1. Trigger Digits: Diagnosis and Treatment
Miguel J. Saldana, MD
Abstract
Stenosing tenosynovitis of the thumb and fingers is a very common problem Pathophysiology
seen by the primary-care physician, the orthopaedic surgeon, and the hand sur-
geon. Primary stenosing tenosynovitis is usually idiopathic and occurs more The flexor digitorum profundus,
frequently in middle-aged women than in men, but can be seen even in infancy. flexor digitorum sublimis, and flex-
Secondary stenosing tenosynovitis of the digits can occur in patients with or pollicis longus (FPL) should
rheumatoid arthritis, diabetes mellitus, gout, and other disease entities that glide through the annular pulley
cause connective tissue disorders. The diagnosis of triggering digits is generally system unobtrusively in flexion
not subtle and can be made on the basis of an adequate clinical examination. and extension of the digits. Nor-
Classification according to the type of tenosynovitis and the time from onset of mally, there is a double synovial
symptoms may be prognostically significant and may also affect the treatment sheath that facilitates smooth glid-
outcome. As many as 85% of triggering fingers and thumbs can be treated suc- ing. This synovial membrane is
cessfully with corticosteroid injections and nonsteroidal anti-inflammatory intimately involved with the ten-
drugs. Surgical release is generally indicated when nonoperative treatment dons and the pulley system.2 The
fails. Percutaneous A1 pulley release can now be performed safely as an office proximal ends of the A1 pulleys are
procedure. fulcrums. Considerable angulation
J Am Acad Orthop Surg 2001;9:246-252 of the flexor tendons occurs at the
proximal edge of the A1 pulley
during forceful flexion of the digits.
Stenosing tenosynovitis is a
Trigger fingers and thumbs are with clinically triggering digits— pathologic disproportion between
characterized by the inability to flex nodular and diffuse.1 This classifi- the volume of the retinacular sheath
or extend the digit smoothly. All cation is based on the findings on and its contents. This disproportion
digits can be affected, but the ring palpation of the swelling of the ten- inhibits gliding as the tendon moves
finger is most often involved, fol- don sheath. If the swelling is con- through the A1 pulley. Inflamma-
lowed by the thumb and the long, tained so that there is a definite tion manifests itself as a spindle-
index, and small fingers, in that nodule that moves back and forth shaped thickening in a localized
order. 1,2 More than one trigger under the examiner’s finger as the area of the flexor tendon. In nodu-
digit can be present on the same digit triggers, the inflammation is lar stenosing tenosynovitis, this
hand. Triggering of digits in both considered nodular. If the swelling occurs just distal to the A1 pulley,
hands is also common. The sensa- is instead more diffuse and less de- where tendon friction deforms the
tion experienced with inability to fined, the condition is considered tendon and causes a nodule to
comfortably make a fist or extend diffuse. Nodular trigger digits will
the fingers adequately is described respond much more favorably to
by most patients as a painful snap- corticosteroid injection and non-
ping, which often makes them steroidal anti-inflammatory drugs Dr. Saldana is in private practice with Hand
reluctant to make a full fist. Even if (NSAIDs) than those with diffuse and Microsurgery Associates, San Antonio, Tex.
only one digit is involved, hand involvement.1
Reprint requests: Dr. Saldana, Hand and
function can be seriously compro- The duration of symptoms is an
Microsurgery Associates, Nix Medical Center,
mised. This is especially true if the important factor in the treatment Suite 809, 44 Navarro, San Antonio, TX 78229.
triggering is so pronounced that it outcome. If the condition has been
locks the finger or thumb in flexion. present for more than 6 months, it Copyright 2001 by the American Academy of
There are two types of pathologic will be less likely to respond to Orthopaedic Surgeons.
