Ganglion ng Flexor Tendon Sheath Impormasyon

Ano ang nararamdaman mo

Maaaring mapansin mo ang isang malambot na buntong sa iyong pulso o kamay. Karaniwang parang maliit na lobo ng tubig sa ilalim ng balat ang pakiramdam nito. Maaaring biglang lumitaw ang buntong o dahan-dahang lumaki ito sa loob ng panahon. Maraming tao ang nagsasabing ang lugar ay tila masikip o may sakit na nakakaabala. Karaniwang mild ang sakit ngunit maaari itong maging matulis kapag gumagalaw ka sa iyong pulso sa mga partikular na paraan. Maaaring makaramdam ka ng discomfort kapag yumuyuko ka pabalik ng iyong pulso o kapag mahigpit na humahawak ka ng mga bagay.

Maaaring maging mahirap ang mga araw-araw na gawain dahil sa buntong o sa sakit. Maaaring maging awkward ang pag-abot sa likod mo upang isara ang bra. Ang pagtutukoy ng isang kamiseta ay maaaring humila sa balat sa ibabaw ng cyst. Ang pag-angat ng mabibigat na bag o pagbubukas ng mga bote ay maaaring magpalala sa lugar. May mga tao na nakakaramdam ng pakiramdam ng tingling kung ang buntong ay pumipindot sa mga malapit na nerbiyos. Maaari nitong gawing mahina o numb ang iyong kamay. Karaniwang lumalala ang mga sintomas pagkatapos ng mga panahon ng paulit-ulit na paggalaw ng pulso o mabigat na aktibidad.

Maaaring mag-flare up ang sakit sa gabi, na nagpapatigil sa komportableng pagtulog. Maaaring mahirap na pahinga ang iyong pulso sa isang unan. Sa paggising, maaaring mas malinaw ang stiffness. Gayunpaman, hindi laging nakakaramdam ng sakit ang buntong mismo. Sa ilang kaso, ito ay isang kitang-kitang bulge lamang na nakakaabala sa iyong cosmetic na aspeto. Humigit-kumulang 40% ng mga ganglion sa pulso ay bumababa ang laki sa loob ng unang 6 taon nang walang anumang paggamot. Ibig sabihin, maaaring magbawi ang iyong mga sintomas nang sarili sa paglipas ng panahon.

Kung lumaki ang buntong, maaari nitong limitahan ang iyong range of motion. Maaaring mapansin mo na hindi na kasing mabilis ng iyong pulso ang pag-yuko kumpara dati. Maaaring makagambala ang discomfort sa trabaho o mga hobby na nangangailangan ng fine motor skills. Maaari mong iwasan ang paggamit ng iyong kamay dahil sa takot na magdulot ng karagdagang sakit. Mahalagang makinig sa iyong katawan at magpahinga kapag ang lugar ay nakakaramdam ng sakit. Tutulungan ka ng iyong surgeon na maunawaan kung ang mga sintomas ay dulot ng ganglion o ng ibang isyu.

Ano ang nangyayari talaga

Ang ganglion cyst ay isang sac na puno ng likido na bumubuo sa malapit sa iyong mga kasukasuan o tendon. Isipin mo ito na parang maliit na water balloon na umuusbong mula sa lining ng kasukasuan. Ang lining na ito, tinatawag na synovium, ay gumagawa ng lubricating fluid upang matulungan ang iyong mga kasukasuan na gumalaw nang maayos. Minsan, lumalabas o lumilipat ang likidong ito sa pamamagitan ng mahinang bahagi ng joint capsule. Ang capsule ay ang matibay na sleeve na nakabalot sa iyong kasukasuan.

Nakokolekta ang likido sa isang sac, na lumilikha ng bula na makikita o maramdaman mo. Ang bula na ito ay maaaring pindutin ang mga kalapit na estruktura. Halimbawa, maaari nitong pindutin ang isang nerve, na nagdudulot ng sakit o kahinaan. Maaari rin itong makagambala sa iyong mga tendon, na mga matibay na tali na nag-uugnay ng kalamnan sa buto. Dahil sa presyur na ito, maaaring maramdaman mo ang discomfort o mapansin ang limitadong galaw.

