Journal of the American Academy of Orthopaedic Surgeons246

Trigger fingers and thumbs arecharacterized by the inability to flexor extend the digit smoothly. Alldigits can be affected, but the ringfinger is most often involved, fol-lowed by the thumb and the long,index, and small fingers, in thatorder.1,2 More than one triggerdigit can be present on the samehand. Triggering of digits in bothhands is also common. The sensa-tion experienced with inability tocomfortably make a fist or extendthe fingers adequately is describedby most patients as a painful snap-ping, which often makes themreluctant to make a full fist. Even ifonly one digit is involved, handfunction can be seriously compro-mised. This is especially true if thetriggering is so pronounced that itlocks the finger or thumb in flexion.

There are two types of pathologicinvolvement of the tendon that occur

with clinically triggering digits—nodular and diffuse.1 This classifi-cation is based on the findings onpalpation of the swelling of the ten-don sheath. If the swelling is con-tained so that there is a definitenodule that moves back and forthunder the examiner’s finger as thedigit triggers, the inflammation isconsidered nodular. If the swellingis instead more diffuse and less de-fined, the condition is considereddiffuse. Nodular trigger digits willrespond much more favorably tocorticosteroid injection and non-steroidal anti-inflammatory drugs(NSAIDs) than those with diffuseinvolvement.1

The duration of symptoms is animportant factor in the treatmentoutcome. If the condition has beenpresent for more than 6 months, itwill be less likely to respond tononoperative management.1

Pathophysiology

The flexor digitorum profundus,flexor digitorum sublimis, and flex-or pollicis longus (FPL) shouldglide through the annular pulleysystem unobtrusively in flexionand extension of the digits. Nor-mally, there is a double synovialsheath that facilitates smooth glid-ing. This synovial membrane isintimately involved with the ten-dons and the pulley system.2 Theproximal ends of the A1 pulleys arefulcrums. Considerable angulationof the flexor tendons occurs at theproximal edge of the A1 pulleyduring forceful flexion of the digits.

Stenosing tenosynovitis is apathologic disproportion betweenthe volume of the retinacular sheathand its contents. This disproportioninhibits gliding as the tendon movesthrough the A1 pulley. Inflamma-tion manifests itself as a spindle-shaped thickening in a localizedarea of the flexor tendon. In nodu-lar stenosing tenosynovitis, thisoccurs just distal to the A1 pulley,where tendon friction deforms thetendon and causes a nodule to

Dr. Saldana is in private practice with Handand Microsurgery Associates, San Antonio, Tex.

Reprint requests: Dr. Saldana, Hand andMicrosurgery Associates, Nix Medical Center,Suite 809, 44 Navarro, San Antonio, TX 78229.

Copyright 2001 by the American Academy ofOrthopaedic Surgeons.

Abstract

Stenosing tenosynovitis of the thumb and fingers is a very common problemseen by the primary-care physician, the orthopaedic surgeon, and the hand sur-geon. Primary stenosing tenosynovitis is usually idiopathic and occurs morefrequently in middle-aged women than in men, but can be seen even in infancy.Secondary stenosing tenosynovitis of the digits can occur in patients withrheumatoid arthritis, diabetes mellitus, gout, and other disease entities thatcause connective tissue disorders. The diagnosis of triggering digits is generallynot subtle and can be made on the basis of an adequate clinical examination.Classification according to the type of tenosynovitis and the time from onset ofsymptoms may be prognostically significant and may also affect the treatmentoutcome. As many as 85% of triggering fingers and thumbs can be treated suc-cessfully with corticosteroid injections and nonsteroidal anti-inflammatorydrugs. Surgical release is generally indicated when nonoperative treatmentfails. Percutaneous A1 pulley release can now be performed safely as an officeprocedure.

J Am Acad Orthop Surg 2001;9:246-252

Trigger Digits: Diagnosis and Treatment

Miguel J. Saldana, MD

Miguel J. Saldana, MD

Vol 9, No 4, July/August 2001 247

form.3 In diffuse stenosing tenosy-novitis, the inflammation will not beas localized and may well extendbeyond the A1 pulley.3 With sec-ondary inflammation, such as thatdue to rheumatoid arthritis, the nor-mal relationship between the reti-nacular sheath and its contents cansometimes be restored by treatingthe underlying disease.

