Trigger finger
Trigger finger, Digital flexor tenosynovitis, Stenosing tenosynovitis

Definition

Trigger finger and trigger thumb consist in the altered movement causing an involuntary catching when flexing the finger towards the palm. In severe cases the fingers are locked in a flexed position and cannot be straightened.

Pathology

Trigger finger is a pathology of the flexor tendon, which connects the phalanges to the muscles in the palmar side of the forearm. The tendon is aligned with the finger and fixed by lateral ligaments named pulleys. The tenosynovium sheath encloses the tendon to facilitate its gliding when the finger is extended or flexed.

In trigger finger the irritated flexor tendon and pulleys become swollen occasionally leading to the formation of a nodule, which limits or blocks the sliding of the tendon during movement. A typical catching and popping noise can be heard during grasping function.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Operating hard tools can cause stress and inflammation of the flexor tendons and consequent trigger finger

Causes

The irritation of the flexor tendon causing trigger finger is mostly a consequence of overuse of the hand; however the aetiology of this pathology remains unknown. The condition is more frequent in women and the adult/aged population. Apart from repetitive grasping/gripping function other causes leading to trigger finger include:

Tear to the flexor tendon

Infection of the synovium

Congenital condition predisposing to tendon nodule formation

Prolonged driving is a risk factor for trigger finger pathology

Risk factors

Although risk factors leading to trigger finger have not been identified, the following factors may pose a risk:

Female gender

Age between 40 and 60 years

Occupational activities: repetitive gripping of power tools

Prolonged driving (grasping the steering wheel)

Daily activities: writing, carrying bags and briefcases

Medical conditions: diabetes increases four times the risk, rheumatoid arthritis

Inability to fully extend the finger as the inflamed tendon is entrapped in the synovium

Symptoms

The symptoms arising from a trigger finger are:

Pain at the nodule site when flexing and extending the finger

Swelling

Clicking sensation when flexing the finger

Impaired finger extension

Movement restrictions (grasping) especially after inactivity

Blockage of the finger in a bent position

 

Medical examination determines changes in the anatomy and function of the fingers
Left: X-ray of trigger thumb with mild osteoarthritis at 1st IP joint; Right: ultrasound shows the thickened, inflamed flexor tendon

Diagnosis

The diagnosis of trigger finger does not require special tests or X-rays. Medical examination is based on:

Observation of the hand anatomy

Palpation to detect the presence of nodules at metacarpo-phalangeal or proximal-phalangeal joints

Assessing changes in finger flexion/extension, stiffness, pain level when opening/closing the fist 10 times

Audible clicking/popping noises

Treatment

Steroid injection within the area of tendon inflammation

Nonoperative treatment

Conservative treatment is the most common and efficacious management of trigger finger. if the condition has not been protracted over four months, physiotherapy and occupational therapy will restore successfully finger function. Conservative management also include:

Immobilisation of the fingers with a splint until the inflammatory condition has subsided

Heat application

Administration of NSAIDs

Local steroid injection

Painkillers

Illustration showing the pulleys that are severed to allow tendon sliding within the synovium

Surgical treatment

Surgery is required in case of severe and prolonged trigger finger symptoms. It consists in the resection of the pulleys at the nodule zone to free the tendon during movement. This an outpatient procedure performed under local anaesthesia. Methods such as endoscopic surgery and percutaneous tendon release are available providing a faster postoperative healing.

Complications

Complications following a surgical treatment of trigger finger are:

Limited straightening of the finger (insufficient tendon release)

Hyperextension of the finger (excessive tendon release)

Ongoing trigger finger

Infection

Ball exercises are useful for rehabilitative treatment of trigger finger

Rehabilitation

A physical or occupational therapist will guide stretching movements to restore flexibility and physical exercises to strengthen the fingers and re-acquire fine motor control. Physiotherapy is recommended for 6 weeks. Full recovery after surgery can take up to 6 months. Advice on modifying daily activities is provided to avoid excessive stress on the affected tendon.

Adopting a correct posture and movement of the hand and fingers can prevent trigger finger

Prevention

There are no specific measures to prevent trigger finger. The best strategy is to avoid excessive strain of the flexor tendon during occupational and daily activities.