Sa ilang kaso, direktang nakakonekta ang cyst sa espasyo ng kasukasuan. Ibig sabihin, maaaring dalhin ng likido ang pagdaloy pabalik-balik sa pagitan ng kasukasuan at cyst. Ipinapaliwanag ng koneksyong ito kung bakit maaaring magbago ang laki ng bula o mawala itong pansamantala. Minsan, tinatanggal ng katawan ang likidong ito nang sarili. Humigit-kumulang 40% ng mga ganglion lesion sa pulso ay bumababa ang laki sa loob ng unang 6 taon pagkatapos ng pagsusuri ng isang hand surgeon.

Gayunpaman, kung nananatili ang cyst, maaari itong magdulot ng patuloy na isyu. Maaari itong magdulot ng trigger finger, kung saan nakakabit ang tendon habang gumagalaw. O maaari itong pindutin ang mga nerve, na nagdudulot ng numbness o tingling. Sasuriin ng iyong surgeon ang lugar upang kumpirmahin ang diagnosis. Maaari silang gumamit ng imaging upang makita ang lokasyon at laki ng cyst.

Ang paggamot ay nakadepende sa iyong mga sintomas. May mga taong pumipili na maghintay at tingnan kung magpapabuti ito. May iba naman na mas gusto ang aktibong paggamot. Ang percutaneous puncture ay isang praktikal na opsyon para sa pamamahala ng flexor tendon sheath ganglions dahil sa mababang gastusin, kawalan ng downtime, at mababang rate ng recurrence. Kasama nito ang pag-drain ng likido gamit ang karayom. Kung bumalik ang cyst, tinatanggal ng surgical excision ang sac nang buo. Ang open surgical excision ay nag-aalok ng malaking pagbaba sa chance ng recurrence kumpara sa aspiration sa paggamot ng wrist ganglions.

Layunin naming alisin ang iyong mga sintomas at ibalik ang normal na function. Tatalakayin ng iyong surgeon ang pinakamainam na paraan para sa iyong partikular na kaso. Ang layunin ay bawasan ang sakit at mapabuti ang kakayahan mong gamitin ang iyong kamay at pulso.

Mga maitutulong namin dito

Ang inyong pamamaraan sa pagharap sa ganglion ng flexor tendon sheath ay madalas na nakadepende sa kung gaano ito nakakapagod at kung gaano katagal itong umiiral. Si Dr. Kieran Hirpara, isang upper-limb surgeon sa Mater Private Hospital Rockhampton, ang nagbibigay-direksyon sa desisyong ito sa aming klinika batay sa iyong mga partikular na sintomas at istilo ng buhay. Sinisimulan namin sa pag-unawa sa kung ano ang kaya mong gawin nang walang sakit. Maraming ganglion ang nagbabawas ng sarili nitong laki. Humigit-kumulang 40% ng mga lesion ng wrist ganglion ay bumababa ang sukat sa loob ng unang 6 taon pagkatapos ng pagsusuri ng isang hand surgeon. Sa mga bata, kung ang cyst ay magre-resolve, karaniwang nangyayari ito sa loob ng 18 buwan.

Maaari mong subukan ang simpleng self-care muna. Kasama rito ang pagbabago ng mga gawain upang maiwasan ang paulit-ulit na stress sa tendon. Ang iyong physiotherapist o hand therapist ay matututuro sa iyo ng mga banayad na ehersisyo upang panatilihin ang malinis na galaw ng kasukasuan. Ang paggamit ng splint ay maaaring tumulong sa pahinga ng lugar at bawasan ang iritasyon. Madalas naming inirerekomenda na bigyan ng patas na pagsubok ang non-operative care bago isaalang-alang ang mas invasive na hakbang. Kung ang ganglion ay hindi nagdudulot ng sakit o hindi naglalimita sa iyong galaw, ang watchful waiting ay isang ligtas at wastong opsyon.

