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Anatomy of trigger

Tendon sheaths of the long flexors run from

the level of metacarpal heads ( distal
palmar crease, superficial; volar plate,
deep)to distal phalanges
They are attached to the underlying bones
and volar plates, which prevent the
tendons from bowstringing
Predictable and efficient thickenings in the
fibrous flexor sheath act as pulleys,
directing the sliding movements of the

The 2types of pulleys are annular (A)

and cruciate ( C).
Annular pulleys are composed of
single fibrous bands, while cruciate
pulleys have 2 crossing fibrous

The order of the pulleys from

proximal to distal :
The A1 pulley overlies the
meatcarpophalangeal joint
Flexor tendons pass within the
tendon sheath and beneath the
A1pulley at approximately the
metacarpal head, beyond which they
travel into the digit.
The A2 pulley overlies the proximal
end of the proximal phalanx

The C1 pulley overlies the middle of the

proximal phalanx
The A3 pulley lies over the proximal
interphalangeal joint
The C2pulley lies over the proximal end
of the middle phalanx
The A4 pulley lies over middle of the
middle phalanx
The C3 pulley lies over the distal end of
the middle phalanx
The A5 pulley lies over the proximal end
of the distal phalanx

Stenosing tenosynovitis
thumb lockswhenit is flexed or
Caused by inflammation of the flexor
tendon sheath.



Infantile Trigger Finger

Abnormal flexion at interphalangeal joint.
Can be bilateral.
Flexor pollcis longus tendon thickened
Abnormal collagen degeneration and synovial
Incr. FPL tendon diameter compared to A1
Disruption in tendon gliding

Fix thumb flexion (interphalangeal joint)

Notta node

Trigger Finger
Common form: Primary type.
Found predominanty in otherwise
healthy middle-aged women with
frequency 2 to 6 times higher than
Most commonly affected digit is the
thumb, followed by ring, long, little
and index finger.

Secondary trigger finger

Seen in patients with diabetes, gout, renal
disease, rheumatoid arthritis and other
rheumatic diseases. Associated with
worse prognosis after conservative or
surgical management.
A locked trigger digit can lead to an
incorrect diagnosis of dislocation,
Dupuytrens disease, focal dystonia or

Classification Trigger Digits

Pain: History of catching,
but not demonstrable on
physical examination,
tenderness over the A1
Grade 11(Active)
Demonstrable catching
but the patient can
actively extend the digit.

Grade 111(Pasive)Demonstrable catching

requiring passive
extension(111A) or
inability to actively
flex(grade 111B)
1V(contracture)Demonstrable catching
with a fixed flexion
contracture of the PIP


Ganglion cyst
Definition :
A tumor or swelling on top of a joint
or the covering of a tendon

Outpouching of synovium, as an
irritation of articular tissue
Degeenerative of connectiontissue and
cystic space formation
Degeneration of the connective tissue is
caused by an irritation or chronic
damage causing the mesenchymal cells
or fibroblasts to produce mucin

Most commonly appears
multilobulated but can still appear
With septa made from connective
tissue separating the lobes or
A ganglion cyst is not a true cyst and
because of this histologic
observation, the theories of synovial
herniation or synovial tumor

Hyaluronic acid predominates the

mucopolysaccharides that make up the
fluid within the cysts cavity, while collagen
fibers and fibrocytes make up the wall
The development of these cysts is
histologically observable beginning with
swollen collagen fibers and fibrocytes,
followed by a degeneration and
liquefaction of these elements, a
termination of degeneration, and a
proliferation of the connective tissue,
resulting in a border that is dense in

Imaging :
- Plain xray : visualization of the cysts,
identify bony abnormaloities that can be
causing the symptoms.
- Confirmation of clinical diagnosis : MRI,
ultrasonography and arthroscopic imaging
Others :
- Allen test performed when the cyst is
located near the radial artery, including
most volar wrist ganglia.

Ganglion cyst

Medical therapy
Early stage: manually compressed until it
bursts, and fluid is absorbed (least invasive
Slightly more invasive approach when a
minimum of 3 aspiration

Corticosteroids injection with aspiration ( yet

has been contraindicated in some cases) :
can cause thinning of the overlying skin.

Another moderately invasive

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

Surgical therapy

Open removal with arthroscopy, including

a reduction in intraoperative risks and
postoperative complications. (40%
recurrence is seen)
Remove a portion of capsule to reduce the
recurrence rate (4%)
Brief splinting of 3-7 days is recommended
for both open and arthrospcopic
ganglionectomy, but it seems that wrist
motion within 3-5 days post operation can
prevent stiffness.

