Trigger finger (TF)

• 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.
• 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.
• 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.
• 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.
• 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 digital flexor sheath is a complex structure through which the flexor tendons of the
fingers run.
• The sheath is essential for normal function of the flexor tendons, it holds the flexor
tendons close to the bone allowing them to effectively ‘turn a corner’ and transfer the
force developed in the muscle-tendon unit into movement at the phalanges.
• The sheath is composed of two distinct tissue components;
• a synovial or membranous component and
• a retinacular or pulley component.
• The membranous portion is composed of a closed synovium lined tube.
• The tube can be imagined with the floor (dorsal) running over the transverse metacarpal
ligament, the palmar surfaces of the metacarpophalangeal, proximal interphalangeal and
distal interphalangeal joints and the palmar surface of the proximal and middle phalanges.
• The membranous part of the sheath is most clearly seen between the flexor pulleys where
it forms folds and out-pouches which allow it to stretch and compress with flexion and
extension of the digits.
• The retinacular portion of the sheath consists of fibrous tissue condensations
which wrap around the flexor tendons.
• These condensations are the flexor tendon pulleys.
• There are five annular pulleys and three cruciform pulleys which are
numbered as they run from proximal to distal.
• Of the pulleys the A3 and A5 pulleys are located over a joint, the proximal
interphalangeal joint and the distal interphalangeal joint respectively.
• The annular pulleys can be divided further into those which insert into bone
(true fibro-osseous pulleys) and those which insert into the volar plate.
• The A2 and A4 pulleys are true fibro-osseous pulleys and are the strongest
pulleys withstanding the greatest forces during pinch and grasp.
• The other annular pulleys (A1, A3, A5) are more flexible and allow for
compression during flexion without impinging on the tendons.
• The anatomical position of the pulleys and their relative insertions can be seen.
The relative position and insertions of the finger flexor tendon pulleys
• 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.
• 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
Flexor tendons pass within the tendon sheath and beneath the A-1 pulley at
approximately the metacarpal head, beyond which they travel into the 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.
• 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.[15, 16, 17] 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. (See the image below.)
An inflamed nodule can restrict the tendon from passing smoothly beneath the A-
1 pulley. If the nodule is distal to the A-1 pulley (as shown in this sketch), then the
digit may get stuck in an extended position. Conversely, if the nodule is proximal
to the A-1 pulley, then the patient's digit is more likely to become stuck in the
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.[19]
• 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.[20]
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[21] :
• 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 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%.[22]
• 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.[23]
• 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
Trigger thumb. A1 pulley exposed within surgical field (arrow). Digital neurovascular bundles behind
retractors.
• 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.
• 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.[24] 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.[14]
• 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.[18]
• Griggs and co-investigators reported an overall success rate of 50% for steroid injection in patients
with DM.[25] 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.[26, 27]
• 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. 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).[28]
• 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
• History
• Patients with trigger finger (TF) may have a history of diabetes mellitus (DM) or
rheumatoid arthritis (RA). In these individuals, multiple digits may be involved in
TF.
• Some patients will have a history of repetitive trauma to the affected area, while
others may have occupational duties requiring repetitive use of the involved
tendons.[31]
• Signs and symptoms of TF are as follows:
• Locking or catching during active flexion-extension activity (passive 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, RA, gout)
• Early signs of triggering in other digits (may be bilateral)
• A classic complaint is difficulty in achieving full extension of a single digit, which eventually releases or snaps open with
pain at the distal palm and into the digit.
• Some patients have difficulty with finger flexion rather than extension, though the former is less common. Other patients
may have a painful nodule in the distal palm without any catching or triggering.
• Some patients report stiffness in the fingers, especially after they have been asleep or following other periods of
inactivity.
• Some patients report swelling of the affected digit, particularly at the digit's base or proximal aspect.
• Pediatric
• 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
• 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
A trigger finger often results in difficulty flexing or (in this case)
extending the metacarpophalangeal joint of the 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.
• 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)
• 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 [32]
• 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.
• Approach Considerations
• Trigger finger (TF) is a clinical diagnosis. Occasionally, the
nodule in the tendon is easily felt, and a palpable and audible
click can be appreciated when the triggering is relieved with
forced extension of the digit.
