What triggers in trigger finger? The flexor tendons at the flexor digitorum superficialis bifurcation

Treatment of trigger finger with metacarpophalangeal joint blocking orthosis vs relative motion extension orthosis: A randomized clinical trial

BACKGROUND

The metacarpophalangeal joint blocking orthosis (MCPJ-BO) is one of the first-line orthotic treatment for patients with trigger finger (TF). Relative motion extension orthosis (RME-O) has recently emerged as a treatment option for various hand disorders involving TF.

PURPOSE

The primary objective of this study was to compare the effectiveness of 6 weeks of orthotic treatment with the MCPJ-BO and the RME-O for pain relief. Function and satisfaction with the orthosis were assessed as secondary objectives.

STUDY DESIGN

Randomized clinical study.

METHODS

Thirty patients with an average age of 50 years with Froimson stage 1-3 A1 pulley triggering participated in the study. They were randomly assigned to either the MCPJ-BO (n = 15; 10 females, five males) or the RME-O group (n = 15; 12 females, three males). The orthoses were worn full time for 6 weeks. All patients received patient education, activity modification, and flexor tendon gliding exercises as part of the rehabilitation program. Pre- and post-assessments included Numeric Pain Rating Scale, Disability of the Arm, Shoulder, and Hand questionnaire, and Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire. The Mann-Whitney U test was conducted to analyze the difference between the two groups.

RESULTS

There were no significant differences between the two groups in pain and function before treatment (p < 0.05). Within-group comparisons indicated that both orthoses relieved pain, but the MCPJ-BO group achieved greater pain relief (p = 0.001). There was a significant improvement in function in the MCPJ-BO group, with a mean change of 12.7 (p = 0.0001). The overall success rates for the MCPJ-BO group and RME-O group were 60% and 27%, respectively. Patients in both groups had high satisfaction with the orthosis.

CONCLUSIONS

MCPJ-BO and RME-O could be used for pain relief in the treatment of TF. The MCPJ-BO appears to be more effective than the RME-O in improving function.

Where do archers hurt? Epidemiology of injuries during archery practice

BACKGROUND

The risk of injury in archery is supposedly low. However, relations between pain, shooting phases and types of bow have not been studied.

OBJECTIVE

Understanding the biomechanical mechanisms of archery-related injuries.

METHODS

Online survey for archers from all types of bow. Variables were analyzed using contingency tables and chi-squared tests.

RESULTS

396 surveys were completed. 36.9% of the archers had practiced archery for more than 10 years, 23.3% between 5 and 10 years. Olympic recurve bow was the most commonly used (38.2%), followed by traditional (23.3%) and compound (22.0%). 57.3% of the archers suffered some kind of injury during archery practice. Drawing shoulder (28.2%) and neck/back injuries (19.9%) were the most prevalent, preventing 50.3% of those who suffered them from continuing archery practice. There was a moderate association between drawing arm injuries and symptomatology in the drawing phase, especially in the shoulder region (0.55), elbow (0.20), and hand (0.13), and to a lesser extent in the neck/back (0.28).

CONCLUSIONS

Our results show that injury chronicity is frequent on archery. Correlations between types of bow, phases of the shoot and areas of pain could be a starting point for future studies on the repercussions of different types of injuries in archery practice.

The cross-sectional area ratio of a specific part of the flexor pollicis longus tendon- a stable sonographic measurement for trigger thumb: a cross-sectional trial

BACKGROUND

Trigger thumb is a pathologic condition of the digital pulleys and flexor tendons. To find a cutoff value of the cross-sectional area ratio of specific parts of the flexor pollicis longus tendon to diagnosis trigger thumb in the high-frequency ultrasound examination.

METHODS

We evaluated 271 healthy volunteers and 57 patients with clinical diagnosis of trigger thumb. The cross-sectional area of the metacarpophalangeal joint of flexor pollicis longus tendon (C1) and the cross-sectional area of the midpoint of the first metacarpal of flexor pollicis longus tendon (C2) were analyzed.

RESULTS

There is no difference between gender, age and left and right hands in the ratio of C1 to C2 (C1/ C2). The mean of C1/ C2 in the healthy thumb was 0.983 ± 0.103, which was significantly smaller in comparison to the diseased thumb (P < 0.05). Based on the receiver operating characteristic curve, we chose the diagnostic cut-off value for the C1/ C2 to be 1.362 and 1.153 in order to differ a trigger thumb from children and adults.

CONCLUSIONS

The C1/ C2 of the healthy thumb was relatively stable, with a mean value of 0.983 ± 0.103. The cutoff value of C1/C2 to distinguish healthy thumb from diseased thumb in children and adults were 1.362 and 1.153, respectively.

