stenosing tenosynovitis of the thumb flexor tendon account for the majority of stenosing tenosynovitis of the hand flexor tendon . the disease was more common in women and manual workers , mainly caused by overuse and causing great pain and inconvenience to the patients . conventional treatments included immobilization , rest , and oral anti - inflammatory drugs , as well as local injection of steroids and other serious cases , require surgical treatment . we knew that transverse incision was the main conventional surgical approach , but it has disadvantages , including both sides of the dorsal nerve being damaged easily , sometimes the annular ligament and flexor tendon are not readily exposed , and its biggest advantage is that it is not prone to form scar contracture . advantages of longitudinal incision are that it readily revealed the annular ligament and flexor tendon , but the biggest drawback is that it is prone to form scar contracture . some surgical methods , such as using a mini - scalpel - needle to perform percutaneous trigger thumb release , often damage tendon , blood vessels   and nerves and lead to incomplete release   and , thus , extremely easy relapse . we designed a kind of page turning style of the annular ligament partial resection with a small longitudinal s incision to more easily expose the tendon and avoid the recurrence of stenosing tenosynovitis . this article represents our experiences in 12 cases of stenosing tenosynovitis of the thumb flexor tendon in which a small longitudinal s incision and page turning style of annular ligament partial resection was performed . during a 2-year period from 1 august 2011 to 31 july 2013 , 96 outpatients with stenosing tenosynovitis of the thumb flexor tendon were treated in our hospital . there were 9 cases of stiff metacarpophalangeal joint of the thumb and 3 cases of snapping thumb . all 12 patients were treated operatively with small longitudinal s incision and page turning style of annular ligament partial resection . the other 84 cases with stenosing tenosynovitis were initially treated with restricted thumb flexion and extension activities , physiotherapy , local injection of steroids , as well as other surgical methods , were excluded from this study cohort . there were 8 re - treatments and 4 initial treatments of patients in this study cohort . after institutional review board approval , the patients were enrolled consecutively in this prospective study . there were 8 women and 4 men with an average age of 45.8 years ( range , 2962 years ) . four patients were agricultural workers and 5 patients were manual workers ( employed mainly in garment factories , mills , and toy factories ) , 1 patient was a fisherman , and 2 patients were housewives . comorbidities included cardiac disease in 1 patient , diabetes in 2 , and heavy smoking in 1 . the preoperative average range of motion of the metacarpophalangeal joint was 6.75 ( range , 225 ) . first , we touch the stenosing tenosynovitis nodules and then the center of it up and down to make the 5-mm s skin incision marks ( figure 1 ) . the operation does not need many surgical instruments , but 2 small retractors are necessary . a small automatic retractor is needed if the operation is performed by just 1 surgeon ( figure 2 ) . if the surgery is done under local anesthesia , the patient needs local lidocaine infiltration after disinfection is completed . the surgeons use a 15 blade to cut open the skin ; blunt dissection is done with a hemostat ( not with the blade ) until the flexor tendon and annular ligament are exposed . the main purpose of not using a blade to expose the tendon and annular ligament is to avoid damage to both sides of the dorsal nerves . we used a page turning style of annular ligament partial excision to manage the annular ligament after we revealed the annular ligament and flexor tendon , which requires cutting open the annular ligament from the extreme lateral or medial part . the advantage of this approach is that you can achieve an effective annular ligament partial resection ; you can avoid the annular ligament contraction of both sides not effectively removed when it was cut from the middle , thus avoiding postoperative recurrence of stenosis tenosynovitis . we used forceps to provoke the flexor tendon to test the extent of tendon release after the annular ligament partial resection to see if it releases thoroughly . the patients were encouraged to flex the thumb metacarpophalangeal joint and interphalangeal joint , and feel the extent of release by themselves . the final release of the stenosing tenosynovitis is tested by moving the thumb through a range of motions . if the release is complete , we directly suture the skin . the patients were encouraged to exercise the thumb metacarpophalangeal joint and interphalangeal joint after the 24 postoperative hour . after the incision stabilized , usually at 3 or 4 days , thumb flexation was encouraged to gain full range of motion of flexion . patients were followed up after surgery at 1 , 3 , 6 , and 12 months after