ट्रिगर फिंगर रिलीज

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

Operative Technique¶

• Local anesthetic infiltration in the palm proximal to the incision site is preferred for trigger finger release [5].
• A pneumatic arm tourniquet may be helpful, although a high forearm Esmarch wrap usually is sufficient [5].
• For middle, ring, and small trigger finger releases, a transverse incision about 2 cm long is made several millimeters distal to the distal palmar crease [5].
• For index trigger finger releases, a transverse incision about 2 cm long is made several millimeters distal to the proximal palmar crease [5].
• Trigger thumb releases can be performed through incisions either distal or proximal to the metacarpophalangeal joint flexion crease [5].
• Alternative incisions for fingers can be made obliquely or longitudinally between the metacarpophalangeal and distal palmar creases [5].
• Alternative incisions for the thumb can be made obliquely across the thumb metacarpophalangeal flexion crease [5].
• The digital nerves on the thumb are more palmar and closer to the flexor sheath than might be anticipated [5].
• The thumb radial digital nerve is especially vulnerable during trigger thumb release [5].
• Subcutaneous tissues are spread away from the underlying annular pulley system to ensure digital nerves are safely protected [5].
• Trigger thumbs require release of only the A1 pulley [5].
• Trigger digits require division of the A1 and A0, or proximal palmar pulley [5].
• Pulley division is usually accomplished with an initial opening of the pulley with a No. 15 knife blade and a pair of tenotomy scissors [5].
• For trigger thumb release, cutting too far distally should be avoided to prevent disrupting the oblique pulley [5].
• The sheath is incised from proximal to distal, approximately 1 cm, and reassessed for triggering [5].
• Persistent triggering after initial release implies that either the A1 and palmar pulleys are incompletely released or an alternate site of triggering is present [5].
• When the distal A1 pulley edge is released, the divided pulley leaves are parallel rather than ending in a V-shaped pattern [5].
• The distinction between the A1 and A2 pulleys may not be apparent during surgery [5].
• Other fingers can be found to trigger at the same surgical setting and can be managed at the same time [5].

Postoperative Care¶

• The compression dressing is removed after 48 hours [5].
• Sutures are removed at 10 to 14 days [5].
• Normal use of the finger or thumb is encouraged postoperatively [5].

Anatomy & Pathophysiology¶

Demographics & Epidemiology¶

• Trigger finger occurs in 2% to 3% of the general population [9].
• Women are more commonly affected than men [9].
• Women older than 50 years of age are the primary demographic for trigger finger [1, 2].
• Middle and ring finger involvement is most common in adults [1, 2].
• The digits are affected in the following order of decreasing prevalence: thumb, ring, long, little, and index [9].
• Stenosing tenosynovitis is more common in diabetic patients than in nondiabetic patients [4].
• Trigger finger is more common in patients with diabetes mellitus, with a 10% to 20% lifetime incidence [9].

Comorbidities & Etiology¶

• Trigger finger is associated with diabetes and inflammatory arthropathy [1, 2].
• Trigger finger is seen in patients with hypothyroidism, sarcoidosis, rheumatoid arthritis, and septic tenosynovitis [9].
• The etiology of trigger finger is possibly associated with repetitive grasping activities [1, 2].
• Gout can present as trigger finger due to monosodium urate precipitation eliciting a fulminant inflammatory reaction in the tenosynovium [9].
• Calcific tendinitis can result in triggering due to calcium salt deposition in the tenosynovium [9].
• Pseudogout can cause triggering via calcium pyrophosphate dihydrate crystal deposition [9].
• Amyloidosis, characterized by beta-2-microglobulin deposition, can cause trigger finger in patients with renal failure undergoing dialysis [9].
• Trigger finger is considered an early indication of Dupuytren’s disease by some authors [12].
• The incidence of concurrent trigger finger and Dupuytren’s disease is higher in the middle and ring fingers than expected by statistical coincidence [11].

Histology & Pathology¶

• Histology of the affected pulley demonstrates fibrocartilaginous metaplasia of the pulley and/or FDS tendon [1, 2].
• Pathologic examination of affected pulleys demonstrates a proliferation of chondrocytes and increased type III collagen [9].
• The flexor digitorum profundus tendon often demonstrates a pathologic nodule, while the flexor digitorum superficialis is often unaffected [9].
• A nodule or fusiform swelling of the flexor tendon just distal to the first annular pulley may be palpable [7].
• The tendon nodule is usually located just proximal to the anulus at the metacarpophalangeal joint level [7].
• In rheumatoid patients, a nodule distal to the metacarpophalangeal joint level may cause triggering [7].
• A volar retinacular ganglion cyst between the A1 and A2 pulleys may be present [9].
• In congenital trigger digits, the pathologic anatomy includes narrowing and thickening of the sheath with occasional formation of a ganglion cyst [10].
• An intratendinous nodule proximal to the first annular pulley, often referred to as Notta’s nodule, may be present in congenital trigger digits [10].

