Trigger finger

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For the Belgian band, see Triggerfinger. "Trigger finger" can also mean the finger which is used to operate the trigger of a gun or of a power tool.
Trigger finger
Classification and external resources
ICD-10 M65.3
ICD-9 727.03
MedlinePlus 000565
eMedicine orthoped/570

Trigger finger, trigger thumb, or trigger digit (also referred to as stenosing tenosynovitis), is a common disorder characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain.[1] A disparity in size between the flexor tendon and the surrounding retinacular pulley system, most commonly at the level of the first annular (A1) pulley, results in difficulty flexing or extending the finger and the “triggering” phenomenon.[1] The label of trigger finger is used because when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

Diagnosis[edit]

Diagnosis is made almost exclusively by history and physical examination alone. More than one finger may be affected at a time, though it usually affects the index, thumb, middle, or ring finger. The triggering is usually more pronounced late at night and into the morning, or while gripping an object firmly.

Treatment[edit]

Post operative photo of trigger finger release surgery in a diabetic patient. See:[2]

Injection of the tendon sheath with a corticosteroid is effective over weeks to months in more than half of patients.[3]

When corticosteroid injection fails, the problem is predictably resolved by a relatively simple surgical procedure (usually outpatient, under local anesthesia). The surgeon will cut the sheath that is restricting the tendon.

One recent study in the Journal of Hand Surgery suggests that the most cost-effective treatment is two trials of corticosteroid injection, followed by open release of the first annular pulley.[4] Choosing surgery immediately is the most expensive option and is often not necessary for resolution of symptoms.[4] More recently, a randomized controlled trial comparing corticosteroid injection with needle release and open release of the A1 pulley reported that only 57% of patients responded to corticosteroid injection (defined as being free of triggering symptoms for greater than 6 months). This is compared to a percutaneous needle release (100% success rate) and open release (100% success rate).[5] This is somewhat consistent with the most recent Cochrane Systematic Review of corticosteroid injection for trigger finger which found only 2 pseudo-randomized controlled trials for a total pooled success rate of only 37%.[6] However, this systematic review has not been updated since 2009.

There is a theoretical greater risk of nerve damage associated with the percutaneous needle release as the technique is performed without seeing the A1 pulley.[7]

Investigative treatment options with limited scientific support include: non-steroidal anti-inflammatory drugs; occupational or physical therapy; steroid iontophoresis treatment; splinting; therapeutic ultrasound, phonophoresis (ultrasound with an anti-inflammatory dexamethasone cream); and Acupuncture.[citation needed]

Prognosis[edit]

The natural history of disease for trigger finger remains uncertain.

There is some evidence that idiopathic trigger finger behaves differently in people with diabetes.[3]

Recurrent triggering is unusual after successful injection and rare after successful surgery.

While difficulty extending the proximal interphalangeal joint may persist for months, it benefits from exercises to stretch the finger straighter.

Epidemiology[edit]

More than one potential cause has been described but the etiology remains idiopathic.[1] It has also been called stenosing tenosynovitis (specifically digital tenovaginitis stenosans), but this may be a misnomer, as inflammation is not a predominant feature.

It has been speculated that repetitive forceful use of a digit leads to narrowing of the fibrous digital sheath in which it runs, but there is little scientific data to support this theory. The relationship of trigger finger to work activities is debatable and scientific evidence for[8] and against[9] hand use as a cause exist. While the mechanism is unclear, there is some evidence that triggering of the thumb is more likely to occur following surgery for carpal tunnel syndrome.[10]

References[edit]

  1. ^ a b c Makkouk AH, Oetgen ME, Swigart CR, Dodds SD (June 2008). "Trigger finger: etiology, evaluation, and treatment". Curr Rev Musculoskelet Med 1 (2): 92–6. doi:10.1007/s12178-007-9012-1. PMC 2684207. PMID 19468879. 
  2. ^ Eisen, Jonathan. "Trigger finger surgery. Fun.". Retrieved 17 May 2013. 
  3. ^ a b Baumgarten KM, Gerlach D, Boyer MI (December 2007). "Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study". Journal of Bone and Joint Surgery (American) 89 (12): 2604–2611. doi:10.2106/JBJS.G.00230. PMID 18056491. 
  4. ^ a b Kerrigan CL, Stanwix MG (Jul–Aug 2009). "Using evidence to minimize the cost of trigger finger care". J Hand Surg Am 34 (6): 997–1005. doi:10.1016/j.jhsa.2009.02.029. PMID 19643287. 
  5. ^ Sato SS, et al (2012). "Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery". Rheumatology 51 (1): 93–99. doi:10.1093/rheumatology/ker315. PMID 22039269. 
  6. ^ Peters-Veluthamaningal, C; van der Windt, DA; Winters, JC; Meyboom-de Jong, B (2009 Jan 21). "Corticosteroid injection for trigger finger in adults.". The Cochrane database of systematic reviews (1): CD005617. doi:10.1002/14651858.CD005617.pub2. PMID 19160256. 
  7. ^ Bain, GI; Turnbull, J; Charles, MN; Roth, JH; Richards, RS (1995 Sep). "Percutaneous A1 pulley release: a cadaveric study.". The Journal of hand surgery 20 (5): 781–4; discussion 785–6. doi:10.1016/S0363-5023(05)80430-7. PMID 8522744. 
  8. ^ Gorsche R, Wiley JP, Renger R, Brant R, Gemer TY, Sasyniuk TM (June 1998). "Prevalence and incidence of stenosing flexor tenosynovitis (trigger finger) in a meat-packing plant". J Occup Environ Med 40 (6): 556–60. doi:10.1097/00043764-199806000-00008. PMID 9636936. 
  9. ^ Kasdan ML, Leis VM, Lewis K, Kasdan AS (November 1996). "Trigger finger: not always work related". J Ky Med Assoc 94 (11): 498–9. PMID 8973080. 
  10. ^ King, Bradley A.; Stern, Peter J.; Kiefhaber, Thomas R. (2013). "The incidence of trigger finger or de Quervain's tendinitis after carpal tunnel release". Journal of Hand Surgery (European Volume) 38 (1): 82–3. doi:10.1177/1753193412453424. PMID 22791612. 

External links[edit]