-Percutaneous Technique:

- Percutaneous Technique:
    - in the report by Gilberts et al, the authors compared the results of an open surgical technique with those of a percutaneous surgical
 technique for the treatment of trigger digits;
           - 96 patients with 100 trigger digits were randomized to either open (n = 46) or percutaneous (n = 54) surgical release of the first annular pulley;
           - trigger digits were successfully treated in 98% of the cases using the open surgical technique and in 100% of the cases using the percutaneous technique;
           - mean operation time was significantely longer using the open technique;
           - mean duration of postoperative pain and time to recovery of motor function   Percutaneous release of the trigger finger: an office procedure

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Eastwood-D-M. Gupta-K-J. Johnson-D-P. Department of Orthopaedic Surgery, University of Bristol, England. J-Hand-Surg-[Am]. 1992 Jan. 17(1). P 114-7. A new technique for percutaneous release of the trigger finger is described. A 21-gauge hypodermic needle is used to release the A1 pulley. The technique is effective, convenient, safe, and well tolerated by patients. Thirty-three of 35 procedures (94%) led to complete relief of symptoms, and in the remaining two digits partial symptomatic relief was achieved. There were no significant complications. After a mean follow-up of 13 months, there had been no recurrences. This technique should be the treatment of choice for the established trigger finger with symptoms of more than 4 months' duration.

[Vichai Vijitpornkul]

 

All About Trigger Finger

There are many different types of repetitive stress injuries that may affect an individual.

One of these types of injuries is known as trigger finger. This is a problem that could just be a minor annoyance, but it could also degenerate into a condition that causes the afflicted individual to feel much pain and limits their range of motion.

Most often, these problems are developed due to an overuse and abuse of a certain limb, digit, muscle, or other body part.

In this article, we’ll discuss the syndrome known as trigger finger, informing you about what the problem is, as well as how it can be developed and the methods that doctors use in order to treat it.

The tendons that allow the bones of our body to move can only do so because of the passageways that are provided through ligaments. Normally, the tendons can move through the ligaments smoothly and effectively, allowing motion to occur naturally and without pain.

In the case of trigger finger, the tendon sheath can become inflamed, causing it to move improperly through the finger. When this occurs, a case of trigger finger is the result. A nodule may form due to the aggravation, and it will grow in size until the problem is treated. If the nodule grows to be big enough, the afflicted individual will be unable to properly move their finger. The causes of trigger finger can vary. It’s often experienced due to many tiny micro-tears in the ligament as a result of trauma.

When beginning treatment for a case of trigger finger, most doctors often prescribe plenty of rest for the afflicted area as well as using medications such as ibuprofen and aspirin.

These fall under the category of non-steroidal anti inflammatory drugs used to reduce the swelling and inflammation. If a few weeks of rest and regular use of anti inflammatory drugs aren’t helping the situation, injections of steroids into the area may be used.

The use of cold packs can also be beneficial in reducing swelling and keeping the pain to a minimum. Massage has also shown to be of merit when it comes to reducing the size of the nodule that is present within the digit affected by trigger finger. Again, however,  the more serious cases of trigger finger may require minor surgery in order to be healed.

After a case of trigger finger has been successfully treated, a carefully selected exercise program can be helpful in preventing a future relapse of the injury. Stretching and strengthening exercises can be of intense benefit in keeping the problem to a minimum.

If you think that you may be experiencing the onset trigger finger, consult with your doctor in order to get a proper diagnosis. The longer that you wait to get treated, the harder it will be to eliminate the problem and get back to regular usage of the affected finger or fingers.

[Suwichaya]

Stenosing Tendovaginitis (Triggerfinger)

Definition
Stenosing tenosynovitis, also known as trigger finger or trigger digit, was first described by Notta in 1850. This is caused by a size mismatch between the flexor tendon and the first annular (A-1) pulley, and the finger may be locked in a flexed position.

Anatomy
In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide. These pulleys hold the tendons close against the bone. The digital flexor tendon sheath has five annular pulleys (A-1 to A-5), and three cruciate pulleys (C-1 to C-3). The A-2 and A-4 pulleys are functionally most important. The thumb has one oblique and two annular pulleys. Wilhelmi described longitudinal and transverse landmarks for determining the proximal and distal edges of the A1 pulley and to avoid injury to neurovascular structures during operation.

Clinical signs and symptoms
Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb. The size mismatch between the flexor tendon and the A-1 pulley make it hard for the tendon to move freely through the pulley, and may give painless clicking with finger movement, painful triggering, and secondary contracture at the PIP joint. The flexor tendon usually locks or clicks at the level of the A-1 pulley, and the finger may become locked in a flexed position. When the tendon catches, it produces inflammation and more swelling. This in turn causes more triggering, inflammation, and swelling. A bump (nodule) may be noticed in the palm of the hand. Because the extensors to the finger are not powerful enough, release of the flexed position requires passive manipulation. Middle-aged women and the ring finger or thumb are most often affected. Sometimes the disease is associated with rheumatoid arthritis, gout, diabetes, or local trauma to the palm/base of the finger. In most cases, however, the cause is unknown. In the rheumatoid trigger finger the A-1 pulley should not be opened, because incising A-1 pulley may cause bowstringing of tendon and deviation of the finger toward midline and propencity for anterior MCP subluxation.

Treatment
The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. There are various methods for the treatment of trigger digits/thumbs. Conservative management includes rest by splinting, but this is not very effective. Taking an oral anti-inflammatory medication may sometimes help. Changing activities may also reduce swelling. Local injection with steroids is another option and can be successful.
Surgery is performed as an outpatient treatment, usually with tourniquet control for a bloodless field and local or regional anesthesia. The goal of all forms of surgery is to open the A1-pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger/thumb begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits.