The palmar plate of the metacar-pophalangeal (MCP) joint of thethumb is associated with the thumbsesamoids and the tendinous slipsof the adductor pollicis, the abduc-tor pollicis brevis, and the A1 pul-ley. The FPL tendon approaches thepalmar plate and the retinaculartunnel of the thumb at a more acuteangle than the flexor tendons of thefingers before they enter the retinac-ular sheaths, which gives the FPL amechanical advantage. This ana-tomic arrangement may contributeto the frequency of triggering in thethumb.3

The A1 pulley may hypertrophyto two to three times its usual thick-ness, thus narrowing the space avail-able for the tendon considerably. Inearly studies, Hueston and Wilson3

described the spiral arrangement ofthe tendon fibers as they unfurlwhen passing through the tight ful-crum of the A1 pulley, creating anodule on the distal side of the pul-ley. They likened this process topulling an oversized thread throughthe eye of a small needle, whichcauses the thread to unravel.

The A1 pulleys of normal andtriggering digits have been exam-ined histologically. The normal A1pulley has two layers: a vascularouter layer and a collagenous innerlayer that extends to the glidingsurface, where most of the frictionbetween the tendon and the pulleyoccurs. On hematoxylin-eosinstaining, the gliding layer has beenshown to contain a biphasic popu-lation of spindle-shaped fibroblastsand ovoid cells. In diseased A1pulleys, the gliding layer hypertro-

phies, and the ovoid cells increasein number and have the histologicappearance of chondrocytes.4,5

The tendon undergoes similarthickening on the avascular side ofthe tendon, which rubs on the A1pulley in nonrheumatoid triggering.4The thickening is due not to prolifer-ation of the synovial membrane cells,but rather to fraying and disintegra-tion of the stenotic segment.4,5 Onhistologic examination of superfi-cialis tendon nodules, immunohisto-chemical staining showed S-100 protein, which is present in chondro-cytes.4 The histologic changes in thetriggering superficialis tendons weresimilar to those observed in the A1pulleys—fibrocartilaginous metapla-sia and positive staining for the S-100protein, with associated chondrocytesat the site of injury to the tendons.

The pathologic changes in chil-dren with trigger digits are quitedifferent from those in adults. Trig-gering generally occurs early in life,and parents note that the thumbsare flexed at the terminal phalanx.There is usually a mass palpable onthe palmar aspect of the MCP joint.The thumb can be actively and pas-sively flexed at the MCP joint, butthere is a block to full extension at10 to 20 degrees. Nonoperativemodalities have not been successfulin infants and children becausemost present with long-standingtrigger digits. The most commonfindings at surgery are nodules onthe FPL without hypertrophy of theA1 pulley.6

Diagnosis

Triggering digits are more commonin women than in men.1 The pre-sentation varies widely. Initially,the triggering may not be painful.The patient may feel a mild click inthe finger or may report inability tofully flex the finger. As the stenos-ing tenosynovitis becomes moresevere, there is distinct discomfort

on the palmar side of the MCP joint,with pain frequently radiating intothe forearm. When triggering oc-curs, it is not uncommon for thepatient to perceive the snapping asoccurring at the proximal interpha-langeal (PIP) joint. Mild triggeringis more apt to be present in the earlymorning and becomes less bother-some as the fingers and hand areused throughout the day. This phe-nomenon of improvement does notoccur if the stenosing tenosynovitisis more severe and locking occurs.

A careful history and a thoroughphysical examination are importantparts of the evaluation. Medicalconditions such as rheumatoidarthritis, diabetes, gout, carpal tun-nel syndrome, de Quervain’s teno-synovitis, Dupuytren’s contracture,and hypertension may be associatedwith the occurrence of triggering.7Tumors of the tendons, foreign bod-ies, and exostoses have also beenimplicated.

