Trigger finger, or stenosing tenosynovitis, is a condition where flexor tendons in fingers lock or catch due to an inflamed A1 pulley, commonly affecting the ring finger and thumb. Symptoms include pain, clicking, and locking of the finger, often exacerbated by conditions like diabetes and rheumatoid arthritis. Management options range from splinting and NSAIDs to corticosteroid injections and possible surgical release if conservative treatments fail.

1. TRIGGER FINGER/STENOSING
TENOSYNOVITIS
Dr Saffee Tariq
PGR Orthopaedic surgery

2. INTRODUCTION
• A condition affecting tendons that flex the fingers and thumb,
resulting in a sensation of locking or catching when you bend
and straighten your digits.
• The ring finger and thumb are most commonly affected digits;
• Trigger thumb.

3. ANATOMY
• The flexor tendons are long cord-like structures that attach the muscles of the
forearm to the bones of the fingers and thumb. When the respective muscles
contract, the flexor tendons pull on the bones of the fingers and thumb, causing
them to bend.
• Each of the flexor tendons to the fingers and thumb passes through a separate
tubular structure, called a tendon sheath, as the tendon makes its way across
the palm and into the digit. The tendon sheaths are firmly attached to the
finger or thumb bones.

4. • Along the tendon sheath, bands of tissue called pulleys hold the flexor
tendons closely to the finger bones as the fingers flex and extend. The
pulley at the base of each digit where the digit meets the palm is called
the A1 pulley. This is the pulley that is most often involved in trigger finger.
As long as the other pulleys are functioning, the A1 pulley can be
sacrificed, if necessary, to treat a trigger finger.

7. DESCRIPTION
• In a patient with trigger finger, the A1 pulley becomes
inflamed and thickened, making it harder for the
flexor tendon to glide through it as the finger bends.
Over time, the flexor tendon may also become
inflamed and develop a small nodule on its surface,
further aggravating the condition. When the digit
flexes and the thickened nodule passes through the
tight pulley, there is a sensation of catching or
popping. This is often painful.

9. Pathophysiology
• caused by stenosing tenosynovitis at the A1 pulley
• fibrocartilaginous metaplasia of tendon and/or
pulley.
• proliferation of chondrocytes.
• increased type III collagen.
• chronic hyperglycemia creates collagen cross-links.
• impairs collagen degradation.

10. Pathophysiology
• occasional pathologic nodule of the flexor
digitorum profundus tendon
• flexor digitorum superficialis often unaffected
• trigger thumb may have a fourth pulley
(variable annular pulley) causing stenosis in up
to 75% of patients.

11. Associated Orthopaedic condtions
• rheumatoid arthritis
• calcific tendinitis
• septic tenosynovitis
• carpal tunnel syndrome
• congenital trigger thumb

12. Associated medical conditions
• diabetes
• bilateral hand and multiple digit involvement
is more common
• amyloidosis
• hypothyroidism
• sarcoidosis
• gout
• pseudogout

13. RISK FACTORS:
• certain medical conditions, such as diabetes
and rheumatoid arthritis.
• common in older individuals
• more common in women
• common in people aged 40 to 60 years

14. SYMPTOMS
• usually progressive
• pain at the level of the A1 pulley
• clicking
• catching
• finger becoming "locked" in flexed position at
the proximal interphalangeal (PIP) joint

15. Physical Examination
• palpation
– tenderness at level of A1 pulley
– palpable nodule of the flexor tendon
• motion
– triggering with digit flexion and extension
– fixed flexion of PIP joint
• provocative test
– flexion and extension of the digit may reproduce
symptoms

16. Differentials
• Lumbrical plus finger
• differentiated by paradoxical extension while
trying to flex the digit
• Joint contracture
• differentiated by history of trauma and inability to
passively extend the digit
• Pyogenic flexor tenosynovitis
• differentiated by signs of infection, including
possible elevated inflammatory markers,

17. Green Classification
• Grade I
• Palm pain and tenderness at A-1 pulley
• Grade II
• Catching of digit
• Grade III
• Locking of digit, passively correctable
• Grade IV
• Fixed, locked digit

18. MANAGEMENT:
• splinting,
• activity modification
• NSAIDs
• corticosteroid injection

19. Splinting
• immobilization either the
metacarpophalangeal (MCP) joint or distal
interphalangeal joint only.
• proximal interphalangeal joint remains
unrestricted.

23. Corticosteroid injections
• give 1 to 3 injections in or just superficial to
flexor tendon sheath
• can be combined with percutaneous A1 pulley
release
• complications
• tendon rupture
• subcutaneous fat atrophy
• transient hyperglycemia

26. Percutaneous Release of A1 Pulley
• typically 18- to 19-gauge needle
• bevel parallel to tendon
• movement of digit confirms placement into
tendon
• needle withdrawn until out of tendon then
advanced to cut ligament
• release confirmed by attempt to reproduce
symptoms
• can be combined with corticosteroid injection

27. complications
• transient inflammation
• hematoma formation
• stiffness
• infection
• damage to neurovascular bundle

29. Open surgical debridement and release of A1
pulley
• local anesthetic allows intraoperative assessment
of triggering to confirm an adequate release
• in addition to A-1 pulley, may also need to
release
• tight band of superficial aponeurosis proximal to
A1 pulley (A0 pulley)
• one or both limbs of the sublimus tendon
• additional pulleys including A-3

32. Complications
• tendon bowstringing
• damage to the digital neurovascular bundle
• stiffness
• Wound dehiscence
• Scar tenderness
• Stiffness