Open release
Surgical treatment traditionally consists of open A-1 pulley release in which the pulley is completely visualized and dissected. A longitudinal or transverse incision is made. Some surgeons prefer a curved incision in order to prevent the skin scar over the area of trigger finger release. In case of a transverse incision, it is placed in the proximal palmar crease for the index finger, between the palmar creases fort he middle finger, and in the distal palmar crease for the ring and small fingers. In case of the thumb a transverse or zig-zag incision at the metacarpophalangeal joint can be made. Some surgeons prefer a transverse incision in the MP flexion crease. Care should be taken for the radial digital nerve in the thumb because of the proximity of the nerve to the skin surface. The neurovascular bundles are retracted, and the A-1 pulley is identified and sectioned. The wound is closed with a suture. The long-term prognosis is excellent.

Endoscopic release
In a Smith & Nephew Technique Plus™ illustrated guide on endoscopic tendon sheath release for trigger finger one can find that endoscopic release of the A1-pulley can be performed as a minimally invasive technique. The A1 pulley is released under direct endoscopic visualization.
Surgery is performed using a pneumatic tourniquet under local anesthesia or wrist block, and fingers are positioned in a hyperextended manner at the MP joints. Two incisions are necessary for this technique, 1 cm proximal and 1 cm distal to the A1 pulley. Thumb portal locations are more distal compared to those in the fingers. The distal incision is located midpoint between the IP joint and the MP joint. The proximal incision should be carefully placed since the flexor pollicis longus is difficult to palpate in the palm. Separation of the flexor tendon and subcutaneous tissue is performed using curved, blunt dissector. The window cannula assembly is inserted subcutaneously along the flexor tendon from the proximal portal and advanced until it passes through the distal portal. The obturator is then removed. An endoscope is passed into the proximal portal to examine the anatomy through the cannula window. A probe can be used to palpate tissue, confirm anatomical structures, and pinpoint the proximal edge of the A1 pulley. Cotton-tipped applicators can be used to clear the operative site and to wipe the endoscope lens. A retrograde knife is inserted into the operative site from the distal portal. The proximal edge of the A1 pulley is hooked, and the entire length is sectioned under direct endoscopic vision. After completion of the A1 pulley release, the synovial sheath may be released if the flexor tendon is longitudinally covered with synovium. A triangle knife is useful for the A-1 pulley release.
This can be seen as a form of overkill treatment for release of a trigger finger. This procedure is relatively expensive, time consuming, and has no functional advantages over the open technique for trigger finger release.

Minimal invasive release
Percutaneous release of the A-1 pulley is even less invasive and cheaper compared to endoscopic and open surgical techniques. In the percutaneous technique a needle or a small (sometimes custom made) knife is used (Fig. 6). After local anesthesia is induced, the needle or knife is introduced through the skin over the A-1 pulley. It is then positioned in such a way that the sharp edges align with the longitudinal axis of the ray. A grating sensation is observed and can also be felt by the tip of the index finger of the surgeon from outside the skin (Fig. 7). After cutting the complete A-1 pulley, the patient confirms the successful release by demonstrating unhindered motion in flexion and extension. Functional results and complications after percutaneous release are not significantly different from open release of the A1 pulley. Although this is a quick and simple technique, the operation is performed without vision of the anatomy, however can be very precisely performed by using Wilhelmi's longitudinal and transverse landmarks for the A-1 pulley. It is advised not to perform this procedure in the thumb and only if the patient has active demonstrable triggering preoperative.
Another minimally invasive technique is using a short incision of a few mm in the palm of the hand at the proximal border of the A-1 pulley. The incision follows the skin crease. The subcutaneous tissue is separated down to the A-1 pulley. The skin and subcutaneous tissue are retracted with skin hooks (including both neurovascular bundles), and the A-1 pulley is exposed. A small speculum is inserted into the wound and gently opened creating a tunnel. The inside of the tunnel is visualized, either by a light source attached to the speculum or by an external light. The A-1 pulley is divided. The wound is closed with one suture. This operation takes about 5 minutes from skin incision to finishing the bandage. In case of proliferative synovitis or amyloid tissue there may be a need to open the skin incision further.

Postoperative
A compression bandage is applied for one day. Mobilization is started immediately. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Sutures are removed after ten days.

Complications
In general complications are rare after trigger finger release.

Digital nerve injury
The nerves supplying sensation to the tip of the finger pulp can be damaged during the surgery and cause temporary or permanent numbness in (part of) the finger. This complication is unusual in trigger finger release, although in trigger thumb release the nerve may be more superficially localized.

Bowstringing
Is a rare complication of trigger finger release caused by excessive loss of the proximal pulleys. As the flexor tendon moves away from the center of rotation of the metacarpophalangeal joint, the flexion moment arm is increased. Thus the flexors gain an increased mechanical advantage over the extensors resulting in limited digital extension.

Vascular injury
The arteries running to the fingers can be damaged during the surgery. Normally two arteries supply each finger and a finger can survive on one artery. A progressive bleeding needs to be stopped. This complication is unusual in triggerfinger release.

Recurrence
A trigger finger can return either after surgery (uncommon) or after more conservative treatment (more common).

Wound infection
Can occur after any operation. This can be painful and may cause wound problems as well. This complication is very uncommon after trigger finger release.

Stiffness and complex regional pain syndrome
About 5% of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation. This cannot be predicted but you will be helped by a handtherapist/rehabilitation doctor. Stiffness of fingerjoints can be the result of too long immobilization.