Trigger Fingers

By Dr. Garry Kitay, Orthopedic Hand Surgeon

Dr. Kitay Describes How to Diagnose and Treat a Trigger Finger

Trigger fingers and thumbs are caused by a swelling in the digit’s flexor tendon, commonly known as tendinitis. The abnormal tendon causes difficulties in both extending and flexing the involved fingers or thumb. The tendons work like wires that connect the muscles in the forearm to the bones of the fingers and thumb. They travel beneath tunnels, also called pulleys, which hold the tendon close against the bone. There is also a slick lining between the tendons and the surrounding tunnel called tenosynovium.

In normal conditions, the tendon will glide effortlessly through the tunnel as an individual straightens and bends their fingers. A trigger finger or thumb occurs when the tendon develops a swelling in its lining.  This nodule, or knot, in the tendon forces it to squeeze through the entrance and exit to the tunnel overlying it. This causes the pain, clicking, and locking commonly encountered in this condition. As the tendon catches this can create more inflammation and swelling, making the condition worse.

Types of Trigger Fingers

There can be two types of swelling of the tendon, nodular and diffuse. Nodular swelling involves a more discreet and palpable swollen area at the base of the digit.  This type tends to respond more favorably to nonsteroidal anti-inflammatory drugs and steroid injections than
those with the diffuse type.

The condition of trigger finger tends to be more common with certain medical conditions including rheumatoid arthritis, gout, and diabetes. However, the cause is often unclear. There is a subset of patients with this diagnosis who are born with the condition.  This is termed congenital trigger finger and thumb.

Diagnosis of Trigger Fingers 

The diagnosis of trigger finger and thumb may begin with discomfort felt at the base of the digit. Occasionally, the patient can actually feel a “knot” in this area. At times, the patient experiences inability to flex the digit or senses a click with this motion. As the condition progresses, the finger actually begins triggering or locking. With this anomaly, the patient often feels that the snap is occurring at the PIP joint (the middle knuckle of the finger).

Treatment of Trigger Fingers

For some early forms of this condition, simple avoidance of obvious irritating activities is adequate to lead to a cure. This can involve avoidance of cutting, sewing, and other activities that involve repetitive stressing of the involved digits. Occasionally splinting can be helpful in the healing process.  However, this is quite restrictive and can take weeks or months to be effective. In the early phase of this condition, the combination of massage, ice therapy, and nonsteroidal anti-inflammatory drugs has led to improvements.

The most effective nonsurgical treatment is a steroid injection. This leads directly to diminution of the swelling around the flexor tendon within the tendon sheath.  This allows improved gliding of the tendon. In general, a Lidocaine injection prior to the steroid or in combination with the steroid is helpful.  The patient should be told that finger numbness could last up to 24 hours. The steroid injections have been found to be very effective and may cure 70% of patients with the nodular type of condition after only one injection.

If the condition recurs, repeating the injection an additional one or two times can enhance the possibility of a cure without a surgical approach. However, if these nonsurgical conditions are not effective and the patient continues to have painful triggering, a surgical release can be indicated. The surgery is usually in an outpatient setting. It involves release of the compressive tunnel, or pulley, overlying the tendon. Active motion of this digit begins immediately after surgery. The procedure is usually done using a local anesthetic with the patient awake and alert to verify that a complete release has been successful.

Percutaneous Release

A newer technique has been developed called percutaneous release. With this procedure the surgical release is actually done in the office. The MD uses with a local anesthetic by insertion of a needle through the skin. Then they use the bevel of the needle to scrape the constrictive portion of the tunnel with a repetitive swiping movements. Once the release is done, the MD asks the patient to fully flex the digit.  When successful, there is no longer any sensation of triggering or clicking There are very few complications with this procedure other than occasional pain.  By injecting steroids at the time of the release we are able to manage pain for this procedure.

Conclusion

Trigger finger and thumb is a very common problem whose causes are not fully clear. When encountered early it can respond to simple avoidance of irritating activities and nonsteroidal anti-inflammatory drugs. In later cases it generally responds to nonoperative treatment in the form of steroid injections. If nonsurgical treatment fails there are excellent surgical options which generally lead to a cure of this troubling condition.

By Garry S. Kitay, M.D.

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