Dorsal proximal interphalangeal joint tenderness is associated with prolonged postoperative pain after A1 pulley release for trigger fingers

BACKGROUND

In some trigger finger patients, tenderness is found in the dorsal proximal interphalangeal (PIP) joint. The etiology and prevalence of this condition are unclear. Furthermore, surgical outcomes for trigger fingers with coexisting dorsal PIP tenderness have not been reported. This study (1) determined the prevalence and risk factors for PIP joint tenderness in trigger fingers and (2) compared postoperative outcomes for trigger fingers with and without joint tenderness.

METHODS

This prospective cohort study was conducted between August 2018 and March 2020. We enrolled 190 patients diagnosed with single-digit trigger fingers undergoing open A1 pulley release. The incidence, demographic data, and surgical outcomes of patients with dorsal PIP tenderness were investigated. Factors associated with tenderness were analyzed, including patient occupation, finger involvement, trigger finger grading, duration of symptoms, previous corticosteroid injections, and presence of diabetes mellitus. A numeric pain scale, a patient-specific functional scale, and the range of motion were evaluated preoperatively and 1, 2, and 6 weeks after surgery, with telephone follow-ups at 3 and 6 months.

RESULTS

Of 190 patients, 46.8% had tenderness of the dorsal PIP joint. Patients with joint tenderness had significantly more overall postoperative pain for up to 6 weeks and reported residual minor pain for up to 3 months. The functional scale and range of motion of the 2 groups did not differ during follow-up. The only risk factor observed was the occupation of the patients.

CONCLUSION

Dorsal PIP 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.

LEVEL OF EVIDENCE

II.

A New Test for Trigger Finger: The Lenox Independent Flexion Test

Background: The diagnosis of trigger finger (TF) in patients who do not demonstrate triggering at presentation can be challenging. We have been using a new test for TF - the Lenox Independent Flexion Test (LIFT). The aim of this study is to determine the sensitivity of LIFT in diagnosing TF. We hypothesise that LIFT will be more sensitive compared to the classic physical exam finding of triggering or locking with active range of motion (AROM). Methods: This is a prospective study of consecutive patients with TF over a 5-month period. Patients with the onset of trigger following trauma and trigger of the thumb were excluded. Patients were examined for tenderness over the first annular (A1) pulley, triggering or locking with AROM, and the LIFT was performed. A two-proportion test was used to determine whether the LIFT was more sensitive than triggering with AROM. Results: The study included 85 patients with 118 TFs. The average age of patients was 63 years and the study included 49 women. There were 69, 49, 0 and 0 grade I, II, III and IV TF, respectively. 108 fingers (92%) had a history of catching or locking of the affected digit, 110 (93%) had tenderness over the A1 pulley, 49 (44%) had triggering or locking with AROM and 102 (91%) had a positive LIFT. The LIFT was found to be more sensitive when compared to triggering with AROM (p < .001). Conclusion: The LIFT is more sensitive than triggering with AROM in the diagnosis of trigger digits. This test is especially useful in the diagnosis of TF in patients who do not have triggering at presentation. Level of Evidence: Level III (Diagnostic).

Adhesions as a component of the trigger finger: a dynamic sonographic study

We performed a detailed dynamic high-resolution ultrasound examination of the flexor tendons in trigger fingers and compared this with normal contralateral digits. There was a loss of defined linear tendon margins and/or traction of the flexor tendons on the surrounding soft tissue during passive flexion of the distal interphalangeal joint in 17 out of 20 trigger fingers, which indicated adherence to the surrounding tissues. The differential motion between the flexor digitorum profundus tendon and the flexor digitorum superficialis tendons was also lost in ten trigger fingers, which suggested adherence between the tendons. No signs of peritendinous or intertendinous adhesions were found in the healthy control fingers. We conclude that tendon adhesions are present in the majority of trigger fingers. We could not determine a relationship between the severity of triggering and the presence of adherence due to limited sample size.Level of evidence: II.

[Tendinopathies - Common Diagnoses in Hand Surgery]

Tendinopathies - Common Diagnoses in Hand Surgery Abstract. Tendinopathies are among the most frequent reasons for consulting a hand surgeon. The diagnosis can usually be made clinically. A supplementary ultrasound examination helps to visualize the pathology. Most of these diseases respond to non-surgical treatment. If surgical treatment is necessary, it can usually be performed as an outpatient procedure under local anesthesia. This article provides an overview of the most common tendinopathies of the hand and wrist, their diagnosis and treatment.

Open Surgery for Trigger Finger Required Combined a1-a2 Pulley Release. A Retrospective Study on 1305 Case

OBJECTIVES

We retrospectively reviewed 1305 open-surgery for idiopathic trigger finger performed by 4 senior hand surgeons between 2014 and 2016.

