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Trigger Finger (Thumb)

This guide on Trigger Finger (including trigger Thumb and Paediatric trigger) is based on
evidence and current research and is intended to inform and guide tertiary referral.

Definition and Pathology ................................................................................................... 1
Epidemiology and Clinical ................................................................................................ 1
Evaluation...............................................................................................................................2
Conservative treatment ...................................................................................................... 2
Paediatric Trigger.. 3
Surgery ............................................................................................................................. 3
British Society for Surgery of the Hand recommendations for Treatment .......................... 4
Treatments without evidence: ............................................................................................ 4
Treatment plan: diagram .................................................................................................... 5
References......................................................................................................................... 6
Detailed References........................................................................................................... 7


Definition / Pathology

Trigger finger (TF), or Stenosing Tenosynovitis, is an acquired condition in which the sheath
for the flexor tendon of a finger or the thumb thickens and narrows such that the
flexor tendon cannot glide freely through it. This may cause pain, intermittent
snapping (triggering) or actual locking (in flexion or extension) of the affected
digit. These symptoms are commonly worse first thing in the morning.

The pathological change in the flexor sheath is fibrocartilaginous metaplasia and hypertrophy
of its A1 pulley
(Sampson, 1991)
. This causes a tender nodule at the base of the finger in
the palm.


Epidemiology/ Clinical

The overall lifetime incidence of trigger digit is 2%
(Moore, 2000)
. It commonly affects the
thumbs, but not the fingers, of young children causing a flexion deformity of the
interphalangeal joint. It also occurs throughout adulthood, most frequently occurs in
the 5
th
-6
th
decades
(Wolfe, 2005)
, and is then more common in woman. Diabetes and
thyroid disease are risk factors for trigger digit, and it may occur in association with
rheumatoid arthritis, kidney disease and other rarer disorders.

Triggering may affect single digits, including the thumb, or multiple digits and the diagnosis
is clinical and based on a history of locking or stiffness of the affected digit(s),
tenderness in the palm of the hand at the base of the affected finger and palpable
clicking or locking of the affected digit during active movement. Differential
diagnoses include Dupuytrens contracture, post-traumatic joint contracture or locking
of the metacarpophalangeal joint (rare). Spontaneous recovery may occur in up to
29% of patients
(Moore, 2000)
. There is no clear association with occupation
(Trezies 1998)
.
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Severity of Trigger Finger
( adapted from Wolfe 2005, Greens operative hand surgery)



o Mild (pre-triggering)
History of
pain
catching or click
Tender A1 pulley; but fully mobile finger

o Moderate
Triggering with:
A - Difficulty actively extending finger
B - Need for passive finger extension
Loss of complete active flexion
o Severe
Fixed contracture



Trigger Digit in Adults

Consevative treatment. Spontaneous recovery may occur with time. In one series 83%
resolved spontaneously, but only after an average of 7 months
(Schofield, 1993)
.

Steroid Injection is an effective therapy for trigger finger and thumb. Success rates for a
single injection of either soluble or insoluble steroid
(Ring 2008 with commentary by: Chung 2008)
, placed either
within, or over, the flexor sheath vary between 49-78%
(Lambert 1992, Murphy 1995, Akhtar 2007, Fleisch 2007, Peters-
Veluthamaningal 2008)
.
A second injection is often (50%) successful if the first has no, or only
temporary, effect
(Akhtar 2007, Ring, 2008)
. Triamcinolone may have a more rapid effect
than Dexamethasone
(Ring, 2008)
. Steroid injections have few complications
(Baumgarten
2008,

Peters-Veluthamaningal 2008)
and are safely given in the primary care setting (
Akhtar 2005,
Peters-Veluthamaningal 2008)
.
The response rates to steroid injection in patients with diabetes, rheumatoid
arthritis is lower than in those with no risk factors for trigger digit
(Akhtar 2005, Akhtar
2007, Baumgarten 2007, Baumgarten 2008)
. However up to 60% of diabetic patients are
successfully treated with steroid injections, though the success rate is lower if
multiple digits are involved. There is no evidence that simple sheath dilatation
with saline or lignocaine offers any therapeutic benefit
(Lambert 1992, Murphy 1995, Baumgarten
2007)
.
Splinting is an alternative therapy for those unwilling to contemplate steroid injection or
surgery. There is some evidence that this may be effective in adult
(Patel 1992)
and paediatric
populations
(Bae 2008, Ogino 2008)
. There is no evidence to suggest that work-place modification
(ergonomic adjustments) or physiotherapy help in the management of work-related trigger
finger.

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Surgery (trigger finger release) is indicated:
after failed conservative treatment
for recurrent triggering after 1-2 injections of steroid
if there are severe symptoms at presentation
in people populations who are unlikely to benefit from steroid
injections (for example a diabetic with many digits affected and severe
symptoms)

Surgical division of the A1 annular pulley of the flexor sheath of the digit, either by
conventional open, or percutaneous, release is an effective treatment with a high
success rate, low complication rate and short recovery period (3-4 weeks). It is
usually done on a daycase basis under local anaesthetic and provides a permanent
cure when performed by appropriately trained surgeons.
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Paediatric Trigger Thumb

This is an acquired condition
(Bae 2008, Ogino 2008)
which usually presents between the ages of 6
months and 2 years. Typically the thumb interphalangeal joint is locked in flexion and
cannot be actively or passively extended, and there is a palpable A1 pulley (Notta node) on
the palmar aspect of the metacarpophalangeal joint. Treatment is not mandatory for mild
cases with only sight flexion deformity. Treatment with steroid injection has not been
reported and is not practiced.

