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Trigger wrist caused by a giant cell tumour of tendon sheath
Trigger Wrist Caused by a Giant Cell Tumour of Tendon Sheath N. SUEMATSU, T. HIRAYAMA and Y. TAKEMITSU From Asahikawa, Japan. Trigger wrist is a rare condition unlike the trigger finger of the metacarpophalangeal joint. This report describes a case of trigger wrist secondary to a giant cell tumour of the flexor tendon sheath. No previous reports are available in the medical literature.
A forty-three-year-old left-handed female had worked as a golf caddy for ten years. Three years prior to examination, a trigger phenomenon developed on flexion and extension of the left ring finger and gradually extended to the middle finger, index finger and little finger in that order. She noticed a mass in the left palm six months prior to examination. With full flexion of four fingers on the ulnar side, pain developed on the volar side of the left wrist with a clicking sound. Recently, a tingling sensation, in the region innervated by the left median nerve, appeared at night following active daytimb use of the hand. On examination, a 2 x 2.5 cm subcutaneous mass was palpated in the left palm with the fingers extended. (Figure la). There was no local heat and no tenderness. The mass moved to a more proximal position with a click accompanied by pain in the wrist joint on volar flexion with flexion of the fingers (Figure lb). At that time, the patient was unable to extend her fingers actively. When the fingers were passively extended, the mass moved distally with a clicking sound accompanied by pain in the wrist joint. Due to the pain, the patient was unable to flex her finger fully. Neither thenar atrophy nor sensory disturbance of the hand was evident. The range of motion of the wrist joint was normal. Grip power was 33 kg on the right, and 26 kg on the left. Tinel's sign was absent and Phalen's test was negative. X-ray examinations revealed no abnormalities. Preoperative conduction-time study of the median nerve showed a distal conduction-time delay in the left median nerve at the carpal tunnel of 5.85 milliseconds compared to a delay of 3.75 milliseconds in the right. All other laboratory tests including blood count, urinalysis, erythrocyte sedimentation rate, serum uric acid level and latex fixation were normal.
-Fig. l
a) Arrow indicates location o f palmar mass. b) Arrow indicates change in mass location when locked in distal carpal tunnel during finger flexion.
~'o
,stal On surgical exploration, an oval shaped mass, 1.5 cm in length and 1 cm in diameter, was found arising from the profundus tendon of the middle finger, proximal to the lumbrical muscle origin (Figure 2). The mass was located on the ring finger-side of the middle finger tendon with adhesions to the profundus tendons of the ring finger, little finger and index finger. Received for publicationMay, 19S4. N. Suematsu,M.D., Asahika~,aMedicalCo11r162Nishikagura4-5, 3-1I, ,Mahikawa,Japan. VOL. 10-B No. I FEBRUARY 1985
Fig. 2
T: T u m o u r . P: Flexor digitorum p r o f u n d u s of middle finger. L: Lumbrical muscle.
Under anaesthesia, the mass was shown not to lock the tendon. The transverse ligament was divided and the mass was excised en bloc. Tenosynovitis was noted in the flexor tendon group within the carpal tunnel. Histological examination of the mass revealed a giant 9cell tumour of the tendon sheath (Figure 3). 121
N. SUEMATSU. T. lnRAYAMA AND Y. TAKEMITSU
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In the present case, with the clinical symptoms and operative findings, the trigger phenomenon probably occurred when the tumour entered and left the distal carpal tunnel.
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The postoperative period was uneventful. The trigger phenomenon disappeared. One month after the operation, finger function was normal. Discussion
Eighteen cases of "trigger wrist" or "snapping wrist" have been reported since the first report by Marti in 1960. The association of carpal tunnel syndrome was present in sixteen cases of the reported eases. It should be noted, however, that cases with definite trigger phenomenon of the wrist joint were included in cases which were reported simply as carpal tunnel syndrome in the past (Matsuzaki, 1971; Kojima, 1971; Dohi, 1972; Asai, 1982). In view of this fact, trigger wrist may have been associated with other cases of carpal tunnel syndrome previously reported. Two cases of bilateral "trigger wrists" have been reported. Both were due to anomalous sublimis muscle belly.