involvement of the tendon that occur nonoperative management.1
246 Journal of the American Academy of Orthopaedic Surgeons

2. Miguel J. Saldana, MD
form.3 In diffuse stenosing tenosy- phies, and the ovoid cells increase on the palmar side of the MCP joint,
novitis, the inflammation will not be in number and have the histologic with pain frequently radiating into
as localized and may well extend appearance of chondrocytes.4,5 the forearm. When triggering oc-
beyond the A1 pulley.3 With sec- The tendon undergoes similar curs, it is not uncommon for the
ondary inflammation, such as that thickening on the avascular side of patient to perceive the snapping as
due to rheumatoid arthritis, the nor- the tendon, which rubs on the A1 occurring at the proximal interpha-
mal relationship between the reti- pulley in nonrheumatoid triggering.4 langeal (PIP) joint. Mild triggering
nacular sheath and its contents can The thickening is due not to prolifer- is more apt to be present in the early
sometimes be restored by treating ation of the synovial membrane cells, morning and becomes less bother-
the underlying disease. but rather to fraying and disintegra- some as the fingers and hand are
The palmar plate of the metacar- tion of the stenotic segment.4,5 On used throughout the day. This phe-
pophalangeal (MCP) joint of the histologic examination of superfi- nomenon of improvement does not
thumb is associated with the thumb cialis tendon nodules, immunohisto- occur if the stenosing tenosynovitis
sesamoids and the tendinous slips chemical staining showed S-100 is more severe and locking occurs.
of the adductor pollicis, the abduc- protein, which is present in chondro- A careful history and a thorough
tor pollicis brevis, and the A1 pul- cytes.4 The histologic changes in the physical examination are important
ley. The FPL tendon approaches the triggering superficialis tendons were parts of the evaluation. Medical
palmar plate and the retinacular similar to those observed in the A1 conditions such as rheumatoid
tunnel of the thumb at a more acute pulleys—fibrocartilaginous metapla- arthritis, diabetes, gout, carpal tun-
angle than the flexor tendons of the sia and positive staining for the S-100 nel syndrome, de Quervain’s teno-
fingers before they enter the retinac- protein, with associated chondrocytes synovitis, Dupuytren’s contracture,
ular sheaths, which gives the FPL a at the site of injury to the tendons. and hypertension may be associated
mechanical advantage. This ana- The pathologic changes in chil- with the occurrence of triggering.7
tomic arrangement may contribute dren with trigger digits are quite Tumors of the tendons, foreign bod-
to the frequency of triggering in the different from those in adults. Trig- ies, and exostoses have also been
thumb.3 gering generally occurs early in life, implicated.
The A1 pulley may hypertrophy and parents note that the thumbs On physical examination, pain at
to two to three times its usual thick- are flexed at the terminal phalanx. the palmar base of the involved
ness, thus narrowing the space avail- There is usually a mass palpable on digit associated with crepitus on
able for the tendon considerably. In the palmar aspect of the MCP joint. palpation is indicative of early
early studies, Hueston and Wilson3 The thumb can be actively and pas- tenosynovitis. Once deformation of
described the spiral arrangement of sively flexed at the MCP joint, but the tendon has occurred, “catching”
the tendon fibers as they unfurl there is a block to full extension at of the digit will be manifested as the
when passing through the tight ful- 10 to 20 degrees. Nonoperative patient tries to extend the fingers
crum of the A1 pulley, creating a modalities have not been successful from a fist position. More severe
nodule on the distal side of the pul- in infants and children because stenosing tenosynovitis will lock
ley. They likened this process to most present with long-standing the finger or thumb in flexion, re-
pulling an oversized thread through trigger digits. The most common quiring the patient or examiner to
the eye of a small needle, which findings at surgery are nodules on push the finger into extension; there
causes the thread to unravel. the FPL without hypertrophy of the will be noticeable “give” on unlock-
The A1 pulleys of normal and A1 pulley.6 ing. The patient will not be able to
triggering digits have been exam- fully extend a finger at the distal
ined histologically. The normal A1 interphalangeal (DIP) joint or an in-
pulley has two layers: a vascular Diagnosis volved thumb. At the initial exami-
outer layer and a collagenous inner nation, it should be determined
layer that extends to the gliding Triggering digits are more common whether the swelling is diffuse or
surface, where most of the friction in women than in men.1 The pre- nodular.1
between the tendon and the pulley sentation varies widely. Initially,
occurs. On hematoxylin-eosin the triggering may not be painful.