• 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), rheumatoid arthritis (RA), or
another connective tissue disease, tests such as those
assessing glycosylated hemoglobin (HbA1c), fasting blood
sugar, or rheumatoid factor should be ordered.
• 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.[33] 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[34] :
• Grade I (pretriggering) - Pain; history of catching that is not demonstrable
on clinical examination; tenderness over the A1 pulley
• Grade II (active) - Demonstrable catching, but with the ability to actively
extend the digit maintained
• 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)
• Grade IV (contracture) - Demonstrable catching, with a fixed flexion
contracture of the proximal interphalangeal (PIP) joint
• Approach Considerations
• Early series recommended surgical treatment of trigger finger (TF) as straightforward and highly effective, while
regarding prolonged conservative treatment as unreliable and expensive. Subsequent series documented poor results
from surgical treatment in 7-9% of cases.
• In 1972, Lapidus reversed his previous recommendation for operative treatment of TF after he and Guidotti reported
uniformly good results following a single injection of prednisolone into the tendon sheath. [35] Rhoades et al subsequently
reported a 72% success rate in a series of 53 digits following injection and immobilization. [36]
• Injection therapy is now generally agreed to be the first line of management. Surgery is reserved for individuals in whom
injection treatment has failed or in whom other pathology, particularly rheumatoid arthritis (RA), is suspected to be
causing triggering that cannot be treated conservatively. [37] No absolute contraindications exist for surgical
management.
• In May 2014, the European HANDGUIDE Group published a guideline for multidisciplinary treatment of trigger finger. [38]
By consensus, suitable treatment options were considered to include the following:
• Orthoses (splinting)
• Corticosteroid injections
• Corticosteroid injections plus use of orthoses
• Surgery
• Severity and duration of disease and prior treatments received were judged to be the primary factors influencing choice
of therapy.[38]
• Conservative treatment
• Most trigger digits in adults can be managed successfully with local steroid injections and splinting. [39] Oral or topical pharmacologic measures have not been demonstrated to be effective.
• The outcome of conservative treatment for pediatric trigger thumb is somewhat controversial. [40] A report by Baek et al on the natural history of this condition demonstrated that after a follow-up period
of 5 years or more in patients who received no treatment for pediatric trigger thumb, complete resolution of flexion deformity occurred in 66 out of 87 thumbs (75.9%), and partial improvement occurred
in the remaining 21 thumbs.[30, 41]
• Another study, by Lee et al, reported that extension splinting for 12 weeks led to improvement in 71% of thumbs, compared with 23% improvement in patients not receiving any treatment. [42] See also
the recommendations described by Ogino.[43]
• 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 interphalangeal (PIP)
contractures. Percutaneous release should be reserved for the index, middle, and ring fingers. [6, 7, 8, 9]
• 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. [44]
• 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 tenosynovitis.[9, 45, 46, 47]
• 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.
• 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.
• 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.
• Corticosteroid Injection Into Tendon Sheath
• Corticosteroid injection in the area of tendon sheath thickening is
considered to be the first-line treatment of choice for TF.[48, 49, 50, 51, 10]
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.[52]
• 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.[53, 48, 54, 55]
• 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.)[26, 27, 56]
• 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
 Movement of the needle with flexion of the digit confirms
Introduction of the needle into the tendon sheath correct positioning of the needle for injection treatment.
at a 45° angle to the palm for injection treatment
• 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 weeks. In patients with symptoms longer than 6 months,
splinting as a sole treatment strategy does not seem to eliminate the triggering
events.[21]
• 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.[66] 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.[13]
• 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, 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.[68]
• 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.[69]
• Preoperative considerations include the following:
• Only digits that actively trigger must be considered for operative release
• Neither PIP contracture nor thumb triggering is suitable for percutaneous release,
and the A1 pulley always is transected under direct vision
• Patients with PIP joint contractures undergo a period of hand therapy and
splinting prior to the procedure
• A tourniquet always is used to obtain a clean operative field
• Approximately 4-5 mL of 1% lignocaine is used to infiltrate the skin overlying the
A1 pulley, with injection performed deeper to the tendon sheath
• The transverse incision is marked with a skin marker corresponding to the digit to
be surgically treated (see the image below)
• The proximal edge of the A1 pulley coincides almost exactly with the distal
palmar crease in the fourth and fifth rays, with the proximal palmar crease in the
index and with the halfway point between the two creases in the middle finger
Incision marked out in the distal palmar crease for surgical
division of the A1 pulley.
