TRIGGER FINGER

Updated: Jul 07, 2016

Author heading Author: Satishchandra Kale, MD, MS, MBBS, MCh, MBA,
FRCS(Edin); Chief Editor: Harris Gellman, MD

In trigger finger (TF), one of the most common causes of hand pain and disability, the
flexor tendon causes painful popping or snapping as the patient flexes and extends the
digit. The patient may present with a digit locked in a particular position, most often
flexion, which may require gentle, passive manipulation into full extension.
Trigger finger often results in difficulty flexing or (in this case) extending
metacarpophalangeal joint of involved digit. Trigger finger often results in difficulty
flexing or (in this case) extending metacarpophalangeal joint of involved digit.
TF results from thickening of the flexor tendon within the distal aspect of the palm.
This thickening causes abnormal gliding and locking of the tendon within the tendon
sheath. Specifically, the affected tendon is caught at the edge of the first annular (A1)
pulley.

BACKGROUND

Trigger finger (TF) is one of the most common upper limb problems to be encountered
in orthopedic practice and is also one of the most common causes of hand pain and
disability. It results from thickening of the flexor tendon within the distal aspect of the
palm. This thickening causes abnormal gliding of the tendon within the tendon sheath.
Specifically, the affected tendon is caught at the edge of the first annular (A1) pulley.
(See Etiology and Pathophysiology.)

Patients can have difficulty flexing the affected digit if the tendon is caught distal to
the A1 pulley, or extending the digit if the tendon is caught proximal to the pulley. The
condition is very painful, especially when the locked digit snaps (releases) beyond the
restriction by the use of increased force.

1
The etiology of TF remains unknown or uncertain, although triggering seems to occur
more frequently in patients with rheumatoid arthritis (RA) or diabetes mellitus (DM).

TF begins as discomfort in the palm during movements of the involved digit(s).

Gradually or, in some cases, acutely, the flexor tendon causes painful popping or
snapping as the patient flexes and extends the digit. The patient may present with a
digit locked in a particular position, most often flexion, which may require gentle,
passive manipulation into full extension.

TF has a predilection for the dominant hand, with the most commonly affected digit
being the thumb, followed by the ring, long, little, and index fingers. (However, a
retrospective study of 577 TFs by Schubert et al found no relation to hand dominance)
The involvement of several fingers is not unusual.

TF occurs much less frequently in the pediatric population than in adults and develops
almost exclusively in the thumb. Historically, the condition in children has been
referred to as congenital trigger thumb. Evidence indicates, however, that it usually
presents sometime after infancy and is thus more appropriately referred to as pediatric
trigger thumb. (See Epidemiology and Presentation.) Yet, by the time medical opinion
is sought, surgery is usually indicated.

In the past, triggering of the digits was treated by splinting in extension, which caused
stiffness and, consequently, loss of metacarpophalangeal and interphalangeal flexion.
Due to dissatisfaction with this form of treatment, researchers used intrasheath steroid
injections instead, which resulted in a high proportion of good results.

In an uncomplicated case of trigger digit, the first-line therapy is still generally agreed
to be injection into the tendon sheath, with surgical release of the A1 pulley as second-
line treatment.

2
Surgery, in the form of release of the A1 pulley, became popular when splinting and/or
injection therapy failed or in the presence of other pathology, such as RA, in which
injection treatment proved futile or there was a risk of tendon rupture or infection.

ANATOMY
Fingers
Tendon sheaths of the long flexors run from the level of the metacarpal heads (distal
palmar crease, superficial; volar plate, deep) to the distal phalanges. They are attached
to the underlying bones and volar plates, which prevent the tendons from bowstringing.
Predictable and efficient thickenings in the fibrous flexor sheath act as pulleys,
directing the sliding movements of the fingers.

The two types of pulleys are annular (A) and cruciate (C). Annular pulleys are
composed of single fibrous bands (ie, rings), while cruciate pulleys have two crossing
fibrous bands.

The order of the pulleys from proximal to distal is as follows:

 The A1 pulley overlies the metacarpophalangeal (MCP) joints; it is released
during surgery for TF (see the image below)
 The A2 pulley overlies the proximal end of the proximal phalanx
 The C1 pulley overlies the middle of the proximal phalanx
 The A3 pulley lies over the proximal interphalangeal (PIP) joint
 The C2 pulley lies over the proximal end of the middle phalanx
 The A4 pulley lies over the middle of the middle phalanx
 The C3 pulley lies over the distal end of the middle phalanx
 The A5 pulley lies over the proximal end of the distal phalanx

3
Flexor tendons pass within tendon sheath and beneath A1 pulley at approximately
metacarpal head, beyond which they travel into digit.
The A2 and A4 pulleys are vital in preventing bowstringing of the flexor tendons and
must be preserved or reconstructed after any damage to them.