Kung mananatili ang mga sintomas, lumilipat kami sa medical management. Karaniwang ito ay kinabibilangan ng mga gamot para sa sakit at anti-inflammatory upang pamahalaan ang discomfort. Maaari rin naming alok ang isang injection. Ang mga injection ng cortisone ay maaaring bawasan ang pamamaga at sakit, bagaman pansamantala ang epekto. Ang mga injection ng hyaluronic acid o platelet-rich plasma (PRP) ay minsan ginagamit upang suportahan ang kalusugan ng tissue, ngunit nag-iiba ang kanilang long-term na benepisyo. Ang aspiration, kung saan inidudren namin ang likido gamit ang karayom, ay isang praktikal na opsyon para sa mga ganglion ng flexor tendon sheath. Ito ay may mababang gastusin, walang downtime, at mababang rate ng pagbabalik. Walang mga recurrence ang napansin pagkatapos ng pangalawang puncture sa ilang mga pag-aaral. Gayunpaman, karamihan sa mga ganglion ay bumabalik pagkatapos ng isang aspiration. Inisip namin ang aspiration bilang isang first-line na intervention para sa mga symptomatic na kaso.

Ang operasyon ay isinasaalang-alang kapag ang conservative care ay hindi nagbigay ng sapat na pagpapabuti o kung ang ganglion ay nagdudulot ng malaking compression sa nerbiyos. Ang surgical excision ay nananatiling isang epektibong opsyon para sa mga symptomatic na kasing ito. Ang open surgical excision ay nag-aalok ng malaking pagbaba sa tsansang mag-recurrence kumpara sa aspiration. Para sa mga wrist ganglion, ang surgical intervention ay may humigit-kumulang 10% na rate ng recurrence. Pinag-uusapan namin ang mga panganib, tulad ng pagkabagabag o mga adverse events, at tinatimbang ito laban sa benepisyo ng pag-alis ng cyst. Sa ilang kaso, ang arthroscopy ay nagbibigay-daan sa amin na gamutin ang ganglion at anumang ibang underlying na isyu ng kasukasuan sa parehong oras. Ginagawa namin ang desisyong ito nang sama-sama, tinitiyak na nauunawaan mo ang inaasahang resulta at ang proseso ng paggaling.

Ano ang inaasahan

Ang iyong ganglion ay isang bula na puno ng likido na madalas ay nag-uugali nang hindi maipapredict. Humigit-kumulang 40% ng mga ganglion sa pulso ay bumababa ang laki sa loob ng unang 6 taon pagkatapos mong makita ang isang hand surgeon. Maraming tao ang nakakaramdam na ang bula ay lumalabas at nawawala o nananatiling pareho ang laki sa loob ng mga taon. Kung iiwanan mo ito, maaari itong mag-iba-iba nang sarili, ngunit maaari ring manatili o lumaki.

Kung pipiliin mong hindi itong gamutin, maaari kang mabuhay kasama ang bula nang walang katapusan. May mga tao na walang nararamdamang sakit sa anumang paraan. May iba naman na nakakaramdam ng stiffness o mild discomfort. Kung pindutin ng bula ang mga kalapit na istruktura, maaaring mapansin mo ang weakness o pagbabago sa sensation. Sa maraming kaso, ang katawan ay natural na reabsorbs ang likido, ngunit hindi ito garantisado.

Kung desisyon mong alisin ito, talakayin ng iyong surgeon ang pinakamainam na paraan para sa iyong partikular na kaso. Ang aspiration, kung saan inididrain ang likido gamit ang karayom, ay isang karaniwang unang hakbang. Gayunpaman, karamihan sa mga ganglion ay bumabalik pagkatapos ng aspiration. Ang surgical removal ay nag-aalok ng malaking pagbaba sa pagkakataon ng recurrence kumpara sa aspiration. Para sa mga ganglion sa pulso, ang surgical intervention ay may humigit-kumulang 10% na recurrence rate. Ibig sabihin, sa humigit-kumulang 9 sa 10 kaso, hindi bumabalik ang bula.

