Template:Short description Template:About Template:Distinguish Template:Infobox medical condition (new)
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>Template:Cite journal</ref> There may be tenderness in the palm of the hand near the last skin crease (distal palmar crease).<ref name="Hub2018">Template:Cite journal</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>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
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 (fibrocytes) 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/>
Trigger digits can resolve without treatment. Treatment options that are disease modifying include steroid injections and surgery.<ref name=Hub2018/> Splinting immobilization of the finger may or may not be disease modifying.
Signs and symptomsEdit
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">Template:Cite journal</ref> There is some evidence that idiopathic trigger finger behaves differently in people with diabetes.<ref name="Baumgarten_2007">Template:Cite journal</ref>
CausesEdit
It is important to distinguish association and causation. The vast majority of trigger digits are 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>Template:Cite journal</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">Template:Cite journal</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>Template:Cite journal</ref> a relationship to hand use with no experimental evidence supporting a relationship.
DiagnosisEdit
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.
TreatmentEdit
Depending on the number of affected digits and the clinical severity of the condition, Corticosteroid injections can cure trigger digits.<ref name="pmid32732655">Template:Cite journal</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>Template:Cite journal</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>Template:Cite journal</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">Template:Cite journal</ref> Choosing surgery immediately is an option and can be affordable if done in the office under local anesthesia.<ref name="Kerrigan_2009" />
SurgeryEdit
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>Template:Cite journal</ref>
Postoperative outcomeEdit
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>Template:Cite journal</ref>