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Trigger Finger

Trigger finger (TF) is a condition involving the flexor tendon sheath, which leads to abnormal gliding of tendon and narrowing of the first annular (A1) pulley causing pain and locking of finger during flexion. The subject experiences painful flexion and difficulty in straightening of digits. It is one of the most common problems of hands and wrist, which leads to pain, dysfunction and disability, if not treated.


Presentation

The patient may complain of clicking which may further develop into catching or popping pain. This may get normalized by manual palpation of digits. Stiffness and pain of the metacarpophalangeal joint in the morning which generally eases along the day, is a common complaint [5].

Pain is present in the distal aspect of the palm and at the proximal end of the digit involved. A painful, swollen nodule can be palpated near the metacarpophalangeal joint, arising due to inflammation or bunching of the fibrous tissue from trauma. At a time, one or more digits can be involved.

Finger Pain
  • Adjustable Trigger Finger Splint by MedicHelp This brace can be worn day or night on any finger for effective trigger finger pain relief.[vivehealth.com]
  • The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury.[ncbi.nlm.nih.gov]
  • Signs and symptoms of osteoarthritis include: Stiffness Swelling and pain Bony nodules at the middle or end joints of the finger Pain and possibly swelling at the base of the thumb Loss of strength in the fingers and the grip of the hand Treatment for[lakelandhealth.org]
  • Trigger finger Other names Historicopous, trigger digit, trigger thumb, [1] stenosing tenosynovitis [1] Specialty Plastic surgery Symptoms Catching or locking of the involved finger, pain [2] [3] Usual onset 50s to 60s years old [2] Risk factors Repeated[en.wikipedia.org]
Chronic Infection
  • Acute or chronic infections, either localized or systemic, may in some cases involve the tenosynovium. Few autoimmune diseases may cause changes in the structure of tendons and pulleys.[symptoma.com]
  • Other conditions like inflammatory arthritis, gout, or chronic infection can also be associated with trigger thumb. Multiple digit involvement is common in conditions diabetes mellitus or rheumatoid arthritis.[boneandspine.com]
  • 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).[emedicine.medscape.com]
Skin Lesion
  • Three months after this operation, a progressively enlarging skin lesion formed at the surgical site.[ncbi.nlm.nih.gov]
Long Arm
  • Herein, we report three cases of patients with trigger finger, who were treated by using long arm casting.[ncbi.nlm.nih.gov]
Polyneuropathy
  • Author information 1 Department of Neurology, Tokyo Metropolitan Neurological Hospital. ukyo@pop06.odn.ne.jp Abstract We describe a Japanese family with transthyretin Val107-related familial amyloid polyneuropathy (FAP).[ncbi.nlm.nih.gov]

Workup

  • TF is presented as tender, easily palpable nodule with pain and click.
  • No laboratory tests or imaging is necessary in the case of an obvious clinical presentation, but in systemic conditions like diabetes and rheumatoid arthritis or other autoimmune diseases, blood sugar (fasting), rheumatoid factor and glycosylated Hb tests can be performed to study the causative condition precipitating TF [6].
  • Radiographs are indicated only in cases of local injury, trauma or foreign body entrapment.
  • Histology shows extracellular matrix, local inflammatory cell infiltration and plasma cells. Metaplasia of tendon sheath, collagen deposits can be seen in chronic cases.

Treatment

For symptomatic relief non-steroidal anti-inflammatory drugs (NSAIDs), and corticosteroids if necessary (methyprednisolone, dexamethasone acetate) may be prescribed.

Conservative release technique

“Graston technique” is the latest technique used in the treatment; this differs from the conventional approach, and aims at re-establishing the extensor strength of the digits by palpation and control of pain using cryotherapy. The second approach is splinting technique; which is done in patients not willing for corticosteroid injections. It involves reducing the friction caused by movement of flexor tendons by immobilizing or splinting them [8].

Conventional approach

Involves corticosteroid injections at the area of thickening of the sheath. It is done under strict aseptic conditions where the steroid injection is given within the tendon sheath and the patient is encouraged to move the digits. A different technique is also used in which the biaxial injection is given at the level of mid proximal phalanx which is less painful [9].

Surgical technique

When the conservative or conventional approach doesn’t work or in the case of a locked TF, surgical technique is opted in which a full sectioning of the A1 pulley is done. Other technique is “Kapandji enlargement plasty” of A1 pulley in which A1 pulley is surgically enlarged. Patient feels early symptomatic relief by this technique. Latest technique is accucision or TRF (Trigger finger release), a microinvasive surgery for TF. Complications of these techniques include digital nerve and artery injury. In some cases infections, bowstring, bleeding, tendon rupture, atrophy of subcutaneous fat can occur [10].

Prognosis

Prognosis of TF is good in most cases following splinting or surgery or both. Corticosteroid injections are beneficial in patients having symptoms for a short time (less than 4 months). In most cases conservative approach, along with digital palpation and cryotherapy works.

Surgical release is proved beneficial in the patients with symptoms for prolonged duration (more than 4 months). Patients are generally cured and recurrence is seen rarely [7].