According to CT scanning by Ryo (1983), the transectional area o f the carpal tunnel in healthy adult males and females is smaller distally than proximally. So far as the transectional area of the carpal tunnel is concerned, therefore, the trigger phenomenon should occur more commonly when a mass passes through the distal tunnel, as in the reported case. In type A trigger wrists, a tumour was present in the index finger in one case, in the middle finger in seven cases, in the ring finger in six cases and in the little finger in two cases. Thus, a tumour appeared most frequently in the middleand ring fingers. Histological examination frequently revealed a fibroma or rheumatoid nodule. No giant cell tumour of the tendon sheath has been previously reported in the medical literature (Table 1). TABLE 1 Review of the reports suggesting three t}pes of triggering depending on the mechanism of development.
Ab. o f Cases
Carpal Tunnel Syndrome
4 4 ! ! l
3 4 l l I
3 2
3 2"
l l
I 0
18
16
Type A--Tumour Fibroma Rheumatoid Nodule Angioma Benign Hbrous ttistioc)aoma Giant Cell Tumour
Type B--Anomalous Muscle Belly Lumbrical Superficialis
T)pe C~Tumour + Anomalous 5htscle Belly Ganglion + Lumbrical Fibroma + Profundus Total Superficialis:
Hexor digitorum superficialis Hexor digitorum profundus Bilaterally
Review of the reports suggested three types of triggering depending on the mechanism of development (Table 1).
Profundus: 9:
T y p e A . The (umour occurring on the flexor tendon or flexor tendon sheath enters and leaves the carpal tunnel (Marti, 1960; Eibel, 1961; Davalbhakta, 1972; Brown, 1974; Iqbal, 1982; Sugawa, 1983; Carvell, 1983; Suematsu, 1984).
In the anomalous muscle belly aetiology of Type B, anomalous lumbrical muscles were reported in three cases, and anomalous superficialis muscles were reported in two cases. In the trigger wrist of Type C, a ganglion associated with an anomalous lumbrical muscle was reported in one case. A fibroma associated with an anomalous flexor digitorum profundus was reported in one case.
T y p e B . A n anomalous muscle belly enters and leaves the carpal tunnel (Matsuzaki, 1971; Kojima, 1971; Dohi, 1972; Agashi, 1980; Kotani, 1982).
C. A combination of tumour and anomalous muscle (Asai, 1982; Kernohan, 1982). Type
122
Of the soft turnouts of the hand, the frequency of giant cell tumour of the tendon sheath was reported as 8.1% by Posch (1956) and 13~0 by Boyes (1970). THE JOURNAL OF tlAND SURGERY
TRIGGER WRIST AND GIANT CELL TUMOUR
As a cause o f giant cell tumour of the tendon sheath, repeated minor trauma has been suggested. In the case reported, her work as a caddy for ten years may have been responsible for the tumour development. A case of giant cell tumour of the tendon sheath causing trigger wrist is reported. References AGtlASI, M. K., RZETELNY, V. and AXER, A. (1980). The Flexor Digitorum Superficialis as a Cause of Bilateral Carpal-Tunnel Syndrome and Trigger Wrist. The Journal of Bone and Joint Surgery et al 62A: 134-135. ASAI, M. KODAMA, N., TAKEUCttl, M. ET AL (1982). A Case of Carpal Tunnel Syndrome Caused by Tv,o Ganglions Associated xvith Aberrant Lumbrical Muscles. The Hokkaido Journal of Orthopaedic and Traumatic Surgery, 17: 124-126. (in Japanese). BOYES, J. H. (1970). Bunnell's Surgery of the |land, 5th ed., Philadelphia and Montreal J. B. Lippincott Company p666-691. BROWN, L. P. and COULSON, D. B. (1974). Triggering at the Carpal Tunnel v,ith Incipient Carpal-Tunnel Syndrome (Report of an Unusual Case). The Jou~-nal of Bone and Joint Surgery 56A: 623-624. CARVELL, J. E., hlOWAT, A. G. and FULLER, D. J. (1983). Trigger Wrist Phenomenon i~ Rheumatoid Arthritis. The Hand 15: 77-81. DAVALBHAKTA, IV. V. and BAILEY, B. N. (1972). Trigger Wrist. Report of Two Cases. British Journal of Plastic Surgery, 25: 376-379.