On physical examination, pain atthe palmar base of the involveddigit associated with crepitus onpalpation is indicative of earlytenosynovitis. Once deformation ofthe tendon has occurred, “catching”of the digit will be manifested as thepatient tries to extend the fingersfrom a fist position. More severestenosing tenosynovitis will lockthe finger or thumb in flexion, re-quiring the patient or examiner topush the finger into extension; therewill be noticeable “give” on unlock-ing. The patient will not be able tofully extend a finger at the distalinterphalangeal (DIP) joint or an in-volved thumb. At the initial exami-nation, it should be determinedwhether the swelling is diffuse ornodular.1

Classification

Quinnell8 first classified the severityof triggering digits into five gradeson the basis of occurrence in both

Trigger Digits

Journal of the American Academy of Orthopaedic Surgeons248

flexion and extension but did notuse the classification as a basis fortreatment. Eastwood et al9 andPatel and Moradia10 have similarclassifications for digital stenosingtenosynovitis. Like Quinnell’s, theirclassifications are based on thedegree of severity of the tenosyno-vitis, with grade 0 involving mildcrepitus in a nontriggering digit;grade 1, uneven movement of thedigit; grade 2, clicking without lock-ing; grade 3, locking of the digit thatis either actively or passively cor-rectable; and grade 4, a locked digit.Both groups of authors agreed thatgrade 0 should be treated by injec-tion; grade 4, by percutaneous re-lease.9,10 Newport et al11 presenteda simpler grading system for stenos-ing tenosynovitis in which the threegrades carried a recommendationregarding treatment with steroid in-jection.

Treatment should be based onwhether the stenosing tenosynovitisis diffuse or nodular and the dura-tion of symptoms1 (Fig. 1). It is im-portant to distinguish betweenthese types at presentation becauseearly nodular tenosynovitis mayrespond to massage, ice therapy, andsplinting. Early diffuse or moreadvanced nodular tenosynovitiswill generally not respond to non-operative modalities.

In one series of 101 triggeringdigits treated with steroid injection,1the combined success of treatmentfor both diffuse and nodular teno-synovitis was 70%. However, 93%of the digits with nodular diseaseresponded successfully to injection,compared with only 48% of thosewith diffuse disease. The averageduration of symptoms for the dif-fuse type of tenosynovitis was 11months, compared with 4.5 monthsfor the nodular type.

Several authors have consideredwhether the duration of symptoms isprognostically related to a favorableresponse to steroid injection.1,9-12

Response to nonoperative manage-

ment and steroid injections mark-edly decreases with a duration ofsymptoms longer than 6 months.

Nonsurgical Treatment

Observation combined with avoid-ance of inciting activities may beadequate in mild cases of stenosingtenosynovitis. Repetitive trauma tothe hands, such as may occur in gar-dening, sewing, cutting with scis-sors, cake decorating, and bongoplaying, may be the cause of the ini-tial trauma to the fingers. If theseactivities are modified or avoided,spontaneous resolution of tenosyno-vitis can occur. However, in most

cases, no causative element can beidentified.13 Treatment should beinstituted as soon after the occur-rence of symptoms as possible.

Noninvasive ModalitiesNonsteroidal anti-inflammatory

drugs should be the initial form oftreatment unless inadvisable be-cause of the patient’s age or thepresence of a peptic ulcer diathesis.Use of NSAIDs can be combinedwith massage, ice therapy, splinting,and injections.

Splinting has been advocated bysome authors.14,15 Some use prefabri-cated splints, and others tailor splintsfor individual patients.14 Someadvocate 0 degrees of flexion of the

Stenosing tenosynovitis

<6 mo >6 mo

Resolved Unresolved

Resolved Unresolved

Unresolved

Resolved

Triggering digit(grades 1 to 3)

No furthertreatment

Locked digit(grade 4)

Surgery orpercutaneous

release

No furthertreatment

Nonoperative treatment(massage, ice, NSAIDs,

splinting)

• Nonoperativetreatment

• Steroid injection• Recheck at 1 mo

• Nonoperativetreatment

• Steroid injection• Recheck at 1 mo

• Second steroidinjection

• Recheck at 1 mo

No furthertreatment

Unresolved

Resolved

Surgery orpercutaneous

release

No furthertreatment

Figure 1 Algorithm for the treatment of stenosing tenosynovitis.