Ang recovery mula sa surgery ay kinabibilangan ng pamamahala ng swelling at sakit. Karamihan sa mga pasyente ay nakakaranas ng malaking pagtaas sa function at pagbaba ng sakit sa loob ng 6 linggo pagkatapos ng arthroscopic ganglion cyst resection. Ang open excision ay nag-iwan ng scar at may ilang risk para sa adverse events. Ang mga arthroscopic techniques ay nag-aalok ng sabay-sabay na paggamot ng iba pang isyu at madalas ay nagreresulta sa katumbas na recurrence rates kumpara sa open surgery.

Tutulungan ka ng iyong surgeon na bigyang-pansin ang mga risks at benefits. Isasama nila ang iyong edad, activity level, at kung gaano karami ang bula na nagpapagal sa iyo. Wala ng iisang pinakamainam na treatment para sa lahat. May mga tao na mas gusto maghintay at tingnan. May iba naman na mas gusto ang definitive removal upang maiwasan ang future uncertainty. Gabayin ka ng iyong surgeon patungo sa opsyon na angkop sa iyong buhay at mga layunin.

Kailan kumonsulta sa doktor

Kumonsulta sa iyong doktor kung mapansin mo ang pamamaga sa iyong pulso o kamay na nagdudulot ng patuloy na sakit, kahinaan, o kawalan ng katatagan. Magpakonsulta sa isang espesyalista kung ang pamamaga ay nagpapa-lock ng iyong kasukasuan, nagdudulot ng pagkahina, o nakakaapekto sa iyong pagtulog o trabaho. Ang biglaang paglala ng mga sintomas ay nangangailangan din ng pagsusuri. Bagama’t maraming ganglion ang nagbabawas ng sukat sa loob ng anim na taon, ang ilang kaso ay nangangailangan ng interbensyon. Ang percutaneous puncture ay nag-aalok ng mababang rate ng pagbalik para sa mga ganglion sa flexor tendon sheath, na walang naitalang pagbalik pagkatapos ng pangalawang puncture sa isang pag-aaral. Gayunpaman, ang karamihan sa mga ganglion ay bumabalik pagkatapos ng simpleng aspiration. Ang iyong surgeon ay makakatulong sa iyo upang magdesisyon kung kailangan pa ng karagdagang paggamot upang maibalik ang function at kaginhawaan.

Evidence & references

Overview

Flexor tendon thickening occurs significantly before patients experience triggering, except in the thumb [1].
Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath [2].
Treatment of an intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion [3].

Anatomy & Pathophysiology

The flexor tendon thickens significantly before patients experience triggering, except in the thumb [1].
The A1 pulley confluence varies on a digit-to-digit basis, with no observed confluence in the thumb and the most common confluence observed in the middle finger [36].
Hand surface landmarks clarify the localization of the thumb A1 pulley and digital neurovascular structures [28].
Relative motion between a tendon and subsynovial connective tissue (SSCT) in the carpal tunnel is maximal at extremes of wrist motion, particularly 60° extension, which may predispose the SSCT to shear injury [32].
The active finger protocol requires the strongest tension of the flexor digitorum profundus tendon and results in the longest excursion [33].
The relative motion concept harnesses normal functional anatomic relationships of the extensor digitorum communis (EDC) and flexor digitorum profundus (FDP) muscles to vary forces on finger joints, allowing immediate controlled active motion while reducing undesirable tension [29].
Injury to the extensor mechanism, specifically the central slip, can lead to snapping or catching at the proximal interphalangeal (PIP) joint [35].
Understanding dynamic and passive stabilizing mechanisms is essential for diagnosing imbalance and for planning reconstructive strategies that restore movement [27].
Hand surgery and hand therapy practice interventions, including the use of relative motion flexion (RMF) orthoses for management of non-surgical and surgical extensor mechanism (EM) injuries, may benefit from an in-depth look at EM zone III and IV anatomy and biomechanics [26].

Classification

Flexor tendon thickening occurs significantly before patients experience triggering, except in the thumb [1].
Adherence around the flexor tendons contributes to the pathology of trigger finger and may be present in all grades of triggering [6].