surgery . at the last follow - up at 1 year , all patients were asked to complete a validated outcome measure , quick disability of arm , shoulder and hand and average short musculoskeletal functional assessment dysfunction score of arm and hand . first , we touch the stenosing tenosynovitis nodules and then the center of it up and down to make the 5-mm s skin incision marks ( figure 1 ) . the operation does not need many surgical instruments , but 2 small retractors are necessary . a small automatic retractor is needed if the operation is performed by just 1 surgeon ( figure 2 ) . if the surgery is done under local anesthesia , the patient needs local lidocaine infiltration after disinfection is completed . the surgeons use a 15 blade to cut open the skin ; blunt dissection is done with a hemostat ( not with the blade ) until the flexor tendon and annular ligament are exposed . the main purpose of not using a blade to expose the tendon and annular ligament is to avoid damage to both sides of the dorsal nerves . we used a page turning style of annular ligament partial excision to manage the annular ligament after we revealed the annular ligament and flexor tendon , which requires cutting open the annular ligament from the extreme lateral or medial part . the advantage of this approach is that you can achieve an effective annular ligament partial resection ; you can avoid the annular ligament contraction of both sides not effectively removed when it was cut from the middle , thus avoiding postoperative recurrence of stenosis tenosynovitis . we used forceps to provoke the flexor tendon to test the extent of tendon release after the annular ligament partial resection to see if it releases thoroughly . the patients were encouraged to flex the thumb metacarpophalangeal joint and interphalangeal joint , and feel the extent of release by themselves . the final release of the stenosing tenosynovitis is tested by moving the thumb through a range of motions . if the release is complete , we directly suture the skin . the patients were encouraged to exercise the thumb metacarpophalangeal joint and interphalangeal joint after the 24 postoperative hour . after the incision stabilized , usually at 3 or 4 days , thumb flexation was encouraged to gain full range of motion of flexion . patients were followed up after surgery at 1 , 3 , 6 , and 12 months after surgery . at the last follow - up at 1 year , all patients were asked to complete a validated outcome measure , quick disability of arm , shoulder and hand and average short musculoskeletal functional assessment dysfunction score of arm and hand . no patients had scar contracture affecting thumb function , incision union , or wound infection . no patients reported soft - tissue irritation as manifested by pain around the thumb flexor tendon . all 12 patients were followed up for 12 months . at final follow - up , the average ran range of motion arc of the metacarpophalangeal thumb joint was 37.1 ( range , 2940 ) . with regard to the formal functional outcome assessment , quick disability of arm , shoulder , and hand was 0.3 out of 100 ( range , 03 ) , and average short musculoskeletal functional assessment dysfunction score of arm and hand was 6.9 out of 40 ( range , 6.311.2 ) . as a point of reference , the average short musculoskeletal functional assessment dysfunction score of arm and hand is 6.02 points for the general population , and quick disability of arm , shoulder , and hand was 0 points for the general population ( table 1 ) . usually , stenosing tenosynovitis of thumb flexor tendon , commonly known as  snapping thumbs  or  trigger thumbs  occurs most commonly in manual workers , especially in elderly women . with the popularity of mobile phones and computers , the manifestations of thumb flexor tenosynovitis include metacarpophalangeal joint soreness and pain or snapping resulting in flexion and extensor dysfunction . in more severe cases , patients can have stiff thumbs or flexion deformity and active and passive extension limitation . the flexor tendon passes through a relatively narrow tunnel composed of thumb metacarpal bones , thumb flexor tendon , and annular ligament . if repeated stimulation occurs , the tunnel gradually becomes more and more narrow , then the flexor tendon is slowly squeezed into the spindle- or gourd - shaped swollen tendon . we have often found localized subcutaneous palpable hard nodules , which cause thumbs movement disorder , snapping , and pain . these greatly affect the function of the hand and thus affect the performance of activities of daily living . some researchers have used closed treatment with steroids and narcotic drugs to treat it , but the effect is not ideal and often causes tendon rupture . some surgeons reported that they treated stenosing tenosynovitis of the thumb with a mini - scalpel needle and achieved good effect , but with mini - scalpel needle surgery it is very easy to damage nerves , blood vessels , and tendons , in which case repeated surgery may be necessary . endoscopic treatment   of stenosing tenosynovitis