Trigger finger and trigger thumb. Trigger finger is a condition where the involved finger will catch as it bends. The finger is straightened with a pop or a snap. The flexor tendon becomes thick and irritated as it slides through the tendon pulley, causing a thickened nodule and triggering of the tendon. There's no smooth gliding of the tendon. Repetitive injuries or occupation are risk factors.. Symptoms. In trigger finger, the pain will be at the level of the A1 pulley. There will be catching and clicking and triggering with finger flexion and extension. Pain before triggering. The pain is usually not well localized and nonspecific. The patient will complain of catching, then locking that is fixed, and these are the typical stages of trigger finger. The locking occurs when the tendon is unable to pass through the sheath. As the tendon becomes inflamed, it gets caught. The condition is progressive, and it may lead to a fixed flexed finger. It commonly affects the ring and long fingers. It is an A1 pulley problem. Here, the arrangement of the pulley system, and here you can find the location of the A1 pulley which causes the symptoms. So, you will find the tenderness at the A1 pulley. 60% or more of patients with trigger fingers usually have associated carpal tunnel syndrome. It occurs more in diabetics and more in females older than 50 years old. In diabetics, both hands and multiple digits in the hand can be affected. Non-diabetic patients have better prognosis. Diabetes has a poor prognosis for non-operative treatment, and these patient are prone to develop stiffness or recurrence of the condition after surgical release. In addition to diabetes, there are some other medical conditions that can be associated with trigger fingers, such as gout, pseudogout, rheumatoid arthritis, sarcoidosis, hypothyroidism. Treatment of trigger finger. Conservative treatment. The most important prognostic indicator for a good result with non-operative treatment is the duration of triggering before coming to the doctor. An irreducible locked trigger finger with flexion contracture of the PIP joint should not be treated conservatively or even by injection. It will need surgery. Conservative treatment with splinting, non-steroidal anti-inflammatory, rest, and modifying activity. It will give some relief to the patients. Injection into the sheath, not into the tendon. Sixty to 80% of non-diabetic patients may get better with injection. Watch the dose of the steroid that is given in diabetic patients. Injection is not very effective in diabetic patients. Also obtain hemoglobin A1C in these patients before considering injection or any surgical intervention. The injection can be repeated up to three times. The majority of the patients get better with injection or surgery. What is the technique of injection? Injection into the flexor tendon sheath may provide relief for triggering of the finger. The neurovascular bundle is on the side of the tendon and the pulley. After the site is marked, use a 25-gauge needle. Advance the needle through the midline down to the bone. Pull the needle back slightly and inject the medication freely. Inject the medication into the sheath or into the pulley freely. Surgery is done if the non-operative treatment fails, and will include release of the A1 pulley. Higher recurrence in diabetic patients with surgery. The release of A1 pulley can be percutaneous or it can be open. Percutaneous release of A1 pulley can be done for the fingers, but not for the thumb because the radial digital nerve almost crosses in the middle of the surgical field and it can be injured. When releasing the A1 pulley, the release should be done at the level of the MP joint. The A2 and A4 pulleys are important structures and should not be released. Only A1 pulley is cut and the flexor tendon is released. Surgical release. How do you release the A1 pulley? The procedure is done with local anesthesia to allow intraoperative assessment and to communicate with the patient to confirm that adequate release was done. Here, there is a surgical case. The incision is marked out in the palmar crease for surgical division of the A1 pulley, the correct fingers are marked before surgery, and the fingers are usually marked on the palmar aspect and the dorsal aspect. The A1 pulley is exposed and released. Notice the patient also had carpal tunnel syndrome, which is frequently associated with the condition of trigger finger. You can see the tendon over the hemostat appears released. Ask the patient to move the fingers to confirm the success of the procedure. Patients with rheumatoid arthritis need excision of a slip of the flexor digitorum superficialis. How about trigger thumb? This is the incision for the surgical release of trigger thumb. The incision for trigger thumb is placed in the MP flexion crease. When releasing the flexor pollicis longus tendon, watch out for the digital radian nerve. It's in the field of surgery.