VOL. 10-B No. I FEBRUARY 1985
DOHI, S., FUJITA, S. and SHIBATA, S. (1972). Anomalous Muscle Belly of the Flexor Digitorum Superficialis Causing Carpal-Tunnel Syndrome~ Report of a Case. Seikei geka 23:1211-1213 (in Japanese). EIBEL, P. (1961). Trigger Wrist With Intermittent Carpal Tunnel Syndrome. A ttitherto Undescribed Entity With Report Of A Case. The Canadian Medical Association Journal, 84: 602-605. IQBAL, Q. M. (1982). Triggering of the Finger at the Flexor'Retinaculum. The Hand, 14: 53-55. KERNOHAN, J. G., BENJAMIN, A. and SIMPSON, D. (1982). Trigger Wrist Due to Anomalous Flexor Digilorum Profundus Muscle in Association ~ith Fibroma of Tendon Sheath. The tland 14: 59-60. KOJIMA, T., SUZUKI, S. and GOTOH, K. (1971). Case Report of Carpal Tunnel Syndrome Due to Anomalous lumbrieal muscle (in Japanese.) Seikei geka 22: 746-748. KOTANI, K., SUZUKI, K. and IJICHI, M. (1980). Snapping Wrist Produced by Anomalous Lumbrieal Muscle (in Japanese). Seikei geka: 1681-1683. MARTI, T. (1960). Schrellendes Handgelenk und Karpal Tunnel Syndrome Schweizerische Medizinische Wochenschrift, 90: 986-988. MATSUZAKI, A. and MITSUYASU, M. (1971). Case Report of Carpal Tunnel Syndrome Caused by Lumbrical Muscle (in Japanese.) Rinsho Seikei geka, 6: 633-636. POSCll, J. L. (1956). Tumors of the Hand. The Journal of Bone and Joint Surgery, 38A: 517-540. RYO, S., TAJIMA, T. and SAITO, T. (1983). Investigation of Crosssectional Area of the Carpal Canal by Ct scanning as a Factor causing Carpal Tunnel Syndrome. Seikei geka, 34:1675-1679 (in Japanese). SUGAWA, I., MORIWAKI, M. and KAMIGAWA, T. (1983). Case Report of Snapping Wrist, Cent. Jap, J Orthop. Traumat. 26:779-780 (in Japanese).
123
A forty-three-year-old left-handed female had worked as a golf caddy for ten years. Three years prior to examination, a trigger phenomenon developed on flexion and extension of the left ring finger and gradually extended to the middle finger, index finger and little finger in that order. She noticed a mass in the left palm six months prior to examination. With full flexion of four fingers on the ulnar side, pain developed on the volar side of the left wrist with a clicking sound. Recently, a tingling sensation, in the region innervated by the left median nerve, appeared at night following active daytimb use of the hand. On examination, a 2 x 2.5 cm subcutaneous mass was palpated in the left palm with the fingers extended. (Figure la). There was no local heat and no tenderness. The mass moved to a more proximal position with a click accompanied by pain in the wrist joint on volar flexion with flexion of the fingers (Figure lb). At that time, the patient was unable to extend her fingers actively. When the fingers were passively extended, the mass moved distally with a clicking sound accompanied by pain in the wrist joint. Due to the pain, the patient was unable to flex her finger fully. Neither thenar atrophy nor sensory disturbance of the hand was evident. The range of motion of the wrist joint was normal. Grip power was 33 kg on the right, and 26 kg on the left. Tinel's sign was absent and Phalen's test was negative. X-ray examinations revealed no abnormalities. Preoperative conduction-time study of the median nerve showed a distal conduction-time delay in the left median nerve at the carpal tunnel of 5.85 milliseconds compared to a delay of 3.75 milliseconds in the right. All other laboratory tests including blood count, urinalysis, erythrocyte sedimentation rate, serum uric acid level and latex fixation were normal.
-Fig. l
a) Arrow indicates location o f palmar mass. b) Arrow indicates change in mass location when locked in distal carpal tunnel during finger flexion.
~'o
,stal On surgical exploration, an oval shaped mass, 1.5 cm in length and 1 cm in diameter, was found arising from the profundus tendon of the middle finger, proximal to the lumbrical muscle origin (Figure 2). The mass was located on the ring finger-side of the middle finger tendon with adhesions to the profundus tendons of the ring finger, little finger and index finger. Received for publicationMay, 19S4. N. Suematsu,M.D., Asahika~,aMedicalCo11r162Nishikagura4-5, 3-1I, ,Mahikawa,Japan. VOL. 10-B No. I FEBRUARY 1985
Fig. 2
T: T u m o u r . P: Flexor digitorum p r o f u n d u s of middle finger. L: Lumbrical muscle.
Under anaesthesia, the mass was shown not to lock the tendon. The transverse ligament was divided and the mass was excised en bloc. Tenosynovitis was noted in the flexor tendon group within the carpal tunnel. Histological examination of the mass revealed a giant 9cell tumour of the tendon sheath (Figure 3). 121
N. SUEMATSU. T. lnRAYAMA AND Y. TAKEMITSU
.'qh'-~'.' ,,' ~t C', :-" . r , , , ~ r
. ~_.
