Sections

Trigger Finger

Presentation

History

Patients with trigger finger (TF) may have a history of diabetes mellitus (DM) or rheumatoid arthritis (RA). In these individuals, multiple digits may be involved in TF.

Some patients will have a history of repetitive trauma to the affected area, while others may have occupational duties requiring repetitive use of the involved tendons.^[31]

Signs and symptoms of TF are as follows:

Locking or catching during active flexion-extension activity (passive manipulation may be needed to extend the digit in the later stages)
Stiff digit, especially in long-standing or neglected cases
Pain over the distal palm
Pain radiating along the digit
Triggering on active or passive extension by the patient
Palpable snapping sensation or crepitus over the A1 pulley
Tenderness over the A1 pulley
Palpable nodule in the line of the flexor digitorum superficialis (FDS), just distal to the metacarpophalangeal (MCP) joint in the palm
Fixed-flexion deformity in late presentations, especially in the proximal interphalangeal (PIP) joint
Evidence of associated conditions (eg, RA, gout)
Early signs of triggering in other digits (may be bilateral)

A classic complaint is difficulty in achieving full extension of a single digit, which eventually releases or snaps open with pain at the distal palm and into the digit.

Some patients have difficulty with finger flexion rather than extension, though the former is less common. Other patients may have a painful nodule in the distal palm without any catching or triggering.

Some patients report stiffness in the fingers, especially after they have been asleep or following other periods of inactivity.

Some patients report swelling of the affected digit, particularly at the digit's base or proximal aspect.

Pediatric

Children with trigger thumb rarely complain of pain. They usually are brought in for evaluation when aged 1-4 years, when the parent first notices a flexed posture of the thumb’s interphalangeal (IP) joint. These children often demonstrate bilateral fixed flexion contractures of the thumb by the time they present to the physician.^[4]

Physical Examination

At the level of the distal palmar crease, a tender nodule can be palpated, usually overlying the MCP joint.

The affected digit may lock in a flexed or (less commonly) extended position. When the patient attempts to move the digit more forcefully beyond the restriction, the digit may snap or trigger beyond the restriction. The triggering movement is very painful for the patient. (See the image below.)

Trigger finger often results in difficulty flexing or (in this case) extending metacarpophalangeal joint of involved digit.

View Media Gallery

In severe cases, the patient is unable to move the digit beyond the restriction, and thus no triggering occurs.

With a trigger thumb, the tenderness to palpation is found at the palmar aspect of the first MCP joints rather than over the distal palmar crease.

Differential Diagnoses

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Media Gallery

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 metacarpophalangeal 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 is now exposed. Retractors have been removed to demonstrate proximity of neurovascular bundles (arrows) to tendon.

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Author

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

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

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 of 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, Florida Medical Association, Florida Orthopaedic 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

P 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.

Trigger Finger Clinical Presentation

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