Treatment of Complications after Surgical Management of Tenosynovitis

3 Treatment of Complications after Surgical Management of Tenosynovitis

Jin Bo Tang

Abstract

This chapter discusses and summarizes the common complications of trigger finger/thumb and de Quervain’s disease, such as nerve injury, bowstringing, or subluxation of the tendons. The methods of preventing and treating the complications are presented and discussed.

Keywords: trigger finger, de Quervain’s disease, surgical release, nerve injury, tendon bowstringing, infection, recurrence

3.1 Introduction

Tenosynovitis in the hand usually indicates either a trigger finger including trigger thumb (caused by constricting A1 pulley in the fingers or thumb) or de Quervain’s disease (tenosynovitis of the first extensor tendon compartment at the wrist). Tenosynovitis is the inflammation of the fluid-filled sheath that surrounds a tendon, typically leading to joint pain, swelling, and stiffness, often after repetitive use of the hand. The disease can be self-resolving after rest or conservative treatment.1^,²^,³^,⁴

Surgical release is indicated if conservative treatment is not effective for several weeks, and the surgical procedures are straightforward, with little risk of complications.¹^,²^,³ I have not encountered any cases of complications in my practice of 30 years. However, because of the proximity of the digital nerve to the A1 pulley in the distal palm, and the radial sensory nerve to the first extensor compartment in the wrist, risk of injuring these nerves can be a complication of surgery. I consider nerve injury an important complication of the surgical release of these sheaths. Reoccurrence is possible if the surgical sheath release is insufficient. Therefore, the nerve injuries and possible reoccurrence should be given sufficient attention, which are discussed in more details in this chapter.

Tendon bowstringing and subluxation after releasing the sheath are rarely possible when the surgery is correctly performed and risk of having surgical infection is rare. To provide a full picture of possible complications, I will include subluxation and bowstringing and infection into discussion.

3.2 Nerve Injury

3.2.1 A1 Pulley Release

The digital nerve to the finger including the distal part of the common digital nerve in the palm to the finger run close to the A1 pulley. By surgical incision to release the A1 pulley, when the skin incision is right over the A1 pulley and about 1 cm long, and the dissection is carried out directly to the A1 pulley without extending the tissue release to either side of the A1 pulley, the risk of cutting the digital nerve is little or low. On the contrary, if the surgical incision is large and the exploration of the A1 pulley involved tissue release on both sides of the A1 pulley, there is a risk of damaging the digital nerve. Such a wide incision and wide release is in fact unnecessary and incorrect.

The correct surgery is a narrow incision (1 cm) and directly reaching the volar aspect of the A1 pulley and releasing the A1 pulley through a longitudinal midline incision with a scissor. The A1 pulley may be tight in these cases, but a release in the sheath just proximal to the margin of the A1 pulley would allow access to the sheath cavity and the tip of the scissor can be inserted to carry out the release. The A1 pulley is about 1 cm, and trigger fingers rarely extend to the other pulleys or involve multiple pulleys; therefore, the release should be confined to the A1 pulley, not extending to the other pulleys. There is a rare chance of trigger fingers of the pulleys other than the A1; in that case only the pulley which causes the triggering as identified by clinical examination or ultrasound examination should be accessed and released.

The radial side digital nerve of the thumb runs across the flexor tendon proximal to the A1 pulley in the thumb (Fig. 3‑1). Therefore, the risk of injuring this digital nerve is higher. The key is to keep the surgical incision short and be alert to the course of this nerve and avoid cutting it. Proximal extension of the surgical incision of releasing the trigger thumb is rarely necessary; if this becomes necessary, the surgeon should be very careful to identify this digital nerve to avoid injury to it. If a digital nerve is cut, repair surgery should be performed.

Fig. 3.1 Anatomy of the radial digital nerve of the thumb. This nerve passes just proximal to the A1 pulley, which can be damaged during the release of the A1 pulley in the thumb.

3.2.2 First Extensor Compartment Release

The radial sensory nerve runs obliquely proximal to the first dorsal compartment of the wrist (Fig. 3‑2). In most cases, it is about 1 cm proximal to the proximal margin of this compartment. However, there is variation of the path of this nerve and extended proximal surgical incision should always be avoided. Before the surgery, the operator may also examine the course of the nerve in non-obese patients as this nerve can be visible in some patients. In obese patients, the operators should take care to identify and protect this nerve if a longer surgical incision is made (which is often necessary in obese patients). I use a longitudinal incision right over the first dorsal compartment of 1 to 1.5 cm (Fig. 3‑3), which sufficiently exposes the tendon sheath and allows easy release of the sheath and any subsheath that separates the two tendons inside the first compartment (Fig. 3‑4).