9
\
- . _ - : ~ . . _ _ - ~ .-
,,
'*.,~ll,
~P
.-
-.
"
, ip : . , .
~-sr.
~
*'"
In the present case, with the clinical symptoms and operative findings, the trigger phenomenon probably occurred when the tumour entered and left the distal carpal tunnel.
.-~
lmp~_l
..~m~
z.
,,,.
a~,e~/.
...,-
..
2-- r"d .].
" - ~ . - "Ii. " ' ~ . ~ - ' ~..~.,,~ -, ~ , - .," ~ 3,..- ,,e ~**=...,,~ " , n m , Y,.~,~] ~ . . q , v, b, . ,~ - ' 2 r r 9 ; , , . ,%. ,,,- ..,..,~ ,,, , ~ , , .~ - \ . q ~ ~. ,,,,.~,,~,-,~ . ~ L p ~ - ~ - - 'It" " ~ b ,
-,,.
"..dr.
-
.
~,~
.
"\ ~
.
-.
.
.~,
1p
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Fig. 3
,---.~
.
_~-. . . . .
~r.,,
"-~-'~-'_~
~y~-,~',~s~,~,,l~.
~.'~,,x\'C--...~.~l,,,.
x
~_
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,i0,,~
P h o t o m i c r o g r a p h d e m o n s t r a t i n g m u l t i n u c l e a t e d g i a n t cells ( x l 0 0 ) in the t u r n o u t .
The postoperative period was uneventful. The trigger phenomenon disappeared. One month after the operation, finger function was normal. Discussion
Eighteen cases of "trigger wrist" or "snapping wrist" have been reported since the first report by Marti in 1960. The association of carpal tunnel syndrome was present in sixteen cases of the reported eases. It should be noted, however, that cases with definite trigger phenomenon of the wrist joint were included in cases which were reported simply as carpal tunnel syndrome in the past (Matsuzaki, 1971; Kojima, 1971; Dohi, 1972; Asai, 1982). In view of this fact, trigger wrist may have been associated with other cases of carpal tunnel syndrome previously reported. Two cases of bilateral "trigger wrists" have been reported. Both were due to anomalous sublimis muscle belly.
According to CT scanning by Ryo (1983), the transectional area o f the carpal tunnel in healthy adult males and females is smaller distally than proximally. So far as the transectional area of the carpal tunnel is concerned, therefore, the trigger phenomenon should occur more commonly when a mass passes through the distal tunnel, as in the reported case. In type A trigger wrists, a tumour was present in the index finger in one case, in the middle finger in seven cases, in the ring finger in six cases and in the little finger in two cases. Thus, a tumour appeared most frequently in the middleand ring fingers. Histological examination frequently revealed a fibroma or rheumatoid nodule. No giant cell tumour of the tendon sheath has been previously reported in the medical literature (Table 1). TABLE 1 Review of the reports suggesting three t}pes of triggering depending on the mechanism of development.
Ab. o f Cases
Carpal Tunnel Syndrome
4 4 ! ! l
3 4 l l I
3 2
3 2"
l l
I 0
18
16
Type A--Tumour Fibroma Rheumatoid Nodule Angioma Benign Hbrous ttistioc)aoma Giant Cell Tumour
Type B--Anomalous Muscle Belly Lumbrical Superficialis
T)pe C~Tumour + Anomalous 5htscle Belly Ganglion + Lumbrical Fibroma + Profundus Total Superficialis:
Hexor digitorum superficialis Hexor digitorum profundus Bilaterally
Review of the reports suggested three types of triggering depending on the mechanism of development (Table 1).
Profundus: 9:
T y p e A . The (umour occurring on the flexor tendon or flexor tendon sheath enters and leaves the carpal tunnel (Marti, 1960; Eibel, 1961; Davalbhakta, 1972; Brown, 1974; Iqbal, 1982; Sugawa, 1983; Carvell, 1983; Suematsu, 1984).
In the anomalous muscle belly aetiology of Type B, anomalous lumbrical muscles were reported in three cases, and anomalous superficialis muscles were reported in two cases. In the trigger wrist of Type C, a ganglion associated with an anomalous lumbrical muscle was reported in one case. A fibroma associated with an anomalous flexor digitorum profundus was reported in one case.
