Tips for managing 4 common soft-tissue finger and thumb injuries

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doi:doi: 10.12788/jfp.0425

Applied Evidence

Tips for managing 4 common soft-tissue finger and thumb injuries

J Fam Pract. 2022 June;71(5):206-213 | doi: 10.12788/jfp.0425

By

Caitlin A. Nicholson, MD

Jeremy A. Alland, MD

After examination and, in some cases, imaging, most of these injuries can be managed conservatively with splinting or injection. Some cases require prompt surgical referral.

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PRACTICE RECOMMENDATIONS

› Treat trigger finger with a corticosteroid injection into the flexor tendon sheath. A

› Refer a case of jersey finger to a hand surgeon within 1 week after injury for flexor tendon repair. C

› Treat mallet finger with strict distal interphalangeal joint immobilization for 6 to 8 weeks. A

› Treat Grades 1 and 2 skier’s thumb with immobilization in a thumb spica splint or a cast for 4 to 6 weeks. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Hirt B, Seyhan H, Wagner M, et al. Hand and Wrist Anatomy and Biomechanics: A Comprehensive Guide. Thieme; 2017:57,58,71,72,75-80.

2. Daley D, Geary M, Gaston RG. Thumb metacarpophalangeal ulnar and radial collateral ligament injuries. Clin Sports Med. 2020;39:443-455. doi: 10.1016/j.csm.2019.12.003

3. Gil JA, Hresko AM, Weiss AC. Current concepts in the management of trigger finger in adults. J Am Acad Orthop Surg. 2020;28:e642-e650. doi: 10.5435/JAAOS-D-19-00614

4. Henton J, Jain A, Medhurst C, et al. Adult trigger finger. BMJ. 2012;345:e5743. doi: 10.1136/bmj.e5743

5. Bates T, Dunn J. Trigger finger. Orthobullets [Internet]. Updated December 8, 2021. Accessed April 14, 2022. www.orthobullets.com/hand/6027/trigger-finger

6. Chhabra AB, Deal ND. Soft tissue injuries of the wrist and hand. In: O’Connor FG, Casa DJ, Davis BA, et al. ACSM’s Sports Medicine: A Comprehensive Review. Lippincott Williams & Wilkins; 2012:370-373.

7. Ballard TNS, Kozlow JH. Trigger finger in adults. CMAJ. 2016;188:61. doi: 10.1503/cmaj.150225

8. Vitale M. Jersey finger. Orthobullets [Internet]. Updated May 22, 2021. 2019. Accessed April 15, 2022. www.orthobullets.com/hand/6015/jersey-finger

9. Shapiro LM, Kamal RN. Evaluation and treatment of flexor tendon and pulley injuries in athletes. Clin Sports Med. 2020;39:279-297. doi: 10.1016/j.csm.2019.12.004

10. Goodson A, Morgan M, Rajeswaran G, et al. Current management of Jersey finger in rugby players: case series and literature review. Hand Surg. 2010;15:103-107. doi: 10.1142/S0218810410004710

11. Lapegue F, Andre A, Brun C, et al. Traumatic flexor tendon injuries. Diagn Interv Imaging. 2015;96:1279-1292. doi: 10.1016/j.diii.2015.09.010

12. Bendre AA, Hartigan BJ, Kalainov DM. Mallet finger. J Am Acad Orthop Surg. 2005;13:336-344. doi: 10.5435/00124635-200509000-00007

13. Lamaris GA, Matthew MK. The diagnosis and management of mallet finger injuries. Hand (N Y). 2017;12:223-228. doi: 10.1177/1558944716642763

14. Sheth U. Mallet finger. Orthobullets [Internet]. Updated August 5, 2021. Accessed April 15, 2022. www.orthobullets.com/hand/6014/mallet-finger

15. Weintraub MD, Hansford BG, Stilwill SE, et al. Avulsion injuries of the hand and wrist. Radiographics. 2020;40:163-180. doi: 10.1148/rg.2020190085

16. Avery III DM, Inkellis ER, Carlson MG. Thumb collateral ligament injuries in the athlete. Curr Rev Musculoskelet Med. 2017;10:28-37. doi: 10.1007/s12178-017-9381-z

17. Steffes MJ. Thumb collateral ligament injury. Orthobullets [Internet]. Updated February 18, 2022. Accessed April 15, 2022. www.orthobullets.com/hand/6040/thumb-collateral-ligament-injury

18. Madan SS, Pai DR, Kaur A, et al. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014;6:1-7. doi: 10.1111/os.12084

