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Trigger finger
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{{short description|Locking of a finger when at full flexion}} {{about|the disorder|other uses|Triggerfinger (disambiguation)}} {{Distinguish|De Quervain syndrome}} {{Infobox medical condition (new) | name = Trigger finger | synonyms = Trigger digit, trigger thumb,<ref name=OI2018/> stenosing tenosynovitis<ref name=OI2018/> | image = TriggerFinger.webm | caption = An example of trigger finger affecting the ring finger | pronounce = | field = [[Hand surgery]], [[orthopedic surgery]], and [[plastic surgery]] | symptoms = Catching or locking of the involved finger, pain<ref name=Mak2008/><ref name=Hub2018/> | complications = | onset = 50s to 60s years old<ref name=Mak2008/> | duration = | types = | causes = | risks = Generally idiopathic, meaning no known cause. Perhaps [[diabetes]]<ref name=Hub2018/> | diagnosis = Symptoms and signs<ref name=Mak2008/> | differential = Sagittal band rupture | prevention = | treatment = [[corticosteroid|Steroid]] injections, surgery. The role of splint immobilization is uncertain<ref name=Hub2018/> | medication = | prognosis = | frequency = Relatively common<ref name=Mak2008/> | deaths = }} <!-- Definition and symptoms --> '''Trigger finger''', also known as '''stenosing tenosynovitis''', is a disorder characterized by catching or locking of the involved [[finger]] in full or near full [[flexion]], typically with force.<ref name=Mak2008>{{cite journal | vauthors = Makkouk AH, Oetgen ME, Swigart CR, Dodds SD | title = Trigger finger: etiology, evaluation, and treatment | journal = Current Reviews in Musculoskeletal Medicine | volume = 1 | issue = 2 | pages = 92–96 | date = June 2008 | pmid = 19468879 | pmc = 2684207 | doi = 10.1007/s12178-007-9012-1 }}</ref> There may be tenderness in the [[palm of the hand]] near the last skin crease (distal [[palmar crease]]).<ref name="Hub2018">{{cite journal | vauthors = Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF | title = Common Soft Tissue Musculoskeletal Pain Disorders | journal = Primary Care | volume = 45 | issue = 2 | pages = 289–303 | date = June 2018 | pmid = 29759125 | doi = 10.1016/j.pop.2018.02.006 | s2cid = 46886582 }}</ref> The name "trigger finger" may refer to the motion of "catching" like a trigger on a gun.<ref name=Mak2008/> The [[ring finger]] and [[thumb]] are most commonly affected.<ref name=OI2018>{{cite web |title=Trigger Finger - Trigger Thumb |url=https://orthoinfo.aaos.org/en/diseases--conditions/trigger-finger/ |website=OrthoInfo - AAOS |access-date=25 June 2018 |date=March 2018}}</ref> <!-- Cause and diagnosis --> The problem is generally [[idiopathic]] (no known cause). People with [[diabetes]] might be relatively prone to trigger finger.<ref name="Hub2018" /> The pathophysiology is enlargement of the flexor [[tendon]] and the [[A1 pulley]] of the [[tendon sheath]].<ref name=Hub2018/><ref name=Mak2008/> While often referred to as a type of stenosing tenosynovitis (which implies [[inflammation]]) the pathology is [[mucoid]] degeneration.<ref name=Hub2018/> Mucoid degeneration is when fibrous tissue, such as tendon, has less organized [[collagen]], more abundant [[extracellular matrix]], and changes in the cells ([[fibrocyte]]s) to act and look more like [[cartilage]] cells (chondroid metaplasia). Diagnosis is typically based on symptoms and signs after excluding other possible causes.<ref name=Mak2008/> <!-- Treatment and epidemiology --> Trigger digits can resolve without treatment. Treatment options that are [[Disease-modifying treatment|disease modifying]] include [[corticosteroid|steroid]] injections and surgery.<ref name=Hub2018/> [[Splint (medicine)|Splinting]] immobilization of the finger may or may not be disease modifying. ==Signs and symptoms== Symptoms include catching or locking of the involved finger when it is forcefully flexed.<ref name=Mak2008/> There may be tenderness in the palm of the hand near the last skin crease (distal palmar crease). Often a nodule can be felt in this area.<ref name="Crop2011">{{cite journal | vauthors = Crop JA, Bunt CW | title = "Doctor, my thumb hurts" | journal = The Journal of Family Practice | volume = 60 | issue = 6 | pages = 329–332 | date = June 2011 | pmid = 21647468 }}</ref> There is some evidence that idiopathic trigger finger behaves differently in people with [[diabetes]].