T y p e B . A n anomalous muscle belly enters and leaves the carpal tunnel (Matsuzaki, 1971; Kojima, 1971; Dohi, 1972; Agashi, 1980; Kotani, 1982).
C. A combination of tumour and anomalous muscle (Asai, 1982; Kernohan, 1982). Type
122
Of the soft turnouts of the hand, the frequency of giant cell tumour of the tendon sheath was reported as 8.1% by Posch (1956) and 13~0 by Boyes (1970). THE JOURNAL OF tlAND SURGERY
TRIGGER WRIST AND GIANT CELL TUMOUR
As a cause o f giant cell tumour of the tendon sheath, repeated minor trauma has been suggested. In the case reported, her work as a caddy for ten years may have been responsible for the tumour development. A case of giant cell tumour of the tendon sheath causing trigger wrist is reported. References AGtlASI, M. K., RZETELNY, V. and AXER, A. (1980). The Flexor Digitorum Superficialis as a Cause of Bilateral Carpal-Tunnel Syndrome and Trigger Wrist. The Journal of Bone and Joint Surgery et al 62A: 134-135. ASAI, M. KODAMA, N., TAKEUCttl, M. ET AL (1982). A Case of Carpal Tunnel Syndrome Caused by Tv,o Ganglions Associated xvith Aberrant Lumbrical Muscles. The Hokkaido Journal of Orthopaedic and Traumatic Surgery, 17: 124-126. (in Japanese). BOYES, J. H. (1970). Bunnell's Surgery of the |land, 5th ed., Philadelphia and Montreal J. B. Lippincott Company p666-691. BROWN, L. P. and COULSON, D. B. (1974). Triggering at the Carpal Tunnel v,ith Incipient Carpal-Tunnel Syndrome (Report of an Unusual Case). The Jou~-nal of Bone and Joint Surgery 56A: 623-624. CARVELL, J. E., hlOWAT, A. G. and FULLER, D. J. (1983). Trigger Wrist Phenomenon i~ Rheumatoid Arthritis. The Hand 15: 77-81. DAVALBHAKTA, IV. V. and BAILEY, B. N. (1972). Trigger Wrist. Report of Two Cases. British Journal of Plastic Surgery, 25: 376-379.
VOL. 10-B No. I FEBRUARY 1985
DOHI, S., FUJITA, S. and SHIBATA, S. (1972). Anomalous Muscle Belly of the Flexor Digitorum Superficialis Causing Carpal-Tunnel Syndrome~ Report of a Case. Seikei geka 23:1211-1213 (in Japanese). EIBEL, P. (1961). Trigger Wrist With Intermittent Carpal Tunnel Syndrome. A ttitherto Undescribed Entity With Report Of A Case. The Canadian Medical Association Journal, 84: 602-605. IQBAL, Q. M. (1982). Triggering of the Finger at the Flexor'Retinaculum. The Hand, 14: 53-55. KERNOHAN, J. G., BENJAMIN, A. and SIMPSON, D. (1982). Trigger Wrist Due to Anomalous Flexor Digilorum Profundus Muscle in Association ~ith Fibroma of Tendon Sheath. The tland 14: 59-60. KOJIMA, T., SUZUKI, S. and GOTOH, K. (1971). Case Report of Carpal Tunnel Syndrome Due to Anomalous lumbrieal muscle (in Japanese.) Seikei geka 22: 746-748. KOTANI, K., SUZUKI, K. and IJICHI, M. (1980). Snapping Wrist Produced by Anomalous Lumbrieal Muscle (in Japanese). Seikei geka: 1681-1683. MARTI, T. (1960). Schrellendes Handgelenk und Karpal Tunnel Syndrome Schweizerische Medizinische Wochenschrift, 90: 986-988. MATSUZAKI, A. and MITSUYASU, M. (1971). Case Report of Carpal Tunnel Syndrome Caused by Lumbrical Muscle (in Japanese.) Rinsho Seikei geka, 6: 633-636. POSCll, J. L. (1956). Tumors of the Hand. The Journal of Bone and Joint Surgery, 38A: 517-540. RYO, S., TAJIMA, T. and SAITO, T. (1983). Investigation of Crosssectional Area of the Carpal Canal by Ct scanning as a Factor causing Carpal Tunnel Syndrome. Seikei geka, 34:1675-1679 (in Japanese). SUGAWA, I., MORIWAKI, M. and KAMIGAWA, T. (1983). Case Report of Snapping Wrist, Cent. Jap, J Orthop. Traumat. 26:779-780 (in Japanese).
123