Trigger-finger trouble
Dr Vichai Vijitpornkul operates on a patient with a trigger finger. For the past six years he has operated on thousands of fingers using his specially designed instruments and a technique which is cheaper, needs no stitches and leaves no wounds nor scars.
A Thai doctor has devised a quick and simple remedy for painfully locked fingers


Housewives, BEWARE!

Carrying heavy purchases in plastic bags and wringing wet clothes out after washing them by hand can be hazardous to your fingers.

The warning comes from Dr Vichai Vijitpornkul, assistant director of Lerdsin Hospital and one of Thailand's leading family physicians, whose name has become synonymous with a condition called "lock finger" or "trigger finger".

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Trigger finger derives its name from the fact that the finger "locks" in place, bent as if to pull the trigger of a gun. The symptoms vary from chronic pain and limited movement, to a finger that won't bend and straighten automatically, often requiring the person to pry it open with considerable difficulty and pain.

Trigger finger may be associated with diabetes, rheumatoid arthritis or carpal tunnel syndrome, in which tendons or ligaments in the wrist become enlarged resulting in the pinching of nerves leading to the fingers and to the muscles at the base of the thumb. But often it also occurs in strong, healthy individuals who abuse their fingers by grasping things forcefully and repeatedly.

"Sheath-covered tendons connect the muscles of the forearm with the bones of the fingers," Dr Vichai explained. "When you bend your fingers, the tendons glide back and forth, guided by restraining pulleys. When the tendon sheath becomes inflamed, it swells and may become thick, fibrous and less elastic, thus obstructing the normal movement of the tendon. This causes further irritation and results in a vicious circle of irritation, swelling, catching and more irritation until, finally, the finger locks in a bent or extended position."

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The tools of the trade: Dr Vichai devised his own tools using dental instruments he sharpened as small knives. 310105_out01 (6K)
Maintaining an overly firm grip on, or the forceful handling of such tools as a screw-driver, saw, hammer, pliers, pruning shears, spade, scissors, knife, badminton/tennis racquet, golf club, etc, while using them repeatedly can eventually lead to trigger finger, he said.

But the leading cause of trigger finger in Thailand is the carrying of heavy plastic bags using just one or two fingers, he added.

Hospitals keep no statistics on the numbers of sufferers but judging from the number of patients who consult him at Lerdsin Hospital and at his own clinic, Dr Vichai is confident that in nearly every other household including women aged 45 and above, there is at least one sufferer. There are also rare cases of children born with the ailment.

Patients come from almost all professions and all walks of life, including dentists, professors, accountants, office secretaries, writers, golfers, gardeners, butchers, masseuses, motorcyclists and even actors.

"Tell me the occupation of the person and I can tell you which of his fingers will likely be affected," Dr Vichai said. "Gardeners are prone to have trigger finger in their right-middle finger, golfers on their left-middle, ring and/or little fingers, while teachers, writers, administrators and accountants are affected in their right thumbs."

Some of his patients had been suffering from the condition for 35 years, he said. "One, a woman in her nineties, had had three operations: on her left-middle finger in 2002 when she was 93, on her right-index in 2003 when she was 94 and on her left-ring finger last year when she was 95."

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The ratio of female to male sufferers is four to one, Dr Vichai said. This he attributes to the fact that Thai housewives do most of the marketing for food and groceries, usually carrying their purchases in plastic bags weighing five to 10kg or more. "Women carrying shopping bags are a familiar sight near markets and supermarts and along every street," he pointed out.

Also, women do more household chores than men, eventually destroying the fingers' pulleys in such activities as washing clothes by hand and wringing them out for drying, as well as chopping meat and peeling vegetables when cooking meals for the family.

Dr Vichai has written books and articles and gone on radio and television to raise public awareness on the subject, but the number of patients needing treatment is still on the increase.

In fact some of the high-risk activities which cause trigger finger can be avoided, he said.

"When carrying plastic bags, have a cloth or small towel ready to wrap around the handle, and carry the bag in your palm instead of having it hang on one or two fingers," he advised. "Whenever possible use a trolley or mechanised equipment instead of doing the work manually."

What happens if the affected finger isn't treated? "Eventually it becomes deformed," Dr Vichai said.

The surgeon grades trigger finger according to severity. "In Grade 1 you feel painful tenderness at the base of the finger; this can be cured by rest and physical therapy. In Grade 2 the finger doesn't bend with the others but when it does it unlocks by itself; this can be cured by rest and physical therapy plus anti-inflammatory drugs and/or steroid injections in the tendon sheath. Grade 3 is when the finger cannot unlock by itself and has to be prised open, and Grade 4 is when the finger is deformed and cannot be unlocked.

