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Trigger Finger Workup

  • Author: Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin); Chief Editor: Harris Gellman, MD  more...
 
Updated: Jul 07, 2016
 

Approach Considerations

Trigger finger (TF) is a clinical diagnosis. Occasionally, the nodule in the tendon is easily felt, and a palpable and audible click can be appreciated when the triggering is relieved with forced extension of the digit.

As a rule, no lab tests are needed in the diagnosis of TF. If there is a concern regarding an associated, undiagnosed condition, such as diabetes mellitus (DM), rheumatoid arthritis (RA), or another connective tissue disease, tests such as those assessing glycosylated hemoglobin (HbA1c), fasting blood sugar, or rheumatoid factor should be ordered.

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Radiography

Radiography rarely is indicated in TF.[5] Hand radiographs are performed only if abnormal pathology (eg, abnormal sesamoids, loose bodies in the metacarpophalangeal [MCP] joint, osteoarthritic spurs on the metacarpal head, or avulsion injuries of collateral ligaments) is suspected.

Radiographs are helpful to exclude osteoarthritis, fracture malunion, foreign body, or a large sesamoid bone that is affecting interphalangeal (IP) joint motion.

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Histologic Findings

The A1 pulley exhibits a marked degree of hypertrophy, described as a white, cicatricial, collarlike thickening. Microscopy demonstrates degeneration, cyst formation, and plasma-cell infiltration. Microscopic studies have also shown chondrocytic proliferation of type III collagen instead of chondrocyte presence in the normal innermost or friction layer of the A1 pulley.[33] The amount of extracellular matrix is increased significantly when compared with controls.

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Staging

Green's classification of triggering is used only for clinical grading and documentation. No correlation has been established between the grading scheme and the outcome following injection therapy. The various grades are defined as follows[34] :

  • Grade I (pretriggering) - Pain; history of catching that is not demonstrable on clinical examination; tenderness over the A1 pulley
  • Grade II (active) - Demonstrable catching, but with the ability to actively extend the digit maintained
  • Grade III (passive) - Demonstrable locking in which passive extension is required (grade IIIA) or in which the patient is unable to actively flex (grade IIIB)
  • Grade IV (contracture) - Demonstrable catching, with a fixed flexion contracture of the proximal interphalangeal (PIP) joint
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Contributor Information and Disclosures
Author

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) FRCS(Tr & Orth), FRCS(Edin), MCh(Orth), Diploma in Sports and Exercise Medicine(UK), MS(Orthopaedics)

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) is a member of the following medical societies: British Orthopaedic Association, Royal College of Surgeons of Edinburgh, Bombay Orthopedic Society

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching

atrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

David R Steinberg, MD Director of Hand Fellowship, Associate Professor, Department of Orthopedic Surgery, University of Pennsylvania Health System

David R Steinberg, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand

Disclosure: Johnson & Johnson nothing received, but have long-term ownership of public equities none

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference would like to thank medical students Dena Abdelshahed and Leia Rispoli, plus Drs. Debra Ibrahim, Evish Kamrava, Jason Lee, Cyrus Kao, and Dev Sinha, for their help in previous revisions of a source article.

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Flexor tendons pass within tendon sheath and beneath A1 pulley at approximately metacarpal head, beyond which they travel into digit.
Inflamed nodule can restrict tendon from passing smoothly beneath A1 pulley. If nodule is distal to A1 pulley (as shown in this sketch), then digit may get stuck in extended position. Conversely, if nodule is proximal to A1 pulley, then patient's digit is more likely to become stuck in flexed position.
Trigger finger often results in difficulty flexing or (in this case) extending metacarpophalangeal joint of involved digit.
Introduction of needle into tendon sheath at 45° angle to palm for injection treatment.
Movement of needle with flexion of digit confirms correct positioning of needle for injection treatment.
Incision marked out in distal palmar crease for surgical division of A1 pulley.
A1 pulley is sectioned by using blunt-tipped, fine scissors, keeping strictly in midline. Note digit being held in hyperextended position by assistant to displace neurovascular bundles away from midline.
Incision for trigger thumb release placed in MP flexion crease, centered over flexor tendon nodule.
Trigger thumb. A1 pulley exposed within surgical field (arrow). Digital neurovascular bundles behind retractors.
Trigger thumb. A1 pulley has been released; flexor pollicis longus tendon now exposed. Retractors have been removed to demonstrate proximity of neurovascular bundles (arrows) to tendon.
 
 
 
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