MATERIAL AND METHODS

Medical records and a telephone interview made with a minimum follow-up of 1 year were used to identify the recurrent rate of triggering and other complications.

RESULTS

This retrospective study let us note that 169 fingers (13%) required simultaneous release of the A1-A2 pulleys because the sectioning of the A1 pulley alone did not lead to complete free sliding of the tendons. We did not record any bowstring complication and we ascribe this to both surgery and bandaging technique. Overall rate of complication was 11.8% and relapse triggering or permanent proximal interphalangeal joint flexion (PPIJF) were among them; notably, however, they occurred only in patients where the A2 pulley was not sectioned.

CONCLUSIONS

Is possible to reduce the percentage of relapse triggering or PPIJF after trigger finger surgery, by performing that combined A1-A2 pulley release.

LEVEL OF EVIDENCE

Level III.

Ultrasound Features of Trigger Finger: Review of the Literature

Trigger finger is a common pathologic condition of the digital pulleys and flexor tendons in the hand. The key clinical finding is a transient blockage of the digit when it is flexed with subsequent painful snapping when it is extended. Imaging is a helpful guide for establishing the severity of the disease, identifying the underlying cause, and deciding the appropriate management. This narrative review aims to recall the anatomic and pathologic bases and describe the ultrasound features of trigger finger, also including common ultrasound findings and complications after therapy. Ultrasound enables an accurate static and dynamic evaluation of trigger finger as well as a comparison with the adjacent normal digits and thus should be considered the radiologic modality of first choice for its diagnosis.

Effect of metacarpophalangeal joint position on A1 pulley and flexor digitorum tendons in trigger digit

BACKGROUND

The aim of this study was to evaluate and compare the cross-sectional area (CSA) of flexor digitorum tendons and the thickness of first annular (A1) pulleys between contralateral normal digits and trigger digits (TDs) at positions of finger flexion and extension using a noninvasive ultrasound system.

METHODS

Seventeen affected fingers of 17 patients (6 men and 11 women) with TDs in one hand, and 17 contralateral normal digits without trigger finger symptoms were examined. The sonographic appearances of flexor digitorum tendons and A1 pulleys were observed at two positions of metacarpophalangeal (MCP) joint flexion: 0° and 60°.

RESULTS

The findings of this study indicate that CSA of flexor digitorum tendons and A1 pulley thickness were significantly larger in both positions of 0° and 60° flexion of MCP joint compared with contralateral normal digits (p < 0.01). In TDs, there was a significantly thicker A1 pulley at 60° flexion of MCP joint than that at 0° flexion (p < 0.01), but no significant change on CSA of flexor tendons.

CONCLUSION

Our results suggested that TDs lead to the thicker A1 pulley and larger CSA of the flexor digitorum tendons. The mismatch in volume change between CSA of flexor digitorum tendons and A1 pulley thickness during MCP flexion may lead to the trigger phenomenon.

A Critical Appraisal of Adult Trigger Finger: Pathophysiology, Treatment, and Future Outlook

Trigger finger (TF) is a common referral to a hand surgeon, with people with diabetess being the most at-risk population. Abnormal thickening, scarring, and inflammation occur at the A1 pulley and flexor tendon, and histological changes correlate well with the clinical severity of TF. Corticosteroid injections decrease the thickness of the A1 pulley and are considered a first-line treatment. However, corticosteroids are only moderately effective, especially for people with diabetes. Patients may elect for surgery if nonoperative treatments prove ineffective; some may choose immediate surgical release instead. To release the A1 pulley, patients have the option of an open or percutaneous approach. The open approach has a greater risk of infection and scar tissue formation in the short run but an overall superior long-term outcome compared with the percutaneous approach.

METHODS

We critically reviewed the efficacy and cost-effectiveness of the treatment methods for TF through a comprehensive search of the PubMed Database from 2003 to 2019.

RESULTS

To reduce costs, while still delivering the best possible care, it is critical to consider the likelihood of success for each treatment method in each subpopulation. Furthermore, some patients may need to return to work promptly, which ultimately may influence their desired treatment method.

CONCLUSIONS

Currently, there is no universal treatment algorithm for TF. From a purely financial standpoint, women without diabetes presenting with a single triggering thumb should attempt 2 corticosteroid trials before percutaneous release. It is the most cost-effective for all other subpopulations to elect for immediate percutaneous release.

Trigger finger: An overview of the treatment options

Stenosing flexor tenosynovitis, more commonly known as trigger finger, is one of the most common causes of hand pain and dysfunction. Clinicians must be able to identify the disorder, know the broad range of treatment options, and counsel patients on the treatment best suited for their condition. Awareness of the economic burden each option entails is central to optimizing treatment outcomes and patient satisfaction.