Thumb
The flexor anatomy of the thumb differs from that of the fingers. The flexor pollicis
longus (FPL) tendon is a single tendon within the flexor sheath that inserts onto the
base of the distal phalanx. The fibro-osseous sheath is composed of two annular pulleys
(A1 and A2) that arise from the palmar plates of the MCP and interphalangeal (IP)
joints, respectively. The oblique pulley, which originates from and inserts onto the
proximal phalanx, is the most important pulley from a biomechanical perspective. The
oblique pulley is approximately 10 mm in length, blending with a portion of the
adductor pollicis insertion.

The digital nerves and arteries run parallel to the tendon sheath distally. At the level of
the MCP flexion crease, they lie just deep to the skin. Proximal to the A1 pulley, the
radial digital nerve of the thumb crosses obliquely over the sheath.

SIGNS AND SYMPTOMS

Signs and symptoms of TF are as follows:

 Locking or catching during active flexion-extension activity (passive

4
 manipulation may be needed to extend the digit in the later stages)
 Stiff digit, especially in long-standing or neglected cases
 Pain over the distal palm
 Pain radiating along the digit
 Triggering on active or passive extension by the patient
 Palpable snapping sensation or crepitus over the A1 pulley
 Tenderness over the A1 pulley
 Palpable nodule in the line of the flexor digitorum superficialis (FDS), just distal
to the metacarpophalangeal (MCP) joint in the palm
 Fixed-flexion deformity in late presentations, especially in the proximal
interphalangeal (PIP) joint
 Evidence of associated conditions (eg, rheumatoid arthritis [RA], gout)
 Early signs of triggering in other digits (may be bilateral)

Children with trigger thumb rarely complain of pain. They usually are brought in for
evaluation when aged 1-4 years, when the parent first notices a flexed posture of the
thumb’s interphalangeal (IP) joint. These children often demonstrate bilateral fixed
flexion contractures of the thumb by the time they present to the physician. By the time
the child presents to the clinic, surgical treatment is already indicated in most instances.

PHYSICAL EXAMINATION

At the level of the distal palmar crease, a tender nodule can be palpated, usually
overlying the MCP joint. The affected digit may lock in a flexed or (less commonly)
extended position. When the patient attempts to move the digit more forcefully beyond
the restriction, the digit may snap or trigger beyond the restriction. The triggering
movement is very painful for the patient. (See the image below.)

5
Trigger finger often results in difficulty flexing or (in this case) extending
metacarpophalangeal joint of involved digit.
Trigger finger often results in difficulty flexing or (in this case) extending
metacarpophalangeal joint of involved digit. In severe cases, the patient is unable to
move the digit beyond the restriction, and thus no triggering occurs. With a trigger
thumb, the tenderness to palpation is found at the palmar aspect of the first MCP joints
rather than over the distal palmar crease.

DIAGNOSIS

As a rule, no lab tests are needed in the diagnosis of TF. If there is a concern regarding
an associated, undiagnosed condition, such as diabetes mellitus (DM), RA, or another
connective tissue disease, tests such as those assessing glycosylated hemoglobin
(HgbA1c), fasting blood sugar, or rheumatoid factor should be ordered.

Radiography rarely is indicated in TF. Hand radiographs are performed only if

abnormal pathology (eg, abnormal sesamoids, loose bodies in the MCP joint,
osteoarthritic spurs on the metacarpal head, avulsion injuries of collateral ligaments) is
suspected.

6
Histologic Findings

The A1 pulley exhibits a marked degree of hypertrophy, described as a white,

cicatricial, collarlike thickening. Microscopy demonstrates degeneration, cyst
formation, and plasma-cell infiltration. Microscopic studies have also shown
chondrocytic proliferation of type III collagen instead of chondrocyte presence in the
normal innermost or friction layer of the A1 pulley. The amount of extracellular matrix
is increased significantly when compared with controls.

STAGING
Green's classification of triggering is used only for clinical grading and documentation.
No correlation has been established between the grading scheme and the outcome
following injection therapy. The various grades are defined as follows :

1. Grade I (pretriggering) - Pain; history of catching that is not demonstrable on

clinical examination; tenderness over the A1 pulley
2. Grade II (active) - Demonstrable catching, but with the ability to actively extend
the digit maintained
3. Grade III (passive) - Demonstrable locking in which passive extension is required
(grade IIIA) or in which the patient is unable to actively flex (grade IIIB)
4. Grade IV (contracture) - Demonstrable catching, with a fixed flexion contracture
of the proximal interphalangeal (PIP) joint

DIAGNOSTIC CONSIDERATIONS

The following situations can simulate the locking found in trigger finger (TF):
• Collateral ligaments of the metacarpophalangeal (MCP) joint catch on a bony
prominence on the side of the metatarsal head (osteophyte)

7
• Localized swelling in the flexor digitorum profundus (FDP) gets entrapped at
the decussation of the FDS
• A partially lacerated flexor tendon catches against the A1 pulley or the FDS
decussation
• A nodule in the FDS catches against the A3 pulley
• Locking is simulated by abnormal sesamoids
• A loose body is present in the MCP joint
• Snapping or subluxation of the extensor digitorum communis (EPC) occurs

Other problems to consider in patients who may have FT include the following:
• Ganglion involving the tendon sheath
• Infection within the tendon sheaths
• Ganglion cyst of the wrist
• Acromegaly - Increased growth hormone stimulates sodium reabsorption in the
distal nephron, increasing extracellular volume and leading to swelling of the flexor
synovium within the digital sheath

Perhaps the most important differential diagnosis is infection, such as suppurative

tenosynovitis. Any such infection requires immediate referral to a hand surgeon or
plastic surgeon for aggressive management, which includes antibiotics and local
procedures.

