Recognizing and treating trigger finger
This inflammatory condition can leave your patient in pain and with impaired function. Here's what you need to know about the diagnosis and Tx options to provide relief.
PRACTICE RECOMMENDATIONS
› Recommend splinting as a first-line conservative treatment for trigger finger if there is not a fixed contracture. B
› Prescribe corticosteroids, which may completely resolve trigger finger in the majority of patients without diabetes. A
› Refer patients for surgical release if they do not respond to conservative management. The surgical success rate is as high as 99%. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Surgical treatments in an office setting
Procedures for TF can be safely performed under conscious sedation or local anesthesia, with or without a tourniquet.26 Wide-awake procedures with local anesthesia and no tourniquet (WALANT) can be performed in an office-based procedure room rather than the operating room. This increases efficiency for the surgeon, reduces the amount of preparation and recovery time for the patient, and helps to keep costs down.
Percutaneous release involves the insertion of a 16-gauge hypodermic needle into the affected A1 pulley. The needle is used to fray and disrupt the pulley by moving the needle tip over the fibrotic A1 pulley.
However, it is not without possible complications.27 Inadvertent A2 pulley damage is particularly troublesome, as it leads to “bowstringing” or protrusion of the flexor tendon into the palm upon flexion. This can cause pain and failure to fully extend or flex the finger.10 Because the anatomy is not well visualized during the percutaneous approach, incomplete release, neurovascular injury, and iatrogenic injury to the A2 pulley or deep tendon may occur.28 Ultrasound-guided percutaneous release techniques have shown effective clinical outcomes with minimal complications compared to nonguided percutaneous release techniques.29,30
Open release is the gold standard surgical treatment for trigger finger (FIGURE 3). A small incision (1-2 cm) is made directly over or proximal to the A1 pulley in the distal palmar crease at the base of the affected digit. After blunt dissection through the subcutaneous tissue, the A1 pulley is sharply incised. An open approach has the clear benefit of avoiding the digital neurovascular bundles, as well as visualizing the resolution of triggering upon flexion and extension prior to closure. The WALANT procedure has the advantage of allowing the awake patient to actively flex and extend the digit to determine if the A1 release has been successful prior to closure of the incision.
Outcomes and complications of surgery. A recent systematic review and meta-analysis has shown percutaneous techniques to be successful in 94% of cases.27 The success rate of open surgery has been reported at 99% to 100% at varying follow-up intervals up to 1 year.25,30,31 The complication rate for percutaneous release (guided and nonguided) was calculated at 2.2% (n = 2114).27 In another study, the overall complication rate of open releases was calculated at 1% (n = 999).32 When comparing percutaneous release (guided and nonguided) and open release, a meta-analysis found no significant difference in complication rate (RR = 0.84) or failure rate (RR = 0.94).32
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