Trigger Finger

Trigger Finger or Trigger Thumb

This often painful annoying problem formally known as tenovaginitis stenosans occurs most commonly in the thumb and/or long finger; in fact, it is one of the more common "congenital" anomalies involving the thumb in infancy. Beyond infancy, however, it is more frequent in people in their fifties on up especially in diabetics. It tends to be age-related. It has not been clearly determined whether it is much more common in men or women.

Thank you for the fabulous results I 've had with my surgery four days ago. On the 2nd day post op I was off any analgesics and I never did take the anti inflammatory medication. Thank you for giving me back the use of my hand -- pretty important in my book.
- N I, Lincoln, NE

What is clear is that trigger finger or trigger thumb mostly occur in the same person who has carpal tunnel syndrome or who has been treated for it. Therefore when a person presents with trigger digit, they must always be checked for carpal tunnel syndrome and vice versa.

Anatomy

Trigger finger has variable treatment results depending upon the age, sex, hand dominance of the patient presenting with the problem, associated diseases such as diabetes and Dupuytren's disease. I believe the literature and certainly my personal experience suggest that trigger digit in a diabetic is unlikely to respond to corticosteroid injection, and it is more likely in a person with Dupuytren's to fail to resolve relatively spontaneously. In the nondiabetic, if a person comes in relatively early with nodular type triggering, corticosteroid injection in the flexor tendon sheath has about a 50-75% chance of resolving the triggering and local pain for months, if not permanently. A person with the more diffuse type of tightness about the tendon is more likely to require minor surgery. One cannot be certain in advance aside from those factors listed above who is going to get a good response to corticosteroid. Injection itself is minimally painful and other than local discomfort, really doesn't have any significant side effects. For the person who comes in with longstanding triggering, severe pain and stiffness in their finger or thumb, and particularly those who have a locked digit; i.e. can't even bend it because it is so severe, immediate A-1 pulley release is probably the best option. The majority of surgeons offer only open A-1 pulley release because this is the way they were taught.This requires a visit to the operating, an incision of about 1.5-2.5 cm (3/4 to 1 inch) and stitches that need to stay in for 10-14 days; thus it hurts more, takes more time, and costs more. Percutaneous A-1 pulley release has an excellent track record in those surgeons with a lot of experience performing hand surgery who have utilized this technique. But alas, there are only a few of us nationally that have been offering this technique. I have personally been offering percutaneus trigger digit release for eleven years with excellent results. The person most suited for percutaneous A-1 pulley release experiences snapping of the digit, whether painful or not, that occurs with just about every flexion or extension of the digit; i.e. if the person cannot make the finger snap to some degree palpably or if it can't be felt by just feeling their hand while doing it, then they are better treated with an open A-1 pulley release for a successful outcome. This does not apply to those coming in with a fixed digit - they tend to do very well and can move their digit immediately upon release of the A-1 pulley; i.e. they will leave the office essentially cured. Causation of Trigger Digit

The cause of the trigger digit is a little unclear. We know that the people who develop triggering have thickening of the A-1 pulley which appears to cause swelling of the underlying tendon (flexor digitorum superficialis, or FDS). Corticosteroid injection, when it works, is probably just getting rid of the swelling of the tendon. What is actually causing the A-1 pulley to thicken and snare the flexor tendon is unclear. There is mucoid degeneration going on in the A-1 pulley. There has been no association specifically for the development of trigger digit in any occupational demand, though people who develop a trigger digit are much more likely to complain of pain, stiffness, swelling, and decreased ability to function if they are in a manual occupation such as a meat cutter in a meat processing plant or similar.

Complications

In the literature, it is suggested that there is a chance of digital nerve injury with percutaneous or open A-1 pulley release. The chance is very small of this occurring in skilled hands, but is an accepted risk. Nerves are quite rubbery and it is quite likely that the nerve is deflected even by the sharp bevel of the needle if it is bumped into the nerve.

Recurrence

Recurrence of trigger digit is extremely rare. In 20 years in practice, I personally encountered it only once in a child - not in any adults.

Persistent Triggering

It is possible that using a percutaneous technique the digit will continue to catch because of incomplete release of the A-1 pulley or some other anatomic factor. This can be resolved by doing formal open surgery which is rarely necessary.

Infection

Using percutaneous technique, I have yet to see a patient develop an infection, though it is possible. Generally, in the United States, the infection rate for a skilled surgeon and his facility run about 1 in 200 overall for all surgeries performed. Ongoing Local Pain

A rare patient, particularly those claiming a problem on a work-related basis, may complain of some digital minor soreness at the site of the A-1 pulley; i.e. triggering.

Disability

Forget about it! Almost everyone I've treated goes back to work doing their usual activities the same day.