Clinical Presentation

Flexor tendon thickening occurs significantly before patients experience triggering, except in the thumb [1].
Adherence around the flexor tendons contributes to the pathology of trigger finger and may be present in all grades of triggering [6].
The A0 pulley is implicated as the primary cause of 31% to 47% of trigger fingers [18].
Ganglion cysts are common benign lesions that may present as masses in the hand and wrist [11].
A volar wrist ganglion can present with triggering pathology at the wrist [10].
An intratendinous ganglion in the extensor pollicis longus tendon can cause tenosynovitis [3].
Clinical examination is a valuable tool for detecting flexor disease due to its high specificity and positive predictive values, although a negative examination does not exclude inflammation [37].
Tendinopathies involving the hand and wrist are common and often diagnosed easily [9].
Unilateral absence of the ring finger flexor digitorum profundus musculotendinous structure can pose a diagnostic challenge when history and examination suggest an acute avulsion injury [23].

Investigations

Sonographic evaluation can assess the flexor tendon, volar plate, and A1 pulley with respect to trigger finger severity [1].
Flexor tendon thickening occurs significantly before patients experience triggering, except in the thumb [1].
Adherence around the flexor tendons contributes to trigger finger pathology and may be present in all grades of triggering [6].

Treatment

Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath [2].
Ganglion cysts may be managed with reassurance, nonoperative treatment such as aspiration, or surgical excision [11].
Treatment of an intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion [3].
A volar wrist ganglion presenting as trigger finger can be treated with interventional radiological measures rather than open surgery [10].
The minimally invasive needle-knife technique for trigger finger achieved a 99% satisfactory result rate with no injuries to flexor tendons, arteries, or nerves [15].
Compared to other common non-image guided flexor tendon sheath injection techniques, the mid-axial injection technique was found to be the most accurate in producing all intra-sheath injection and least likely to result in intra-tendinous injection [13].
Tendinopathies involving the hand and wrist are managed straightforwardly with nonsurgical treatments such as splinting, injection, or therapy, or surgical techniques such as tendon release [9].

Complications

Flexor tendon thickening occurs significantly before patients experience triggering, except in the thumb [1].
Adherence around the flexor tendons contributes to the pathology of trigger finger and may be present in all grades of triggering [6].
The A0 pulley is implicated as the primary cause of 31% to 47% of trigger fingers [18].
Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath [2].
Treatment of an intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion [3].
Ganglion cysts are common benign lesions that may be managed with reassurance, nonoperative treatment such as aspiration, or surgical excision [11].
A volar wrist ganglion can present as trigger finger [10].
Even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection despite aggressive and prompt antibiotic therapy and surgical intervention [7].
The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively [4].
Whether or not to repair the flexor digitorum superficialis in acute Zone 2B injuries is an intraoperative decision based on the ease of gliding of the repaired tendon(s) [5].
Six-strand repair technique is an effective procedure to assure early active motion after flexor pollicis longus tendon injuries, and good results can also be achieved by omitting the circumferential suture [12].
Minimally invasive needle-knife release achieved a 99% satisfactory result rate with no injuries to flexor tendons, arteries, or nerves [15].

Recovery

Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath [2].
Treatment of an intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion [3].
The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively [4].
Whether or not to repair the flexor digitorum superficialis in acute Zone 2B injuries is an intraoperative decision based on the ease of gliding of the repaired tendon(s) [5].
Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [7].
The use of patient-reported outcomes, in addition to clinician-reported outcomes, provided deeper insight into patients' perceptions of their recovery after flexor tendon injury [8].
A six-strand repair technique is an effective procedure to assure early active motion after flexor pollicis longus tendon injuries [12].
Good results can be achieved by omitting the circumferential suture in six-strand flexor pollicis longus tendon repairs [12].
The wide-awake approach to flexor tendon repair has decreased rupture and tenolysis rates and permitted consistently good results in cooperative patients [17].
The hand requires a stable wrist and at least two sensate digits that can oppose with some power for functional prehension [20].
A patient with congenital hypoplasia of the extensor tendons of the fingers regained nearly full extension of the affected fingers at 6 months and was able to return to work [25].