requires specialized equipment to perform complicated operations , thus it is not widely used . the classic surgical approach is to cut the skin with a transverse or longitudinal incision , revealing the nerve , artery , and flexor tendon , and cutting open the annular ligament and then releasing the flexor tendon , then the incision is sutured . transverse incision has some disadvantages ; for example , tendons are often more difficult to expose , sometimes requiring extension of the incision , which can easily damage the dorsal nerve of the thumb , especially the radial . the longitudinal incision often causes scarring of the skin , thus affect the thumb activities . in addition , only cutting open the annular ligaments often leads to stenosing tenosynovitis recurrence . we designed a small longitudinal s incision and page turning style of annular ligament partial resection to treat the stenosing tenosynovitis . the patients are asked to begin active functional exercise beginning 24 hours after the operation . firstly , it can easily expose the flexor tendons in a longitudinal direction along the metacarpal and phalanx bones . secondly , it does not easily damage the dorsal nerves . for the incision located in the middle of the metacarpophalangeal joint , when we cut open the skin , we separate subcutaneous tissue with a vascular clamp ( not with surgical blades ) until the flexor tendon is exposed , which avoids the surgical blades damaging dorsal nerves . thirdly , the s incision can effectively avoid thumb flexion and extension activities and restricting skin scarring . fourthly , the page turning style of annular ligament partial resection ensures that the annular ligament is effectively resected , because cutting open the annular ligament in the middle causes the flexor tendon to squeeze the 2 parts of the annular ligament into lateral and medial sides , which causes the annular ligament to not be effectively resected . the surgical release is thorough , safe , and effective , and lessens the chance of recurrence of annular ligament adhesion , even if the patient could not exercise due to wound pain . the small longitudinal s incision and page turning style of annular ligament partial resection to treat stenosing tenosynovitis of the thumb flexor tendon to relieve the flexor tendon is simple , safe , causes less damage , and is worthy of promotion . conservative therapy should be chosen for serious cases such as those with snapping or stiff thumbs to ensure annular ligament partial resection effectively allows full release the thumb flexor tendon . in patients without snapping or stiff thumbs or in pediatric patients with congenital conditions , we should cut open the annular ligament in the extreme lateral or medial side , and be careful to not damage the flexor tendons . finally , we test if the snapping or stiff thumbs can disappear and release completely . the clinical results of this method are good and recurrence rate is very low . the small longitudinal s incision and page turning style of annular ligament partial resection causes less trauma , has low cost and low rate of recurrence , is effective , and leads to rapid recovery . it is a reliable treatment method with full release and with early range of motion .
backgroundto present the treatment outcome for patients with stenosing tenosynovitis of thumb flexor tendon treated with a small s incision and page turning style of annular ligament partial resection.material/methodsduring a 2-year period between august 2011 and july 2013 , 12 consecutive patients ( mean age , 45.8 years ) with stenosing tenosynovitis of the thumb flexor tendon were prospectively enrolled into this study . 
 all 12 patients underwent longitudinal s skin incision to expose annular ligament and thumb flexor tendon , and with page turning style of annular ligament partial resection to finish the operation . the average range of motion of metacarpophalangeal thumb joint , quick disability of arm , shoulder , and hand and short musculoskeletal function assessment dysfunction score of arm and hand were primary outcome measures.resultsthere were 9 cases of stiff metacarpophalangeal joint of thumb and 3 cases of snapping thumb for stenosing tenosynovitis . at 1-year follow - up , all stenosing tenosynovitis had healed by an average of 4 weeks . 
 the average range of motion of the metacarpophalangeal joint was 37.1 ( range , 3440 ) . 
 no patients had recurrence , cicatricial contraction , or postoperative infection . 
 the average disability of arm , shoulder , and hand was 0.3 out of 100 ( range , 01.67 ) , and average short musculoskeletal functional assessment dysfunction score of arm and hand was 6.9 out of 40 ( range , 015.6 ) . 
 all 12 patients stated that they were highly satisfied.conclusionssmall s incision and page turning style of annular ligament partial resection for stenosing tenosynovitis of thumb flexor tendon is a safe , simple , and reliable alternative treatment with minimal soft - tissue irritation , good functional results and recovery can be expected .