Many people have heard of certain common conditions that affect the hand. They may even know the symptoms of those conditions and certain ways to treat the problems. However, I find that very few of my patients actually understand what is happening inside their body to produce a given problem or set of symptoms. Hopefully, this article will give you a clearer picture of the anatomy and pathophysiology involved in the condition commonly known as trigger finger, while briefly discussing causes and treatment options.
Quite often, people come in to my office complaining of their finger or fingers getting stuck in a bent position, and then snapping when they straighten them. This is almost always a trigger finger, and is a problem with the gliding of the flexor tendon (the tendon that bends your finger) in your palm. Tendons are the rope like structures that connect muscle to bone. Many of the muscles that move your fingers are located in your forearm, and are connected to your fingers by tendons.
Trigger finger occurs when the tendon that bends your finger has trouble fitting through the tight sheath, or pulley, that holds it close to the bone near the base of your finger in the palm. You can usually feel a small lump in your tendon move up and down when you bend your finger. Symptoms seem to be worst in the morning. No one really knows why trigger finger develops in one person and not another, or in one finger and not another. However, as with carpal tunnel syndrome, conditions such as diabetes and thyroid disease increase your likelihood of getting one or more trigger fingers. Trigger fingers can become quite painful, and the pain and loss of use of the finger is what brings most people in for treatment.
Treatment options for a significant trigger finger include splinting, up to 3 cortisone injections and surgery. Diabetics tend to respond less well than others to injection, but it is still usually worth a try. If non-operative treatment fails, surgery can be performed in a few different ways, but the primary objective is to release the so-called A1 pulley where the tendon is getting stuck. During surgery, the tight pulley is divided, and your tendon is able to move without catching. The surgery can be done in the office with a local anesthetic using a needle through the skin to divide the pulley (percutaneous trigger finger release) or in a procedure room or operating room using local anesthetic (with or without sedation) and making an incision to divide the pulley under direct visualization. There are other methods that a small number of surgeons use, but two methods above are the most common. I would recommend asking your doctor how he likes to perform the surgery.
It is interesting to note that there are different success rates with different treatment methods. A series of up to two injections is thought to be successful about 80% of the time. For those that fail conservative care or choose to move directly to surgery, the open surgery has a success rate of over 95%, while the percutaneous method has a success rate of about 80%. Of course, the percutaneous method has the advantage of avoiding a trip to the OR, having no sutures to remove, and simply walking out of the office with a Band-Aid in place. The actual surgery might take only 10 or 15 minutes, even though the process can take much longer.
With any treatment or procedure, there are risks. Trigger finger cortisone injections are fairly painful, and (especially if more than one injection is given at a time) can cause the blood sugar level of diabetics to go up for a few days. They also can (rarely) cause flexor tendon rupture, which is why we limit injections to a maximum of 3 in a one year period. With trigger finger surgery, as with many other hand surgeries, the risks are of infection, nerve damage (to the digital nerves that run next to the flexor tendons and supply sensation to your fingers), tendon damage, failure to relieve symptoms (due to incorrect diagnosis or unusual cause of the triggering), loss of motion after surgery, continued tenderness, and anesthetic complications. As I tell my patients, the risk of having any of these problems is small, but not zero.
After you have the surgery, whichever way it is performed, the most important things are to keep the dressing clean and dry, and to start bending your fingers right away. You will need to keep working on finger motion every hour while awake. For the first 48 hours, elevate your hand as much as possible. You may start to use the hand for light activities (up to 2 lbs of lifting) right away. Sutures (if any) will be removed about 10-14 days after the surgery. It is normal for the area at the base of the finger to remain sore for up to two months, but it is not unusual for people to resume normal activities within 2-3 weeks. Occasionally, I send a post-op patient for hand therapy so that they may help the patient achieve their functional goals more quickly, or if the fingers are unusually stiff when they return for their first visit after the surgery.
Dr. Carl B. Weiss received his orthopedic surgery training at the State University of New York at Stony Brook. He then completed the Joseph Boyes Hand Surgery Fellowship in Los Angeles, California. Dr. Weiss is certified by the American Board of orthopedic surgery in both orthopedics and hand surgery. He is a member of the American Academy of Orthopedic Surgeons, the American Society for Surgery of the Hand, and the Southern Orthopedic Association. Dr. Weiss currently practices at James River Orthopedics, located on the campus of Memorial Regional Medical Center in Mechanicsville, Virginia.