Key Evidence

[L4] The flexor tendon thickened significantly before patients experienced triggering except in the thumb. [1] (10.1016/j.jhsa.2012.06.027)
[L4] Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath. [2] (10.1007/s11552-007-9028-4)
[Case_report] Treatment of the intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion. [3] (10.1177/1753193412453428)
[L4] The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. [4] (10.1016/j.jhsa.2022.01.015)
[L3] Whether or not to repair flexor digitorum superficialis is an intraoperative decision based on the ease of gliding of the repaired tendon(s). [5] (10.1177/1753193420932446)
[L2] Adherence around the flexor tendons contributes to the pathology of trigger finger and may be present in all grades of triggering. [6] (10.1177/1753193420969293)
[L5] Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. [7] (10.5435/jaaos-20-06-373)
[L3] The use of patient-reported outcomes, in addition to clinician-reported outcomes, provided deeper insight into patients' perceptions of their recovery after flexor tendon injury. [8] (10.1016/j.jht.2024.12.011)
[L5] Tendinopathies involving the hand and wrist are common, often diagnosed easily, and managed straightforwardly with nonsurgical treatments such as splinting, injection, or therapy, or surgical techniques such as tendon release. [9] (10.5435/jaaos-d-14-00216)
[L4] This is the first reported case of triggering pathology at the wrist to be treated with interventional radiological measures rather than open surgery and demonstrates the efficacy of the technique. [10] (10.1177/1753193412453699)
[L5] Ganglion cysts are common benign lesions that may be managed with reassurance, nonoperative treatment such as aspiration, or surgical excision. [11] (10.1016/j.hcl.2004.03.015)
[L3] Six-strand repair technique is an effective procedure to assure early active motion after flexor pollicis longus tendon injuries and good results can also be achieved by omitting the circumferential suture. [12] (10.1177/15589447211057295)
[L5] Compared to other common non-image guided flexor tendon sheath injection techniques, the mid-axial injection technique was found to be the most accurate in producing all intra-sheath injection and least likely to result in intra-tendinous injection. [13] (10.1177/15589447221093676)
[L4] The minimally invasive needle-knife overcomes disadvantages of previously reported knives and achieved a 99% satisfactory result rate with no injuries to flexor tendons, arteries, or nerves. [15] (10.1177/1753193411436294)
[L5] The wide-awake approach to flexor tendon repair has decreased rupture and tenolysis rates and permitted consistently good results in cooperative patients. [17] (10.1016/j.hcl.2013.02.009)
[L1] These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in this study. [18] (10.1177/1558944721994231)
[L5] The hand requires a stable wrist and at least two sensate digits that can oppose with some power for functional prehension. [20] (10.1016/s0749-0712(02)00130-0)
[L4] This case illustrates a patient with unilateral absence of the ring finger FDP musculotendinous structure, which can pose a diagnostic challenge when the history and examination suggest an acute avulsion of the ring finger FDP tendon. [23] (10.1016/j.jhsa.2016.02.003)
[Case_report] The patient regained nearly full extension of the affected fingers at 6 months and was able to return to work. [25] (10.1016/j.jhsa.2019.03.018)
[L5] Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics. [26] (10.1016/j.jht.2023.01.002)
[L5] Understanding the dynamic and passive stabilizing mechanisms is essential for diagnosing imbalance and for planning reconstructive strategies that restore movement. [27] (10.1177/17531934261427638)
[L5] The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. [28] (10.1016/j.jhsa.2013.02.028)
[L5] The relative motion concept harnesses normal functional anatomic relationships of the EDC and FDP muscles to vary forces on finger joints, allowing immediate controlled active motion while reducing undesirable tension. [29] (10.1016/j.jht.2022.12.006)
[L5] Relative motion between a tendon and SSCT in the carpal tunnel is maximal at extremes of wrist motion, particularly 60° extension, which may predispose the SSCT to shear injury. [32] (10.1016/j.jhsa.2008.09.021)
[L4] The active finger protocol was found to require the strongest tension of the tendon and with the longest excursion. [33] (10.1016/j.jht.2021.01.006)
[Case_report] Hand surgeons should be aware that injury to the extensor mechanism and specifically the central slip can lead to snapping or catching at the PIP joint in the finger. [35] (10.1177/15589447221081876)
[L5] A1 pulley confluence varies on a digit-to-digit basis, with no observed confluence in the thumb and the most common confluence observed in the middle finger. [36] (10.1016/j.jhsa.2022.02.011)
[L3] Clinical examination can be a valuable tool for detecting flexor disease in view of its high specificity and positive predictive values, but a negative clinical examination does not exclude inflammation and an US should be considered. [37] (10.1186/1471-2474-12-91)