Etiology

Etiology of the condition is mostly unknown. One of the causes is using of hand held tools and repeating motions. Activities involving prolonged stress and exertion of the pulleys can lead to trigger finger. Systemic conditions like diabetes mellitus or rheumatoid arthritis may also lead to the tendon sheath inflammation.

Acute or chronic infections, either localized or systemic, may in some cases involve the tenosynovium. Few autoimmune diseases may cause changes in the structure of tendons and pulleys. Collagen vascular diseases like sarcoidosis, amyloidosis and hypothyroidism may act as an underlying factor [2].

Epidemiology

Trigger finger is a relatively common problem of the hand and wrist region and is over six times more common in women than men. It commonly affects the person during fifth and sixth decade of life. TF occurs commonly in patients with systemic diseases like diabetes, carpel tunnel syndrome, autoimmune disorders, De Quervain disease, renal diseases, hypothyroidism, and amyloidosis. The sequence of digit involvement includes thumb, middle, index and little fingers [3].

Sex distribution
Age distribution

Pathophysiology

Trigger finger arises due to repetitive movements, pressure, stress and inflammation of the tendon sheath leading to accumulation of inflammatory exudates which results in pain during movement. Histological studies have shown accumulation of inflammatory cell infiltrate in extracellular matrix in some cases, and the appearance of chondrocytes also restrict the tendon sheath movement. Repetitive forceful movements also add to the accumulation of collagen type 3 in some areas, thus contributing to the inability of movement [4].

If the trigger finger is not treated for long time, it results in fibrous metaplasia of the tendon sheath.

Prevention

Prevention can be done by avoiding repetitive movements and over exertions of fingers. Any of the tasks involving forceful flexion movements for longer durations should be avoided. Persistent pain and inflammation in the digits indicates the diagnosis of TF, where immediate medical attention is required. In case of excessive use or forceful flexion for longer period of time, adequate rest between works should be given to the hands and digits.

Summary

In trigger finger (TF) or stenosing tenosynovitis, the pathology lies in the tendon sheath and not the synovial lining, so it is more appropriately referred as "Tendovaginitis”. Tendon sheaths comprising of annular and cruciform pulleys form the pulley system that helps in the movement, and in force distribution of the flexor tendons during different motions. Among all the pulleys A1, A2, and A3, the first annular (A1) pulley which is located near the head of metacarpal, bears the most of stress and is responsible for many actions. It is affceted the most amongst all pulleys [1].

In some cases, congenital trigger thumb may be present as a pediatric condition, for which surgical intervention is required.

Patient Information

  • Definition: Trigger finger (TF) is a complication arising due to local inflammation of the tendon sheaths of the fingers from overuse, trauma or systemic diseases. Pain, stiffness, clicking and popping are the early signs. Patient should note for any sign of infection, tenderness, pain and bleeding.
  • Cause: Local trauma or any underlying disease plays an important role, causing TF. The tendon sheath of the finger may thicken leading to difficulty in straightening of fingers. It might present as stiffness in the morning that eases as the day proceeds.
  • Symptoms: One can suspect TF, if a swelling, lump or nodule is present in the palm. It can be avoided by resting fingers and hands between extensive activities, and treating the underlying causes that may increase its incidence, like diabetes and arthritis.
  • Treatment: Cryotherapy along with NSAIDS is a good symptomatic and conservative approach towards the treatment. In any case, if the symptoms persist for a longer time, intervention may be required with corticosteroid injections, surgery or splinting. If numbness of the digits is present after injection, then it may be due to digital nerve injury.
  • Prognosis is very good in the cases of intra sheath injections and surgical intervention. However in some cases, reappearance of the symptoms is seen for unknown reasons or as a result of systemic manifestations.

References

Article

  1. Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed.Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.
  2. Kim HR, Lee SH. Ultrasonographic assessment of clinically diagnosed trigger fingers. Rheumatol Int. Oct 23 2009
  3. Schramm JM, Nguyen M, Wongworawat MD. The safety of percutaneous trigger finger release. Hand (N Y). Mar 2008;3(1):44-6.
  4. Breen TF. Wrist and hand. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rded. Baltimore, Md: Lippincott Williams & Wilkins; 1999:99-138.
  5. De Smet L, Steenwerckx A, Van Ransbeeck H. The so-called congenital trigger digit: further experience.Acta Orthop Belg. Sep 1998;64(3):306-8.
  6. Brinker MR, Miller MD. The adult hand. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:196-220.
  7. Sampson SP, Badalamente MA, Hurst LC, et al. Pathobiology of the human A1 pulley in trigger finger. J Hand Surg [Am]. Jul 1991;16(4):714-21.
  8. Kumar P, Chakrabarti I. Idiopathic carpal tunnel syndrome and trigger finger: is there an association?. J Hand Surg Eur Vol. Feb 2009;34(1):58-9. 
  9. Baek GH, Lee HJ. The natural history of pediatric trigger thumb: a study with a minimum of five years follow-up. Clin Orthop Surg. Jun 2011;3(2):157-9.
  10. Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg [Am]. Nov 1999;24(6):1156-61

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Last updated: 2019-07-11 21:57