Sections

Trigger Finger

Medication

Medication Summary

For patients with trigger finger (TF), medications are used primarily to decrease pain and inflammation in conjunction with the rehabilitation plan. Thus, the most common medication treatments are focal corticosteroid injection at the site of maximal tenderness or inflammation and the administration of nonsteroidal anti-inflammatory drugs (NSAIDs).

The most common corticosteroid preparations used include prednisolone, dexamethasone, and triamcinolone. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection.

Class Summary

Oral NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used, although none of these agents holds a clear distinction as the drug of choice (DOC). The choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Ibuprofen (Motrin, Advil, NeoProfen, Provil)

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Ibuprofen is the drug of choice for patients with mild to moderate pain. NSAIDs inhibit inflammatory reactions and pain by decreasing prostaglandin synthesis.

Diclofenac topical (Zorvolex, Zipsor, Cambia, Cataflam, Voltaren XR)

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NSAIDs inhibit inflammatory reactions and pain by decreasing prostaglandin synthesis.

Ketoprofen

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Ketoprofen has good anti-inflammatory properties and exceptional analgesic properties. It is a first-line medication because of its daily dosing, which helps with compliance. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Naproxen or naproxen sodium (Naprelan, Naprosyn, Aleve, Anaprox)

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Naproxen is used for relief of mild to moderate pain and inflammation; it inhibits inflammatory reactions and pain by decreasing activity of COX, which results in a decrease of prostaglandin synthesis. Naproxen is available in many dosages and delivery systems. It is fairly inexpensive and has a therapeutic profile similar to those of other NSAIDs.

Indomethacin (Indocin)

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Indomethacin is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Celecoxib (Celebrex)

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Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to the GI toxicity of NSAIDs. At therapeutic concentrations, the COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. The lowest dose that is effective in a given patient should be given.

Class Summary

In contrast to the widespread systemic distribution that occurs when an oral anti-inflammatory drug is administered, a local corticosteroid injection can achieve the focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. A variety of corticosteroid preparations are available. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. The clinician has numerous local anesthetic agents from which to choose.

Methylprednisolone (A-Methapred, Depo-Medrol, Solu-Medrol, Medrol)

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Corticosteroids are commonly used in local injections administered to bursae or joints. The drugs provide a local anti-inflammatory effect while minimizing some of the gastrointestinal and other risks of systemic medications.

Dexamethasone acetate (Baycadron)

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This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reducing capillary permeability. The dosage varies with the degree of inflammation and the size of the affected area.

Hydrocortisone acetate (Solu-Cortef, Cortef, A-Hydrocort)

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Hydrocortisone acetate decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. The dosage varies with the degree of inflammation and the size of the affected area.

Betamethasone (Celestone, Celestone Soluspan)

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Betamethasone is the drug of choice for intra-articular injections. It does not crystallize if used with paraben-free anesthetic preparations.

Triamcinolone (Aristospan, Kenalog-10, Kenalog-40)

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Triamcinolone is used for inflammatory conditions responsive to steroids; it decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. This is the preferred drug, owing to its longer duration of action.

Questions

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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.