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

By

Evan Johnson, MD

John Stelzer, MD, MS

Andrew B. Romero, MD, MS

Joanne R. Werntz, MD

This inflammatory condition can leave your patient in pain and with impaired function. Here's what you need to know about the diagnosis and Tx options to provide relief.

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PRACTICE RECOMMENDATIONS

› Recommend splinting as a first-line conservative treatment for trigger finger if there is not a fixed contracture. B

› Prescribe corticosteroids, which may completely resolve trigger finger in the majority of patients without diabetes. A

› Refer patients for surgical release if they do not respond to conservative management. The surgical success rate is as high as 99%. A

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. 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

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

25. Hansen RL, Sondergaard M, Lange J. Open surgery versus ultrasound-guided corticosteroid injection for trigger finger: a randomized controlled trial with 1-year follow-up. J Hand Surg Am. 2017;42:359-366. doi: 10.1016/j.jhsa.2017.02.011

26. Mohd Rashid MZ, Sapuan J, Abdullah S. A randomized controlled trial of trigger finger release under digital anesthesia with (WALANT) and without adrenaline. J Orthop Surg (Hong Kong). 2019;27:2309499019833002. doi: 10.1177/2309499019833002

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

29. Wu KC, Chern TC, Jou IM. Ultrasound-assisted percutaneous trigger finger release: it is safe [letter]. Hand (N Y). 2009;4:339. doi: 10.1007/s11552-009-9179-6

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

31. Lim M-H, Lim K-K, Rasheed MZ, et al. Outcome of open trigger digit release. J Hand Surg Eur Vol. 2007;32:457-459. doi: 10.1016/j.Jhsb.2007.02.016

32. Wang J, Zhao J-G, Liang C-C. Percutaneous release, open surgery, or corticosteroid injection, which is the best treatment method for trigger digits? Clin Orthop Relat Res. 2013;471:1879-1886. doi: 10.1007/s11999-012-2716-6

33. Ng WKY, Olmscheid N, Worhacz K, et al. Steroid injection and open trigger finger release outcomes: a retrospective review of 999 digits. Hand (N Y). 2018;15:399-406. doi: 10.1177/1558944718796559

34. Ho SWL, Chia CY, Rajaratnam V. Characteristics and clinical outcomes of open surgery for trigger digits in diabetes. J Hand Microsurg. 2019;11:80-83. doi: 10.1055/s-0038-1670927

35. Sato ES, dos Santos JB, Belloti JC, et al. Percutaneous release of trigger fingers. Hand Clin. 2014;30:39-45. doi: 10.1016/j.hcl.2013.08.017

CASE

A 55-year-old right-hand-dominant woman presented to the clinic with a chief complaint of right ring finger pain and stiffness. There was no history of trauma or prior surgery. She had no tingling or numbness. She had a history of type 2 diabetes that was well controlled. She worked as a clerk for a government office for many years, and her painful, limited finger motion interfered with keyboarding and picking up items. Physical examination revealed tenderness to palpation over the palmar aspect of the metacarpophalangeal joint (MCPJ) of the ring finger with no other joint tenderness or swelling. When she made a fist, her ring finger MCPJ, proximal interphalangeal joint (PIPJ), and distal interphalangeal joint (DIPJ) locked in a flexed position that required manipulation to extend the finger. A firm mass was palpated in the palm with finger flexion that moved into the finger with extension.

Stenosing tenosynovitis, also known as trigger finger (TF), is an inflammatory condition that causes pain in the distal palm and proximal digit with associated limited motion. The most commonly affected digits are the middle and ring fingers of the dominant hand.¹ The disorder is particularly noticeable when it inhibits day-to-day functioning.

TF affects 2% to 3% of the general population and up to 20% of patients with diabetes.^2,3 Patient age and duration of diabetes are commonly cited as contributing factors, although the effect of well-controlled blood glucose and A1C on the frequency and cure rate of TF has not been established.^3,4 TF is most commonly seen in individuals ages 40 to 60 years, with a 6 times’ greater frequency in females than males.⁵

In the United States, there are an estimated 200,000 cases of TF each year, with initial presentation typically being to a primary care physician.⁶ For this reason, it is essential for primary care physicians to recognize this common pathology and treat symptoms early to prevent progression and the need for surgical intervention.

An impaired gliding motion of the flexor tendons

In each finger, a tendon sheath, consisting of 5 annular pulleys and 3 cruciate pulleys, forms a tunnel around the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS). The tendon sheath allows for maximum force by eliminating bowstringing of the tendons when the digit is flexed. Deep to the tendons and surrounding the tendons is a synovial membrane that provides nutrition and reduces friction between the tendons and the tendon sheath.⁷

Trigger finger affects 2% to 3% of the general population and up to 20% of patients with diabetes.

The FDP is longer and assists in flexion of the MCPJ and the PIPJ. It is the sole flexor of the DIPJ. The shorter FDS assists in flexion of the MCPJ and is the primary flexor of the PIPJ. The bifurcation of the shorter FDS tendon allows the longer FDP tendon to pass through to continue to its insertion on the distal phalanx.

In the thumb, the flexor pollicis longus (FPL) is the only flexor within its tendon sheath. The FPL assists in flexion of the MCPJ and flexes the thumb interphalangeal joint (IPJ). The intrinsic muscles (lumbricals and interossei) do not extend into the tendon sheath and do not contribute to TF.

Continue to: TF occurs when