Compared to open ganglionectomy,

arthroscopy uses smaller incisions
and therefore leaves smaller scars.
Arthroscopy allows better

Dorsal Wrist Ganglion

Most common : 60-70%
Arise from scapholunate ligament.
Can occur anywhere else between extensor
tendons and connected to ligament through a
long pedicle.
Extend and direction-palpation with digital
Transillumination and aspiration confirms the

Occult Dorsal Carpal

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

Clinical Features
Clinical Features

Differential Diagnosis

Chronic tenosynovitis
of the extensor
Unexplained wrist pain
and disproportionately

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

For further diagnostic studies: MRT,
CT, ultrasonography

Conservative(best initially)
Immobilization and steroid injections directly
into the dorsal capsule
Excision of the posterior interosseous nerve
at the level of the radiocarpal joint - alleviate
the pain and postoperative comfort.

Volar Retinacular
(Flexor Tendon


The third most common ganglion,about

10%-12%,which arises from the proximal
annular ligament(A1 pulley) to the flexor
tendon sheath.
This ganglion is invariably small(3mm-8mm)
Firm,tender mass palpable under the MP
flexion crease.

The cyst is attached to the tendon

sheath and does not move with the
Needle rupture followed by a steroid
injection and digital massage
disperse the cysts contents can
frequently delay or obviate the need
for surgery.

Several attempts at conservative

treatment are recommended before
surgery with patients
understandings that reccurences
might happen.
The proximity of digital nerves must
be appreciated.

The incision must allow identification

and mobilization of radial and ulnar
neurovascular bundles.
The ganglion can then be traced to
the tendon sheath and excised to a
small portion of the sheath.

The ganglion is approached through
an oblique incision over the mass.
Transverse incisions are more
popular but dont allow adequate
exposure with undue skin traction
and are not easily incorporated into
an extensile incision.

The synovial side of the specimen

usually reveals a defect in its
smooth,white homogenous surface
suggestive of a communication
between a tendon space and cyst.
After skin closure,a simple dressing is
applied and early motion allowed.

Rare,although injuries to the digital
nerves have been reported

Ganglion of the DIP joint that occurs between
5th and 7th decades.
The earliest sign maybe longitudinal grooving
of the nail,without a visible mass,caused by
pressure on the nail matrix.
Usually,the patient is seen after the cyst has
enlarged and attenuated the overlying skin.

The cyst,3mm to 5mm,typically lies

on one side of the extensor tendon
and between the dorsal distal joint
crease and eponychium.
The patient often has Herbedens
nodes and radiographic evidence of
osteoarthritis changes in the joint.

The cyst and osteophytes should be

treated to ensure satisfactory result.

The cyst has historically been
approached through L-shaped or
curved incision and any attenuated
or involved skin that cannot be easily
separated from the cyst wall,is
excised elliptically.
The cyst is immobilized,traced to the
joint capsule and excised with the
joint capsule.

All soft tissue,between the retracted extensor

tendon and adjacent collateral ligament is
excised and the DIP joint is left exposed.
Care is taken to not disturb the incision of the
extensor tendon or nail matrix.
With the joint extended and tendon retracted
dorsally,the opposite site is explored and occult
cyst or hypertrophied synovial tissue is excised.

Osteophytes can be excised with a rongeur

or a fine powder bur
Skin closure may require rotation and
advancement of dorsal skin flap or a fullthickness skin graft.
An alternative and current prefered
approach is to make a transverse incision
centred over the DIP joint

The base of mucous cyst is identified

and excised while leaving the distal and
superficial portion of the cyst intact.
Osteophytes and the joint capsule are
excised while leaving the skin closed.
The remaining portion of the cyst will
involute over several weeks.

If a skin graft was used,the distal
joint is supported with a cast or splint
for 2 weeks.
Earlier motion is permitted if a local
rotation flap was used.
Motion and theraphy can then be
undertaken until full painless motion
has been achieved.

Recurrences maybe due to
inadequate excision of the capsular
attachment of the ganglion and
failure to recognize extension of the
ganglion under the extensor tendon
to the opposite site.
The underlying arthritic process
persist and may result in new
ganglion formation.

Relief of pressure on the nail matrix

by decompression or excision of
ganglion usually restores the nail to
its normal appearance
Stiffness is a rarely functional


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


Dorsally over the PIP joint on the other
side of the extensor tendon.
They arise from the joint capsule and
pierce the oblique fibres between the
central slip and lateral band.
These cysts are small(3mm-5mm),tender
and may interfere with joint motion.

A curve incision over the PIP joint
exposes the ganglion.
The lateral margin of the lateral band
is released from the transverse
retaining ligament and retracted
dorsally to expose the PIP joint.

The pedicle from the main cyst can usually be

followed through the extensor system into
the joint capsule.
A small elliptical incision through the oblique
extensor fibres mobilize the cyst and pedicle.
The entire joint capsule and synovial lining
are excised between the collateral ligament
and extensor insertion on the middle phalanx.

A simple skin closure and early

Typically occur over the metarcarpals
and are distinguished by their
proximal motion with their fingers in
Tenderness,aching or snapping of the
tendon with motion

The ganglion is approached through a transverse
incision and the intimate broad attachment to
the extensor tendon is readily appreciated.
The ganglion is dissected off the extensor
tendon with all the synovial tissue surrounding
the involved tendon
Rupture of the tendon is difficult to avoid but
recurrence are rare.