[doctor] this is philip gutierrez , date of birth 1/12/71 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 polyregion , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger , because there was concern about a capsular strain plus or minus rupture of , quote , " fds tendon , " end quote . he has been seen at point may orthopedics largely by the physical therapy staff and a pr , pa at that institution .
[doctor] at that practice , an mri was obtained on 4/24/2021 , which showed just focal soft tissue swelling over the right index mcp joint , partial-thickness tear of the right fds , and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact , as the mcp joint capsule . extensor tendons also deemed intact .
[doctor] his x-rays , four views of the right hand today , show no bony abnormalities , joint congruency throughout all lesser digits on the right hand , no soft tissue shadows of concern , no arthritis . hi , how are you , mr . gutierrez ?
[patient] i'm good , how about you ?
[doctor] well , how can i help you today ?
[patient] so i was a passenger in , uh , a car that was rear-ended , and we were hit multiple times . i felt two bumps , which slung me forward and caused me to stretch out my right index finger .
[doctor] so hitting the car in front of you all made that finger go backwards ?
[patient] um , i do n't really know . i just felt , like , it felt like i laid on my finger , and so , i felt like it went back , and it's been hurting since about march . and it's been like that ever , ever since the wreck happened . so i , and i ca n't make a fist , but sometimes the pain's unbearable . and , like , even driving hurts .
[doctor] okay , so this was march of this year , so maybe about three months ago ?
[patient] yeah , and it's still swollen . so i was seeing , uh , an orthopedist , and they sent me to an occupational therapist . and i've been doing therapy with them , and then they sent me to go back and get an mri . so i went and got the mri . uh , then they told me that the mri came back , and it said i had a tear in my finger , but he was n't gon na give me an injection , because the injection was going to make the tear worse .
[doctor] mm-hmm .
[patient] and then , after he got the mri , he said that i have , uh , a tear in my finger , and that he did n't wan na do surgery , but he would do an injection . then i'm thinking that you told me you would n't do an injection in there , and then the oper- , occupational therapy says it's because of the tear . and then , they do n't want me to keep rubbing the thing , and doing things with my hand . so i feel like i'm not getting medical care , really .
[doctor] yeah , i see that .
[patient] so i came to see if you could do anything for this hand , because i am right-handed , and i kinda need that hand .
[doctor] what do you do for a living ?
[patient] uh , i'm an x-ray tech .
[doctor] well , um , so do you have any diabetes or rheumatoid arthritis ?
[patient] nope .
[doctor] uh , do you take any chronic medications of su- , significance ?
[patient] uh , i do take a blood pressure pill , and that's it .
[doctor] okay , and it looks like you suffer from itching with the methylprednisolone ?
[patient] uh , that's correct .
[doctor] all right , well , i'm gon na scoot up closer and just take a quick look at your hand . all right , so , lean over here . all right , so on this exam today , we have a very pleasant , cooperative , healthy male , no distress . his heart rate is regular rate , rhythm , 2+ radial pulse , no swelling or bruise , bruising in the palm over the volar surface of his index finger , normal creases , slightly diminished over the pip of the index finger compared to the middle finger .
[doctor] his index finger rests in a 10-degree pip-flexed , uh , position . all right , is that uncomfortable to correct that , and is it uncomfortable now here ?
[patient] yeah , uh , when you push on it , yeah .
[doctor] all right , how about here ?
[patient] um , there , it's not .
[doctor] okay , not as bad ?
[patient] yeah , it feels , uh , a little numb .
[doctor] gotcha , all right . bend , bend the tip of this finger . bend it as hard as you can . keep bending . keep bending . all right , straighten it out . all right , and now , bend it for me as best you can .
[patient] my goodness . it feels like it's , it's tearing in there .
[doctor] okay , okay . well , bend the tip of this finger , and bend it as hard as you can . keep bending . all right , straighten that out , and now , bend it for me as best you can . all right , good . now , bend that finger , and i'm going to pull , put it down like this . and then bend that finger for me . okay , sorry , can you bend it for me ? all right . now , make a fist . great , so relax the finger . all right , so just keep it , keep , when i bend the finger , we're just going to bend that finger where it meets the hand . is that okay there ?
[patient] ow , .
