Recognizing and treating trigger finger

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doi:10.12788/jfp.0239

Applied Evidence

Recognizing and treating trigger finger

J Fam Pract. 2021 September;70(7):334-340 | 10.12788/jfp.0239

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References

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4. Junot HSN, Anderson Hertz AFL, Gustavo Vasconcelos GR, et al. Epidemiology of trigger finger: metabolic syndrome as a new perspective of associated disease. Hand (N Y). 2019:1558944719867135. doi: 10.1177/1558944719867135.

5. Matthews A, Smith K, Read L, et al. Trigger finger: an overview of the treatment options. JAAPA. 2019;32:17-21. doi: 10.1097/01.Jaa.0000550281.42592.97

6. Pencle FJ, Waheed A, Molnar JA. Trigger thumb. StatPearls [Internet]. StatPearls Publishing; 2020. www.ncbi.nlm.nih.gov/books/NBK441854/

7. Giugale JM, Fowler JR. Trigger finger: adult and pediatric treatment strategies. Orthop Clin North Am. 2015;46:561-569. doi: 10.1016/j.ocl.2015.06.014

8. Bianchi S, Gitto S, Draghi F. Ultrasound features of trigger finger: review of the literature. J Ultrasound Med. 2019;38:3141-3154. doi: 10.1002/jum.15025

9. Chuang XL, Ooi CC, Chin ST, et al. What triggers in trigger finger? The flexor tendons at the flexor digitorum superficialis bifurcation. J Plast Reconstr Aesthet Surg. 2017;70:1411-1419. doi: 10.1016/j.bjps.2017.05.037

10. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am. 2006;31:135-146. doi: 10.1016/j.jhsa.2005.10.013

11. Chapter 56: Tendinoapthy. In: Wolfe SW, Peterson WC, Kozin SH, Cohen MS. Green’s Operative Hand Surgery. Vol 2. 7th ed. Elsevier; 2017: 1904-1925.

12. Tarbhai K, Hannah S, von Schroeder HP. Trigger finger treatment: a comparison of 2 splint designs. J Hand Surg Am. 2012;37:243-249, 249.e241. doi: 10.1016/j.jhsa.2011.10.038

13. Valdes K. A retrospective review to determine the long-term efficacy of orthotic devices for trigger finger. J Hand Ther. 2012;25:89-95. doi: 10.1016/j.jht.2011.09.005

14. Drijkoningen T, van Berckel M, Becker SJE, et al. Night splinting for idiopathic trigger digits. Hand (N Y). 2018;13:558-562. doi: 10.1177/1558944717725374

15. Colbourn J, Heath N, Manary S, et al. Effectiveness of splinting for the treatment of trigger finger. J Hand Ther. 2008;21:336-343. doi: 10.1197/j.jht.2008.05.001

16. Teo SH, Ng DCL, Wong YKY. Effectiveness of proximal interphalangeal joint-blocking orthosis vs metacarpophalangeal joint-blocking orthosis in trigger digit management: A randomized clinical trial. J Hand Ther. 2018;32:444-451. doi: 10.1016/j.jht.2018.02.007

17. Ring D, Lozano-Calderon S, Shin R, et al. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger. J Hand Surg Am. 2008;33:516-522; discussion 523-514. doi: 10.1016/j.jhsa.2008.01.001

18. Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: A level I and II systematic review. J Am Acad Orthop Surg. 2007;15:166-171. doi: 10.5435/00124635-200703000-00006

19. Shinomiya R, Sunagawa T, Nakashima Y, et al. Impact of corticosteroid injection site on the treatment success rate of trigger finger: a prospective study comparing ultrasound-guided true intra-sheath and true extra-sheath injections. Ultrasound Med Biol. 2016;42:2203-2208. doi: 10.1016/j.ultrasmedbio.2016.05.015

20. Earp BE, Stanbury SJ, Mora AN, et al. Needle-free jet lidocaine administration for preinjection anesthesia in trigger finger injection: a randomized controlled trial. J Hand Surg Am. 2017;42:618-622. doi: 10.1016/j.jhsa.2017.05.001

21. Castellanos J, Munoz-Mahamud E, Dominguez E, et al. Long-term effectiveness of corticosteroid injections for trigger finger and thumb. J Hand Surg Am. 2015;40:121-126. doi: 10.1016/j.jhsa.2014.09.006

22. Dala-Ali BM, Nakhdjevani A, Lloyd MA, et al. The efficacy of steroid injection in the treatment of trigger finger. Clin Orthop Surg. 2012;4:263-268. doi: 10.4055/cios.2012.4.4.263

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While the location of the injection has been debated, recent literature suggests that symptoms can be effectively alleviated regardless of the specific anatomic injection site, such as intra-sheath or extra-sheath (FIGURE 2).¹⁹ This allows flexibility for the clinician, as the injection does not have to be placed within the tendon sheath. Corticosteroids should not be injected into the tendon itself, and the needle tip should be slightly withdrawn if there is resistance while injecting. Patients who are averse to injections have been shown to benefit from needle-free jet lidocaine (J-tip) administration prior to the actual steroid injection.²⁰

A randomized controlled trial comparing dexamethasone to triamcinolone injections found no difference in outcome at the 3-month follow-up (n = 84).¹⁷ This may suggest that the choice of corticosteroid is at the clinician’s discretion. In terms of long-term efficacy of steroid injections, it has been shown that 70% of trigger digits had complete resolution of symptoms at a mean follow-up of 8 years after just 1 injection (n = 43).²¹

Some patients, though, may require additional corticosteroid injections to maintain symptom control. If multiple injections are performed, they should not be given in intervals shorter than 4 months between treatments.⁵ Furthermore, steroids can be administered safely up to 3 times in the same digit before surgery is recommended.²²

A patient’s options should be reconsidered if efficacy is not demonstrated with prior injections. Notably, a lower success rate has been shown in patients with type 2 diabetes (66%) compared to those without diabetes (90%).^4,23 This difference in success rates is not well understood, as there is no causal relationship between well-controlled diabetes and TF.⁴ Complications of corticosteroid injections include local pain, fat atrophy, and hypopigmentation at the site of the injection, as well as short-term elevations in blood glucose levels in patients with diabetes.^5,24

Surgical correction (to be discussed) remains superior to steroid injections in terms of cure rate and resolution of symptoms. A randomized controlled trial (n = 165) found that an injection-only group reported 86% and 49% success at 3-month and 12-month follow-up, respectively, compared to 99% success at both 3- and 12-month follow-up for the surgical group. Further, at 12-month follow-up, the median pain scores were significantly higher in the injection group (3; range, 1-9) than in the surgery group (1; range, 1-7).²⁵ If conservative treatment modalities lead to unresolved symptoms or recurrence, referral to a hand specialist for surgery is recommended.

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