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Trigger Finger

This is one of the most common causes of hand pain. This is also referred to as stenosing tendovaginitis or tenosynovitis and is associated with thickening of the tendon or the retinacular sheath in which the tendon slides. The tenosynovium is a very fine and thin layer of tissue almost like a elly which covers the tendons allowing smooth gliding within the sheath. The tendons pass through fibro-osseous canals or sheaths on the back of the wrist (dorsum) as well as on the palmar side of the hand. They provide fulcrums for the acute angulation of these tendons. These canals are narrow and during this constant motion, there can be swelling and bunching of the tendon fibres which can lead to a restriction of gliding and finally catching or locking of the tendon. This process leads to an acute inflammatory response with resultant edema and thickening of the retinacular sheath. There are thickened areas within the sheath called pulleys. This process most commonly occurs at the first of such thickenings called the A1 pulley.

Common sites of occurrence

Each of the fibro-osseous canals may be involved in the condition but the most commonly involved are the first and sixth extensor compartments on the back of the hand.

On the flexor or palmar surface, a very common site is deep to the A1 pulley or the first thickening in the sheath which is approximately over the head of the metacarpal or the palmar side of the knuckle.

Associated factors

There is a common association or concurrence with conditions such as carpal tunnel syndrome, trigger digits,, tennis or golfer’s elbow, De Quervain’s disease e.t.c.

It is more common in women than men, more common in the dominant hand and trauma may play a role. It is more common in the sixth to seven decades of life.
It can also occur secondary to diabetes mellitus and rheumatoid arthritis.

Did you know!

Though triggering can occur both on the palmar as well as the dorsum or back of the hand, the phrase ‘trigger finger’ is most commonly used to refer to its occurrence on the palmar or flexor surface of the hand.
What may patients notice or complain of?
Symptoms you may notice include local pain and tenderness, swelling or puffiness and redness. You may just feel in the early stages that your hand is ‘slow’ in flexion.

Triggering or ‘painful catching’ or ‘popping’ of the digits as you flex or extend the finger may occur. Sometimes it may lock in flexion and you may manually have to use the other hand to manipulate it into extension. You may also have noted weakening of the grip strength.

How is it treated?
There are many ways that are used to help relieve symptoms. These include the use of pain killers, splints, anti inflammatory drugs, and advice on a reduction of the activity that worsens the symptoms. Most patients in addition require treatment with steroids and/or surgery.

Injection of steroid and local anaesthetic into the area – Up to three injections may be satisfactory. About 75% of patients can be successfully treated in this ways. After three injections, if the condition persists or returns, surgical release is advised.

Surgery – this is the definitive treatment and may be recommended after a failed non surgical treatment or in presence of severe symptoms and signs.

What anaesthesia?
This is usually performed under local anaesthesia and the constricting band or pulley is divided. It is done as a day case so the patient can go home the same day.
What to expect post operatively?
The operated hand is placed in a bulky dressing with the fingers free.

The patient can reduce the dressings in 5 days and place a simple plaster over the area.

Hand therapy is useful and one or two sessions may suffice.

Usually there are no stitches to remove as they fall off themselves after a week.

What are some of the problems that may arise?
As with any surgery there are risks.

Infection can occur as with any surgery and is usually treated with antibiotics.

Collection of blood under the skin (haematoma) can occur especially in patients on aspirin or warfarin. It can usually be drained without much difficulty.

The scars may be tender or sensitive. Massage with cream does help and it settles with time.

Very few patients may react abnormally to surgery and develop a condition called complex regional pain syndrome which can cause pain and stiffness of the fingers. The aim is to detect the early signs and treat it before it becomes a major problem.

Is it caused by work?
The reports are varied with some for and others against.

The controversies will be discussed at the consultation.

When can I go back to work?
This depends on the occupation of the patient. Most patients in administrative or office posts may be able to go back earlier (within 2weeks) while people in heavy manual jobs may take up to 4 weeks. Patients are however able to resume earlier if they can temporarily arrange their duties at work to be more supervisory during the convalescence.

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