Miguel J. Saldana, MD

Vol 9, No 4, July/August 2001 249

MCP joint; others allow 10 to 15degrees of MCP joint flexion. Allsplints should allow free motion ofthe PIP and DIP joints. Grade 4(locked) digits will not respond tosplinting. For the splints to be suc-cessful, they may have to be wornfor as long as 4 months. Even custom-ized splints are very cumbersome,and lack of success with splintingmay be due to lack of compliance.In early nodular tenosynovitis, thecombination of massage, fingersplinting, and NSAIDs has beensuccessful.

Corticosteroid InjectionNonoperative treatment of trig-

ger digits may include corticosteroidinjections into the tendon sheath. Ifsteroid injection is to be used, boththe physician and the patient shouldhave a clear understanding of therisks and benefits. First introducedby Howard et al16 in 1953, the use ofsteroid injections has been amplyreported with varying degrees ofsuccess. All grades of tenosynovitishave been treated with injections,and all have been reported to re-spond. The response has variedfrom 42% to as high as 92% with asmany as three injections.13-19

Many forms of injectable cortico-steroids have been used, among thembetamethasone sodium phosphateand acetate suspension, precipitatedhydrocortisone, triamcinolone, tri-amcinolone acetonide, and methyl-prednisolone. Betamethasone sodiumphosphate and acetate suspension isthe most commonly used because itis water-soluble; does not precipi-tate, leaving a residue in the tendonsheath; and does not cause tenosyno-vitis after injection. It is also knownto cause less fat necrosis if it is in-jected into fat around the tendonsheath.

Early nodular trigger digit can betreated with an injection into thetendon sheath. An NSAID shouldaccompany the injection if there isno history of ulcer disease. Diffuse

stenosing tenosynovitis should betreated with only one steroid injec-tion1 and only if symptoms havebeen present for less than 4 months.If symptoms have been present forlonger than 4 months or persist afterthe initial injection, surgical releaseis appropriate without further non-operative treatment.1,12

Steroid injection into the tendonsheath can be done from either a lat-eral or a palmar approach. Bothapproaches involve injection intothe tendon sheath. The tendon-sheath volumes of the index, long,and ring fingers are limited becausethe sheaths end at the proximaledges of the A1 pulleys. The sheathsof the small finger and the thumbpotentially communicate with eachother through the wrist and canaccept larger volumes.2

The lateral approach is less pain-ful (because the neurovascular bun-dle lies palmar to the area of in-jection) and perhaps easier. A 1-cm3

syringe with a 25- or 27-gauge 0.5-inch needle is used. From the radialborder of the finger, the needle isinserted into the midlateral area ofthe proximal phalanx above a lineconnecting the PIP and DIP jointcreases over the first cruciate pulley(the neurovascular bundle lies pal-mar to that line).2 The skin and sub-cutaneous area are anesthetizedwith 1% xylocaine without epi-nephrine.

The needle is inserted only untilslight resistance is felt. The patientis asked to wiggle the finger. Slightgrating can be felt at the end of theneedle. If the needle is in the tendonproper, there is paradoxical motionof the needle and syringe (i.e., withdigit extension, the syringe movesproximally). The rest of the anes-thetic is then injected into the tendonsheath. The needle is disconnectedfrom the 1-cm3 syringe but left inplace, and the syringe is reloaded.When a corticosteroid is used, 0.75mL of such an agent and 0.25 mL of1% xylocaine are loaded in the sy-

ringe, which is reconnected to theneedle left in the finger. The patientis again asked to wiggle the finger toascertain the correct position of theneedle. The injection is finished,and the needle is withdrawn.20

It is preferable to use the midlat-eral approach for patients who pre-sent with grade 1 or grade 2 diseaseand a small nodule and for patientswith diffuse tenosynovitis of the fin-gers. The treated digit should re-main anesthetized for 3 to 4 hours.Benefits from the steroid injectionshould persist for 2 to 5 days afterthe procedure.