Clinical Presentation¶

• Patients present with pain and tenderness in the palm at the proximal edge of the digital A1 pulley [4].
• Patients frequently note catching or triggering of the affected finger or thumb after forceful flexion [4].
• In more severe cases, the opposite hand must be used to force the finger or thumb passively into extension [4].
• In the most severe cases, the finger becomes locked in a flexed position [4].
• Triggering is often more pronounced in the morning than later in the day [4].
• A common complaint is referred pain at the dorsal MCP/PIP area [1, 2].
• Patients frequently state that the problem is in the proximal interphalangeal joint with trigger finger or trigger thumb [7].
• Concomitant trigger finger and carpal tunnel syndrome occurs in 40% to 60% of patients [1, 2].
• Local tenderness may be present but is not a prominent complaint [7].
• Pressure accentuates the apparent snapping or triggering of the more distal joints [7].

Anatomical Variations & Specific Structures¶

• Newer evidence has found a fourth pulley (variable annular pulley) in 75% of patients with thumb trigger finger, which may contribute to stenosis [1, 2].
• The radial digital nerve is at risk of iatrogenic injury during thumb trigger finger release due to its superficial location [1, 2].
• On the thumb, digital nerves are more palmar and closer to the flexor sheath than might be anticipated [5].
• The thumb radial digital nerve is especially vulnerable during surgical release [5].
• Trigger thumbs require release of only the A1 pulley, whereas trigger digits require division of the A1 and A0 (or proximal palmar) pulley [5].
• The distinction between the A1 and A2 pulleys may not be apparent during surgery; however, when the distal A1 pulley edge is released, the divided pulley leaves are parallel rather than ending in a V-shaped pattern [5].
• The fibers of the A2 pulley must be spared to preserve effective digital flexion [4].
• In patients with rheumatoid arthritis, the entire annular pulley system should be preserved to prevent further ulnar drift of the fingers [4].

Classification¶

• Green Classification Grade I is defined as pain and tenderness at the A1 pulley [1, 2, 9].
• Green Classification Grade II is defined as catching of the finger [1, 2] or mechanical catching of the digit without locking [9].
• Green Classification Grade III is defined as locking of the finger that is passively correctable [1, 2] or mechanical locking of the digit which is passively correctable [9].
• Green Classification Grade IV is defined as a fixed, locked finger [1, 2, 9].

Classification¶

• The Green classification of trigger finger consists of four grades [1].
• Grade I is defined as pain and tenderness at the A1 pulley [1].
• Grade II is defined as catching of the finger [1].
• Grade III is defined as locking of the finger that is passively correctable [1].
• Grade IV is defined as a fixed, locked finger [1].

Clinical Presentation¶

Demographics and Epidemiology¶

• Trigger finger is most common in women older than 50 years of age [1, 2].
• Trigger finger is more common in patients with systemic diseases such as diabetes mellitus, hypothyroidism, sarcoidosis, rheumatoid arthritis, and septic tenosynovitis [9].
• Diabetes mellitus has a 10% to 20% lifetime incidence of trigger finger [9].
• When multiple digits are involved, the possibility of diabetes should be considered [4].

Etiology and Pathology¶

• Trigger finger is possibly associated with repetitive grasping activities [1, 2].
• Histology of the affected pulleys demonstrates fibrocartilaginous metaplasia of the pulley and/or FDS tendon [1, 2].
• Pathologic examination of the affected pulleys demonstrates a proliferation of chondrocytes and increased type III collagen [9].
• The flexor digitorus profundus tendon often demonstrates a pathologic nodule, while the flexor digitorus superficialis is often unaffected [9].
• A fourth pulley (variable annular pulley) is found in 75% of patients with thumb trigger finger, which may contribute to stenosis [1, 2].

Symptoms and Signs¶

• Patients present with pain and tenderness in the distal palm [1, 2].
• Pain and tenderness are located at the proximal edge of the digital A1 pulley [4].
• Symptoms progress to mechanical catching or locking of the finger [1, 2].
• In severe cases, the opposite hand must be used to force the finger or thumb passively into extension [4].
• Patients may note a lump or knot in the palm [7].
• The lump may be a thickened area in the first annular pulley or a nodule/fusiform swelling of the flexor tendon just distal to it [7].
• The tendon nodule can be palpated by the examiner’s fingertip and moves with the tendon [7].
• The tendon nodule is usually just proximal to the anulus at the metacarpophalangeal joint level [7].
• In rheumatoid patients, a nodule distal to the MCP joint level may cause triggering [7].
• Patients frequently state that the problem is in the proximal interphalangeal joint [7].
• Concomitant trigger finger and carpal tunnel syndrome occur in 40% to 60% of patients [1, 2].

