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Tendinitis, Cubital Tunnel Syndrome and Hand Problems

So what causes these tendinitises in the hand? The synovial lubricating system that we have in our joints, we have a pulley system in the fingers that keeps our flexor tendons for bolstering across the hand, this is great because it allows us to grab things tendonitis, cubital tunnel syndrome, hand pain, hand injury, to cup our hand and grab things, but we pay for those pulleys that keep the tendon close to the bones by having friction, so just like the joints, we have a lubricating system here, so here are your pulleys tendonitis, cubital tunnel syndrome, hand pain, hand injury, this is the A1 pulley and thatís the most important one for us to know about in this lecture because this is the one that gets irritated the most as we use it all the time. This is where you get tenosynovitis or a trigger finger.

The patient tells you they wake up in the morning, their finger is stuck in flexion and then it pops open, and they tell you the pain is over their PIP joint and they think they have arthritis in that joint, and itís interesting because that is where they perceive it. When your finger is stuck, and the PIP joint is what feels like it pops, and for some reason our brain tells us thatís where the pain is.

So what do I do, itís in your little hand-out, I take Ĺ cc of Xylocaine 1% and a 1/4 cc of 10 mg per cc of Kenalog which is 2 mg approximately of Kenalog, I mix then in a syringe, I use a 27 gauge needle and I fill the flexor tendon sheath. Now some people inject right at the A1 pulley and thatís okay, except for two things, your skin is a little bit more tender there than here, and this is the area where itís inflamed and that pulley is a little bit thickened, so it hurts to stick right there. I find that if you come out here, right over the middle.

If youíre intendant, you will get resistance, otherwise it will flow smoothly, it will fill the sheath, you will actually feel the sheath fill, this is an uncomfortable injection no matter what you do to patientís, so you tell them that, but it only takes about five seconds to do it, stick down, push, fill take the needle out and put a band aid on it. Their finger falls asleep almost immediately, and they can start to move it and feel better, 90% of patientís are cured with one injection, another 5% with a second injection, three to four weeks later if they need it and only rarely do they need to go to surgery. They go to surgery if they have a locked finger.

I have also drawn a picture here of where the digital nerves run. On either side of the finger, itís common digital nerve that splits to go up the finger, guess what? If the finger falls asleep when you are doing a trigger finger, injection from your Xylocaine is useful.

There is a soft spot, and if you touch that soft spot just ulnar to your palmaris longus, you can feel your flexor tendons move, you take an injection of 1 cc of Xylocaine, Ĺ cc of Kenalog or 5 mg, and go in at 45-45 degrees, put your opposite thumb just distal to your transverse carpal ligament in the middle of the palm right here, you can feel your injection go in. If you hit the nerve, they will tell you, then you just redirect a little bit, you want to go into the synovial sheath under the nerve and reduce the inflammation or the swelling, which is what it really is in the synovial sheath, and most patientís get numb, this is also a good way of doing a wrist block. This is an open carpal tunnel release and that is a severely compressed median nerve, you can see how it goes from this size to about a third of the size as in the back normal, and the transverse carpal ligament was right here.

Cubital tunnel syndrome, similar symptoms, but itís the ring and little finger that wakes them at night, flexion of the elbow thatís the problem, talking on the phone, sleeping curled up with their arms bent and they can get complete numbness and loss of pinch, and this is normal pinch here, and this is a your first dorsal interosseous and you lose that. Here is your elbow flexion test and again, elbow flexion with compression, so bend the elbow, not 130 degrees, but about 100 degrees and put direct pressure over the cubital tunnel on the nerve there, and that will stimulate it rapidly if they have a cubital tunnel syndrome. X-rays arenít

Again, if you can give a local injection going parallel to the nerve as a test, and similar causes, similar differential diagnosis, and your treatments are rest, splinting. What we do is we splint peopleís elbow in extension, people donít like to sleep with a true splint on, so I tell them to take an Acre wrap and Ace wrap a pillow into their elbow at night, and they learn not to sleep with their arms bent. Itís something you have to train people to do, you wear an elbow pad during the day so they donít rest.