The palmar approach is equallyeffective, but it can be more painfulbecause the palmar aspect of thehand has more sensory endingsthan the lateral and medial aspectsof the fingers. The neurovascularbundles are located on the medialand lateral aspects of the pulley sys-tem. They are more dorsally locatedthan the palmar surface of the ten-don sheath and therefore should notbe encountered if the injection isgiven in the midline of the tendon.2,9

The palmar approach is preferredfor grade 3 or grade 4 disease andfor the second injection. For moreadvanced disease, a larger dose ofsteroid is recommended, and a 3-cm3

syringe is used instead of a 1-cm3

syringe.The distal palm in the area of the

A1 pulley is cleansed with povidone-iodine solution or an alcohol swab.A 30-gauge 0.5-inch needle is usedto anesthetize the area around the A1pulley as well as the tendon sheathwith 1 mL of 1% xylocaine withoutepinephrine. Then 1 mL of the ste-roid is mixed with 1 mL of 1% xylo-caine and 1 mL of 0.25% bupivacaineand injected into the tendon sheathand around the nodule. It has beenshown that steroid injection aroundthe tendon sheath can be of benefit.12

When bupivacaine is used as part ofthe injection mix, the patient shouldbe warned that the anesthesia maylast as long as 24 hours.

Trigger Digits

Journal of the American Academy of Orthopaedic Surgeons250

Surgical Treatment

Surgical release of the A1 pulleycan be done through either a trans-verse or a longitudinal incision inthe palm.6-8,21,22 It is important toprotect the neurovascular bundleson both the medial and the lateralside. Local anesthesia is preferablebecause it allows active flexion andextension on the operating table,and the completeness of the releasecan be confirmed.

Open release of the A1 pulley isthe traditional form of surgical treat-ment. However, percutaneous re-lease has been advocated by someauthors.9,10,23 It has several advan-tages, including the fact that it canbe safely performed in the office.Local anesthesia allows immediateconfirmation of trigger release.Avoiding a surgical incision on theskin allows the patient to get back toemployment or activities of dailyliving almost immediately. The op-erating room cost, anesthesia cost,and time lost from work are avoidedwith successful percutaneous re-lease.

Drawbacks of percutaneous re-lease include incomplete release ofthe A1 pulley and potential injuryto adjacent neurovascular struc-tures, to the tendons themselves, orto the volar plate. The proximity ofthe radial sensory nerve to the A1pulleys of the thumb and the indexfinger has prompted some authorsto recommend that these digits notbe treated with percutaneous re-lease.9,23 Others have safely usedpercutaneous release for all digits.10

Surgical TechniqueSurgical release of the A1 pulley is

done with local anesthesia andtourniquet control. Either a longitu-dinal incision starting at the distalpalmar crease or a transverse inci-sion in the distal palmar crease canbe used. The neurovascular bundleson either side should be identifiedand protected. The A1 pulley release

is performed, and the patient isasked to flex and extend the digitintraoperatively. If triggering is stilloccurring, the release should bechecked for completeness; furtherrelease of the A1 pulley may be war-ranted. If no further triggeringoccurs, the tourniquet is released,bleeding is checked, and the patientis asked to make a fist. Sometimes, ifthe tourniquet has been inflated for15 to 20 minutes, the patient will beunable to make a full fist, and trig-gering may occur at the extremes ofmotion. Therefore, triggering shouldbe checked for again while thetourniquet is deflated. The incisionis closed with interrupted sutures,and a simple dressing is applied.

Percutaneous TechniqueFor percutaneous release of the

A1 pulley, the affected hand anddistal forearm are prepared anddraped with the patient sittingacross the examination table. A 3-cm3 syringe is used to anesthetize

the area of the A1 pulley. A corti-costeroid is used with the initiallocal anesthetic because painfultenosynovitis without triggeringcan occur after release when asteroid is not used.10

After the finger or thumb hasbeen well anesthetized, the patientis asked to actively trigger theaffected digit. A 20-gauge, 1-inchneedle is then inserted with thesharp bevel parallel to the tendon.The needle is inserted one third thedistance from the distal palmarcrease to the base of the long, ring,or small finger. In the case of theindex finger, the needle is insertedone third the distance from the dis-tal thenar crease and the base of thefinger. These locations have beenfound to consistently correlate withthe middle of the A1 pulley and toallow cutting both proximally anddistally to completely transect it24

(Fig. 2). In the thumb, the needle isinserted at the intersection of theproximal thumb crease and a line

Figure 2 Technique for percutaneous sectioning of the A1 pulley in the fingers. A, Needleentrance points (dots) are located approximately one third the distance from the distal pal-mar crease and two thirds the distance from the proximal digital crease. This correspondsto the center of the A1 pulley. B, Diagram depicts the location of the A1 pulleys in the fin-gers and the A2 pulley in the small finger. Half of the A2 pulleys are located in the distalpalm.

