Original source : http://researchonmedical.com
Posted : October 2013
Author : The admin
When you have a trigger digit it gets locked in a flexed
position and you are unable to unlock and extend it except by pulling it with
the other hand. This triggering of the finger or thumb is a common problem,
which can lead to a significant disability resulting in loss of hand function
and the performance of routine activities. A similar condition may also affect
children but in much less frequency.
Focal degenerative changes within the long flexor tendon
cause a localized swelling that limits tendon excursion within the tendon
sheath leading the tendon to get caught under the A1 pulley of the flexor
tendon sheath, which in turn leads to triggering of the digit.
2. Which Digits Are Affected by Triggering:
The most commonly affected digits among adults with
triggering include the thumb, long finger, and ring finger in that order. While
in children triggering occurs only in the thumb.
3. Who is Affected The Most:
Idiopathic trigger finger or thumb is 4 times more likely to
develop in women than in men, usually affects women in the fifth and sixth
decades of life, and is often bilateral. It develops more frequently in
individuals suffering from diabetes, osteoarthritis and any condition that
causes proliferation of the tenosynovium, such as inflammatory arthritis, gout,
or chronic infection (eg, fungus or atypical mycobacteria).
4. What Are The Symptoms and Signs of A Trigger Digit:
During the initial stages of development of trigger digits
patients usually complain of painful clicking of the digit or crackling of the
proximal interphalangeal joint. There can also be associated morning stiffness
of the fingers without any triggering at this stage. Frank locking occurs in
more advanced stage, the digit gets locked usually in flexed position and
rarely in extension. Locking of digit must be released by passively
manipulating with the other hand. On an intermediate stage there may be
stiffness in the finger with reduced sliding and gliding of tendon. At this
stage index of suspicion for a trigger digit should be high because triggering
may not be evedent when just tendon gliding is decreased.
You will find a tender nodule over the metacarpophalangeal
joint of the affected thumb or at proximal interphalangeal joint of the
affected finger on examination. This nodule moves in the direction of motion
when the patient is asked to flex or extend of the digit and crepitus may also
be felt on movement. There is a possibility that locking or snapping of the
interphalangeal joint can be confused with subluxation of the finger. In children only trigger thumb occurs, rest of the digits
are almost never affected and trigger thumb in children rarely causes pain. It
usually is bilateral in children and they present at an age between one and
four years.
5. What are The Required Laboratory Tests:
No specific tests are indicated for idiopathic trigger
digit. With suspicion of an associated systemic medical condition, such as
diabetes, rheumatoid arthritis, or crystal deposition, order appropriate blood
studies. X-rays are helpful to exclude osteoarthritis, fracture malunion,
foreign body, or a large sesamoid bone that is affecting interphalangeal joint
motion.
6. How to Treat Trigger Digits:
Taking NSAIDs (nonsteroidal anti-inflammatory drugs) by
mouth is the mainstay of conservative treatment of trigger digits. NSAIDs not
only control pain but also suppress inflammation. Inflammation can also be
brought under control by injecting a steroid directly into the lesion. Motion
of the metacarpophalangeal (MP) and interphalangeal (IP) joints of the thumb
and fingers can be controlled by using a hand based splint, which maintains
them in 15 degrees of flexion.
7. When and How to Perform Surgical Release:
Surgical intervention in patients with trigger digits is
indicated if those who present with locking are less likely to respond to medical
treatment, there is a history of triggering for more than 4-6 months or if
you are dealing with pediatric trigger thumb because the outcome of
conservative treatment for pediatric trigger thumb is not reliable. Tourniquet using local anesthesia is the best technique for surgical
decompression of trigger digits. Use of additional intravenous sedation is
optional.
8. What is The Postoperative Care:
During the postoperative period early active movement should
be started to prevent formation of adhesions and subsequent restriction of
movement. If the patient develops adhesions and/or a prominent scar then
a formal hand therapy may be required.
9. What are The Possible Postoperative Complications:
Transection of a digital nerve is the most common
complication reported after surgical decompression of a trigger digit. If
tendon handling is excessive and rough during operation or mobilization is
delayed during immediate postoperative period then adhesions and subsequent
stiffness can develop. Another uncommon but devastating complication can be flexor
tendon sheath infection.
10. What is The Prognosis With Different Types of Treatment:
Half of these patients can get relief with splinting alone.
While the corticosteroid injection has a success rate of almost 90%,
although it may have to be repeated for upto 3 treatments. The success rate of
surgical release of the A1 pulley is more than 95% with a recurrence rate of
3%. Spontaneous resolution of trigger digits has been observed
in 23-63% of cases. Children with congenital trigger digits must be treated
before the age of 4 years because by that time they may develop permanent
flexion contractures.
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