metacarpal to abduct the thumb while the EPB extends the metacarpophalangeal joint and contributes to abduction of the thumb.
De quervain disease may occur together with carpal tunnel syndrome and trigger finger CITATION Pat98 l 1086 (Patry, Rossignol, Costa, & Baillargeon, 1998).

AetiologyOveruse of the tendon
Excessive ulnar deviation of the hand during grasping, for example when playing tennis or gardening causes the abductor pollicis brevis tendon and extensor pollicis brevis tendon that rub over the radial styloid to irritate. Hence, causes the tendon to inflame CITATION Mad18 l 1086 (Madden, Putukian , McCarty, & Young, 2018).

Inflammatory conditions
Inflammatory conditions such as rheumatoid disease causes inflammation to the joint, tendons, or ligament. Therefore, inflammation to the APB and EPB tendon may contribute to the occurent of de quervain disease. CITATION Fer18 l 1086 (Ferri, 2018)Direct blow to the thumb
Sudden and direct hit to the thumb may cause acute trauma to the first extensor dorsal compartment,thus, results in de quervain disease CITATION Fer18 l 1086 (Ferri, 2018).

PrevalenceDe Quervain’s tenosynovitis is the most common tenosynovitis affecting the dorsal tendons of the wrist. It usually occurs in individual age between 30 and 50 years old and it is ten times prevalent among women than men. Higher risk for worker or sports that perform repetitive activities increases the risk of developing De Quervain’s tenosynovitis. CITATION Cos17 l 1033 (Costa, Patry, Rossignol, &Baillargeon, 2017).Anatomy of De Quervain’s tenosynovitisAbductor PollicisLongus muscle (APL) and Extensor Pollicis Brevis muscle (EPB) have their own roles in order to allow the thumbs to do abduction and extension. The origin of the APL muscle is at the posterior surfaces of ulna and it is insertion at the base of 1st metacarpal. Next, EPB muscle originates at posterior surface of radius and interosseous membrane and it is insertion at the base of the proximal phalanx of the thumbs. These muscles are innervated by radial nerve, which is to allow its action, abduction of the thumb and extends proximal phalanx of thumb at carmpometacarpal joint ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “2921146703”, “author” : { “dropping-particle” : “”, “family” : “Costa”, “given” : “Marie-jeanne”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “Tenosynovitis”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=1bb1d66e-553c-4ce6-81df-c4331a1258ce” }, { “id” : “ITEM-2”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tenosynovitis”, “given” : “Stenosing”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-2”, “issued” : { “date-parts” : “1895” }, “title” : “De quervain u2019 s stenosing tenosynovitis Wrist and thumb splint / bulky dressing”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=7172faac-6ab2-4ff2-82ab-dce6a39cab50” } , “mendeley” : { “formattedCitation” : “(Costa, n.d.; Tenosynovitis, 1895)”, “plainTextFormattedCitation” : “(Costa, n.d.; Tenosynovitis, 1895)”, “previouslyFormattedCitation” : “(Costa, n.d.; Tenosynovitis, 1895)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Costa, n.d.; Tenosynovitis, 1895).
-222252538095 The tendons of APL and EPB muscles are located at the first dorsal compartment which made of extensor retinaculum (thick fibrous layer)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tenosynovitis”, “given” : “Stenosing”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “1895” }, “title” : “De quervain u2019 s stenosing tenosynovitis Wrist and thumb splint / bulky dressing”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=7172faac-6ab2-4ff2-82ab-dce6a39cab50” } , “mendeley” : { “formattedCitation” : “(Tenosynovitis, 1895)”, “plainTextFormattedCitation” : “(Tenosynovitis, 1895)”, “previouslyFormattedCitation” : “(Tenosynovitis, 1895)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tenosynovitis, 1895).