staining, the gliding layer has been The patient may feel a mild click in Classification
shown to contain a biphasic popu- the finger or may report inability to
lation of spindle-shaped fibroblasts fully flex the finger. As the stenos- Quinnell8 first classified the severity
and ovoid cells. In diseased A1 ing tenosynovitis becomes more of triggering digits into five grades
pulleys, the gliding layer hypertro- severe, there is distinct discomfort on the basis of occurrence in both
Vol 9, No 4, July/August 2001 247

3. Trigger Digits
flexion and extension but did not
use the classification as a basis for Stenosing tenosynovitis
treatment. Eastwood et al 9 and
Patel and Moradia10 have similar
classifications for digital stenosing Triggering digit Locked digit
tenosynovitis. Like Quinnell’s, their (grades 1 to 3) (grade 4)
classifications are based on the
degree of severity of the tenosyno-
vitis, with grade 0 involving mild <6 mo >6 mo
crepitus in a nontriggering digit;
Surgery or
grade 1, uneven movement of the Unresolved percutaneous
digit; grade 2, clicking without lock- Nonoperative treatment • Nonoperative release
(massage, ice, NSAIDs, treatment
ing; grade 3, locking of the digit that splinting) • Steroid injection
is either actively or passively cor- • Recheck at 1 mo
No further
rectable; and grade 4, a locked digit. Resolved
treatment
Both groups of authors agreed that Resolved Unresolved
grade 0 should be treated by injec-
tion; grade 4, by percutaneous re-
lease.9,10 Newport et al11 presented No further • Nonoperative
a simpler grading system for stenos- treatment treatment
• Steroid injection
ing tenosynovitis in which the three • Recheck at 1 mo
grades carried a recommendation
regarding treatment with steroid in-
jection. Resolved Unresolved
Treatment should be based on
Surgery or
whether the stenosing tenosynovitis Unresolved percutaneous
is diffuse or nodular and the dura- No further • Second steroid
release
tion of symptoms1 (Fig. 1). It is im- treatment injection
portant to distinguish between • Recheck at 1 mo
No further
these types at presentation because Resolved
treatment
early nodular tenosynovitis may
respond to massage, ice therapy, and Figure 1 Algorithm for the treatment of stenosing tenosynovitis.
splinting. Early diffuse or more
advanced nodular tenosynovitis
will generally not respond to non-
operative modalities. ment and steroid injections mark- cases, no causative element can be
In one series of 101 triggering edly decreases with a duration of identified.13 Treatment should be
digits treated with steroid injection,1 symptoms longer than 6 months. instituted as soon after the occur-
the combined success of treatment rence of symptoms as possible.
for both diffuse and nodular teno-
synovitis was 70%. However, 93% Nonsurgical Treatment Noninvasive Modalities
of the digits with nodular disease Nonsteroidal anti-inflammatory
responded successfully to injection, Observation combined with avoid- drugs should be the initial form of
compared with only 48% of those ance of inciting activities may be treatment unless inadvisable be-
with diffuse disease. The average adequate in mild cases of stenosing cause of the patient’s age or the
duration of symptoms for the dif- tenosynovitis. Repetitive trauma to presence of a peptic ulcer diathesis.
fuse type of tenosynovitis was 11 the hands, such as may occur in gar- Use of NSAIDs can be combined
months, compared with 4.5 months dening, sewing, cutting with scis- with massage, ice therapy, splinting,
for the nodular type. sors, cake decorating, and bongo and injections.
