Tendinitis of the Wrist  

Tendinitis of the Wrist  

Tenosynovitis of the wrist can affect the following tendons:

  • •Extensor pollicis longus (EPL)
  • •Extensor carpi ulnaris (ECU)
  • •Flexor carpi radialis (FCR)
  • •Muscle bellies of the abductor pollicis longus and the extensor pollicis brevis (intersection syndrome)
  • •Fourth extensor compartment (extensor digitorum communis and extensor indicis proprius)
  • •Extensor digiti minimi

Intersection syndrome describes pain and swelling about the muscle bellies of the abductor pollicis longus and the extensor pollicis brevis at the point in which they cross the radial wrist extensors.

  • •Anatomically located 4 cm proximal to the wrist on the dorsoradial aspect
  • •Originally thought to occur as a result of friction between the muscle bellies of the abductor pollicis longus and extensor pollicis brevis tendons and the radial wrist extensors; now believed to be entrapment of the second dorsal compartment (extensor carpi radialis longus and extensor carpi radialis brevis)
  • EPL tenosynovitis is rare and occurs on the dorsal wrist at the Lister tubercle (the location at which the EPL wraps around and heads for the thumb).
    • •If undiagnosed, can lead to tendon rupture
    • •Can occur with blunt trauma or fractures of the distal radius
  • •ECU tenosynovitis is a more common problem and occurs on the dorsoulnar aspect of the wrist.
    • •Common cause of ulnar-side wrist pain
    • •Can be initiated by a twisting injury of the wrist
    • •Can cause dysesthesias along the distribution of the dorsal sensory branch of the ulnar nerve
    • •Can cause pain at night
  • •FCR tendinitis can occur at the point where the tendon crosses the ridge of the trapezium on the volar radial aspect of the wrist.
    • •Uncommon
    • •Can lead to rupture of the FCR tendon
  • •Fourth extensor compartment tendinitis most commonly affects the tendons of the ECU to the small and index fingers because of the more acute angle that these tendons take from the compartment to their respective insertions.
    • •Uncommon except in rheumatoid arthritis
    • •Can occur after a distal radius fracture and has been associated with dorsal hardware on the dorsal distal radius
  • •Extensor digiti minimi tendinitis is uncommon, except in rheumatoid arthritis.

History

  • •Pain and swelling around the wrist
  • •Pain with certain motions and activities
  • •Most commonly worse with activity but can occur at night (especially ECU tendinitis)
  • •Prolonged pain after blunt trauma or distal radius fracture
  • •Crepitus with certain conditions may be reported.

Physical Examination

  • •Intersection syndrome
    • •Can have swelling and even redness
    • •Tenderness to palpation 4 cm proximal to the radial styloid 
    • The extensor pollicis brevis and the abductor pollicis longus cross the radial wrist extensors approximately 4 cm proximal to the radial styloid.
    • •Pain with wrist extension and radial deviation
    • •Occasionally palpable crepitus
  • •EPL
    • •Pain with resisted thumb extension
    • •Pain on palpation over Lister tubercle
    • •Swelling at Lister tubercle
  • •ECU
    • •Pain on palpation of tendon with resisted wrist extension and ulnar deviation
    • •Can have palpable crepitus
  • •Flexor carpi ulnaris (FCU)
    • •Can have swelling over volar wrist
    • •Pain on palpation of tendon with resisted wrist flexion
  • •Fourth dorsal compartment and extensor digiti minimi
    • •Swelling and pain on palpation over central dorsal wrist
    • •Pain with resisted finger extension

Imaging

  • •Plain radiographs do not tend to be helpful in the diagnosis except in a rare case of calcific tendinitis.
  • •Magnetic resonance imaging can be used to confirm or assist with diagnosis and will show inflammation around the tendon.

Additional Tests

  • •Injection of a local anesthetic agent into the respective tendon sheath should give substantial or complete relief of symptoms and can be used for diagnostic purposes.

Differential Diagnosis

  • •Most other causes of wrist pain are included in the differential diagnosis for tendinitis.
  • •ECU tendinitis is typically the most difficult diagnosis of the different types of tendinitis.
    • •Symptoms may mimic those from both triangular fibrocartilage complex pathology as well as distal radioulnar joint pathology.
  • •FCR tendinitis can be difficult to diagnose also because its symptoms can mimic those of basal joint arthritis, scaphoid fractures and nonunions, and volar ganglion cysts.