Physical Examination Findings¶

• Tenderness to palpation of the flexor tendon at the level of the A1 pulley is a physical examination finding [9].
• Palpable triggering or pain with flexion and extension of the finger is a physical examination finding [9].
• Nodularity of the flexor tendon just proximal to the A1 pulley is a physical examination finding [9].
• Presence of a volar retinacular ganglion cyst between the A1 and A2 pulleys is a physical examination finding [9].
• Presence of a fixed flexion deformity of the proximal interphalangeal (PIP) joint is a physical examination finding [9].

Classification¶

• Green classification Grade II is defined as catching of the finger [1, 2].
• Green classification Grade II is defined as mechanical catching of the digit without locking [9].
• Green classification Grade III is defined as locking of the finger that is passively correctable [1, 2].
• Green classification Grade III is defined as mechanical locking of the digit which is passively correctable [9].

Differential Diagnosis Considerations¶

• Intraarticular disorders such as loose bodies, degenerative joint disease, and fractures can cause symptoms similar to trigger finger [7].
• Common extensor tendon subluxation can cause symptoms similar to trigger finger [7].
• Gout can mimic infectious tenosynovitis with marked pain, erythema, swelling, and warmth [9].
• Calcific tendinitis can resemble an infection and result in triggering [9].
• Pseudogout can present with calcium pyrophosphate dihydrate crystal deposition localized to the triangular fibrocartilage or within the carpal tunnel [9].
• Amyloidosis can present with beta-2-microglobulin deposition along flexor tendons, most commonly in patients with renal failure undergoing dialysis [9].

Investigations¶

Clinical Presentation and History¶

• Trigger finger is characterized by pain and tenderness in the palm at the proximal edge of the digital A1 pulley [4].
• Pain and tenderness in the distal palm progress to mechanical catching or locking, and may become fixed [1].
• A common complaint is referred pain at the dorsal MCP or PIP area [1].

Physical Examination Findings¶

• Physical examination may reveal tenderness to palpation of the flexor tendon at the level of the A1 pulley [9].
• Nodularity of the flexor tendon just proximal to the A1 pulley may be present on examination [9].
• A volar retinacular ganglion cyst between the A1 and A2 pulleys may be present on examination [9].
• A fixed flexion deformity of the proximal interphalangeal (PIP) joint may be present on examination [9].

Classification¶

Associated Conditions and Demographics¶

• The lifetime incidence of trigger finger in patients with diabetes mellitus is 10% to 20% [9].
• Calcific tendinitis can result in triggering and is affected five times more frequently in males than females [9].
• Pseudogout involves calcium pyrophosphate dihydrate crystal deposition often localized to the triangular fibrocartilage or within the carpal tunnel [9].
• Amyloidosis is characterized by the deposition of beta-2-microglobulin in thick, plaque-like accumulations along the flexor tendons [9].

Imaging and Histology¶

• MR imaging findings of trigger thumb have been described [3].

Treatment¶

Nonoperative¶

• Corticosteroid injection into the flexor tendon sheath is curative in about 60% of patients initially [1].
• Diabetic patients are generally less responsive to corticosteroid injection [1].
• There is no difference between soluble and insoluble corticosteroid preparations for trigger finger injection [1].
• In a study of 292 corticosteroid injections, repeat injections provided symptomatic relief for a year or more in 50% of patients [7].
• Corticosteroid injections may elevate serum glucose levels for 5 days or more in patients with diabetes mellitus [7].
• Patients with unstable diabetes may be better treated without corticosteroid injection [7].
• Preoperative hypoglycemia increases infection risk after trigger finger injection and release [7].
• Immediate surgical release in the clinic was identified as the most cost-effective treatment strategy for trigger finger in diabetic patients [7].
• Nonoperative methods for trigger digits include stretching, night splinting, and combinations of heat and ice [7].

