|Synonyms||Historicopous, trigger digit, trigger thumb, stenosing tenosynovitis|
|Symptoms||Catching or locking of the involved finger, pain|
|Usual onset||50s to 60s years old|
|Risk factors||Repeated injury, diabetes, kidney disease, thyroid disease, inflammatory disease|
|Diagnostic method||Based on symptoms|
|Differential diagnosis||Fracture, tumor, injury|
|Treatment||Rest, splinting the finger, NSAIDs, steroid injections, surgery|
Trigger fingers is a disorder characterized by catching or locking of the involved finger. Pain may occur in the palm of the hand or knuckles. The name is due to the popping sound made by the affected finger when moved. Most commonly the index finger or thumb is affected.
Risk factors include repeated injury, diabetes, kidney disease, thyroid disease, and inflammatory disease. The underlying mechanism involves the tendon sheath being too narrow for the flexor tendon. This typically occurs at the level of the A1 pulley. While often referred to as a type of stenosing tenosynovitis, little inflammation appears to be present. Diagnosis is typically based on symptoms after excluding other possible causes.
Initial treatment is generally with rest, splinting the finger, NSAIDs, or steroid injections. If this is not effective surgery may be used. Trigger finger is relatively common. Females are affected more often than males. Those in their 50s and 60s are most commonly affected. The condition was formally described in 1850.
Signs and symptoms
The cause of trigger finger is unclear but several causes have been proposed. It has also been called stenosing tenosynovitis (specifically digital tenosynovitis 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 and against 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. It may also occur in rheumatoid arthritis.
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.
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. Choosing surgery immediately is the most expensive option and is often not necessary for resolution of symptoms. 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 six months). This is compared to a percutaneous needle release (100% success rate) and open release (100% success rate). This is somewhat consistent with the most recent Cochrane Systematic Review of corticosteroid injection for trigger finger which found only two pseudo-randomized controlled trials for a total pooled success rate of only 37%. 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.
Thread trigger finger release is an ultrasound guided minimally invasive procedure using a piece of dissecting thread to transect A1 pulley without incision.
The natural history of disease for trigger finger remains uncertain.
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.
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- Peters-Veluthamaningal, C; van der Windt, DA; Winters, JC; Meyboom-de Jong, B (Jan 21, 2009). "Corticosteroid injection for trigger finger in adults". The Cochrane Database of Systematic Reviews (1): CD005617. doi:10.1002/14651858.CD005617.pub2. PMID 19160256.
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