Trigger Finger
Original and Lead Editors - Holly Pulket, Hilary Zachary, Angela Dempski, Dana Williams, Shannon Davis
Search Strategy[edit | edit source]
Databases: CINAHL, PUBMED, PeDro
Keywords: trigger finger, trigger thumb, stenosing tenosynovitis, flexor tenosynovitis, flexor tendon stenosis, A1 pulley AND tendonitis, A2 pulley AND tendonitis
Timeline: 9/15/2011 - 11/28/2011
Definition/Description[edit | edit source]
Each digit of the hand (excluding the thumb) has the ability to move freely throughout a full ROM into flexion and extension. The efficiency and fluidity of the movement is made possible by several "pulleys" along each digit. These pulley systems are comprised of a series of annular and cruciform-shaped retinaculum.[1]
Trigger finger is a common condition that is thought to be caused by inflammation and subsequent narrowing of the A1 pulley. This can cause pain, clicking, catching, and loss of motion, especially into flexion, of the involved digit.[1] Commonly, trigger finger is referred to as "stenosing tenosynovitis". However, there have been histologic studies showing that the inflammation occurs more so in the tendon sheaths rather than the tendosynovium, making this name a false depiction of the pathophysiology.[1]
Epidemiology/Etiology[edit | edit source]
As with most conditions, trigger finger can occur in anyone, but it is statistically shown to occur most frequently in the diabetic population as well as in women who are typically in their fifth to sixth decade of life.[1] caused by a difference in diameters of a flexor tendon and its retinacular sheath due to thickening and narrowing of the sheath.[1]
Characteristics/Clinical Presentation[edit | edit source]
Trigger finger can have a range of clinical presentations. (Makkouk et al). Initially the patient may present with painless clicking with movement of the digit. This can progress to painful catching or popping typically at the MCP or PIP joints, stiffness and swelling especially in the morning, loss of full flexion/extension, palpable painful nodule, and/or finger locked into a flexed position. (Makkouk)
Other symptoms are slight thickening at the base of the digit, pain that may radiate to the palm or to the end of the digit.(Harvard)
Differential Diagnosis[edit | edit source]
The main characteristic of trigger finger is a popping and/or catching with movement of the digit, especially in flexion to extension. However, this is not a unique characteristic to trigger finger. Other etiologies associated with a locking digit can include:
- Dupuytren's contracture (Schoffl et al)
- Focal dystonia
- Flexor tendon/sheath tumor
- Sesamoid bone anomalies
- Post-traumatic tendon entrapment on the metacarpal head
- Hysteria
Complaints of pain at the MCP joint could be associated with any of the following:
- DeQuervain's (for trigger thumb only)
- Ulnar collateral ligament injury/Gamekeeper's thumb (Schoffl et al)
- MCP joint sprain
- Extensor apparatus injury
- MCP joint osteoarthritis (Schoffl et al)
(Makkouk et al)
Diagnosis of trigger finger can be confirmed with the injection of lidocaine into the flexor sheath, which could relieve pain and allow flexion/extension of the joint. Imaging is not typically indicated, but ultrasound and MRI may be used to rule out other etiologies (Makkouk et al).
Outcome Measures[edit | edit source]
NPRS, Open& Close Hand 10 Times, Stages of Stenosing Tenosynovitis, Participant Perceive Improvement in Symptoms, Grip Strength (Jamar dynameter) [2] DASH Outcome Measure
(need charts for Stages of Stenosing Tenosynovitis & Participant Perceive Improvement in Symptoms)
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
Hx: recent trauma to the area may be reported.[1] Job related repetitive movements. A history of locking or snapping while flexing or extending the affecter finger or thumb. [3]Patient might complain of a snapping sensation that causes pain that radiates to the palm or toward the end of the finger or thumb.[3]
PMH: Diabetes have an almost 4-fold increased risk for developing trigger finger [3] and Rheumatoid Arthritis; Associated with disorders that cause connective tissue changes such as RA, Gout, and Diabetes [2].
Observation: may present with a digit locked in flexion; boney proliferative changes could be seen in the subadjacent distal phalangeal joint [4]
Palpation: painful nodule in the palmar MCP area as a result of intratendinous swelling [1]
ROM: Loss of motion should be seen in the affected finger with patient unable to fully extend finger.
MMT: Muscles involved are Flexor Digitorum Profundus and Flexor Digitorum Superficialis, if the finger is locked in place it would be impossible to test. Gripe strength may be measured utilizing the Jamar Dynameter. [2]
Joint Accessory Mobilization: Secondary to the development of PIP contracture and digital stiffness, joint mobility of all the effecting digits should be assessed, especially PIP joint [1]. Most cases are secondary to thickening of the digits A-1 pulley but other pulley sights , the MCP joint or the Carpal Tunnel can be involved. As a result a consideration of these areas and surrounding tissues is reasonable and should be considered in a complete assessment.[4] Wrist joint accessory mobilization can be beneficial for digit pathologies. .