Several authors have considered playing, may be the cause of the ini- Splinting has been advocated by
whether the duration of symptoms is tial trauma to the fingers. If these some authors.14,15 Some use prefabri-
prognostically related to a favorable activities are modified or avoided, cated splints, and others tailor splints
response to steroid injection. 1,9-12 spontaneous resolution of tenosyno- for individual patients. 14 Some
Response to nonoperative manage- vitis can occur. However, in most advocate 0 degrees of flexion of the
248 Journal of the American Academy of Orthopaedic Surgeons

4. Miguel J. Saldana, MD
MCP joint; others allow 10 to 15 stenosing tenosynovitis should be ringe, which is reconnected to the
degrees of MCP joint flexion. All treated with only one steroid injec- needle left in the finger. The patient
splints should allow free motion of tion 1 and only if symptoms have is again asked to wiggle the finger to
the PIP and DIP joints. Grade 4 been present for less than 4 months. ascertain the correct position of the
(locked) digits will not respond to If symptoms have been present for needle. The injection is finished,
splinting. For the splints to be suc- longer than 4 months or persist after and the needle is withdrawn.20
cessful, they may have to be worn the initial injection, surgical release It is preferable to use the midlat-
for as long as 4 months. Even custom- is appropriate without further non- eral approach for patients who pre-
ized splints are very cumbersome, operative treatment.1,12 sent with grade 1 or grade 2 disease
and lack of success with splinting Steroid injection into the tendon and a small nodule and for patients
may be due to lack of compliance. sheath can be done from either a lat- with diffuse tenosynovitis of the fin-
In early nodular tenosynovitis, the eral or a palmar approach. Both gers. The treated digit should re-
combination of massage, finger approaches involve injection into main anesthetized for 3 to 4 hours.
splinting, and NSAIDs has been the tendon sheath. The tendon- Benefits from the steroid injection
successful. sheath volumes of the index, long, should persist for 2 to 5 days after
and ring fingers are limited because the procedure.
Corticosteroid Injection the sheaths end at the proximal The palmar approach is equally
Nonoperative treatment of trig- edges of the A1 pulleys. The sheaths effective, but it can be more painful
ger digits may include corticosteroid of the small finger and the thumb because the palmar aspect of the
injections into the tendon sheath. If potentially communicate with each hand has more sensory endings
steroid injection is to be used, both other through the wrist and can than the lateral and medial aspects
the physician and the patient should accept larger volumes.2 of the fingers. The neurovascular
have a clear understanding of the The lateral approach is less pain- bundles are located on the medial
risks and benefits. First introduced ful (because the neurovascular bun- and lateral aspects of the pulley sys-
by Howard et al16 in 1953, the use of dle lies palmar to the area of in- tem. They are more dorsally located
steroid injections has been amply jection) and perhaps easier. A 1-cm3 than the palmar surface of the ten-
reported with varying degrees of syringe with a 25- or 27-gauge 0.5- don sheath and therefore should not
success. All grades of tenosynovitis inch needle is used. From the radial be encountered if the injection is
have been treated with injections, border of the finger, the needle is given in the midline of the tendon.2,9
and all have been reported to re- inserted into the midlateral area of The palmar approach is preferred
spond. The response has varied the proximal phalanx above a line for grade 3 or grade 4 disease and
from 42% to as high as 92% with as connecting the PIP and DIP joint for the second injection. For more
many as three injections.13-19 creases over the first cruciate pulley advanced disease, a larger dose of
Many forms of injectable cortico- (the neurovascular bundle lies pal- steroid is recommended, and a 3-cm3
steroids have been used, among them mar to that line).2 The skin and sub- syringe is used instead of a 1-cm3
betamethasone sodium phosphate cutaneous area are anesthetized syringe.
