FLEXOR TENDON INJURIES

Muscles that provide fingers to bent inside are called flexor muscles. They are connected to finger bones with structures which exits from the current muscles in the forearm and look like chords and called tendons. Flexor muscles start from the elbow and forearm and extends to finger ends by converting into tendons in the middle of the arm (Figure 1). Flexor tendons in the finger passes inside of tunnels called pulleys. Pulleys prevent tendons to move away from the bone by forming tunnels on tendon and they provide active operation of joints.

Flexor tendon injuries may arise after deep cuts of the forearm, wrist, hand and fingers.

Flexor tendons are very close with vessel-nerve structures anatomically. Therefore, in palmar side injuries of the hand, injury is frequently together with vessel, nerve injuries as well as flexor tendons. When tendon injury is occurred, tendon ends move away from each other due to muscle traction. Tendon ends may not be found in the cut area immediately. When flexor tendon cut arises, the patient can not bend his/her finger. If the tendon is not completely cut, bending may be possible by the patient. Generally pain accompanies to this situation. If incomplete tendon cuts are not treated, tendon may be broken away from the cut region.

If tendon ends are not exposed surgically, recovery is not provided. If repair of tendon cuts delays, length of the tendon shorten due to muscle traction and tendon exposing may not be possible. To protect tunnels called pulley that tendons pass in is very important for tendons to perform its functions after the recovery. Vessel-nerve structures which are very close to tendons should be repaired with microsurgerical methods during the surgery. 3-4 weeks of bracing is made to protect sutured structures after the surgical intervention. Movement is not provided just after the plaster is removed. During tendon recovery, cohesion arises to surrounding tissues. Early physical therapy may start with plaster or physical therapy should be given after the plaster. Generally professional physiotherapy is required after flexor tendon injuries. If providing movements are insufficient even after the physiotherapy, cohesion around the tendon should be opened and physiotherapy should start immediately. Early term physiotherapy is important. If physiotherapy does not start on time, to gain movements will be difficult.

Source: flexor tendon injuries

EXTENSOR TENDON INJURIES

Extensor tendons take place on the upper surface of the hand. They play role in lifting the hand and fingers. Extensor tendons are chorda extensions of forearm muscles extending to the fingers. Tendons in the finger tapers and flattens. Besides chorda extensions staring from muscles of the palm (lumbrical and interosseos) also participates to the extensor mechanism which lifts the fingers. (Figure 1.2)

They play important role in finger movements and coordination.

Extensor tendons are just under the skin. Therefore, extensor mechanism injury may arise even with small cuts. After traumas such as compression and crashing, disconnection of thin tendons by dissevering from bone connection points (mallet finger, boutoniere deformity) may be observed. Fingers up-lifting is not performed after extensor mechanism injuries. Surgical treatment may gain old functions in extensor tendon injuries.

Treatment of extensor mechanism cut or disintegration is provided by sewing the cut or disintegrated area. For injuries which is close to finger joints, joints should be fixed by a wire to protect continuity of sutured thin tendon structure. Because of natural features of the extensor tendon, 5 weeks of brace treatment is required for relaxing and not having debility for lifting the finger up.

In cases that extensor mechanisms separate from connection of the extensor mechanism after compression and crushing (mallet finger, boutoniere deformity), re-connection of the tendon from disintegration place is provided by methods such as bracing, finger ring application, using three point braces. Patient compliance is very important in these treatment methods. Another treatment option is to fix by threading pin from bones and joints.

DE QUERVAIN TENOSYNOVITIS (COMPRESSION OF THUMB TENDON)

Our tendons that allows us to lift the thumb and to move away from other fingers pass under a tunnel which is near the thumb base in the wrist. By thickening and hardness in this tunnel, swellings occurred in sheath of the tendon make This table with pain and sensibility in the wrist is called with the name of the surgeon (Fritz de Quervain) who described the disease first.

It is mostly seen after forcible and recurrent movements which are just started to be done. Especially the position of the hand of which new mothers make during carrying their baby; and effects of hormonal fluctuations in pregnancy and lactation period facilitates this situation to be arisen. De Quervain tendinitis may occur after old wrist fractures, traumas, and exercises after unusual weights.

The most typical symptom is pain in the thumb side of the wrist. The pain diffuses to the thumb in downwards and to the front arm in upwards. The pain increases in strong clutching and wrist twisting that the thumb is used. (Figure 1)Also swelling may be observed in the pain area of the wrist. The pain which occurs when we twist the wrist in the direction of the little finger by taking the thumb in the fist is typical for diagnosis.

To relax the hand by using a splint which inactivates the painful movements of the thumb in the beginning period is very important. (Figure 2) Besides, swellings of the tunnel and the tendon are tried to be decreased by using non-steroid anti-inflammatory drugs. If symptoms are persistent or getting worse, the tunnel which compresses tendons should be opened surgically. This surgery may be performed by local anesthesia to whole arm or only to the wrist.

Source: de quervain tenosynovitis

TRIGGER FINGER

Also known as stenosing tenosynovitis in medical literature, trigger finger is a pulley system disorder of finger flexor tendons functioning to bend the fingers of the hand and their bridges that they run under on certain points.

Tendons are like long strings that start from muscles of forearm and continue to the fingers, while pulleys are structures that tendons pass under at certain points and provide the tendon movements. These pulleys bring the tendons closer to the bone. Around the tendons, there is a thin structure enabling it to run through the tunnels. (tenosinovyum)

Trigger finger is called as the thickening of the pulley found in the base of the finger and sometimes called as the dysfunction and pain during finger movements due to swellings occurred on tendon sheath. Using the finger after the problem has started causes more swelling of the structures there and even makes it worse. Sometimes finger dysfunction and locking may occur.

Usually the main cause is unknown. It is more frequently seen in systemic diseases such as Rheumatoid arthritis, Gout, diabetics. Traumas to palm and finger base can rarely cause trigger finger.
The trigger finger begins with a feeling of discomfort at the connection point of fingers in palm. There is sensitivity to pressure on this point where sometimes nodules are felt. In following periods the finger starts to dysfunction and lock.

The aim for the treatment is to prevent dysfunctioning of the finger and to remove the feel of discomfort during its movement. Reducing the swelling of flexor tendon and the tendon sheath enables it to run easier during its movement. Following this aim, reducing the activities, usage of oral anti-inflammatory drugs and cast are preferred for the patients who have earlier symptoms. Injection of the location with steroids may help reducing of the symptoms, but we do not use them due to their harms to the structures of tendons on the long view.

In cases that lasted long and have not responded to medical treatment, the surgical loosening of the pulley that caused the incarceration is the necessary treatment option to choose. The operation is performed with a small cut in the palm under local anaesthesia. It is important to take vessel nerve structures that are close to the tendon sheath under protection during the operation. In post-operational period, the symptoms reduces and never repeat especially after a successful surgery. In some patients, hardness on injury point may occur due to extremely improved tissue, which usually recedes in time by the massages performed at home.

Source: trigger finger