PATHOPHYSIOLOGY

A mismatch between the flexor tendon and the proximal pulley mechanism occurs in
most cases of TF. Normally, the tendons of the finger flexors glide back and forth under
a restraining pulley. Thickening of the flexor tendon sheath restricts the normal gliding
mechanism. A nodule may develop on the tendon, causing the tendon to get stuck at
the proximal edge of the A1 pulley when the patient is attempting to extend the digit,
thereby causing difficulty.

8
Inflamed nodule can restrict tendon from passing smoothly beneath A1 pulley. If
nodule is distal to A1 pulley (as shown in this sketch), then digit may get stuck in
extended position. Conversely, if nodule is proximal to A1 pulley, then patient's digit
is more likely to become stuck in flexed position.

When more forceful attempts are made to extend the digit, by using increased force
from the finger extensors or by applying an external force (for example, by exerting
force on the finger with the other hand), the digit classically snaps open with significant
pain at the distal palm and into the proximal aspect of the affected digit. Less
commonly, the nodule is restricted distal to the A1 pulley, resulting in difficulty flexing
the digit.

Using sonoelastography, a newer technique for quantitative assessment of the stiffness

of soft tissues, the data from one study noted that the causes for snapping in trigger
finger were increased stiffness and thickening of the A1 pulley. Three weeks after
corticosteroid injection, the pulley thickness and the ratio of subcutaneous fat to the
pulley both decreased; snapping disappeared in all patients studied.

ETIOLOGY

The etiology of TF is unknown or uncertain. It is suspected that nodule formation in

the tendon, morphologic changes in the pulley, or both in combination may effect
triggering, though why these changes are actually initiated remains unknown.

Several studies have demonstrated a correlation between TF and activities that require
exertion of pressure in the palm while a powerful grip is used or that involve repetitive,
forceful digital flexion (eg, arc welding, use of heavy shears). Proximal phalangeal
flexion in power-grip activities causes high annular loads at the distal edge of the A1
pulley. Hueston and Wilson have suggested that bunching of the interwoven tendon
fibers causes the reactive intratendinous nodule observed at surgery.

9
Thus, in conclusion, the exact etiology remains unknown, but certain conditions such
as diabetes mellitus (DM) or rheumatoid arthritis (RA) may predispose an individual
to triggering of the digit.

Sampson et al concluded that the underlying pathobiologic mechanism for triggering

is fibrocartilaginous metaplasia of the pulleys due to trauma or disease. Several studies
have failed to demonstrate the presence of acute or chronic inflammatory cells within
the tenosynovium. The suffix -itis in the term stenosing tendovaginitis actually is a
misnomer unless the condition is associated with RA or inflammatory arthritis.

The exact etiology is still unknown, but it is thought that DM or autoimmune conditions
may contribute to morphological changes in the pulley and/or the tendon sheath to
cause triggering. Systemic causes of TF are collagen-vascular diseases, including the
following :
 RA
 DM
 Psoriatic arthritis
 Amyloidosis
 Hypothyroidism
 Sarcoidosis
 Pigmented villonodular synovitis

Septic causes of TF are secondary infections (eg, tuberculosis). A few case reports have
documented rare causes of TF, including tenosynovitis that itself resulted from a
Mycobacterium kansasii infection in an immunocompetent patient; triggering
following the development of calcific tendonitis has been reported in a child. Such
cases should invoke a high degree of suspicion.

The association of idiopathic TF with idiopathic carpal tunnel syndrome has long been

10
suggested. A study of 551 patients with no predisposing causes diagnosed with either
TF, carpal tunnel syndrome, or both based on clinical grounds reported that 43% of
patients with TF also had concomitant carpal tunnel syndrome; this is significantly
higher than the population prevalence of carpal tunnel syndrome, which is about 4%.
A retrospective study by Grandizio et al indicated that the risk of developing TF
following surgical carpal tunnel release is greater in patients with DM than in those
without DM. In the study, the investigators found that out of 1003 carpal tunnel releases
in patients without DM, the incidence of TF at 6 and 12 months was 3% and 4%,
respectively, whereas out of 214 carpal tunnel releases in patients with DM, the
incidence at 6 and 12 months was 8% and 10%, respectively. The severity of the DM,
however, was not found to be a significant factor in the development of TF.