Figure 3.4.1 ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tenosynovitis”, “given” : “Stenosing”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “1895” }, “title” : “De quervain u2019 s stenosing tenosynovitis Wrist and thumb splint / bulky dressing”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=7172faac-6ab2-4ff2-82ab-dce6a39cab50” } , “mendeley” : { “formattedCitation” : “(Tenosynovitis, 1895)”, “plainTextFormattedCitation” : “(Tenosynovitis, 1895)”, “previouslyFormattedCitation” : “(Tenosynovitis, 1895)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tenosynovitis, 1895) Figure 3.4.2ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tenosynovitis”, “given” : “Stenosing”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “1895” }, “title” : “De quervain u2019 s stenosing tenosynovitis Wrist and thumb splint / bulky dressing”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=7172faac-6ab2-4ff2-82ab-dce6a39cab50” } , “mendeley” : { “formattedCitation” : “(Tenosynovitis, 1895)”, “plainTextFormattedCitation” : “(Tenosynovitis, 1895)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tenosynovitis, 1895)
PathophysiologyIn de Quervain’s tenosynovitis condition, abductor pollicislongus (APL) and extensor pollicis brevis (EPB) tendon are resisted from gliding in the fibro-osseous canal and produced pain CITATION Ast07 l 17417 (Ast, Alyssa, Thoder, & Ilyas, 2007).Acute trauma or repetitive use increase risk of APL and EPB tendon entrapment. As inflammation occurs, the soft tissues that make up the tunnel thicken and narrowed the tunnel. Besides, an increase amount of soft tissue within the tunnel also narrowed the tunnel because the tendon takes up extra space in the tunnel CITATION DeQ17 l 17417 (De Quervain’s Tenosynovitis, 2017).

centercenter
Sign and SymptomPatient with de Quervain’s disease will have tenderness and swelling over the tendons sheath along the distal radius. Inflammation of tendon will cause tenderness over styloid process of radius (Figure 3.6.1) CITATION Wal11 l 17417 (Waldman, 2011). Next, symptom of de Quervain’s disease is pain over the thumb side of the wrist CITATION DeQ13 l 17417 (De Quervain’s Tendinosis – Symptoms and Treatment – OrthoInfo – AAOS, 2013). The pain usually become worse when the patient grasping objects or twisting the wrist forcefully. Other than that, creaking and squeaking sound produced when doing flexion and extension of the thumb. This happen because the tendons rub against the muscles and move with swollen sheaths CITATION deQ17 l 17417 (de Quervain’s Tenosynovotis: Causes ; Treatment – familydoctor.org, 2017).

Source: https://www.schreibermd.com/de-quervain-syndrome/
Figure 3.6.1Tenderness over styloid process of radius
AssessmentIn order to collect information from the patient, therapists need to ask about the history including past and current and nature of work to find out the cause of the conditionCITATION Dio11 l 17417 (Ryder, 2011). The patient may note the history of overuse injury or acute trauma, repetitive movements of the upper extremities with ADL and pain localized over the base of thumb and dorsolateral aspect of the wrist near radial styloid process. Then, pain assessment should be carried out to identify the area of pain, quality of pain, intensity of pain using Numeric Pain Rating Scale (NPRS), aggravating factor, easing factor and also twenty-four hours behaviour of symptom CITATION Dio11 l 17417 (Ryder, 2011). Other information such as family history, social history such as hobby, hand dominance, general health and underlying disease such as diabetes mellitus, inflammatory arthritis and cardiovascular disease will be helpful in determining the most efficient treatment.

After the subjective assessment, observation of local may find out that patient tend to put the hand or thumb in resting posture. Inflammation near the radial styloid process may be found during local observation indicated by swellingCITATION ONe15 l 17417 (O’Neill, 2015). Next, palpation of radial styloid process, anatomical snuff box, 1st carpometacarpal joint and also soft tissue surrounding involve area may detect palpable thickening of the synovial sheath and also tenderness. Following the palpation, therapists will check for range of motion of the wrist (for flexion, extension, ulnar deviation and radial deviation) and also all digits (for flexion, extension, abduction and adduction). Range of motion of the thumb may produce a ‘catching’ or ‘snapping sensation’ due to restrictive mobility of tendon through tendon sheath. Range of motion for cervical movement, shoulder, elbow and forearm also need to be check to rule out their involvement with the condition. After that, manual muscle testing is carried on to determine the grip strength and also pinch strength. The tests are accomplish using JAMAR set, hand-held dynamometer and pinch gauge may indicated decrease in strength due to pain or disuse secondary to pain CITATION con17
l 17417 (De Quervain’s Tenosynovitis, 2017).

