Injuries to the Shoulder: When should you worry?
By Greer E. Noonburg, M.D.
Triggering of the fingers or thumb is a common problem in adults, usually presenting in individuals who are 40 to 60 years old. Often, the patient will complain of a painful “locking” or “catching” of the digit. Though not as serious as many other orthopedic conditions, a trigger finger or trigger thumb can be very annoying and interfere with many of the daily activities that we take for granted.
The tendons that we use to bend our fingers and thumb are the flexor tendons. The flexor tendons glide through a series of soft tissue loops called pulleys, which keep the tendon next to the bone and increase its efficiency. Trauma, infection, or chronic irritation to the flexor tendon may cause inflammation in the sheath surrounding the tendon, resulting in a “lump,” called a nodule.
Triggering is common in people with medical problems such as diabetes, gout, and rheumatoid arthritis. Sometimes, there is no identifiable reason for the triggering. Whatever the cause, the subsequent swelling makes it more difficult for the flexor tendon to slide through the pulley.
Triggering results when the swollen tendon is forced through the pulley. It occurs with flexion (bending) of the finger, keeping it in a bent position. Inactivity tends to worsen the condition. The result is a painful snap or locking of the finger in a flexed position. Initially the triggering may be occasional. Over time, however, the triggering can occur every time the finger or thumb is flexed. As the condition progresses, the patient may be forced to “unlock” the finger by pulling it into a straight position. In severe cases, the triggering is so painful that the patient is unable to bend the finger or it becomes fixed in a flexed position.
The middle and ring fingers are most commonly involved, followed by the thumb. Rarely, children may be born with this condition, called a congenital trigger finger (or thumb). More than one finger may be involved and it can affect both hands. In some instances, the triggering resolves when the individual stops certain repetitive activities that may be irritating the flexor tendons. The problem for most patients, however, is that halting all activities that require gripping or grasping may not be a viable option.
Initially, very mild cases are managed with over-the-counter nonsteroidal anti-inflammatories (NSAIDs) and rest. Splinting the finger in extension is sometimes attempted. Patients with early symptoms, generally less than 3 months, may be injected with a steroid solution. More than one injection may be needed and the relief in triggering may last only a few weeks or months. Patients with certain illnesses (such as diabetes or rheumatoid arthritis) or prolonged triggering over several months tend to have recurring symptoms despite steroid injections.
Individuals with triggering that occurs despite injections or other conservative measures may consider surgery. The operation is perform on an outpatient basis (in and out of the hospital on the same day), and takes less than 30 minutes to perform. The decision to have surgery is based on the severity of the patient’s symptoms. Patients who have undergone surgical treatment report a 97% success rate in relieving their triggering.
A trigger finger release involves making a small incision in the palm over the affected flexor tendon nodule. The incision usually measures 1/4 to 1/2 inche and is often placed in one of the creases of the palm or at the base of the thumb. The surgeon carefully exposes the A-1 pulley of the affected digit. Using a scalpel, the A-1 pulley is released over the flexor tendon. The surgeon bends and straightens the finger or thumb to ensure that there is full motion of the tendon without restriction or residual triggering. The incision is closed with a few sutures and covered with a bandage.
After a trigger finger or trigger thumb release, the patient is able to move the digit immediately. Some tenderness in the palm or at the base of the thumb is common, but generally resolves within 3 to 6 weeks. A return to normal activities is encouraged as soon as possible after suture removal. The patient may need to see an occupational therapist for help in moving a digit with residual stiffness.
Although triggering of the fingers or thumb is not a serious condition, it can be irritating and interfere with participation in sports as well as many of the activities we perform daily. Most triggering improves with rest, NSAIDs, and a steroid injection. Cases that recur or do not respond to conservative treatment may undergo surgery to release the A-1 pulley over the affected tendon. The success rate for operative trigger finger release is very high with short recovery period, compared to many other hand procedures. Further questions may be answered by your orthopedic surgeon, who can provide specific information regarding your condition.
For more information about triggering or other orthopædic concerns-contact Dr. Noonburg at Chatham Orthopædics, 4425 Paulsen Street, Savannah, GA 31405, (912)355-6615