Trigger thumb

Trigger thumb (see the image below) usually occurs idiopathically, though it develops
more frequently in individuals with diabetes or osteoarthritis. Trigger thumb is more
likely to occur in an individual with any condition that causes diffuse proliferation of
the tenosynovium, such as inflammatory arthritis, gout, or chronic infection (eg,
fungus, atypical mycobacteria). This process can extend distal to the MCP joint and,
when severe, cause stiffness rather than intermittent triggering.

11
Trigger thumb. A1 pulley exposed within surgical field (arrow). Digital neurovascular
bundles behind retractors.

Certain people appear more prone to tenosynovitic conditions; patients with trigger
thumb are more likely to develop carpal tunnel syndrome and de Quervain disease. The
roles of overuse and trauma in trigger thumb are controversial, though the condition
does have a predilection for the dominant hand.

EPIDEMIOLOGY

TF is a relatively common condition and occurs two to six times more frequently in
women than in men. Several series found the peak incidence of trigger digit to be in
individuals aged 55-60 years. Age distribution has not changed significantly despite an
increase in computing activities and repetitive tasks. As previously mentioned, TF in
the pediatric population occurs much less frequently than in adults and develops almost
exclusively in the thumb.
MANAGEMENT

Conservative treatment
Corticosteroid injection in the area of tendon sheath thickening is considered to be the

12
first-line treatment of choice for TF. Custom-made splinting of the MCP joint, albeit
rarely used, is another conservative treatment, used in patients who do not wish to
undergo a steroid injection or as an adjuvant to injection. Typically, a custom-made
splint is used to hold the MCP joint of the involved finger at 10-15° of flexion, leaving
the PIP and distal interphalangeal (DIP) joints free.
Surgery

Trigger digits that fail to respond to 2 injections usually require surgical treatment, in
the form of surgical release of the A1 pulley, under local anesthesia. During the
procedure, the proximal edge of the A1 pulley is identified, and a scalpel blade is used
to divide the entire A1 pulley in the midline under vision. Dissection of the nodule in
the tendon is rarely indicated and may actually cause tendon weakening or rupture.
With relief of triggering and friction following the release of the A1 pulley, the nodule
usually regresses in size.

If a percutaneous approach is favored, a pair of blunt-tipped, fine scissors is introduced

through the incision, and the A1 pulley is transected.
The open technique is absolutely essential for the thumb or little finger or in the
presence of PIP contractures. Percutaneous release should be reserved for the index,
middle, and ring fingers.

Surgical release
The chief indications for surgical management of TF are as follows:
• Failure of splinting and/or injection treatment
• Irreducibly locked TF
• Trigger thumb in infants - Without surgical release, these infants are likely to
develop a fixed flexion deformity of the interphalangeal (IP) joint

Although the results of percutaneous release are well established, the open technique
is absolutely essential for the thumb or little finger or in the presence of proximal

13
interphalangeal (PIP) contractures. Percutaneous release should be reserved for the
index, middle, and ring fingers.
In a study from Oxford comparing percutaneous and open surgical methods, the two
approaches displayed similar effectiveness, and both proved superior to conservative
corticosteroid-injection treatment with regard to trigger cure and relapse rates.

In children, triggering has varying causes. Release of the A1 pulley alone does not
always correct the problem. Additional treatment (eg, resection of one or both limbs of
the flexor digitorum superficialis [FDS] tendon, A3 pulley release) may be required
and is recommended in RA

In infants, the nodule on the flexor pollicis longus (FPL) tendon can be resected with
good results. Corticosteroid injections are generally not helpful in these cases of trigger
thumb.

a. Pregnant patients
Splinting and local corticosteroid injection can be performed if the patient is pregnant.
Surgical release of the A1 pulley is generally an elective procedure and is usually
deferred until after delivery.

b. Elderly patients
In elderly patients with a history of gastrointestinal problems or other complications
from nonsteroidal anti-inflammatory drugs (NSAIDs), consider cyclo-oxygenase-2
(COX-2) inhibitors if oral NSAIDs are needed.

Consultations
Surgical consultation for operative treatment may be required. Typically, such
procedures are performed by an orthopedic hand surgeon or a plastic surgeon.

Corticosteroid Injection Into Tendon Sheath

14
Corticosteroid injection in the area of tendon sheath thickening is considered to be the
first-line treatment of choice for TF. Research in 2009 concluded that the most
successful and cost-effective management strategy for TF is the algorithm of two
steroid injections prior to surgical intervention, if needed.
A variety of preparations have been used—most commonly prednisolone,
dexamethasone, and triamcinolone—in the steroid injection treatment of TF, and most
are uniformly successful in relieving symptoms.
A highly satisfactory rate of success can be predicted in female patients and in patients
with single digit involvement, short duration of symptoms (ie, <4 months), no
associated conditions (eg, RA, diabetes mellitus [DM]), or a discrete, palpable nodule.
(Patients with RA or DM seem to be more resistant to injection treatment.)

Procedure

The author's technique for steroid injection is as follows. A mixture of triamcinolone,

1% lidocaine, and 0.5% bupivacaine is used, in a ratio of 2:1:1, respectively; adrenaline
is not used. The nodule in the palm is well localized and circled out using an indelible
skin marker. The procedure is performed in an office setting, using strict aseptic
precautions, with alcoholic povidone-iodine used for injection-site preparation. Ethyl
chloride is used only if requested; frequently, it is unnecessary, and most patients
tolerate this procedure quite well

A 26-gauge needle is introduced in a proximal-to-distal direction in the nodule, making

an angle of 45° with the palm (see the first image below). The needle enters the nodule
with a distinct grating sensation; positioning of the needle is verified by asking the
patient to move the digit when it is possible to clearly observe the needle moving with
the digit (see the second image below)

15
Introduction of needle into tendon sheath at 45° angle to palm for injection treatment.

Movement of needle with flexion of digit confirms correct positioning of needle for
injection
The syringe with the steroid preparation then is attached to the needle. Attempting to
inject the drug with light pressure confirms the intratendinous location of the needle.
Do not inject the solution if significant resistance to injection flow is noted, because
this may indicate that the needle tip is in the tendon rather than just within the tendon
sheath. The needle is withdrawn very carefully until a give-way sensation is felt,
indicating that the tip of the needle is out of the tendon and in the sheath. The
preparation is then injected. A small water-impermeable dressing is applied. The
patient is actively encouraged to move the digit; in most cases, the triggering is relieved

16
A follow-up appointment is made for 3-4 weeks after the treatment. Splinting is not
used routinely for these cases, although a hand-based MP-block Orthoplast splint has
been described as useful.

Although injection treatment has long been administered by "feel" and experience,
research suggests that using ultrasonographically guided steroid injection may
maximize the injection's accuracy and, consequently, its beneficial effects in the
treatment of trigger digits.

No major complications from injection treatment are noted. A transient rise in blood
and urine sugar levels is common in patients with diabetes. Advise these patients that
this is likely to occur. Theoretically, repeated steroid injections could cause attrition
and/or rupture of tendons, but only 1 such case has been reported to date.

Pain relief

While corticosteroid injections into the palm are considered highly effective in treating
TF, the injection itself may be significantly painful. A study that compared
conventional injection with injection preceded by median and ulnar nerve blocks
performed at the wrist found that of the study’s 19 patients, who were treated with 47
total injections, 88% preferred to have the median and ulnar nerve block prior to the
injection.

Both study groups, however, had excellent resolution of TF, with excellent resolution
being defined in the study as an asymptomatic hand (without triggering) and a pain
score on the 0-10 cm Visual Analog Scale of less than 2 cm.

Repeat injections

17
A second corticosteroid injection may be performed 3-4 weeks after the first one. If
two or perhaps three injections fail to provide adequate resolution, consider referring
the patient for surgical release. Repetitive injections theoretically increase the
likelihood of tendon rupture, although such a risk was not found in Anderson's study
of repeated injections for TF.

Alternative injection techniques

Proximal phalanx technique
Another injection method, the proximal phalanx technique, allows for injection directly
into the tendon sheath through the palmar surface of the midproximal phalanx.
Injections performed this way were found to be less painful than injecting the flexor
tendon sheath directly over the metacarpal head. There was no statistically significant
difference in the rate of recurrent pain between the two injection methods.

Subcutaneous injection
Although corticosteroid injection has traditionally been administered into the tendon
sheath (but not into the tendon itself), studies now seem to indicate that subcutaneous
injection may be as effective as the intrasheath approach. Additionally, in some cases,
steroid injection into the subcutaneous tissue seems to result in better clinical outcomes
than does injection into the sheath alone.

Corticosteroids
Class Summary
In contrast to the widespread systemic distribution that occurs when an oral anti-
inflammatory drug is administered, a local corticosteroid injection can achieve the
focal placement of a potent anti-inflammatory agent at the site of maximal tenderness
or inflammation. A variety of corticosteroid preparations are available. Commonly, the
corticosteroid is mixed with a local anesthetic agent prior to injection. The clinician
has numerous local anesthetic agents from which to choose.

18
Methylprednisolone (A-Methapred, Depo-Medrol, Solu-Medrol, Medrol)
Corticosteroids are commonly used in local injections administered to bursae or joints.
The drugs provide a local anti-inflammatory effect while minimizing some of the
gastrointestinal and other risks of systemic medications.

Dexamethasone acetate (Baycadron)

This agent decreases inflammation by suppressing the migration of polymorphonuclear
leukocytes and reducing capillary permeability. The dosage varies with the degree of
inflammation and the size of the affected area.

Hydrocortisone acetate (Solu-Cortef, Cortef, A-Hydrocort)

Hydrocortisone acetate decreases inflammation by suppressing the migration of
polymorphonuclear leukocytes and reversing increased capillary permeability. The
dosage varies with the degree of inflammation and the size of the affected area.
Betamethasone is the drug of choice for intra-articular injections. It does not crystallize
if used with paraben-free anesthetic preparations.

Triamcinolone (Aristospan, Kenalog-10, Kenalog-40)

Triamcinolone is used for inflammatory conditions responsive to steroids; it decreases
inflammation by suppressing the migration of polymorphonuclear leukocytes and
reversing capillary permeability. This is the preferred drug, owing to its longer duration
of action.

Splinting
Custom-made splinting of the metacarpophalangeal (MCP) joint is another
conservative treatment, used in patients who do not wish to undergo a steroid injection
or as an adjuvant to injection. Typically, a custom-made splint is used to hold the MCP
joint of the involved finger at 10-15° of flexion, leaving the proximal interphalangeal
(PIP) and distal interphalangeal (DIP) joints free. The average length of splinting is 6

19
weeks. In patients with symptoms longer than 6 months, splinting as a sole treatment
strategy does not seem to eliminate the triggering events.

Although traditionally splinting has not been thought to be an effective treatment for
TF, one study of thermoplastic splinting of MCP joint flexion showed improvement in
stenosing tenosynovitis, the numeric pain rating scale, and the number of triggering
events and also demonstrated an overall perceived participant improvement in
symptoms. Another study determined that 87% of patients who wore custom-made,
thermoplastic orthoses for 8-10 weeks did not require an injection or surgical
intervention in the 1-year follow-up after institution of the orthoses.

Surgical Release
Trigger digits that fail to respond to two or perhaps three injections may require
surgical treatment, including dissection of the nodule on the tendon and surgical release
of the A1 pulley, under local anesthesia.
The benefits of operative treatment of trigger finger and trigger thumb were revealed
in 3 studies of surgical pulley release.
Between 1994 and 2004, Li et al treated 7 children (9 thumbs; 3 right, 2 left, 2 bilateral)
for trigger thumb with hyperextensible MCP anomaly (>60°) by surgical release of the
first annular pulley (A1 pulley) and proximal advancement of the MCP volar plate. The
patients (4 girls and 3 boys), who had a mean age of 46 months at surgery (range, 26-
82 months), were observed over a mean follow-up period of 64 months (range, 1-8
years).
All patients in the study at last follow-up had returned to full activity without limitation
or pain, and none of the patients had a recurrence of triggering or MCP hyperextension
deformity, demonstrating, according to the authors, that trigger thumb with
concomitant MCP hyperextension deformity can be treated in children by A1 pulley
release and advancement of the volar plate.
In a study of 93 trigger thumbs in 83 patients, Chao et al compared the results of
miniscalpel-needle percutaneous release with those of steroid injection. At 12 months,

20
44 of the 46 trigger thumbs treated with the miniscalpel-needle release had satisfactory
results (measured by visual analogue pain scale and patient satisfaction), but only 12
of 47 thumbs treated with steroid injection had satisfactory results. No nerve injuries
occurred in either group.

Trigger thumb in children almost always calls for surgical management. Trigger thumb
in an adult not responding to corticosteroid tendon sheath injection needs surgery. The
technique of release itself is irrelevant. Open and not percutaneous surgery is the norm
for trigger thumb in children and adults alike, since the neurovascular bundles in the
thumb are closer to the midline than in other digits. A single series as quoted above
comparing the efficacy of percutaneous surgery vis-a-vis a corticosteroid injection still
proves surgery is more effective than injection treatment, but this technique of surgical
release itself is not ad rigeur.
Lange-Rieb et al presented long-term results of open operative treatment of TF and
trigger thumb in adults. Of the operations performed, 210 (76%) were for a single-digit
release and 76 (24%) for multiple digits. All operations were performed under
tourniquet control with local anaesthesia as outpatient procedures using a transverse
incision just distal to the distal palmar crease or on the flexor crease of the thumb at the
MCP joint. At latest follow-up (average, 14.3 y), 234 patients were evaluated, with no
complaints, and there were no serious complications, such as nerve transection or
bowstringing, or recurrence.

1. Physical Therapy
sect2: d12 para, childcount:0
Physical therapy is generally not required for patients with TF. For cases of chronic
TF, however, treatment may include a trial of heating modalities followed by sustained,
nonballistic stretching of the flexor tendon, as well as soft-tissue mobilization of the
A1 pulley. Following injection or surgery, a home exercise (stretching) program may
be one component of treatment for patients. No therapy programs have been
documented to improve TF.