In order to confirm the diagnosis, special test, Finkelstein test (Figure 3.7.1) is performed by grasping the patient’s thumb and quickly abducting the hand in ulnar deviation. Reproduction of pain indicates a positive test result CITATION She13 l 17417 (Shehab & Mirabelli, 2013).

Other special test such as Grind test (Figure 3.7.2) is performed to rule our osteoarthritis of 1st carpometacarpal. The test is performed by axial compression and slight rotation of the metacarpophalangeal joint and should produce a negative result in de Quervain patient CITATION She13 l 17417 (Shehab& Mirabelli, 2013).

Figure 3.7.1 Finkelstein test Figure 3.7.2 Grind test
ManagementDoctor ManagementDe Quervain’s tenosynovitis is a disorder characterised by pain on the radial (thumb) side of the wrist and functional disability of the hand ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1002/14651858.CD005616.pub2.1”, “ISSN” : “1465-1858”, “author” : { “dropping-particle” : “”, “family” : “Peters-Veluthamaningal”, “given” : “C”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Windt”, “given” : “DAWM”, “non-dropping-particle” : “van der”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Winters”, “given” : “JC”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Meyboom-de Jong”, “given” : “B”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Cochrane Database of Systematic Reviews”, “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2009” }, “page” : “CD005616”, “title” : “Corticosteroid injection for de Quervain u2019 s tenosynovitis ( Review )”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=d9afa034-c47b-4e13-98f3-cffbed7f1c42”, “http://www.mendeley.com/documents/?uuid=25f1e3be-fff6-482a-a76e-44125a6d4ba4” } , “mendeley” : { “formattedCitation” : “(Peters-Veluthamaningal, van der Windt, Winters, & Meyboom-de Jong, 2009)”, “plainTextFormattedCitation” : “(Peters-Veluthamaningal, van der Windt, Winters, & Meyboom-de Jong, 2009)”, “previouslyFormattedCitation” : “(Peters-Veluthamaningal, van der Windt, Winters, & Meyboom-de Jong, 2009)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Peters-Veluthamaningal, van der Windt, Winters, ; Meyboom-de Jong, 2009). The doctor management for De Quervain’s tenosynovitis are either conservative treatments (corticosteroid injection and splinting) or non-conservative treatments (open release surgery).

Commonly, De Quervain’s tenosynovitis is treated using conservative treatments. According ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1002/14651858.CD005616.pub2.1”, “ISSN” : “1465-1858”, “author” : { “dropping-particle” : “”, “family” : “Peters-Veluthamaningal”, “given” : “C”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Windt”, “given” : “DAWM”, “non-dropping-particle” : “van der”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Winters”, “given” : “JC”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Meyboom-de Jong”, “given” : “B”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Cochrane Database of Systematic Reviews”, “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2009” }, “page” : “CD005616”, “title” : “Corticosteroid injection for de Quervain u2019 s tenosynovitis ( Review )”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=25f1e3be-fff6-482a-a76e-44125a6d4ba4”, “http://www.mendeley.com/documents/?uuid=d9afa034-c47b-4e13-98f3-cffbed7f1c42” } , “mendeley” : { “formattedCitation” : “(Peters-Veluthamaningal et al., 2009)”, “plainTextFormattedCitation” : “(Peters-Veluthamaningal et al., 2009)”, “previouslyFormattedCitation” : “(Peters-Veluthamaningal et al., 2009)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Peters-Veluthamaningal et al., 2009), corticosteroid injection (Figure 3.8.1a) can relieve pain. The combination of corticosteroid with hand therapy and immobilisation with splint ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jotr.2014.04.001”, “ISSN” : “22104925”, “abstract” : “Background: De Quervain’s tenosynovitis is a common cause of wrist pain in pregnant and postpartum females. This study provides objective evidence regarding the therapeutic efficacy of phonophoresis in treating de Quervain’s disease during pregnancy. Methods: In a single blind, randomised, controlled trial (. n=50), ketoprofen phonophoresis was given to the intervention group and conventional ultrasound (US) was given to controls, coupled with thumb splint immobilisation, and supervised strengthening and stretching exercises for 1 month. Symptomatic and functional improvement was assessed by visual pain analogue, grip, tip, key, and palmer pinch scales. Results: There was a statistically significant improvement in the intervention group compared to the control group in grip and pinch strength, and pain reduction. Conclusion: Ketoprofen phonophoresis as an adjunct to supervised exercise and splint immobilisation is a safe and effective therapy for de Quervain’s tenosynovitis during pregnancy. Phonophoresis augments the benefits of US in terms of reducing pain and inflammation, and improving functional strength.”, “author” : { “dropping-particle” : “”, “family” : “Hasan”, “given” : “Tabinda”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Fauzi”, “given” : “Mahmood”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Orthopaedics, Trauma and Rehabilitation”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2015” }, “page” : “2-6”, “publisher” : “Elsevier (Singapore) Pte Ltd”, “title” : “De quervain’s tenosynovitis and phonophoresis: A randomised controlled trial in pregnant females. de quervain”, “type” : “article-journal”, “volume” : “19” }, “uris” : “http://www.mendeley.com/documents/?uuid=d7ed0285-64de-4773-abaa-c2c89be2fbe0”, “http://www.mendeley.com/documents/?uuid=b1fc04dd-510a-4895-bd1d-01aa71c3a6c7” } , “mendeley” : { “formattedCitation” : “(Hasan & Fauzi, 2015)”, “plainTextFormattedCitation” : “(Hasan & Fauzi, 2015)”, “previouslyFormattedCitation” : “(Hasan & Fauzi, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Hasan ; Fauzi, 2015).

