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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2. Makkouk AH, Oetgen ME, Swigart CR, et al. Trigger finger: etiology, evaluation, and treatment. Curr Rev Musculoskelet Med. 2008;1:92-96. doi: 10.1007/s12178-007-9012-1

3. Fitzgibbons PG, Weiss AP. Hand manifestations of diabetes mellitus. J Hand Surg Am. 2008;33:771-775. doi: 10.1016/j.jhsa.2008.01.038

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

23. Griggs SM, Weiss AP, Lane LB, et al. Treatment of trigger finger in patients with diabetes mellitus. J Hand Surg Am. 1995;20:787-789. doi: 10.1016/s0363-5023(05)80432-0

24. Stepan JG, London DA, Boyer MI, et al. Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist. J Hand Surg Am. 2014;39:706-712. doi: 10.1016/j.jhsa.2014.01.014

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27. Zhao J-G, Kan S-L, Zhao L, et al. Percutaneous first annular pulley release for trigger digits: a systematic review and meta-analysis of current evidence. J Hand Surg Am. 2014;39:2192-2202. doi: 10.1016/j.jhsa.2014.07.044

28. Guler F, Kose O, Ercan EC, et al. Open versus percutaneous release for the treatment of trigger thumb. Orthopedics. 2013;36:e1290-1294. doi: 10.3928/01477447-20130920-22

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30. Nikolaou VS, Malahias M-A, Kaseta M-K, et al. Comparative clinical study of ultrasound-guided A1 pulley release vs open surgical intervention in the treatment of trigger finger. World J Orthop. 2017;8:163-169. doi: 10.5312/wjo.v8.i2.163

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Surgical treatments in an office setting

Procedures for TF can be safely performed under conscious sedation or local anesthesia, with or without a tourniquet.²⁶ Wide-awake procedures with local anesthesia and no tourniquet (WALANT) can be performed in an office-based procedure room rather than the operating room. This increases efficiency for the surgeon, reduces the amount of preparation and recovery time for the patient, and helps to keep costs down.

Percutaneous release involves the insertion of a 16-gauge hypodermic needle into the affected A1 pulley. The needle is used to fray and disrupt the pulley by moving the needle tip over the fibrotic A1 pulley.

While NSAIDs are commonly recommended to resolve the local inflammation secondary to triggering, there is no scientific evidence to support their use.

However, it is not without possible complications.²⁷ Inadvertent A2 pulley damage is particularly troublesome, as it leads to “bowstringing” or protrusion of the flexor tendon into the palm upon flexion. This can cause pain and failure to fully extend or flex the finger.¹⁰ Because the anatomy is not well visualized during the percutaneous approach, incomplete release, neurovascular injury, and iatrogenic injury to the A2 pulley or deep tendon may occur.²⁸ Ultrasound-guided percutaneous release techniques have shown effective clinical outcomes with minimal complications compared to nonguided percutaneous release techniques.^29,30

Open release is the gold standard surgical treatment for trigger finger (FIGURE 3). A small incision (1-2 cm) is made directly over or proximal to the A1 pulley in the distal palmar crease at the base of the affected digit. After blunt dissection through the subcutaneous tissue, the A1 pulley is sharply incised. An open approach has the clear benefit of avoiding the digital neurovascular bundles, as well as visualizing the resolution of triggering upon flexion and extension prior to closure. The WALANT procedure has the advantage of allowing the awake patient to actively flex and extend the digit to determine if the A1 release has been successful prior to closure of the incision.

Outcomes and complications of surgery. A recent systematic review and meta-analysis has shown percutaneous techniques to be successful in 94% of cases.²⁷ The success rate of open surgery has been reported at 99% to 100% at varying follow-up intervals up to 1 year.^25,30,31 The complication rate for percutaneous release (guided and nonguided) was calculated at 2.2% (n = 2114).²⁷ In another study, the overall complication rate of open releases was calculated at 1% (n = 999).³² When comparing percutaneous release (guided and nonguided) and open release, a meta-analysis found no significant difference in complication rate (RR = 0.84) or failure rate (RR = 0.94).³²

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