Updated: 5/19/2021

Flexor Carpi Radialis Tendinitis

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  • Summary
    • Flexor carpi radialis tendinitis is a condition characterized by pain over the volar radial wrist caused by inflammation of the FCR tendon sheath.
    • Diagnosis is made clinically with pain over the FCR tendon that worsens with resisted wrist flexion.
    • Treatment usually involves immobilization, NSAIDs and injections. In rare refractory cases operative release of the FCR tendon sheath may be indicated. 
  • Epidemiology 
    • Incidence
      • rare
        • < 1 per 100,000 annually
    • Risk factors
      • repetitive wrist flexion
        • golfers and racquet sports
        • manual labor
  • Etiology
    • 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
  • 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 cyst
    • De Quervain's tenosynovitis
    • Carpal tunnel syndrome
  • Diagnosis
    • Clinical and MRI
      • diagnosis is made with careful history and physical examination and can be confirmed with MRI studies
  • 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
  • TechniqueS
    • 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
  • Prognosis
    • Poor prognostic variables
      • history of overuse
      • worker's compensation
      • failure to respond to local injection
      • long duration of symptoms
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