Operative¶

• Surgical release of the A1 pulley is curative in digits refractory to steroid injection [4].
• Surgical release reliably relieves the problem for most patients, with approximately 97% of patients having complete resolution after operative treatment [7].
• Persistence of triggering is more common than recurrence after surgical release [7].
• Trigger release should be performed with a local block so that the cessation of triggering can be evaluated intraoperatively [7].
• Adjacent finger triggering may become obvious only after a given finger is released and can be managed at the same surgical setting [7].
• In patients with rheumatoid arthritis, the preference is to excise a slip of the FDS tendon rather than to release the A1 pulley to prevent exacerbation of ulnar drift at the MCP joint [1].
• The fibers of the A2 pulley must be spared during surgical release to preserve effective digital flexion [4].
• Minor complications of surgical release include wound dehiscence, scar tenderness, and decreased range of motion [1].
• Incomplete pulley release and damage to the flexor tendons and digital nerves remain concerns, especially in the index finger and thumb with limited exposure techniques [7].
• Percutaneous release of the A1 pulley may be accomplished with a needle on the middle and ring fingers, especially if they actively lock [4].
• The safety and effectiveness of percutaneous trigger finger release using a needle or a push knife have literature support [7].
• For percutaneous release, an 18- or 19-gauge needle may suffice [8].
• During percutaneous release, the bevel of the needle should be oriented longitudinally parallel to the flexor tendons [8].
• Injection of corticosteroid is optional during percutaneous trigger finger release [8].
• Postoperative compression dressing for open trigger finger release is removed after 48 hours [5].
• Sutures for open trigger finger release are removed at 10 to 14 days [5].
• Normal use of the finger or thumb is encouraged after open trigger finger release [5].
• Active hand and finger use with stretching exercises is encouraged after percutaneous trigger finger release [8].

Complications¶

Operative¶

• Digital nerves on the thumb are more palmar and closer to the flexor sheath than might be anticipated, making the thumb radial digital nerve especially vulnerable [5].
• Minor complications of trigger finger release are relatively high and include wound dehiscence, scar tenderness, and decreased range of motion [1].
• Incomplete pulley release remains a concern with limited exposure techniques [7].
• Damage to flexor tendons remains a concern with limited exposure techniques, especially in the index finger and thumb [7].
• Damage to digital nerves remains a concern with limited exposure techniques, especially in the index finger and thumb [7].
• Patients may experience triggering after operative release because of catching of the tendon on the palmar aponeurosis transverse fibers [7].
• Triggering caused by catching on palmar aponeurosis transverse fibers usually resolves with time [7].
• A partially lacerated flexor tendon at the metacarpophalangeal joint level may heal with a nodule sufficiently large to cause triggering [7].
• Persistence of triggering is more common than recurrence after operative treatment [7].
• Preoperative hypoglycemia increases infection risk after trigger finger release [3].
• Preoperative hypoglycemia increases infection risk after trigger finger injection [3].
• In patients with rheumatoid arthritis, release of the A1 pulley carries a chance of exacerbating ulnar drift at the MCP joint [1].

Non-Operative¶

• Corticosteroid injections may elevate serum glucose levels for 5 days or more [7].

References¶

[1] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > 2. Flexor tendon injury > 3. Stenosing tenosynovitis (trigger finger).

[2] Miller S Review Of Orthopaedics. 2. Flexor tendon injury > 3. Stenosing tenosynovitis (trigger finger).

[3] Campbell S Operative Orthopaedics 4 Volume Set. EXCISION OF NECROTIC MUSCLES COMBINED WITH NEUROLYSIS OF MEDIAN AND ULNAR NERVES FOR SEVERE CONTRACTURE > REFERENCES > TRIGGER THUMB AND TRIGGER FINGER.

[4] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > 2. Flexor Tenosynovitis (Trigger Finger and Trigger Thumb).

[5] Campbell S Operative Orthopaedics 4 Volume Set. EXCISION OF NECROTIC MUSCLES COMBINED WITH NEUROLYSIS OF MEDIAN AND ULNAR NERVES FOR SEVERE CONTRACTURE > TRIGGER FINGER AND THUMB > SURGICAL RELEASE OF TRIGGER FINGER.

[7] Campbell S Operative Orthopaedics 4 Volume Set. EXCISION OF NECROTIC MUSCLES COMBINED WITH NEUROLYSIS OF MEDIAN AND ULNAR NERVES FOR SEVERE CONTRACTURE > TRIGGER FINGER AND THUMB.

[8] Campbell S Operative Orthopaedics 4 Volume Set. EXCISION OF NECROTIC MUSCLES COMBINED WITH NEUROLYSIS OF MEDIAN AND ULNAR NERVES FOR SEVERE CONTRACTURE > PERCUTANEOUS RELEASE OF TRIGGER FINGER.

[9] Aaos Comprehensive Orthopaedic Review 3. Tendinopathy of the Hand and Wrist* > II. Trigger Finger.

[10] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > TRIGGER FINGERS.

[11] Dupuytren S Disease And Related Hyperproliferative Disorders. 31. The Influence of Dupuytren’s Disease on Trigger Fingers and Vice Versa > 31.5 Discussion.

[12] Dupuytren S Disease And Related Hyperproliferative Disorders. 31. The Influence of Dupuytren’s Disease on Trigger Fingers and Vice Versa > 31.5 Discussion > 31.5.1 Why Is DD Concurring with TF?.