Updated: 8/23/2017

Flexor Carpi Radialis Tendinitis

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https://upload.orthobullets.com/topic/6033/images/fcr mri.jpg
https://upload.orthobullets.com/topic/6033/images/fcr musculotendinous unit.jpg
https://upload.orthobullets.com/topic/6033/images/incision.jpg
Introduction
  • A condition characterized by inflammation of the FCR tendon sheath 
  • Demographics
    • incidence
      • uncommon
    • risk factors
      • repetitive wrist flexion 
        • golfers and racquet sports
        • manual labor
  • Pathoanatomy
    • primary stenosing tenosynovitis within the fibroosseous tunnel (see Anatomy)
    • secondary tendinitis associated with
      • scaphoid fracture
      • scaphoid cysts
      • distal radius fracture
      • scaphoid-trapezium-trapezoid joint arthritis
      • thumb CMC joint arthritis
  • Prognosis
    • prognosis is poor if the following are present
      • history of overuse
      • worker's compensation
      • failure to respond to local injection
      • long duration of symptoms
Anatomy
  • Flexor carpi radialis musculotendinous unit  
    • FCR muscle 
      • bipennate
    • FCR tendon  
      • enveloped by sheath from musculotendinous origin to trapezium
        • no fibrous sheath distal to trapezium
      • enters fibroosseous tunnel at the proximal border of the trapezium 
        • boundaries  
          • radial = body of the trapezium
          • palmar = trapezial crest, transverse carpal ligament
          • ulnar = retinacular septum from transverse carpal ligament (separates FCR from carpal tunnel)
          • dorsal = reflection of retinacular septum on trapezium body
        • space
          • within the tunnel
            • the FCR tendon occupies 90% of space 
            • is in direct contact with the roughened surface of the trapezium
            • more prone to constriction, tendinitis, attrition, rupture
          • proximal to the tunnel
            • the FCR tendon occupies 50-65% of space within FCR sheath proximal to the tunnel
            • less prone to constriction
            • but more prone to mechanical irritation from osteophytes
      • insertion 
        • small slip (1-2mm) inserts into trapezial crest
        • 80% of remaining tendon inserts into 2nd metacarpal
        • 20% of remaining tendon inserts into 3rd metacarpal
Presentation
  • Symptoms
    • volar radial aspect of the wrist
  • Physical exam
    • tenderness over volar radial forearm along FCR tendon at distal wrist flexion crease
    • provocative test
      • resisted wrist flexion triggers pain
      • resisted radial wrist deviation triggers pain
Imaging
  • Radiographs
    • findings
      • in primary tendinitis, radiographs are unremarkable
      • in secondary tendinitis, the following may be present
        • healed scaphoid fracture
        • healed distal radius fracture
        • exostosis or arthritis of scaphotrapezoid joint or thumb CMC
  • MRI
    • views
      • best seen on T2
    • findings
      • increased signal around FCR sheath on T2 image 
      • may find associated conditions in secondary tendinitis 
        • ganglion 
        • scaphoid cyst
Studies
  • Diagnostic injection
    • injection of local anesthetic along FCR sheath relieves symptoms
Differentials
  • Thumb CMC arthritis
  • Scaphoid cyst
  • Ganglion
  • De Quervain's tenosynovitis
Treatment
  • Nonoperative
    • immobilization, NSAIDS, steroid injection
      • indications
        • first line of treatment
      • technique
        •  direct steroid injection in proximity, but not into tendon
      • outcomes
        • usually effective for primary tendinitis
        • unsuccessful in secondary tendinitis if other lesions are present (e.g. osteophytes)
  • Operative
    • surgical release of FCR tendon sheath
      • indications
        •  rarely needed but can be effective in recalcitrant cases
Surgical Technique
  • Surgical release of FCR tendon sheath
    • approach
      • volar longitudinal incision starting proximal to the wrist crease, extending over proximal thenar eminence  
        • care taken to avoid 
          • palmar cutaneous branch of median nerve
          • lateral antebrachial cutaneous nerve
          • superficial sensory radial nerve
    • technique
      • elevate and reflect thenar muscles radially
      • expose FCR sheath
      • open FCR sheath proximally in the distal forearm, and extend to the trapezial crest
      • at the trapezial crest, the tendon enters the FCR tunnel
      • at this point, incise the sheath along the ulnar margin, taking care not to injure the tendon
      • mobilize tendon from trapezoidal groove (releasing trapezial insertion)
Complications
  • Complications of disease
    • FCR attrition and rupture
  • Complications of surgical release
    • cutaneous nerve injury
      • palmar cutaneous branch of median nerve
      • lateral antebrachial cutaneous nerve
      • superficial sensory radial nerve
    • injury to deep palmar arch
    • injury to FPL tendon (lies superficial to FCR tendon)
    • injury to FCR tendon within the tunnel
      • decompression is easy proximal to the tunnel (incision of FCR sheath)
      • within FCR fibroosseous tunnel, take care to avoid cutting FCR tendon
 

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