19. Dardas AZ, VandenBerg J, Shen T, et al. Long-term effectiveness of repeat corticosteroid injections for trigger finger. J Hand Surg Am. 2017;42:227-235. doi: 10.1016/j.jhsa.2017.02.001

20. Huisstede BM, Gladdines S, Randsdorp MS, et al. Effectiveness of conservative, surgical, and postsurgical interventions for trigger finger, Dupuytren disease, and de Quervain disease: a systematic review. Arch Phys Med Rehabil. 2018;99:1635-1649.e21. doi: 10.1016/j.apmr.2017.07.014

21. Lunsford D, Valdes K, Hengy S. Conservative management of trigger finger: a systematic review. J Hand Ther. 2019;32:212-221. doi: 10.1016/j.jht.2017.10.016

22. Fiorini HJ, Tamaoki MJ, Lenza M, et al. Surgery for trigger finger. Cochrane Database Syst Rev. 2018;2:CD009860. doi: 10.1002/14651858.CD009860.pub2

23. Salazar Botero S, Hidalgo Diaz JJ, Benaïda A, et al. Review of acute traumatic closed mallet finger injuries in adults. Arch Plast Surg. 2016;43:134-144. doi: 10.5999/aps.2016.43.2.134

24. Lin JS, Samora JB. Surgical and nonsurgical management of mallet finger: a systematic review. J Hand Surg Am. 2018;43:146-163.e2. doi: 10.1016/j.jhsa.2017.10.004

25. Handoll H, Vaghela MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev. 2004;(3):CD004574. doi: 10.1002/14651858.CD004574.pub2

26. Pulos N, Shin AY. Treatment of ulnar collateral ligament injuries of the thumb: a critical analysis review. JBJS Rev. 2017;5:e3. doi: 10.2106/JBJS.RVW.16.00051

Finger injuries are often seen in the primary care physician’s office. The evidence—and our experience in sports medicine—indicates that many of these injuries can be managed conservatively with bracing or injection; a subset, however, requires surgical referral. In this article, we provide a refresher on finger anatomy (see “A guide to the anatomic structures of the digits of the hand”^1,2) and review the diagnosis and management of 4 common soft-tissue finger and thumb injuries in adults: trigger finger, jersey finger, mallet finger, and skier’s thumb (TABLE^2-18).

Trigger finger

Also called stenosing flexor tenosynovitis, trigger finger is caused by abnormal flexor tendon movement that results from impingement at the level of the A1 pulley.

Causes and incidence. Impingement usually occurs because of thickening of the A1 pulley but can also be caused by inflammation or a nodule on the flexor tendon.^3,4 The A1 pulley at the metacarpal head is the most proximal part of the retinacular sheath and therefore experiences the greatest force upon finger flexion, making it the most common site of inflammation and constriction.⁴

^{Copyright Brian Stauffer}

(Left to right: Jersey finger, trigger finger, mallet finger.)

Trigger finger occurs in 2% to 3% of the general population and in as many as 10% of people with diabetes.⁵ The condition typically affects the long and ring fingers of the dominant hand; most cases occur in women in the sixth and seventh decades.^3-5

Multiple systemic conditions predispose to trigger finger, including endocrine disorders (eg, diabetes, hypothyroidism), inflammatory arthropathies (gout, pseudogout), and autoimmune disorders (rheumatoid arthritis, sarcoidosis).^3,5 Diabetes commonly causes bilateral hand and multiple digit involvement, as well as more severe disease.^3,5 Occupation is also a risk factor for trigger finger because repetitive movements and manual work can exacerbate triggering.⁴

Presentation and exam. Patients report pain at the metacarpal head or metacarpophalangeal (MCP) joint, difficulty grasping objects, and, possibly, clicking and catching of the digit and locking of the digit in flexion.^3,5

Trigger finger occurs in 2% to 3% of the general population and in as many as 10% of people with diabetes.

On exam, there might be tenderness at the level of the A1 pulley over the volar MCP joint or a palpable nodule. In severe cases, the proximal interphalangeal (PIP) joint or entire finger can be fixed in flexion.⁵ Repeated compound finger flexion (eg, closing and opening a fist) or holding a fist for as long as 1 minute and then slowly opening it might provoke triggering.

More than 60% of patients with trigger finger also have carpal tunnel syndrome.⁵ This makes it important to assess for (1) sensory changes in the distribution of the median nerve and (2) nerve compression, by eliciting Phalen and Tinel signs.^4,5

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