Treatment

  • •At diagnosis
    • •First-line therapies for the stenotic conditions of the wrist are modification of activity, nonsteroidal antiinflammatory drugs, and splinting.
    • •Immobilization is best accomplished with a well-formed thermoplastic splint with the wrist in approximately 20 degrees of extension.
    • •Steroid injection into the tendon sheath can be considered as first-line therapy with immobilization, or in cases in which immobilization alone has failed.
  • •Later
    • •Surgical release of the affected tendon should be performed if nonoperative therapy has failed.
    • •Intersection syndrome
      • •A longitudinal incision is made over the radial wrist extensors from the level of their insertion and carried proximally approximately 4 cm.
      • •The muscle bellies of the abductor pollicis longus and extensor pollicis brevis are retracted proximally, and the second dorsal compartment is released.
      • •The retinaculum does not need to be reconstructed, and the wrist should be immobilized for 2 weeks.
    • •EPL tendinitis
      • •A longitudinal incision is made over the Lister tubercle.
      • •The third dorsal compartment is identified, and the EPL tendon is completely released.
      • •It is translocated to the radial side of the tubercle in a subcutaneous plane.
      • •The compartment is reclosed to prevent the tendon from re-entering the compartment.
      • •After a short period of immobilization (5 to 7 days), unrestricted activity is allowed.
    • •Fourth and fifth compartment tendinitis (extensor digitorum communis, extensor indicis proprius, extensor digiti minimi)
      • •The need for surgical release of these compartments is very rare.
    • •ECU tendinitis
      • •A longitudinal incision is made over the ECU tendon.
      • •Care is taken to preserve and protect the dorsal sensory branches of the ulnar nerve.
      • •The entire fibro-osseous canal is released.
      • •Surgical reconstruction of the canal is not necessary.
    • •FCR tendinitis
      • •A longitudinal incision is made over the FCR tendon volarly.
      • •Care is taken to protect the palmar cutaneous branch of the median nerve.
      • •The sheath of the tendon is released past the level of the trapezial tubercle.
      • •Any osteophytes on the trapezium should be removed, and any frayed portion of the tendon should be debrided.

When to Refer

  • •The patient should be referred to a hand specialist if conservative measures have not brought about improvement in 4 to 6 weeks.
  • •Many of the steroid injections for these conditions are difficult and should be performed only by those with previous experience or by a hand surgeon.

Prognosis

  • •Good with conservative measures and excellent with operative intervention

Troubleshooting

  • •With splint immobilization, patients need to wear a splint continually.
    • •Try to assess and ensure patient compliance.
  • •Steroid injections most commonly are not effective because of improper injection location.
    • •Lidocaine injection either preceding the steroid or mixed with it will help determine whether the injection is located properly.
  • •For surgical release, proper diagnosis and adequate tendon release are essential.
    • •Continued pain after release may be caused by cutaneous nerve irritation or damage.

Patient Instructions

  • •Patients need to be educated on the disease process.
  • •Instruct patients that if splint immobilization is prescribed, it is important to wear the splint full time with the possible exception of bathing and sleeping.
  • •If a nonsteroidal antiinflammatory drug is prescribed, the patient should take it regularly for the period prescribed and not only as needed for pain.
  • •If a steroid injection is used, instruct patients that pain may increase for 24 to 48 hours and that the effect of the steroid will not be experienced for 5 to 7 days.
  • •Have patients return in 2 weeks if there is no pain relief.
  • •When surgery is recommended, patients should be educated on the risks and benefits of the procedure.

Considerations in Special Populations

  • •Patients with diabetes should be instructed to monitor their blood sugar level after a steroid injection.
  • •A steroid injection should be considered first-line therapy in patients who cannot tolerate immobilization.

Suggested Readings

Brown J, Helms CA: Intersection syndrome of the forearm . Arthritis Rheum 2006; 54: pp. 2038.

Costa CR, Morrison WB, Carrino JA: MRI features of intersection syndrome of the forearm . AJR Am J Roentgenol 2003; 181: pp. 1245-1249.

Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: intersection syndrome . J Hand Surg Am 1985; 10: pp. 299-302.

Ostric SA, Martin WJ, Derman GH: Intersecting the intersection: a reliable incision for the treatment of de Quervain’s and second dorsal compartment tenosynovitis . Plast Reconstr Surg 2007; 119: pp. 2341-2342.

Wolfe SW: Tenosynovitis . In Green DP, Hotchkiss RN, Pederson WC, Wolfe SW (eds): Operative Hand Surgery ., 5th ed 2005. Churchill Livingstone , Philadelphia pp. 2137-2158.

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