"For Grade 3, surgery is necessary when all other remedies prove useless, while Grade 4 can be cured only by surgery."

The traditional method is open surgery at the base of the affected finger. This takes about half an hour. The incision is at least about two centimetres long, is more prone to infection and takes months to heal fully. Over years the scar may contract in some cases, causing tenderness in the area which has been operated on.

In his early years at Lerdsin, where he has worked for the past 20 years, Dr Vichai used to operate using the traditional method. Six years ago, he devised a new technique which is cheaper, needs no stitches and leaves no wounds nor scars, and takes only five to 10 minutes from the time the hand is scrubbed up to the time it is bandaged. It can be carried out while the patient is in either a sitting or a prone position.

This writer had one such operation on her forefinger recently. A nurse instructed me to wash my hand, then she applied a tourniquet around my wrist and sterilised my palm before Dr Vichai took over. He probed the base of my affected finger to feel for uneven movement, then he injected it with a local anaesthetic before puncturing the skin with the tip of his instrument to release the pulley and the fibrous sheath. Before I knew it he had cleared the tendon of impediments and I could move my finger freely. The whole operation took only about five minutes.

When I removed the dressing three days later I was surprised to find no puncture mark on my palm. By the third week my finger had healed fully. By contrast, an open surgery I had on my left-middle finger in another hospital left not only the scars of three stitches but a lingering pain in my palm _ nearly eight years after I had had the operation.

"Actually this probing or percutaneous technique is not new," Dr Vichai said. "Since an orthopaedic surgeon named Lorthioir came up with the idea in 1958, several methods using a hook or a needle had been reported with satisfactory results. I devised my own tools using dental instruments I sharpened as small knives, which are easier to handle and strong enough even for the toughest cases."

Over the past six years Dr Vichai has operated on thousands of fingers using his specially designed instruments. After trying his method, a satisfied Dr Pongsak Vathana, chairman of the Arthritis Foundation and a member of the advisory board to the Royal College of Orthopaedic Surgeons of Thailand, predicted that in the near future the technique will be used as a world standard for the treatment of trigger finger.

Already, surgeons from Canada and the US have adopted the Thai doctor's technique. "I taught a Canadian hand surgeon, Dr Phil Narini, three years ago and he has informed me of his continued success with my technique," Dr Vichai said with pride. "He no longer practises open surgery like he did before."

More recently Dr David Rowe from the Medical College of Wisconsin, an academic institution in the US, spent two weeks in Bangkok observing Dr Vichai's work and learning from him.

Dr Rowe was observing when this writer went to consult Dr Vichai at Lerdsin Hospital. I was the 25th patient he checked that day, but the first to be operated on, with the surgeon explaining every step to the US observer.

Dr Rowe was surprised at the number of patients coming to see Dr Vichai. "In America cases like this are very rare," he said, adding that he believed the number of percutaneous trigger-finger releases that Dr Vichai had performed during the two weeks he himself was in Bangkok was far more than the number of cases ever reported in the US.

Over the years Dr Vichai and his colleagues have brought their know-how to Chanthaburi, Nakhon Ratchasima, Surin, Ubon Ratchathani, Udon Thani and several other provinces, doing mass operations free of charge to mark royal birthdays. On His Majesty the King's birthday on December 5 last year, they performed 94 surgical operations on 84 patients at the State Tower next to Lerdsin Hospital as a tribute to His Majesty.

"In the past we received support from the Rotary clubs of Charoen Nakhon and Phrakhanong, as well as District Governor 3350 Rotary International," Dr Vichai said. "The operations were both cheap and effective, and if we get further support we might go to neighbouring countries [to alleviate the suffering of patients there]."

For Dr Vichai, the satisfaction comes from being able to help people with deformed fingers regain full use of their hands. "Since I started the new technique, the number of fingers I've operated on has reached nearly 5,000, and I expect to operate on another 5,000 in the next two years.

"Treatment for trigger finger is available in any hospital in Thailand. But prevention is better than cure, and I'd be happiest if people were to heed my warnings and avoid doing things that could trigger trigger finger in the first place."

Dr Vichai Vijitpornkul can be found at Lerdsin Hospital (02-353-9799) from 8:30am to noon on Mondays, Tuesdays and Thursdays, and from 1:30 to 4pm on Fridays. At other times, and on weekend mornings, he treats patients at Rungjaroen Polyclinic. Web site: