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

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

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

248 Journal of the American Academy of Orthopaedic Surgeons

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

Surgical Treatment
Surgical release of the A1 pulley
can be done through either a trans-
verse or a longitudinal incision in
the palm.6-8,21,22 It is important to
protect the neurovascular bundles
on both the medial and the lateral
side. Local anesthesia is preferable
because it allows active flexion and
extension on the operating table,
and the completeness of the release
can be confirmed.
Open release of the A1 pulley is
the traditional form of surgical treat-
ment. However, percutaneous re-
lease has been advocated by some
authors.9,10,23 It has several advan-
tages, including the fact that it can
be safely performed in the office.
Local anesthesia allows immediate
confirmation of trigger release.
Avoiding a surgical incision on the
skin allows the patient to get back to
employment or activities of daily
living almost immediately. The op-
erating room cost, anesthesia cost,
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
is performed, and the patient is
asked to flex and extend the digit
intraoperatively. If triggering is still
occurring, the release should be
checked for completeness; further
release of the A1 pulley may be war-
ranted. If no further triggering
occurs, the tourniquet is released,
bleeding is checked, and the patient
is asked to make a fist. Sometimes, if
the tourniquet has been inflated for
15 to 20 minutes, the patient will be
unable to make a full fist, and trig-
gering may occur at the extremes of
motion. Therefore, triggering should
be checked for again while the
tourniquet is deflated. The incision
is closed with interrupted sutures,
and a simple dressing is applied.
Percutaneous Technique
For percutaneous release of the
A1 pulley, the affected hand and
distal forearm are prepared and
draped with the patient sitting
across the examination table. A 3-
cm3 syringe is used to anesthetize
the area of the A1 pulley. A corti-
costeroid is used with the initial
local anesthetic because painful
tenosynovitis without triggering
can occur after release when a
steroid is not used.10
After the finger or thumb has
been well anesthetized, the patient
is asked to actively trigger the
affected digit. A 20-gauge, 1-inch
needle is then inserted with the
sharp bevel parallel to the tendon.
The needle is inserted one third the
distance from the distal palmar
crease to the base of the long, ring,
or small finger. In the case of the
index finger, the needle is inserted
one third the distance from the dis-
tal thenar crease and the base of the
finger. These locations have been
found to consistently correlate with
the middle of the A1 pulley and to
allow cutting both proximally and
distally to completely transect it24
(Fig. 2). In the thumb, the needle is
inserted at the intersection of the
proximal thumb crease and a line
} ⁄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

 Miguel J. Saldana, MD

perpendicular to it. Insertion at this

point avoids the radial digital nerve
of the thumb24 (Fig. 3).
The A1 pulley is cut with a swip-
ing movement of the needle. A def-
inite grating should be felt. Once
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
the A1 pulley. The needle is then
reinserted so as to cut more proxi-
mally or distally.
After percutaneous release, a
small adhesive-strip bandage is
placed on the puncture wound,
and the patient is asked to be care-
ful for 24 hours, because the finger
is usually anesthetized for that
period of time. Activities of daily
living or full job responsibilities
can be undertaken on the next day.
Complications
No complications as a result of corti-
costeroid injection for trigger digit
have been reported6-8,12,24; however,
injection of steroid into the neuro-
vascular bundle can cause perma-
nent damage of the digital nerve or
artery. Complications of surgical
release include digital nerve transec-
tion, A2 pulley injury with subse-
Digitopalmar crease
Sensory
nerves
Distal interphalangeal crease
A B
Figure 3 Technique for percutaneous sectioning of the A1 pulley in the thumb. A, At the
point where a perpendicular line bisecting the thumb crosses the digitopalmar thumb
crease (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.
quent bowstringing of the tendons, ondary open release of the A1 pul-
bothersome scars, recurrent symp- ley. No injuries to neurovascular
toms, stiffness, and sympathetic dys- bundles due to percutaneous release
trophy.25-27 have been reported to date.9,10,23
Percutaneous release also has
had reported complications.10 In
one study (M. R. Patel, personal Summary
communication, 1997), 50% of the
patients in the early part of the Stenosing tenosynovitis is a common
series, when only local anesthesia problem that responds well to nonop-
was used, had persistent pain asso- erative treatment. This is especially
ciated with finger flexion several true if the condition is treated early
months after the release. The addi- and the inflammation is of the nodu-
tion of a corticosteroid to the anes- lar type. If nonoperative modalities
thesia mixture eliminated this com- fail, open release and percutaneous
plication. In that study, several release are both safe and relatively
incomplete releases required sec- simple treatment options.

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