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Trigger Finger

Author: David P Johnson MD
Consultant Orthopaedic Surgeon
Spire Hospital Bristol.
http://www.bristol-knee-clinic.co.uk/

Key words: Orthopaedic Surgery, Orthopaedic Surgeon, hand surgery, steroid injection, finger pain, repetitive strain injury, keyboard injury, tendonitis, tenosynovoitis, injection, steroid injection, platelet rich plasma injection, release of trigger finger, percutaneous release of trigger finger.
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Introduction
A trigger finger is a finger that becomes ‘locked’ after it has been bent (flexed) and then can forcibly be unlocked with a click. This can usually be achieved by straightening it out without pulling on it by the other hand. One or more fingers may be affected. Sometimes there is mild pain and/or a small swelling in the palm at the base of the affected finger.

What causes trigger finger?
It is usually due to repetitive trauma or inflammation which causes localised swelling of a tendon or tendon sheath in the palm.

A tendon attaches a muscle to a bone and allows the muscle to move the finger. In this case the tendon comes from a muscle in the forearm. It passes through the palm and attaches to the finger. The muscle pulling on this tendon bends (flexes) the finger towards the palm.

A tendon sheath is like a tunnel that covers and protects parts of a tendon. Normally, the tendon slides easily in and out of the sheath as you bend and straighten the finger. In trigger finger the tendon can slide out of the sheath when you bend your finger. However, it cannot easily slide back in due to the nodule or localised swelling. The finger then remains bent (flexed) unless it is gently straightened with the other hand.

Most cases occur for no apparent reason. In some cases it occurs after overuse for example, after jobs which involved a lot of screwdriving, or using tools that press on the palm. These can cause some inflammation in the palm. Sometimes trigger finger occurs as part of an illness such as rheumatoid arthritis, amyloidosis, or hypothyroidism. It is also more common in people on dialysis, and in people with carpal tunnel syndrome.

What is the treatment for trigger finger?
Not treating is an option at first. Simply resting the hand and allowing any inflammation to settle may resolve the problem without the need for treatment

A steroid injection into the tendon sheath is the usual treatment. It is combined with a local anaesthetic to make the injection painless. Steroids work by reducing inflammation. A finger splint may be advised for a few days after the injection to rest the finger. This treatment works in about 9 in 10 cases. A second injection may be needed if the first does not work.
However injection into the palm can be painful and sore. The improvement may also only be temporary with a return to clicking in due course.

A percutaneous Minimal Invasive Surgical solution. This was described by David P Johnson in the Journal of Hand Surgery (Percutaneous Release of the Trigger Finger: an office procedure. DM Eastwood, DP Johnson. J. Hand Surg. Jan. 1992; 17:1: 114-7.)

In this technique a small injection of local anaesthetic is inserted into the palm around the tight pulley just distal to the tendon nodule in the extended finger. A percutaneous needle of 18gauge is then used like an injection to cut the pulley in line with the tendon. This usually avoids damage to the digital sensory nerves. The procedure is an office procedure not requiring hospital admission. The finger may be sore for a day or so before normal activities can be resumed.

An operation under local anaesthetic may be advised if the above does not work. A small cut is made at the base of the finger and the tendon sheath is widened. With this operation there is a small risk of damaging the tiny finger nerve, and causing some numbness to the finger. Also, as with any operation, there is a small risk of the wound becoming infected.

© OrthopaedicsOpinionOnline 2011 www.OrthopaedicOpinionOnline.co.uk
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