Special Test:
Open and Close hand 10x- Ask patient to actively make ten fists. The number of triggering events in ten active full fists was then scored out of 10. If participant’s finger remained locked at any time they were to stop and given a score of 10/10.[2]
Medical Management
[edit | edit source]
Individuals planning on undergoing medical management of trigger finger should attempt conservative treatment before considering the medical treatments listed below[5].
Corticosteroids
Corticosteroid use has been shown to be effective in reducing pain and the frequency of triggering. The shot is injected into the affected tendon and reduces the inflammation and pressure on the tendon for better gliding through the flexor pulleys. Ultimately, application, by a primary care provider, is an effective and safe alternative to surgical therapy. Patient satisfaction, safety, and functional improvement are characteristic of steroidal injections in comparison to surgical treatment[6]. Open and percutaneous surgical division of the A1 pulley is associated with higher costs, longer absence from work, and the possibility of surgical complications. Studies have also shown the combination of corticosteroid injections with lidocane to have significantly more effectiveness than lidocane alone[7].
Side effects (may include)[6]:
Flaring at injection site, local infections, tendon ruptures, allergic reactions, and atrophy of subcutaneous fat tissue.
Contraindications[6]:
Those under the age of 18, those with prior treatment or surgery to the area within the last six months, or possible traumatic or neoplastic origin of symptoms.
Video courtesy of the American Society for Surgery of the Hand
Open Surgical Technique[8]:
This technique, considered to be the gold standard[5], is performed by making a longitudinal incision in the palmar crease over the metacarpophalangeal joint of the involved digit and followed by release of the flexor digitorum superficialis and profundus tendons. This procedure, which lasts 2-7 minutes, has a longer average time of discomfort (45 days) post op. An advantage to this technique is it allows the pulley to be visualized and there is less risk of damage to the digital nerves in comparison to endoscopic techniques.
Endoscopic Surgical Technique[8]:
This technique is performed by making two incisions: one at the palmar crease over the metacarpophalangeal and the other at the volar crease of the finger. An endoscope is then introduced to cut the pulley to allow a release of the flexor tendons. This procedure, which lasts 2-9 minutes, has a shorter average time of discomfort (23 days). Other advantages are the absence of scars and scar related problems and a shorter post-op rehabilitation. However, there is a large learning curve and the instruments are costly for this procedure.
Percutaneous Release[5]:
This technique can be performed with or without imaging. Non-image-guided (blind) percutaneous release is performed by using anatomical landmarks to avoid injury to the tendons and neurovascular structures. The recovery time is shorter than an open surgery but the potential for damage to digital nerves is more probable, especially to digits 1, 2, and 5 (thumb, index and little finger). A new technique using ultrasound-guidance helps clearly identify the tendons and neurovascular structures, preventing potential complications that are present with non-image-guided percutaneous release and compares favorably with surgical techniques as well.
Physical Therapy Management
[edit | edit source]
add text here
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Resources
[edit | edit source]
add appropriate resources here
Clinical Bottom Line[edit | edit source]
add text here
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10
References[edit | edit source]
see adding references tutorial.
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Makkouk AH, Oetgen ME, Swigart CR, Dodds SD. Trigger finger: etiology, evaluation, and treatment. Curr Rev Musculoskelet Med. 2008; 1:92–96.
- ↑ 2.0 2.1 2.2 2.3 Colbourn J, Heath N, Manary S, Pacifico D. Effectivenes of Splinting for the Treatment of Trigger Finger. Journal of Hand Therapy.2008; 21(4):36-343.
- ↑ 3.0 3.1 3.2 Tendon Trouble in the Hand: De Quarvain's Tenosynovitis and Trigger Finger. Harvard Women's Health Watch.2010:4-5.
- ↑ 4.0 4.1 Howitt S. The Conservative Treatment of Trigger Thumb Using Graston Techniques and Active Pelease Technique. JCCA. 206;50(4):249-254.
- ↑ 5.0 5.1 5.2 Rajeswaran G., Lee J.C., Eckersley R., et al. Ultrasound-guided percutaneous release of the annular pulley in trigger digit. European Society of Radiology. 2009;19:2232-2237.
- ↑ 6.0 6.1 6.2 Peters-Veluthamaningal C, Winters JC, Groenier KH et al. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. Annals of the Rheumatic Diseases. 2008;67;1262-1266.
- ↑ Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom-de Jong B. Corticosteroid injection for trigger finger in adults. Cochrane Database Syst Rev. 2009;(1):CD005617.
- ↑ 8.0 8.1 Pegoli, L., Cavalli E., Cortese, P., et al. A comparison of endoscopic and open trigger finger release. Hand Surgery 2008;13(3):147-151.
