Updated: 4/13/2020

Trigger Finger

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https://upload.orthobullets.com/topic/6027/images/trigger finger.jpg
https://upload.orthobullets.com/topic/6027/images/finger_pulleys_2.jpg
Introduction
  • Overview
    • Trigger finger (trigger thumb when involving the thumb) is the inhibition of smooth tendon gliding due to mechanical impingement at the level of the A1 pulley that causes progressive pain, clicking, catching, and locking of the digit 
      • treatment consists of splinting, anti-inflammatory medications, steroid injections, and surgical release
      • may present as congenital trigger thumb 
  • Epidemiology
    • incidence
      • 2-3% of general population
      • 10% of diabetic population
    • demographics
      • more common in diabetics 
      • more common in females older than 50
    • location
      • ring and long fingers are most commonly involved in adults
    • risk factors
      • diabetes
  • Pathophysiology
    • mechanism
      • caused by stenosing tenosynovitis at the A1 pulley 
    • pathophysiology
      • fibrocartilaginous metaplasia of tendon and/or pulley
      • proliferation of chondrocytes
      • increased type III collagen
      • chronic hyperglycemia creates collagen cross-links
        • impairs collagen degradation
    • pathoanatomy
      • occasional pathologic nodule of the flexor digitorum profundus tendon
      • flexor digitorum superficialis often unaffected
      • trigger thumb may have a fourth pulley (variable annular pulley) causing stenosis in up to 75% of patients
  • Associated conditions
    • orthopaedic conditions
      • rheumatoid arthritis
      • calcific tendinitis
      • septic tenosynovitis
      • carpal tunnel syndrome
        • >60% of patients with trigger digits have clinical or electrodiagnostic evidence of carpal tunnel syndrome
    • medical conditions and comorbidities
      • diabetes
        • bilateral hand and multiple digit involvement is more common
      • amyloidosis
      • hypothyroidism
      • sarcoidosis
      • gout 
      • pseudogout
  • Prognosis
    • natural history of disease
      • progressive symptoms beginning with pain over A1 pulley and progressing to a fixed flexed digit
    • prognostic variables
      • favorable
        • non-diabetic
    • survival with treatment
      • relief with injections alone is achieved in up to 90% of non-diabetics 
      • relief with surgery is achieved in >90% of all patients
Anatomy
  • Muscles
    • flexor digitorum profundus 
      • may develop pathologic nodule that inhibits smooth tendon gliding through A1 pulley
    • flexor digitorum superficialis 
      • often unaffected
      • one slip may be released to allow for smooth tendon gliding
  • Ligaments
    • first annular ligament (A1 pulley) overlies the MP joints 

Classification
 
Green Classification
Grade I Palm pain and tenderness at A-1 pulley
Grade II Catching of digit
Grade III Locking of digit, passively correctable
Grade IV Fixed, locked digit
 
Presentation
  • Symptoms
    • common symptoms
      • usually progressive
      • pain at the level of the A1 pulley
      • clicking
      • catching
      • finger becoming "locked" in flexed position at the proximal interphalangeal (PIP) joint
      • may have referred pain to dorsal MCP/PIP region
  • Physical exam
    • palpation
      • tenderness at level of A1 pulley 
      • palpable nodule of the flexor tendon
    • motion
      • triggering with digit flexion and extension
      • fixed flexion of PIP joint
    • provocative test
      • flexion and extension of the digit may reproduce symptoms
Imaging
  • Radiographs
    • not required in diagnosis or treatment
Tested Differential
  • Lumbrical plus finger 
    • differentiated by paradoxical extension while trying to flex the digit
  • Joint contracture
    • differentiated by history of trauma and inability to passively extend the digit
  • Pyogenic flexor tenosynovitis 
    • differentiated by signs of infection, including possible elevated inflammatory markers, and positive Kanavel signs
Treatment
  • Nonoperative
    • splinting, activity modification, NSAIDs
      • indications
        • first line of treatment
      • outcomes
        • relief in 40% to 97% of cases
    • corticosteroid injection 
      • indications
        • best initial treatment for fingers, not for thumb
      • outcomes
        • relief in 60% to 90% of cases
        • diabetics may be less likely to obtain relief of symptoms
          • recent literature suggests success rates are not influenced by diabetic status
        • poorer response associated with longer duration of symptoms
  • Operative 
    • percutaneous release of A1 pulley
      • indications
        • failed nonoperative treatment
      • outcomes
        • success rate >90%
          • use of ultrasound may provide higher success rate
        • higher recurrence in diabetic patients
        • potential earlier return to work compared to open release
    • open surgical debridement and release of the A1 pulley
      • indications
        • failed nonoperative treatment
        • open release is standard operative management with high success rates
        • easier to assess quality of release compared to percutaneous method
      • outcomes
        • satisfactory results achieved in >90% of cases
        • higher recurrence in diabetic patients
    • release of A1 pulley and 1 slip of FDS (usually ulnar slip)  
      • indications
        • persistent/recurrent triggering after A1 pulley release
        • rheumatoid arthritis patients may benefit from FDS slip excision without A1 pulley release
          • sparing of A1 pulley may prevent exacerbation of ulnar drift at the MCP joint
        • pediatric trigger finger 
          • presents with Notta's node (proximal to A1 pulley), flexion contracture and triggering
          • surgical treatment at 2-4 years of age to prevent interphalangeal joint contracture
          • may need to release remaining FDS slip and A3 pulley 
      • outcomes
        • success rate >90% 
Techniques
  • Splinting, activity modification, NSAIDs
    • technique
      • immobilization either the metacarpophalangeal (MCP) joint or distal interphalangeal joint only
      • proximal interphalangeal joint remains unrestricted
  • Corticosteroid injection
    • technique
      • give 1 to 3 injections in or just superficial to flexor tendon sheath
      • can be combined with percutaneous A1 pulley release
    • complications
      • fat atrophy
      • tendon rupture
      • subcutaneous fat atrophy
      • transient hyperglycemia
        • primarily affects diabetic patients
  • Percutaneous release of A1 pulley
    • technique
      • typically 18- to 19-gauge needle
      • bevel parallel to tendon
      • movement of digit confirms placement into tendon
      • needle withdrawn until out of tendon then advanced to cut ligament
      • release confirmed by attempt to reproduce symptoms
      • can be combined with corticosteroid injection
    • complications
      • transient inflammation
      • hematoma formation
      • persistent pain and tenderness
      • stiffness
      • infection
      • damage to neurovascular bundle
  • Open surgical debridement and release of A1 pulley
    • approach
      • longitudinal, transverse, or oblique incision
    • technique
      • local anesthetic allows intraoperative assessment of triggering to confirm an adequate release
      • slip of FDS released if persistent triggering
      • in addition to A-1 pulley, may also need to release
        • tight band of superficial aponeurosis proximal to A1 pulley (A0 pulley)
        • one or both limbs of the sublimus tendon
        • additional pulleys including A-3
      • postoperative
        • early passive and active ROM 4 times a day
        • if the patient does not have FROM at first post-op visit then send to PT
    • complications
      • tendon bowstringing
      • damage to the digital neurovascular bundle
      • stiffness
  • Release of A1 pulley and 1 slip of FDS
    • approach
      • longitudinal, transverse, or oblique incision
    • technique
      • local anesthetic allows intraoperative assessment of triggering to confirm an adequate release
      • slip of FDS detached from insertion and removed as far as the palm
        • release of ulnar slip may help prevent ulnar drift at metacarpophalangeal joint
      • carefully debride to ensure it will not catch on the proximal pulley
Complications
  • Radial digital nerve injury 
    • risk factors
      • trigger thumb release due to superficial location and oblique orientation 
    • treatment
      • may require digital nerve and artery repair
  • Bowstringing
    • risk factors
      • damage to the A2 or A4 pulley
    • treatment
      • may require pulley reconstruction
  • Wound dehiscence
  • Scar tenderness
  • Stiffness
  • Tendon scoring (percutaneous technique)
 

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Questions (5)
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(OBQ11.56) A 2-year-old child has a flexion deformity of the interphalangeal joint of his thumb as seen in Figure A. Surgical correction of this deformity places what structure most at risk as it crosses the surgical field? Tested Concept

QID: 3479
FIGURES:
1

Princeps pollicis artery

7%

(217/3334)

2

Ulnar digital nerve

9%

(315/3334)

3

Oblique pulley

8%

(258/3334)

4

Ulnar digital artery

2%

(72/3334)

5

Radial digital nerve

74%

(2453/3334)

L 2 C

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(OBQ10.113) When surgically treating a trigger finger in a child, what structure may need to be released in addition to the A-1 pulley? Tested Concept

QID: 3207
1

One or both limbs of the sublimis tendon

70%

(2909/4170)

2

A-4 pulley

5%

(220/4170)

3

Lumbrical origin

6%

(232/4170)

4

Dorsal interosseous insertion

2%

(68/4170)

5

Anomalous insertion of the MCP joint collateral ligament

17%

(716/4170)

L 3 C

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(OBQ05.164) A 64-year-old diabetic female presents with sudden catching and locking of her ring finger when trying to extend it. Attempts at finger extension are painful, and she notes tenderness in her distal palm. A clinical photo is shown in Figure A. Which of the following structures are implicated in the pathogenesis of this condition? Tested Concept

QID: 1050
FIGURES:
1

Extensor digitorum tendon

1%

(28/3999)

2

Grayson's ligament

2%

(76/3999)

3

Oblique retinacular ligament

1%

(41/3999)

4

A1 pulley

96%

(3824/3999)

5

Transverse carpal ligament

0%

(9/3999)

L 1 D

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