Patient Comments: Trigger Finger - TreatmentsOct 24, Author: InLapidus reversed his previous recommendation for operative treatment of TF after he and Guidotti reported uniformly good results following a single injection of prednisolone into the tendon sheath. Injection therapy is now trigger finger cortisone injection pain agreed to be the first line of management. Surgery is reserved for individuals in whom injection treatment has failed or in whom other pathology, particularly rheumatoid arthritis RAis suspected to be causing triggering that cannot be treated conservatively. Severity and duration of disease and prior treatments received were judged to be the primary factors influencing choice of therapy.
Steroid Injections - Purpose and Procedure - The Hand Society
Oct 24, Author: In , Lapidus reversed his previous recommendation for operative treatment of TF after he and Guidotti reported uniformly good results following a single injection of prednisolone into the tendon sheath. Injection therapy is now generally agreed to be the first line of management. Surgery is reserved for individuals in whom injection treatment has failed or in whom other pathology, particularly rheumatoid arthritis RA , is suspected to be causing triggering that cannot be treated conservatively.
Severity and duration of disease and prior treatments received were judged to be the primary factors influencing choice of therapy. Most trigger digits in adults can be managed successfully with local steroid injections and splinting.
The outcome of conservative treatment for pediatric trigger thumb is somewhat controversial. Although the results of percutaneous release are well established, the open technique is absolutely essential for the thumb or little finger or in the presence of proximal interphalangeal PIP contractures. Percutaneous release should be reserved for the index, middle, and ring fingers. In children, triggering has varying causes. Release of the A1 pulley alone does not always correct the problem.
In infants, the nodule on the flexor pollicis longus FPL tendon can be resected with good results. Corticosteroid injections are generally not helpful in these cases of trigger thumb. Splinting and local corticosteroid injection can be performed if the patient is pregnant. Surgical release of the A1 pulley is generally an elective procedure and is usually deferred until after delivery. Surgical consultation for operative treatment may be required. Typically, such procedures are performed by an orthopedic hand surgeon or a plastic surgeon.
Corticosteroid injection in the area of tendon sheath thickening is considered to be the first-line treatment of choice for TF. A variety of preparations have been used—most commonly prednisolone, dexamethasone, and triamcinolone—in the steroid injection treatment of TF, and most are uniformly successful in relieving symptoms. The author's technique for steroid injection is as follows.
The nodule in the palm is well localized and circled out using an indelible skin marker. The procedure is performed in an office setting, using strict aseptic precautions, with alcoholic povidone-iodine used for injection-site preparation. Ethyl chloride is used only if requested; frequently, it is unnecessary, and most patients tolerate this procedure quite well.
The needle enters the nodule with a distinct grating sensation; positioning of the needle is verified by asking the patient to move the digit when it is possible to clearly observe the needle moving with the digit see the second image below. The syringe with the steroid preparation then is attached to the needle. Attempting to inject the drug with light pressure confirms the intratendinous location of the needle. Do not inject the solution if significant resistance to injection flow is noted, because this may indicate that the needle tip is in the tendon rather than just within the tendon sheath.
The needle is withdrawn very carefully until a give-way sensation is felt, indicating that the tip of the needle is out of the tendon and in the sheath. The preparation is then injected. A small water-impermeable dressing is applied. The patient is actively encouraged to move the digit; in most cases, the triggering is relieved. Carlson and Curtis prefer a midaxial injection at the level of the midproximal phalanx as a simple and painless way to access the flexor sheath for the purpose of injection.
A follow-up appointment is made for weeks after the treatment. Splinting is not used routinely for these cases, although a hand-based MP-block Orthoplast splint has been described as useful. Although injection treatment has long been administered by "feel" and experience, research suggests that using ultrasonographically guided steroid injection may maximize the injection's accuracy and, consequently, its beneficial effects in the treatment of trigger digits. No major complications from injection treatment are noted.
A transient rise in blood and urine sugar levels is common in patients with diabetes. Advise these patients that this is likely to occur. While corticosteroid injections into the palm are considered highly effective in treating TF, the injection itself may be significantly painful. Both study groups, however, had excellent resolution of TF, with excellent resolution being defined in the study as an asymptomatic hand without triggering and a pain score on the cm Visual Analog Scale of less than 2 cm.
A second corticosteroid injection may be performed weeks after the first one. If two or perhaps three injections fail to provide adequate resolution, consider referring the patient for surgical release. Repetitive injections theoretically increase the likelihood of tendon rupture, although such a risk was not found in Anderson's study of repeated injections for TF.
Another injection method, the proximal phalanx technique, allows for injection directly into the tendon sheath through the palmar surface of the midproximal phalanx. Injections performed this way were found to be less painful than injecting the flexor tendon sheath directly over the metacarpal head.
Although corticosteroid injection has traditionally been administered into the tendon sheath but not into the tendon itself , [ 60 ] studies now seem to indicate that subcutaneous injection may be as effective as the intrasheath approach.
Custom-made splinting of the metacarpophalangeal MCP joint is another conservative treatment, used in patients who do not wish to undergo a steroid injection or as an adjuvant to injection. The average length of splinting is 6 weeks. In patients with symptoms longer than 6 months, splinting as a sole treatment strategy does not seem to eliminate the triggering events.
