Trigger finger

Diagnosis and presentation

Description

Trigger finger is a disorder characterised by intermittent triggering or locking of the finger or thumb with or without pain, generally occurring in the palm at the level of the metacarpophalangeal (MCP) joint. In most cases it is due to a non-inflammatory thickening of the digit’s A1 pulley with secondary entrapment and/or sometimes thickening of the tendon(s)/ inflammatory nodules; however the exact aetiology remains unclear.

Diagnosis

Initially made on the basis of clinical symptoms and physical examination

History; Patients often present complaining of painful triggering or sticking of the finger on flexion or extension, with symptoms usually worse in the morning. It is more common in women than men and most common during the 5^th or 6^th decade.

Physical Examination

Palpation along the tendon, in particular at the level of the A1 pulley may reveal tenderness and/or swelling/ palpable nodule.
Grinding or swelling may be felt on movement of the affected finger and triggering may be reproduced.

Differential diagnosis

Dupuytren’s contracture
Flexor tendon/sheath tumour (rare and would not trigger)
Subluxed extensor tendons (severe RA)
Ganglion

Signs and Symptoms

Mild - Moderate

Catching or clicking or triggering
Pain
Difficult active extension
Interrupted movement pattern
Needs passive extension

See 1st line management

Moderate - Severe

Regular catching that requires passive correction
Locked finger
Trauma

See 2nd line management or Surgical review

Management

First line management

If symptoms <6/52 / only nocturnal symptoms

Information on the nature of trigger finger and management should be given to the patient. National Trigger Finger Patient Information Leaflet

Advice on use of night splint to avoid flexion if nocturnal triggering. Splint can be self manufactured for example using ice lolly sticks to keep the fingers as straight as possible.

Treatment with limited evidence

NSAIDs

Second line management

The patient may be offered a corticosteroid injection. Guidelines suggest this can be repeated within the recommended time frame, with a maximum of 2 injections in total.

If the patient declines injection or there is minimal benefit, consider referral for splinting to a hand therapist. At present no off the shelf splint is recommended within GG&C.

Treatment with limited evidence

NSAIDs

Progression and escalation

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other

Escalate if:

No improvement with conservative treatment

CSI not an option

Severe Triggering

Surgical review

Post operative

NHSGGC Hand Service Orthopaedic and Therapy Post Operative Guidelines

Trigger Finger

Day of Surgery

Bulky dressing in situ, to be reduced in 48hrs by the patient.
Give patient 2 mepore dressings.
Discharge with/ without sling as per surgeon’s protocol.
Check circulation, sensation and movement.
Instructions on elevation of limb, mobilisation of fingers and the rest of upper limb.
Patient provided with post operative information sheet if they do not already have it.
Specify how and who to contact if there are any problems.
Fit note provided for the duration of expected absence if required.

Review Clinic (10-21 days) (in some localities suture removal may be done by practice nurse with/ without additional post operative review)

Remove dressing/ sutures if required.
Check wound

Any evidence of infection contact surgical team.

Continue with light finger dressing only if required.

Check ROM

Stiffness of wrist and hand - is the patient able to fully open and close fist. Advise on exercises as per leaflet.

Scar Care

Once wound has healed gently massage with an emollient hand cream 3-4 times daily.

Returning to work

Avoid dirty environments and ensure dressing remains dry.
Light manual 2-3 weeks.
Heavy manual 4-6 weeks.

Driving

Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.

Provide patient information leaflet if they don’t already have.
Specify how and who to contact, if there are any problems.

Problematic Pain

Consult the Pain Service section within Exit Routes [add link to exit routes RDS page?] for information and guidelines on diagnosis and management of Complex Regional Pain Syndrome.

Evidence

Huisstede, B.M.A. et al. (2014) Multidisciplinary consensus guideline for managing trigger finger: results from the European HANDGUIDE Study, Physical therapy, 94(10), pp. 1421–1433. Available at: https://doi.org/10.2522/ptj.20130135. https://nhs.primo.exlibrisgroup.com/permalink/44NHSS_INST/nf660i/cdi_unpaywall_primary_10_2522_ptj_20130135

Peters‐Veluthamaningal C., et al (2009) Corticosteroid injection for trigger finger in adults. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD005617. DOI: 10.1002/14651858.CD005617.pub2. https://www-cochranelibrary-com.knowledge.idm.oclc.org/cdsr/doi/10.1002/14651858.CD005617.pub2/full?highlightAbstract=finger%7Cthe%7Cinjections%7Ctreatment%7Cin%7Cof%7Ccorticosteroid%7Ctrigger%7Cinject

Lu, S.-C. et al. (2015) Finger Movement Function After Ultrasound-Guided Percutaneous Pulley Release for Trigger Finger: Effects of Postoperative Rehabilitation, Archives of physical medicine and rehabilitation, 96(1), pp. 91–97. Available at: https://doi.org/10.1016/j.apmr.2014.09.001. https://nhs.primo.exlibrisgroup.com/permalink/44NHSS_INST/nf660i/cdi_proquest_miscellaneous_1640330610