<ref name="Baumgarten_2007">{{cite journal | vauthors = Baumgarten KM, Gerlach D, Boyer MI | title = Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 89 | issue = 12 | pages = 2604–2611 | date = December 2007 | pmid = 18056491 | doi = 10.2106/JBJS.G.00230 }}</ref> ==Causes== It is important to distinguish association and causation. The vast majority of trigger digits are [[Idiopathic disease|idiopathic]], meaning there is no known cause. However, recent publications indicate that diabetes and high blood sugar levels increases the risk of developing trigger finger.<ref>{{cite journal | vauthors = Rydberg M, Zimmerman M, Gottsäter A, Eeg-Olofsson K, Dahlin LB | title = High HbA1c Levels Are Associated With Development of Trigger Finger in Type 1 and Type 2 Diabetes: An Observational Register-Based Study From Sweden | journal = Diabetes Care | volume = 45 | issue = 11 | pages = 2669–2674 | date = November 2022 | pmid = 36006612 | doi = 10.2337/dc22-0829 | s2cid = 251809634 }}</ref> Some speculate that repetitive forceful use of a digit leads to narrowing of the fibrous digital sheath in which it runs,<ref name= "Gor1998">{{cite journal | vauthors = Gorsche R, Wiley JP, Renger R, Brant R, Gemer TY, Sasyniuk TM | title = Prevalence and incidence of stenosing flexor tenosynovitis (trigger finger) in a meat-packing plant | journal = Journal of Occupational and Environmental Medicine | volume = 40 | issue = 6 | pages = 556–560 | date = June 1998 | pmid = 9636936 | doi = 10.1097/00043764-199806000-00008 }}</ref> but there is little scientific data to support this theory. The relationship of trigger finger to work activities is debatable and there are arguments for<ref name= "Gor1998"/> and against<ref>{{cite journal | vauthors = Kasdan ML, Leis VM, Lewis K, Kasdan AS | title = Trigger finger: not always work related | journal = The Journal of the Kentucky Medical Association | volume = 94 | issue = 11 | pages = 498–499 | date = November 1996 | pmid = 8973080 }}</ref> a relationship to hand use with no experimental evidence supporting a relationship. ==Diagnosis== [[File:20230326 Trigger finger - right middle finger.jpg|thumb| Side view of trigger finger in the right middle finger]] Diagnosis is made on interview and physical examination. More than one finger may be affected at a time. It is most common in the thumb and ring finger. The triggering more often occurs while gripping an object firmly or during sleep when the palm of the subject’s hand remains closed for an extended period of time, presumably because the enlargement of the tendon is maximum when the finger is not being used. Upon waking, the affected person may have to force the triggered fingers open with their other hand. In some, this can be a daily occurrence. ==Treatment== [[File:Post-operative photo of trigger finger release surgery.jpg|thumb|Post operative photo of trigger finger release surgery in a diabetic patient. See:<ref name="Eisen 2013">{{cite web |url = https://plus.google.com/103101121348859087349/posts/V492nruyUTK |title = Trigger finger surgery. Fun. | vauthors = Eisen J |access-date = 17 May 2013 }}</ref>]] Depending on the number of affected digits and the clinical severity of the condition, [[Corticosteroid]] injections can cure trigger digits.<ref name="pmid32732655">{{cite journal | vauthors = Gil JA, Hresko AM, Weiss AC | title = Current Concepts in the Management of Trigger Finger in Adults | journal = J Am Acad Orthop Surg | volume = 28 | issue = 15 | pages = e642–e650 | date = August 2020 | pmid = 32732655 | doi = 10.5435/JAAOS-D-19-00614 | s2cid = 220892746 }}</ref> Treatment consists of injection of a corticosteroid such as [[methylprednisolone]] often combined with a local anesthetic ([[lidocaine]]) at the A1 pulley in the palm. The infiltration of the affected site is straightforward using standard anatomic landmarks. There is evidence that the steroid does not need to enter the sheath.<ref>{{cite journal | url=https://pubmed.ncbi.nlm.nih.gov/9708388/ | pmid=9708388 | year=1998 | last1=Taras | first1=J S | last2=Raphael | first2=J S | last3=Pan | first3=W T | last4=Movagharnia | first4=F | last5=Stereanos | first5=D G | title=Corticosteroid injections for trigger digits: is intrasheath injection necessary? | journal=The Journal of Hand Surgery | volume=23 | issue=4 | pages=717–722 | doi=10.1016/S0363-5023(98)80060-9}}</ref> The role of sonographic guidance is therefore debatable. Injection of the tendon sheath with a corticosteroid is effective over weeks to months in more than half of people.