If conservative management failed to reduce the pain, doctor will consider to perform surgery. Although there are some complication after the surgery i.e; unhealed wound and keloid formation, open release surgery can completely relief all the De Quervain’s tenosynovitis symptoms ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1007/s00264-008-0667-z”, “ISSN” : “03412695”, “PMID” : “18956185”, “abstract” : “The management of de Quervain’s disease (DD) is nonoperative in the first instance, but surgery should be considered if conservative measures fail. We present the long-term results of operative treatment of DD. From July 1988 to July 1998, 94 consecutive patients with DD were treated operatively by a single surgeon. There were 80 women and 14 men. Average age at the time of operation was 47.4 years (range 22-76). The right wrist was involved in 43 cases, the left in 51 cases. All operations were done under tourniquet control with local infiltration anaesthesia using a longitudinal incision and partial resection of the extensor ligament. There were six perioperative complications, including one superficial wound infection, one delayed wound healing, and four transient lesions of the radial nerve. A successful outcome was achieved in all cases with negative Finkelstein’s test. Simple decompression of both tendons and partial resection of the extensor ligament with a maximum of 3 mm can be recommended in operative treatment of DD with excellent long-term results.”, “author” : { “dropping-particle” : “”, “family” : “Scheller”, “given” : “Alexander”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Schuh”, “given” : “Ralph”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hu00f6nle”, “given” : “Wolfgang”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Schuh”, “given” : “Alexander”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “International Orthopaedics”, “id” : “ITEM-1”, “issue” : “5”, “issued” : { “date-parts” : “2009” }, “page” : “1301-1303”, “title” : “Long-term results of surgical release of de Quervain’s stenosing tenosynovitis”, “type” : “article-journal”, “volume” : “33” }, “uris” : “http://www.mendeley.com/documents/?uuid=164812c9-90d7-4ea9-ad79-feeaddfc6345”, “http://www.mendeley.com/documents/?uuid=def2c093-11e5-43a7-a595-5b27e218d9c6” } , “mendeley” : { “formattedCitation” : “(Scheller, Schuh, Hu00f6nle, ; Schuh, 2009)”, “plainTextFormattedCitation” : “(Scheller, Schuh, Hu00f6nle, ; Schuh, 2009)”, “previouslyFormattedCitation” : “(Scheller, Schuh, Hu00f6nle, ; Schuh, 2009)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Scheller, Schuh, Hönle, & Schuh, 2009).

