Non-steroidal anti-inflammatory drugs
No evidence exists in the literature to suggest that non-steroidalanti-inflammatory drugs alone have any benefit other than temporaryrelief of pain in the palm.
Splintage
The aim of splintage is to reduce or remove tendon excursionthrough the A1 pulley for a long enough time to allow the synovitisaround the pulley to resolve. Rodgers et al found that treatingmanual workers, who used repetitive hand movements, with splintageof the distal interphalangeal joint for six weeks resulted inresolution of symptoms in 53% of patients.17 Patel et al successfullytreated 70% of digits by means of splintage of the metacarpophalangealjoint but were successful in treating only 50% of thumbs inthis way.18 In both studies, those patients with more severedisease and longer duration of symptoms were less likely tobenefit from splintage.
Steroid injection
The injection of steroid into the flexor sheath was advocatedas a method of treatment in 1950. Success rates between 38%and 93% have been reported.7 9 14 Higher success rates are seenwhen injecting the thumb and in patients in whom a well definednodule was palpable or whose symptoms had been present for lessthan six months. In patients in whom treatment fails or whohave a recurrence of symptoms, a second steroid injection offersapproximately half the efficacy of the first injection.9 14w8
No studies have shown that the steroid must be placed withinthe sheath to be effective; on the contrary, Taras et al showedthat steroid injected into the subcutaneous tissue around theA1 pulley gave better clinical outcomes than that injected intothe sheath alone.w9 Injecting into the flexor sheath can provedifficult, as shown by Kamhin et al, who injected trigger fingerswith dye and then went on to do an open A1 pulley release. Theynoted that only half of the injected fingers had dye withinthe sheath and that failure to introduce dye into the flexorsheath was higher in those patients with a longer duration ofsymptoms.19 Complications include dermal or subcutaneous atrophy,skin hypopigmentation, infection, and in one rare case tendonrupture.w10
Percutaneous trigger finger release
Lorthioir first described percutaneous trigger finger releasein 1958, and authors have since described its successful usein the outpatient department.20 The technique involves placingthe extended hand palm up with the metacarpophalangeal jointsin a hyperextended position. The extended position facilitatesaccess and ensures that the A2 pulley is held out to lengthand a maximal distance from the A1 pulley. The A1 pulley isstretched out and held stable in extension. The position alsopresents the pulley in a more superficial position, with theneurovascular bundles drawn medially and laterally away fromthe sheath. The tip of a 16/18 gauge needle is introduced throughthe skin on to the surface of the A1 pulley; the sharp tip ofthe needle is then used to incise the A1 pulley. Pope and Wolfedo not advise this method for release of a trigger index fingerowing to proximity of the radial neurovascular bundle,21 andBain et al apply the same rationale (proximity of the ulnardigital nerve) for not using this technique for the little finger.22Cadaver studies, however, show that safe landmarks are availablefor percutaneous release for both little finger and index finger.1516
Success rates are over 90%.23 w11 w12 Complications are rarebut include digital nerve injury, bowstringing (if release extendsinto the A2 pulley), infection, haematoma, and persistent pain.21-23w11
Surgery
Surgery is done under local anaesthetic in the operating theatre.The A1 pulley is exposed through a palmar skin incision, andthe pulley is divided under direct vision. Success rates varyfrom 60% to 97%. Complication rates can be high; complicationsinclude long term scar tenderness, inadequate release, nervedamage, and flexor sheath infection.24 25
Treatment in children
Children represent a distinct group of patients not only epidemiologicallybut also for treatment. The thumb is involved in 90% of cases.Treatment has traditionally entailed surgical release, but thishas become increasingly controversial as authors have presentedgood results with non-operative methods of treatment.6 w13-w15
Non-operative methods of treatment include physiotherapy administeredby the parents with or without splintage. With physiotherapyalone, success rates of between 52% and 80% cure have been reportedin patients whose thumb is not fixed in flexion or extension.w13w14 With splintage, reports give success rates of 77-89%. Inboth groups, success rates seem to be higher in younger childrenand decrease with age.w14 w15
Clinical review
Management and referral for trigger finger/thumb
Sohail Akhtar, clinical/research fellow1, Mary J Bradley, research and postgraduate manager2, David N Quinton, consultant hand surgeon2, Frank D Burke, professor of hand surgery2
1 27 Belle Vue Avenue, Oakwood, Leeds LS8 2NN, 2 Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby
Correspondence to: S Akhtar [email protected]