<ref name="Baumgarten_2007" /> Steroid injection is not effective in people with Type 1 diabetes.<ref>{{cite journal | url=https://pubmed.ncbi.nlm.nih.gov/18056491/ | pmid=18056491 | year=2007 | last1=Baumgarten | first1=K. M. | last2=Gerlach | first2=D. | last3=Boyer | first3=M. I. | title=Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study | journal=Journal of Bone and Joint Surgery | volume=89 | issue=12 | pages=2604–11 | doi=10.2106/JBJS.G.00230 }}</ref> If triggering persists 2 months after injection, a second injection can be considered. Most specialists recommend no more than 3 injections because corticosteroids can weaken the tendon and there is a possibility of tendon rupture. Triggering is predictably resolved by a relatively simple surgical procedure under local anesthesia. The surgeon will cut the sheath that is restricting the tendon. The patient should be awake in order to confirm adequate release. On occasion, triggering does not resolve until a slip of the FDS (flexor digitorum superficialis) tendon is resected.<ref name="pmid32732655"/> One study suggests that the most cost-effective treatment is up to two corticosteroid injections followed by open release of the first annular pulley.<ref name="Kerrigan_2009">{{cite journal | vauthors = Kerrigan CL, Stanwix MG | title = Using evidence to minimize the cost of trigger finger care | journal = The Journal of Hand Surgery | volume = 34 | issue = 6 | pages = 997–1005 | date = Jul–Aug 2009 | pmid = 19643287 | doi = 10.1016/j.jhsa.2009.02.029 }}</ref> Choosing surgery immediately is an option and can be affordable if done in the office under local anesthesia.<ref name="Kerrigan_2009" /> ===Surgery=== Trigger digits can be released percutaneously using a needle. This is not used for the thumb where the digital nerves are at greater risk.<ref>{{cite journal | vauthors = Pavlicný R | title = [Percutaneous release in the treatment of trigger digits] | journal = Acta Chirurgiae Orthopaedicae et Traumatologiae Čechoslovaca | volume = 77 | issue = 1 | pages = 46–51 | date = February 2010 | doi = 10.55095/achot2010/008 | pmid = 20214861 | s2cid = 26595001 | doi-access = free }}</ref> ====Postoperative outcome==== In some trigger finger patients, tenderness is found in the dorsal proximal interphalangeal (PIP) joint. Dorsal PIP joint tenderness is more common in trigger fingers than previously thought. It is also associated with higher and prolonged levels of postoperative pain after A1 pulley release. Therefore, patients with pre-existing PIP tenderness should be informed about the possibility of sustaining residual minor pain for up to 3 months after surgery.<ref>{{cite journal | vauthors = Monteerarat Y, Misen P, Laohaprasitiporn P, Wongsaengaroonsri P, Lektrakul N, Vathana T | title = Dorsal proximal interphalangeal joint tenderness is associated with prolonged postoperative pain after A1 pulley release for trigger fingers | journal = BMC Musculoskeletal Disorders | volume = 24 | issue = 1 | pages = 13 | date = January 2023 | pmid = 36611160 | pmc = 9824922 | doi = 10.1186/s12891-023-06130-5 | doi-access = free }}</ref> == References == {{Reflist}} == External links == {{Medical resources | DiseasesDB = | ICD10 = {{ICD10|M|65|3|m|65}} | ICD9 = {{ICD9|727.03}} | ICDO = | OMIM = | MedlinePlus = 003248 | eMedicineSubj = orthoped | eMedicineTopic = 570 }} {{wiktionary|trigger finger}} * [https://www.youtube.com/user/DrsGutowandSchneider#p/a/u/0/zSFUpNeAIBA Video of Trigger Finger Release Surgery on YouTube] * [https://orthoinfo.aaos.org/en/diseases--conditions/trigger-finger/ American Academy of Orthopaedic Surgeons information on trigger finger] * [http://www.mayoclinic.com/health/trigger-finger/DS00155 Information from the Mayo Clinic] {{Soft tissue disorders}} {{DEFAULTSORT:Trigger Finger}} [[Category:Ailments of unknown cause]] [[Category:Fingers]] [[Category:Inflammations]] [[Category:Disorders of synovium and tendon]] [[Category:Wikipedia medicine articles ready to translate]]
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