• Procedure
• The MCP joint is hyperextended to displace the neurovascular structures dorsally, minimizing the
risk of injury.
• A transverse incision measuring 1-1.5 cm is made over the involved metacarpal head. Blunt
dissection is used to spread the subcutaneous fat and expose the tendon sheath.
• 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. Care is taken to avoid incising too distally and risk cutting into the
A2 pulley, which can result in bowstringing. A study suggests that the proximal part of the A2 pulley
can be safely incised if the release of the A1 pulley in isolation does not result in relief of
triggering.[70] This is still experimental and is best left to hand or plastic and reconstructive surgeons.
• The patient is asked to actively move the digit to confirm full release. Meticulous hemostasis is
achieved with a bipolar cautery, and the wound is closed with two or three skin sutures. The hand is
left free, and motion is encouraged immediately following the procedure.
• If a percutaneous approach is favored, a pair of blunt-tipped, fine scissors is introduced through the
incision, and the A1 pulley is transected (see the image below). Care is taken not to drift too distally.
Disappearance of a grating sensation indicates complete section of the pulley through a separate,
distal oblique incision.
A1 pulley is sectioned using blunt-tipped, fine scissors, keeping strictly in the midline. Note the digit
being held in a hyperextended position by an assistant to displace the neurovascular bundles away from
the midline.
• A study by Rogo-Manaute et al showed that it is possible to use
ultrasonographically guided percutaneous release to achieve a success rate of
100%. With adequate anatomic knowledge, technical training, and a basic
ultrasound machine, sonographically directed A1 pulley release can be performed
safely and successfully, thus offering an alternative to conventional open
technique.[71]
• On rare occasions, sectioning the A1 pulley does not relieve triggering, indicating
that the A3 pulley might be involved. If that is the case, the A3 pulley requires
division. This percutaneous technique as described here usually applies to most
cases of triggering, exceptions being surgery for trigger thumb in children and
triggering involved in conditions like RA, in which the nodule formation may be
distal to the A1 pulley and for which open surgery may be required.
• Trigger thumb
• Surgery for trigger thumb is performed as follows. The A1 pulley is approached
through a transverse incision in the flexion crease overlying the MCP joint (see
the image below). Palpate the flexor pollicis longus (FPL) to ensure that the
incision is centered appropriately.
Incision for trigger thumb release placed in MP flexion crease, centered over flexor tendon
nodule.
• Bluntly dissect through subcutaneous tissue; identify and gently
retract radial and ulnar neurovascular bundles. Expose the A1
pulley, identify its proximal and distal edges, and incise it
longitudinally (see the first image below).[72] Avoid injury to the
underlying tendon
Trigger thumb. A1 pulley exposed within surgical field
(arrow). Digital neurovascular bundles behind retractors.
Trigger thumb. A1 pulley has been released; flexor pollicis longus tendon now exposed.
Retractors have been removed to demonstrate proximity of neurovascular bundles (arrows)
to tendon.
• Inspect the tendon nodule during full passive motion of the
interphalangeal (IP) joint. Ensure that no further restrictions to
excursion are present. A band of tissue proximal to A1 may exist that
also requires release.[73] Observe FPL excursion while the patient
actively flexes the thumb to verify a complete surgical
decompression.
• Deflate the tourniquet, obtain hemostasis, and close the incision with
nylon. Dress the wound with a soft compressive bandage
• Postoperative care
• Active motion is encouraged on the day of surgery. Anti-inflammatory
drugs and elevation are advised for a period of 2-3 days following
surgery. Sutures are removed on postoperative day 10
• Kapandji Enlargement-Plasty of A1 Pulley
• Future treatment for TF may involve Kapandji enlargement-
plasty of the A1 pulley. In this procedure, which is complex and
technically demanding, the A1 pulley is enlarged by making a
diagonal incision in it, followed by suture instead of simple
longitudinal division, thus increasing the mean diameter of the
canal.
• In a study by Migaud et al, 15 patients who underwent this
procedure and who were followed up for a mean period of 5
years had complete symptomatic relief without any recurrences
• Physical Therapy
• 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.