Although traditionally splinting has not been thought to be an effective treatment for TF, one study of thermoplastic splinting of MCP joint flexion showed improvement in stenosing tenosynovitis, the numeric pain rating scale, and the number of triggering events and also demonstrated an overall perceived participant improvement in symptoms.
The benefits of operative treatment of trigger finger and trigger thumb were revealed in 3 studies of surgical pulley release. The patients 4 girls and 3 boys , who had a mean age of 46 months at surgery range, months , were observed over a mean follow-up period of 64 months range, years. All patients in the study at last follow-up had returned to full activity without limitation or pain, and none of the patients had a recurrence of triggering or MCP hyperextension deformity, demonstrating, according to the authors, that trigger thumb with concomitant MCP hyperextension deformity can be treated in children by A1 pulley release and advancement of the volar plate.
In a study of 93 trigger thumbs in 83 patients, Chao et al compared the results of miniscalpel-needle percutaneous release with those of steroid injection. At 12 months, 44 of the 46 trigger thumbs treated with the miniscalpel-needle release had satisfactory results measured by visual analogue pain scale and patient satisfaction , but only 12 of 47 thumbs treated with steroid injection had satisfactory results. No nerve injuries occurred in either group.
Trigger thumb in children almost always calls for surgical management. Trigger thumb in an adult not responding to corticosteroid tendon sheath injection needs surgery. The technique of release itself is irrelevant. Open and not percutaneous surgery is the norm for trigger thumb in children and adults alike, since the neurovascular bundles in the thumb are closer to the midline than in other digits.
A single series as quoted above comparing the efficacy of percutaneous surgery vis-a-vis a corticosteroid injection still proves surgery is more effective than injection treatment, but this technique of surgical release itself is not ad rigeur. Lange-Rieb et al presented long-term results of open operative treatment of TF and trigger thumb in adults.
All operations were performed under tourniquet control with local anaesthesia as outpatient procedures using a transverse incision just distal to the distal palmar crease or on the flexor crease of the thumb at the MCP joint. At latest follow-up average, The MCP joint is hyperextended to displace the neurovascular structures dorsally, minimizing the risk of injury. A transverse incision measuring Blunt dissection is used to spread the subcutaneous fat and expose the tendon sheath.
The proximal edge of the A1 pulley is identified, and a scalpel blade is used to divide the entire A1 pulley in the midline under vision. Care is taken to avoid incising too distally and risk cutting into the A2 pulley, which can result in bowstringing.
A study suggests that the proximal part of the A2 pulley can be safely incised if the release of the A1 pulley in isolation does not result in relief of triggering. The patient is asked to actively move the digit to confirm full release. Meticulous hemostasis is achieved with a bipolar cautery, and the wound is closed with two or three skin sutures. The hand is left free, and motion is encouraged immediately following the procedure. If a percutaneous approach is favored, a pair of blunt-tipped, fine scissors is introduced through the incision, and the A1 pulley is transected see the image below.
Care is taken not to drift too distally. Disappearance of a grating sensation indicates complete section of the pulley through a separate, distal oblique incision. With adequate anatomic knowledge, technical training, and a basic ultrasound machine, sonographically directed A1 pulley release can be performed safely and successfully, thus offering an alternative to conventional open technique.
On rare occasions, sectioning the A1 pulley does not relieve triggering, indicating that the A3 pulley might be involved. If that is the case, the A3 pulley requires division. This percutaneous technique as described here usually applies to most cases of triggering, exceptions being surgery for trigger thumb in children and triggering involved in conditions like RA, in which the nodule formation may be distal to the A1 pulley and for which open surgery may be required.
Surgery for trigger thumb is performed as follows. The A1 pulley is approached through a transverse incision in the flexion crease overlying the MCP joint see the image below. Palpate the flexor pollicis longus FPL to ensure that the incision is centered appropriately.
Bluntly dissect through subcutaneous tissue; identify and gently retract radial and ulnar neurovascular bundles. Expose the A1 pulley, identify its proximal and distal edges, and incise it longitudinally see the first image below. Inspect the tendon nodule during full passive motion of the interphalangeal IP joint. Ensure that no further restrictions to excursion are present. A band of tissue proximal to A1 may exist that also requires release. Deflate the tourniquet, obtain hemostasis, and close the incision with nylon.
Dress the wound with a soft compressive bandage. Active motion is encouraged on the day of surgery. Anti-inflammatory drugs and elevation are advised for a period of days following surgery.
Sutures are removed on postoperative day Future treatment for TF may involve Kapandji enlargement-plasty of the A1 pulley. In this procedure, which is complex and technically demanding, the A1 pulley is enlarged by making a diagonal incision in it, followed by suture instead of simple longitudinal division, thus increasing the mean diameter of the canal. In a study by Migaud et al, 15 patients who underwent this procedure and who were followed up for a mean period of 5 years had complete symptomatic relief without any recurrences.
Physical therapy is generally not required for patients with TF. For cases of chronic TF, however, treatment may include a trial of heating modalities followed by sustained, nonballistic stretching of the flexor tendon, as well as soft-tissue mobilization of the A1 pulley.
Following injection or surgery, a home exercise stretching program may be one component of treatment for patients.