21
COMPLICATIONS

Corticosteroid injection
Potential complications of corticosteroid injection include the following:
• Infection - The use of sterile technique can minimize this problem
• Bleeding
• Weakening of the tendon
• Fat atrophy occurring locally at the injection site
• Nerve infiltration and subsequent nerve injury - This complication is
uncommon; it can be monitored by assessing sensation throughout the affected digit

This can be minimized by applying direct pressure immediately after the procedure.
Caution should be exercised before injecting a patient who is taking anticoagulants or
an individual with a bleeding disorder

Weakening of the tendon increases the risk of subsequent tendon rupture, a possibility
that is of particular concern if the injection is performed incorrectly (specifically, if the
injection is administered into the tendon itself rather than just within the tendon sheath).
A study demonstrated that ultrasonographically guided injections were safer than blind
injections in that 30% of fingers injected blindly demonstrated dye within the tendon,
while no tendon injected under ultrasonographic imaging was infiltrated with dye.

The risk of tendon rupture may increase with multiple injections, although at least some
clinical researchers (eg, Anderson and Kaye) found no episodes of tendon rupture after
corticosteroid injection for TF, even with repeated injections.

Fat atrophy can occur locally at the injection site if the corticosteroid is injected into
the subcutaneous tissue. This complication can cause a cosmetic depression in the skin,
and tenderness can result from the loss of padding provided by the fat.

22
Surgical release
If the surgeon maintains a careful surgical technique, the incidence of complications
should be low. Potential complications of TF surgery include the following:
• Tenderness over the site of the incision - This occurs quite frequently but
usually settles on its own
• Adhesions and subsequent stiffness - This may develop with excessive handling
of the tendon or delayed postoperative mobilization
• Digital nerve injury - Overall, this is extremely rare, even though the digital
nerves lie within 2-3 mm of the midline; prompt repair or reconstruction is indicated
in the event of this unfortunate complication; observation for suspected neurapraxia is
appropriate; digital nerve transection is the most common complication reported after
trigger thumb surgery; the radial digital nerve is injured more frequently because of its
superficial location and oblique course over the flexor sheath
• Superficial scoring of the FDS tendon - This has been reported frequently but
does not require further treatment
• Accidental cutting into the A2 pulley - This can cause bowstringing, with loss
of full finger flexion; pulley exploration and reconstruction may be indicated if
bowstringing does not resolve
• Scarring - This is more likely to occur after TF surgery than after trigger thumb
surgery
• Recurrence - This has been reported but is extremely rare
• Infection - This is a risk in patients who are diabetic or immunosuppressed and
may be problematic if septic flexor tenosynovitis results
Research has shown no statistically significant differences in surgical complication
rates between persons with diabetes and those without it. This was also found to be true
when patients with type 1 diabetes were compared with individuals who had type 2
diabetes.

23
PROGNOSIS

Injection with or without splinting

The prognosis in TF is very good; most patients respond to corticosteroid injection with
or without associated splinting. Some cases of TF may resolve spontaneously and then
reoccur without obvious correlation with treatment or exacerbating factors.

Freiberg et al found a greater success rate for TF injection therapy when the treatment
was used in patients in whom an examiner could palpate a discrete, rather than a
diffuse, nodular consistency in the flexor sheath. Digits with a discrete, palpable nodule
had a 93% success rate with a single injection of triamcinolone at 3 months' follow-up,
whereas digits with a diffuse pattern had a 52% failure rate.

Marks and Gunther reported an 84% success rate in trigger digits and a 92% success
rate in trigger thumbs following a single injection of triamcinolone.

Using sonoelastography, a newer technique for quantitative assessment of the stiffness

of soft tissues, one group noted that the causes for snapping in trigger finger were
increased stiffness and thickening of the A1 pulley. Three weeks after corticosteroid
injection, the pulley thickness and the ratio of subcutaneous fat to the pulley both
decreased; snapping disappeared in all patients studied.
Griggs and co-investigators reported an overall success rate of 50% for steroid injection
in patients with DM. Patients with insulin-dependent diabetes had a higher incidence
of multiple digit involvement and required surgical release more frequently than did
patients who were not insulin dependent.

Surgery
Patients who need surgical release generally have a very good outcome. Percutaneous
TF release has been reported by several authors to be safe and efficacious, with success
rates of 74-94% and no complications having been found at medium-term follow-up.

24
The procedure is advised for individuals with established primary TF who have
symptoms lasting longer than 4 months or for patients in whom injection therapy has
failed to relieve symptoms. It is considered a reasonable choice following 1 injection
failure and actually may confer cost benefits through permanent relief.

The prognosis is also very good for congenital trigger thumb that is treated with
resection of the tendon nodule.
A study suggests that perioperative characteristics and outcomes differ between TF and
trigger thumb and that the surgical outcome is poorer for TF than for trigger thumb
(partly due to flexion contracture of the PIP joint).

Pediatric
Triggering may resolve spontaneously in 23-63% of pediatric cases. If patients are not
treated by the time they are aged 4 years, some may be left with permanent flexion
contractures. Surgical release of the A1 pulley prior to this age leads to excellent
results.

PATIENT EDUCATION
As with patient education following any local injection, patients should be told to watch
for signs and symptoms of infection and bleeding. Any suggestion of infection or
excessive bleeding should be reported to the physician immediately.