Observational and retrospective studies suggest that paediatric trigger
thumbs spontaneously resolve in between 36-78% of patients by skeletal
maturity. This recovery may be assisted by splinting and passive
stretching programmes.
Surgical release of the A1 pulley of the flexor sheath of the thumb is
almost always successful
(Bae 2008, Ogino 2008)
and is typically performed as a
day-case under a short general anaesthetic. There is no ideal age for
surgery, the timing of which is determined by the severity of the flexion
deformity, the duration of the problem and the parents attitude to a wait
and see policy in the hope of spontaneous resolution. However surgery is
typically performed by the age of 3 years
(Dinham 1974 )
although other authors
suggest waiting to the age of 5
( Ogino 2008)
.


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British Society for Surgery of the Hand recommendations for Treatment of
Trigger Digit in Adults


Mild
o Analgesia

Moderate
o Steroid injection to flexor sheath

Severe or failed non-operative treatment
o Surgical trigger release


Treatments without evidence:

No effect is demonstrated for the following treatments which are Not Recommended:
NSAIDs, except for simple analgesia
Placebo injection
(Lambert 1992, Murphy 1995, Baumgarten 2007)
Work-place modifications
(Trezies 1998)

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Treatment plan: diagram




















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Research Opportunities

Proper community-based study of untreated trigger thumb in children


References

Wolfe SW. Tenosynovitis, 2137-2158, Chapter 60. Greens Operative Hand Surgery
Eds Green DP, Hotchkiss RN, Pederson WC, Wolfe SW . Elsevier, Churchill
Livingstone, 2005.

Sampson SP, Badalamente MA, Hurst LC, Seidman J. Pathobiology of the human
A1 pulley in trigger finger. J Hand Surg [Am]. 1991 Jul;16(4):714-21.

Ryzewicz M, Wolf JM. Trigger digits: principles, management, and
complications. J Hand Surg [Am]. 2006 Jan;31(1):135-46. Review.
Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger
thumb). J Occup Environ Med. 2000 May;42(5):526-45. Review.

Trezies AJ, Lyons AR, Fielding K, Davis TR. Is occupation an aetiological
factor in the development of trigger finger? J Hand Surg [Br]. 1998
Aug;23(4):539-40.

Schofield CB, Citron ND. The natural history of adult trigger thumb. J Hand Surg [Br].
1993 Apr;18(2):247-8.

Ring D, Lozano-Caldern S, Shin R, Bastian P, Mudgal C, Jupiter J. A prospective
randomized controlled trial of injection of dexamethasone versus triamcinolone for
idiopathic trigger finger. J Hand Surg [Am]. 2008 Apr;33(4):516-22; discussion 523-4.

Murphy D, Failla JM, Koniuch MP. Steroid versus placebo injection for trigger
finger. J Hand Surg [Am]. 1995 Jul;20(4):628-31. Erratum in: J Hand Surg [Am]
1995 Nov;20(6):1075. Comment in: J Hand Surg [Am]. 1996 May;21(3):530.

Lambert MA, Morton RJ, Sloan JP. Controlled study of the use of local steroid
injection in the treatment of trigger finger and thumb. J Hand Surg [Br]. 1992
Feb;17(1):69-70.

Akhtar S, Burke FD. Study to outline the efficacy and illustrate techniques for steroid
injection for trigger finger and thumb. Postgrad Med J. 2006 Nov;82(973):763-6.
Review.

Akhtar S, Bradley MJ, Quinton DN, Burke FD. Management and
referral for trigger finger/thumb. BMJ. 2005 Jul 2;331(7507):30-3.

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
Mar;15(3):166-71. Review.
:
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Peters-Veluthamaningal C, Winters JC, Groenier KH, Jong BM. Corticosteroid
injections effective for trigger finger in adults in general practice: a double-blinded
randomised placebo controlled trial. Ann Rheum Dis. 2008 Sep;67(9):1262-6. Epub
2008 Jan 7.

Baumgarten KM. Current treatment of trigger digits in patients with diabetes mellitus. J
Hand Surg [Am]. 2008 Jul-Aug;33(6):980-1. Review.

Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients
with trigger finger. A prospective, randomized, controlled double-blinded study. J
Bone Joint Surg Am. 2007 Dec;89(12):2604-11.

Taras JS, Raphael JS, Pan WT, Movagharnia F, Sotereanos DG. Corticosteroid
injections for trigger digits: is intrasheath injection necessary? J Hand Surg [Am].
1998 Jul;23(4):717-22.

Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J
Hand Surg [Am]. 1992 Jan;17(1):110-3.

Bae DS. Pediatric trigger thumb. J Hand Surg [Am]. 2008 Sep;33(7):1189-91.

Ogino T. Trigger thumb in children: current recommendations for treatment. J Hand
Surg [Am]. 2008 Jul-Aug;33(6):982-4. Review.

Dinham JM, Meggitt BF. Trigger thumbs in children. A review of the natural history
and indications for treatment in 105 patients. J Bone Joint Surg Br. 1974
Feb;56(1):153-5.
.

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