A B

2 ⁄3

1 ⁄3}

}

Miguel J. Saldana, MD

Vol 9, No 4, July/August 2001 251

perpendicular to it. Insertion at thispoint avoids the radial digital nerveof the thumb24 (Fig. 3).

The A1 pulley is cut with a swip-ing movement of the needle. A def-inite grating should be felt. Oncethe pulley is thought to have beentransected, the needle is withdrawn,and the patient is asked to flex thedigit. If triggering has ceased, theprocedure is finished. If triggeringpersists, the nodule is gently pal-pated to feel where it is catching onthe A1 pulley. The needle is thenreinserted so as to cut more proxi-mally or distally.

After percutaneous release, asmall adhesive-strip bandage isplaced on the puncture wound,and the patient is asked to be care-ful for 24 hours, because the fingeris usually anesthetized for thatperiod of time. Activities of dailyliving or full job responsibilitiescan be undertaken on the next day.

Complications

No complications as a result of corti-costeroid injection for trigger digithave been reported6-8,12,24; however,injection of steroid into the neuro-vascular bundle can cause perma-nent damage of the digital nerve orartery. Complications of surgicalrelease include digital nerve transec-tion, A2 pulley injury with subse-

quent bowstringing of the tendons,bothersome scars, recurrent symp-toms, stiffness, and sympathetic dys-trophy.25-27

Percutaneous release also hashad reported complications.10 Inone study (M. R. Patel, personalcommunication, 1997), 50% of thepatients in the early part of theseries, when only local anesthesiawas used, had persistent pain asso-ciated with finger flexion severalmonths after the release. The addi-tion of a corticosteroid to the anes-thesia mixture eliminated this com-plication. In that study, severalincomplete releases required sec-

ondary open release of the A1 pul-ley. No injuries to neurovascularbundles due to percutaneous releasehave been reported to date.9,10,23

Summary

Stenosing tenosynovitis is a commonproblem that responds well to nonop-erative treatment. This is especiallytrue if the condition is treated earlyand the inflammation is of the nodu-lar type. If nonoperative modalitiesfail, open release and percutaneousrelease are both safe and relativelysimple treatment options.

Figure 3 Technique for percutaneous sectioning of the A1 pulley in the thumb. A, At thepoint where a perpendicular line bisecting the thumb crosses the digitopalmar thumbcrease (bisecting the A1 pulley), a needle can be safely inserted without damage to the neu-rovascular bundle. B, Diagram depicts the optimal insertion point for the needle.

A B

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11. Newport ML, Lane LB, Stuchin SA:Treatment of trigger finger by steroid

Sensory nerves

Digitopalmar crease

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Journal of the American Academy of Orthopaedic Surgeons252

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ger fingers. Acta Orthop Scand 1970;41:428-432.

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20. Griggs SM, Weiss APC, Lane LB,Schwenker C, Akelman E, Sachar K:Treatment of trigger finger in patientswith diabetes mellitus. J Hand Surg[Am] 1995;20:787-789.

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method of choice? J R Coll Surg Edinb1992;37:341-342.

22. Carlson CS Jr, Curtis RM: Steroidinjection for flexor tenosynovitis. JHand Surg [Am] 1984;9:286-287.

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24. Saldana MJ: Percutaneous trigger fingerrelease. Atlas Hand Clin 1999;4:23-37.

25. Carrozzella J, Stern PJ, Von Kuster LC:Transection of radial digital nerve ofthe thumb during trigger release. JHand Surg [Am] 1989;14:198-200.

26. Heithoff SJ, Millender LH, Helman J:Bowstringing as a complication of trig-ger finger release. J Hand Surg [Am]1988;13:567-570.

27. Thorpe AP: Results of surgery for triggerfinger. J Hand Surg [Br] 1988;13:199-201.