References

[1] Sonographic Appearance of the Flexor Tendon, Volar Plate, and A1 Pulley With Respect to the Severity of Trigger Finger. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.06.027 [2] Flexor Tendon Sheath Ganglions: Results of Surgical Excision. HAND. 2007. DOI: 10.1007/s11552-007-9028-4 [3] Tenosynovitis of the extensor pollicis longus tendon caused by an intratendinous ganglion: a case report. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412453428 [4] Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.015 [5] Flexor digitorum profundus with or without flexor digitorum superficialis tendon repair in acute Zone 2B injuries. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420932446 [6] Adhesions as a component of the trigger finger: a dynamic sonographic study. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420969293 [7] Flexor Tendon Sheath Infections of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-373 [8] Finger flexor tendon injuries repaired surgically followed by an early active motion program: A prospective cohort study of clinician- and patient-reported outcomes. Journal of Hand Therapy. 2026. DOI: 10.1016/j.jht.2024.12.011 [9] Tendinopathies of the Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00216 [10] Volar wrist ganglion presenting as trigger finger. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412453699 [11] Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.03.015 [12] Six-Strand Flexor Pollicis Longus Tendon Repairs With and Without Circumferential Sutures: A Multicenter Study. HAND. 2022. DOI: 10.1177/15589447211057295 [13] Accuracy and Safety of Non-Image Guided Trigger Finger Injections: A Cadaveric Study. HAND. 2022. DOI: 10.1177/15589447221093676 [15] A technique for accurately marking the A1 pulley on the skin. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193411436294 [17] Wide-awake Flexor Tendon Repair and Early Tendon Mobilization in Zones 1 and 2. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.02.009 [18] Differential Pulley Release in Trigger Finger: A Prospective, Randomized Clinical Trial. HAND. 2021. DOI: 10.1177/1558944721994231 [20] Biomechanics and hand trauma: what you need. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(02)00130-0 [23] Absent Ring Finger Flexor Digitorum Profundus Presenting as a Jersey Finger. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.02.003 [25] Congenital Hypoplasia of the Extensor Tendons of the Fingers: A Case Report and Review of the Literature. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.03.018 [26] An in-depth look at zone III and IV anatomy of the finger extensor mechanism and some clinical implications for use of the relative motion flexion orthosis. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.01.002 [27] The balanced finger: biomechanics of intrinsic and extrinsic systems and principles of reconstruction. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261427638 [28] Hand Surface Landmarks and Measurements in the Treatment of Trigger Thumb. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.028 [29] A commentary from the pioneers on the innovation of the relative motion concept: History, biologic considerations, and anatomic rationale. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2022.12.006 [32] Shear Strain and Motion of the Subsynovial Connective Tissue and Median Nerve During Single-Digit Motion. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.09.021 [33] Ultrasonographic assessment in vivo of the excursion and tension of flexor digitorum profundus tendon on different rehabilitation protocols after tendon repair. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2021.01.006 [35] Longitudinal Tear of the Central Slip Causing Painful and Unusual Snapping of the Finger: A Case Report. HAND. 2022. DOI: 10.1177/15589447221081876 [36] Defining the Digit-Specific Confluence of the A1 Pulley. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.02.011 [37] A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-91