Patients should understand that some increased tenderness may be noted at the injection
site for 2-4 days, until the corticosteroid begins to have a significant therapeutic effect.
If there is an inordinate amount of pain after the procedure, patients should contact the
physician who performed the injection.

Patients should understand that a certain amount of numbness in the digit may occur if
some of the local anesthetic has come into contact with a digital nerve; however, the
numbness should resolve within a matter of hours after the injection. Significant,

25
persistent numbness should be reported to the physician who performed the injection.

To minimize the risk of tendon rupture after corticosteroid injection, the patient should
be advised that for a few weeks after the injection, he or she should avoid using the
injected structures for excessively strenuous or forceful activity.

26
DAFTAR PUSTAKA

• Fam AG. Regional pain problems. Klippel JH, Dieppe PA, eds. Practical Rheumatology.
London, England: Mosby; 1997.
• Trigger finger. Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American
Academy of Orthopaedic Surgeons; 1997. 249-53.
• Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes.
Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB
Saunders; 1996. 756-82.
• Bae DS. Pediatric trigger thumb. J Hand Surg Am. 2008 Sep. 33(7):1189-91. [Medline].
• Kim HR, Lee SH. Ultrasonographic assessment of clinically diagnosed trigger fingers.
Rheumatol Int. 2009 Oct 23. [Medline].
• Bamroongshawgasame T. A comparison of open and percutaneous pulley release in trigger
digits. J Med Assoc Thai. 2010 Feb. 93(2):199-204. [Medline].
• Will R, Lubahn J. Complications of open trigger finger release. J Hand Surg Am. 2010 Apr.
35(4):594-6. [Medline].
• Schramm JM, Nguyen M, Wongworawat MD. The safety of percutaneous trigger finger
release. Hand (N Y). 2008 Mar. 3(1):44-6. [Medline]. [Full Text].
• para, childcount:2Masquijo JJ, Ferreyra A, Lanfranchi L, Torres-Gomez A, Allende V.
Percutaneous Trigger Thumb Release in Children: Neither Effective Nor Safe: A
Cross-over Controlled Trial. J Pediatr Orthop. 2013 Dec 6. [Medline].
• Schubert C, Hui-Chou HG, See AP, Deune EG. Corticosteroid injection therapy for trigger
finger or thumb: a retrospective review of 577 digits. Hand (N Y). 2013 Dec. 8(4):439-
44. [Medline]. [Full Text].
• Rodgers WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg Am. 1994
May. 19(3):364-8. [Medline].
• De Smet L, Steenwerckx A, Van Ransbeeck H. The so-called congenital trigger digit: further
experience. Acta Orthop Belg. 1998 Sep. 64(3):306-8. [Medline].
• Li Z, Wiesler ER, Smith BP, Koman LA. Surgical treatment of pediatric trigger thumb with
metacarpophalangeal hyperextension laxity. Hand (N Y). 2009 Dec. 4(4):380-4.
[Medline]. [Full Text].

27
• Marks MR, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and
thumbs. J Hand Surg [Am]. 1989 Jul. 14(4):722-7. [Medline].
• Breen TF. Wrist and hand. Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in
Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999. 99-138.
• Brinker MR, Miller MD. The adult hand. Fundamentals of Orthopaedics. Philadelphia, Pa:
WB Saunders; 1999. 196-220.
• McGee DJ. Forearm, wrist and hand. Orthopedic Physical Assessment. 2nd ed. Philadelphia,
Pa: WB Saunders; 1992. 168-215.
• Miyamoto H, Miura T, Isayama H, Masuzaki R, Koike K, Ohe T. Stiffness of the first
annular pulley in normal and trigger fingers. J Hand Surg Am. 2011 Sep. 36(9):1486-
91. [Medline].
• Hueston JT, Wilson WF. The aetiology of trigger finger explained on the basis of
intratendinous architecture. Hand. 1972 Oct. 4(3):257-60. [Medline].
• Sampson SP, Badalamente MA, Hurst LC, et al. Pathobiology of the human A1 pulley in
trigger finger. J Hand Surg [Am]. 1991 Jul. 16(4):714-21. [Medline].
• Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand
Surg Am. 2006 Jan. 31(1):135-46. [Medline].
• Kumar P, Chakrabarti I. Idiopathic carpal tunnel syndrome and trigger finger: is there an
association?. J Hand Surg Eur Vol. 2009 Feb. 34(1):58-9. [Medline].
• Grandizio LC, Beck JD, Rutter MR, Graham J, Klena JC. The incidence of trigger digit after
carpal tunnel release in diabetic and nondiabetic patients. J Hand Surg Am. 2014 Feb.
39(2):280-5. [Medline].
• Freiberg A, Mulholland RS, Levine R. Nonoperative treatment of trigger fingers and thumbs.
J Hand Surg (Am). 1989. May 14(3):553-8. [Medline].

28