Figure 3.8.1a: corticosteroid injection
3.8.2Physiotherapy ManagementPhysiotherapy management for De Quervain’s tenosynovitis are electrical stimulation, heat therapy, massage and hand therapy.
The combination of heat therapy and hand therapy will reduce the pain at the thumb faster. Paraffin bath or paraffin wax combining with hand exercise will relieve the pain much faster rather than exercise alone ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.5958/j.0973-5674.8.1.033”, “ISSN” : “0973-5666”, “author” : { “dropping-particle” : “”, “family” : “Malty”, “given” : “Abul-Majeed”, “non-dropping-particle” : “Al”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Jebril”, “given” : “Mohammad”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “AbuTariah”, “given” : “Hashem”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Albostanji”, “given” : “Shaden”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Indian Journal of Physiotherapy and Occupational Therapy – An International Journal”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “0” }, “page” : “170”, “title” : “The Effect of Paraffin Wax and Exercise vs. Exercise Treatment on Keyboard User’s Hands Pain and Strength”, “type” : “article-journal”, “volume” : “8” }, “uris” : “http://www.mendeley.com/documents/?uuid=b46070ea-552e-4f2f-b895-66973e366ec7”, “http://www.mendeley.com/documents/?uuid=783526b7-11ba-43df-9112-030e62c27e93” } , “mendeley” : { “formattedCitation” : “(Al Malty et al., n.d.)”, “plainTextFormattedCitation” : “(Al Malty et al., n.d.)”, “previouslyFormattedCitation” : “(Al Malty et al., n.d.)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Al Malty et al., n.d.).

A combination of Graston technique and eccentric exercises involving forearm, wrist and fingers can reduce pain in De Quervain’s tenosynovitis and making patient easier to perform ADL (J.Papa et al, 2012).
Electrical stimulation that is used to treat De Quervain’s tenosynovitis is therapeutic pulsed ultrasound. This device may help in decreasing pain in De Quervain’s tenosynovitis patients ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/j.jht.2017.10.016”, “ISSN” : “1545004X”, “abstract” : “Study Design: Systematic review. Introduction: Trigger finger (TF) is a common condition in the hand. The primary purpose of this systematic review was to evaluate the current evidence to determine the efficacy of orthotic management of TF. A secondary purpose was to identify the characteristics of the orthotic management. The tertiary purpose of this study was to ascertain if the studies used a patient-reported outcome to assess gains from the patient’s perspective. Methods: All studies including randomized controlled trials, prospective, and retrospective cohort studies were included in this review due to limited high-level evidence. Results: Four authors demonstrated moderate to large effect sizes ranging from 0.49 to 1.99 for pain reduction after wearing an orthotic device. Two authors demonstrated a change in the stages of stenosing tenosynovitis scale scores showing a clinically important change with a large effect size ranging from 0.97 to 1.63. Seven authors immobilized a single joint of the affected digit using a variety of orthoses. Conclusion: All authors reported similar results regardless of the joint immobilized; therefore for orthotic management of the TF, we recommend a sole joint be immobilized for 6-10 weeks. In assessing TF, most authors focused on body structures and functions including pain and triggering symptoms, 2 authors used a validated functional outcome measure. In the future therapists should use a validated patient report outcome to assess patient function that is sensitive to change in patients with TF. Furthermore, more randomized controlled trials are needed.”, “author” : { “dropping-particle” : “”, “family” : “Lunsford”, “given” : “Dianna”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Valdes”, “given” : “Kristin”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hengy”, “given” : “Selena”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Hand Therapy”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2018” }, “publisher” : “Elsevier Inc”, “title” : “Conservative management of trigger finger: A systematic review”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=94f01407-ae96-4f5f-8284-284ebdb79542”, “http://www.mendeley.com/documents/?uuid=ab309ff2-bd3a-4daa-bc49-c5fa1b45372f” } , “mendeley” : { “formattedCitation” : “(Lunsford et al., 2018)”, “plainTextFormattedCitation” : “(Lunsford et al., 2018)”, “previouslyFormattedCitation” : “(Lunsford et al., 2018)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Lunsford et al., 2018).

Although there are some modalities that can be used to reduce pain in De Quervain patient, but manual hand exercise also important as the combination of both modalities and hand exercise may decrease the pain even faster.

ComplicationComplication of de Quervain’s disease is tendon sheath become oedematous due to friction. Fibrosis of tendon also will occur over time as the tendon sheath thickened. Next, patient who takes NSAIDs as a treatment may have side effect in gastric, hepatic, and renal systems. Other than that, patient who takes steroid injection may have risk of bleeding. Repeated steroid injections may weaken the tendon and cause a tendon ruptured (Figure 3.9.1). Patient who undergoes surgical treatment may have complication at radial nerve injury, incomplete retinacular release and tendon subluxation CITATION ONe15 l 17417 (O’Neill, 2015).