[doctor] okay , okay . so all the hurt , it seems , is stretching , because you have n't been doing this for so long . so , you know what i mean ? so , um , you're going to have to start really doing that .
[patient] well , i've tried . i even bought myself a splint .
[doctor] well , but a splint does n't help move you . it actually immobilizes you .
[patient] okay . i thought it would straighten it out .
[doctor] no , no . so , so you really need to start bending the finger right here for me , as hard as you can , and keep going , going . all right , so , so you're okay . all right , so i would say the following , that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds , and the fds is the least important of the two . so the mri shows that it's the fds , the flexor digitorum superficialis , which is the least important of the two .
[patient] okay .
[doctor] uh , now , there's two halves of it . so it's a partial tear of one half of a whole tendon . that's not that important , and the other one is just fine .
[patient] so the good one is good ?
[doctor] yes , correct . so the one that goes all the way to the tip is good .
[patient] okay , good .
[doctor] yeah , so you know , i think what you have got so much scar tissue and inflammation around the fds tendon blocking excursion of these other tendons , that they ca n't get through to the pulley .
[patient] okay , all right .
[doctor] so what i would recommend what we try is a cortisone injection , and i would avoid the dexamethasone , because i saw you have a little reaction to that . but we could use the betamethasone , which is a celestone .
[patient] i've gotten another , uh , methylprednisolone , and that itched me like crazy .
[doctor] did it ? yeah , this one is water-soluble , and i think it's fairly low toxicity , but high benefit , and i think decreasing the pain will encourage you to move that finger .
[patient] all right , we'll give it a try .
[doctor] good . so , you do the shot , and it's going to take about three to five days before it starts feeling better . and then probably over the next couple of weeks , it'll start feeling even better .
[patient] perfect .
[doctor] all right , so take advantage of that . you've got ta start moving the finger . you're not going to tear anything or break a bone , uh , because your intensors , extensors are intact . but your collateral ligaments are intact , so you've got a stiff , sore finger . i'm going to try to help as much as i can with this soreness part , and then you have to do all the stiff part .
[patient] the lady in occupational therapy tried some maneuvers to straighten the finger out , but it even hurt after i left . the whole thing just swelled up .
[doctor] hmm . okay , so it was injured , and you had scar tissue . and then , you had post-traumatic inflammation . and so , this will help some with all of that . it's not going to make it to where your finger is like , , my finger does n't hurt at all , but it will make it to where at least tolerable , to where you can make some gains . and we actually might need to repeat this as well .
[patient] will i be able to drive ? i drove myself here today , so ...
[doctor] yeah , it may feel a little weird , but it's totally safe for you to drive .
[patient] okay , good .
[doctor] so for mr . gutierrez , just put that he has a post-traumatic rather severe stenosing tenosynovitis of his right index finger , and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so , mr . gutierrez , do you have , um , therapy scheduled or set up ?
[patient] uh , not at the moment .
[doctor] all right , well , i mean , you know that you need to move that finger , and i think to the degree that they can help you do that . so i want you to move that finger , finger , but i think it would be , uh , beneficial for you to have an accountability , um , so at least you know to check in with them once a week with somebody .
[patient] um , okay . that's kinda why i'm here , for you to tell me what needs to be done , you know ?
[doctor] yeah , so i'll write you out , um , an outpatient prescription . i think if you go back to the same people where you were before , i'm hoping that after this injection , you're going to be able to do a whole lot more with them . so let's do outpatient once a week for six weeks , um , and then full active and passive range of motion is the goal with no restrictions .
[patient] all right , sounds like a plan .
[doctor] all right , well , i will have the nurse set up the injection procedure , and we'll , and i'll be back shortly .
[patient] thanks , doc .
[doctor] right trigger finger injection template . attempted to inject one cc of celestone with f- , a half a cc of lidocaine . however , the patient had a dramatic and violent painful reaction to the introduction of the needle , with contortions of the hand , and with dangerously withdrawing the hand with concerns for secondary needle stick . needle was withdrawn . the patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath . we attempted a second time for a similar injection using the same technique with one cc of celestone and half a cc of lidocaine . a small parma- , uh , palmar vein bled a scant amount , which was cleaned up and band-aid applied . reassured on multiple occasions that no harm was done to his finger . recommended icing in it this evening , and taking ibuprofen .

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