and acetate suspension, precipitated with 1% xylocaine without epi- The distal palm in the area of the
hydrocortisone, triamcinolone, tri- nephrine. A1 pulley is cleansed with povidone-
amcinolone acetonide, and methyl- The needle is inserted only until iodine solution or an alcohol swab.
prednisolone. Betamethasone sodium slight resistance is felt. The patient A 30-gauge 0.5-inch needle is used
phosphate and acetate suspension is is asked to wiggle the finger. Slight to anesthetize the area around the A1
the most commonly used because it grating can be felt at the end of the pulley as well as the tendon sheath
is water-soluble; does not precipi- needle. If the needle is in the tendon with 1 mL of 1% xylocaine without
tate, leaving a residue in the tendon proper, there is paradoxical motion epinephrine. Then 1 mL of the ste-
sheath; and does not cause tenosyno- of the needle and syringe (i.e., with roid is mixed with 1 mL of 1% xylo-
vitis after injection. It is also known digit extension, the syringe moves caine and 1 mL of 0.25% bupivacaine
to cause less fat necrosis if it is in- proximally). The rest of the anes- and injected into the tendon sheath
jected into fat around the tendon thetic is then injected into the tendon and around the nodule. It has been
sheath. sheath. The needle is disconnected shown that steroid injection around
Early nodular trigger digit can be from the 1-cm3 syringe but left in the tendon sheath can be of benefit.12
treated with an injection into the place, and the syringe is reloaded. When bupivacaine is used as part of
tendon sheath. An NSAID should When a corticosteroid is used, 0.75 the injection mix, the patient should
accompany the injection if there is mL of such an agent and 0.25 mL of be warned that the anesthesia may
no history of ulcer disease. Diffuse 1% xylocaine are loaded in the sy- last as long as 24 hours.
Vol 9, No 4, July/August 2001 249

5. Trigger Digits
Surgical Treatment is performed, and the patient is the area of the A1 pulley. A corti-
asked to flex and extend the digit costeroid is used with the initial
Surgical release of the A1 pulley intraoperatively. If triggering is still local anesthetic because painful
can be done through either a trans- occurring, the release should be tenosynovitis without triggering
verse or a longitudinal incision in checked for completeness; further can occur after release when a
the palm.6-8,21,22 It is important to release of the A1 pulley may be war- steroid is not used.10
protect the neurovascular bundles ranted. If no further triggering After the finger or thumb has
on both the medial and the lateral occurs, the tourniquet is released, been well anesthetized, the patient
side. Local anesthesia is preferable bleeding is checked, and the patient is asked to actively trigger the
because it allows active flexion and is asked to make a fist. Sometimes, if affected digit. A 20-gauge, 1-inch
extension on the operating table, the tourniquet has been inflated for needle is then inserted with the
and the completeness of the release 15 to 20 minutes, the patient will be sharp bevel parallel to the tendon.
can be confirmed. unable to make a full fist, and trig- The needle is inserted one third the
Open release of the A1 pulley is gering may occur at the extremes of distance from the distal palmar
the traditional form of surgical treat- motion. Therefore, triggering should crease to the base of the long, ring,
ment. However, percutaneous re- be checked for again while the or small finger. In the case of the
lease has been advocated by some tourniquet is deflated. The incision index finger, the needle is inserted
authors.9,10,23 It has several advan- is closed with interrupted sutures, one third the distance from the dis-
tages, including the fact that it can and a simple dressing is applied. tal thenar crease and the base of the
be safely performed in the office. finger. These locations have been
Local anesthesia allows immediate Percutaneous Technique found to consistently correlate with
confirmation of trigger release. For percutaneous release of the the middle of the A1 pulley and to
Avoiding a surgical incision on the A1 pulley, the affected hand and allow cutting both proximally and
skin allows the patient to get back to distal forearm are prepared and distally to completely transect it24
employment or activities of daily draped with the patient sitting (Fig. 2). In the thumb, the needle is
living almost immediately. The op- across the examination table. A 3- inserted at the intersection of the
erating room cost, anesthesia cost, cm3 syringe is used to anesthetize proximal thumb crease and a line
and time lost from work are avoided
with successful percutaneous re-
lease.
Drawbacks of percutaneous re-
lease include incomplete release of
the A1 pulley and potential injury
to adjacent neurovascular struc-
tures, to the tendons themselves, or
to the volar plate. The proximity of
the radial sensory nerve to the A1 } ⁄3
1
pulleys of the thumb and the index
finger has prompted some authors
}⁄2 3
to recommend that these digits not
be treated with percutaneous re-
lease.9,23 Others have safely used
percutaneous release for all digits.10
Surgical Technique
Surgical release of the A1 pulley is
done with local anesthesia and
A B
tourniquet control. Either a longitu-
dinal incision starting at the distal Figure 2 Technique for percutaneous sectioning of the A1 pulley in the fingers. A, Needle
palmar crease or a transverse inci- entrance points (dots) are located approximately one third the distance from the distal pal-
sion in the distal palmar crease can mar crease and two thirds the distance from the proximal digital crease. This corresponds
to the center of the A1 pulley. B, Diagram depicts the location of the A1 pulleys in the fin-
be used. The neurovascular bundles gers and the A2 pulley in the small finger. Half of the A2 pulleys are located in the distal
on either side should be identified palm.
and protected. The A1 pulley release
250 Journal of the American Academy of Orthopaedic Surgeons

6. Miguel J. Saldana, MD
perpendicular to it. Insertion at this
point avoids the radial digital nerve Digitopalmar crease
of the thumb24 (Fig. 3).
The A1 pulley is cut with a swip-
ing movement of the needle. A def- Sensory
inite grating should be felt. Once nerves
the pulley is thought to have been
transected, the needle is withdrawn,
and the patient is asked to flex the
digit. If triggering has ceased, the
procedure is finished. If triggering
persists, the nodule is gently pal-
pated to feel where it is catching on Distal interphalangeal crease
the A1 pulley. The needle is then
reinserted so as to cut more proxi- A B
mally or distally.
Figure 3 Technique for percutaneous sectioning of the A1 pulley in the thumb. A, At the
After percutaneous release, a point where a perpendicular line bisecting the thumb crosses the digitopalmar thumb
small adhesive-strip bandage is crease (bisecting the A1 pulley), a needle can be safely inserted without damage to the neu-
placed on the puncture wound, rovascular bundle. B, Diagram depicts the optimal insertion point for the needle.
and the patient is asked to be care-
ful for 24 hours, because the finger
is usually anesthetized for that quent bowstringing of the tendons, ondary open release of the A1 pul-
period of time. Activities of daily bothersome scars, recurrent symp- ley. No injuries to neurovascular
living or full job responsibilities toms, stiffness, and sympathetic dys- bundles due to percutaneous release
can be undertaken on the next day. trophy.25-27 have been reported to date.9,10,23
Percutaneous release also has
had reported complications.10 In
Complications one study (M. R. Patel, personal Summary
communication, 1997), 50% of the
No complications as a result of corti- patients in the early part of the Stenosing tenosynovitis is a common
costeroid injection for trigger digit series, when only local anesthesia problem that responds well to nonop-
have been reported6-8,12,24; however, was used, had persistent pain asso- erative treatment. This is especially
injection of steroid into the neuro- ciated with finger flexion several true if the condition is treated early
vascular bundle can cause perma- months after the release. The addi- and the inflammation is of the nodu-
nent damage of the digital nerve or tion of a corticosteroid to the anes- lar type. If nonoperative modalities
artery. Complications of surgical thesia mixture eliminated this com- fail, open release and percutaneous
release include digital nerve transec- plication. In that study, several release are both safe and relatively
tion, A2 pulley injury with subse- incomplete releases required sec- simple treatment options.
References
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252 Journal of the American Academy of Orthopaedic Surgeons