Nonoperative treatment of trigger fingers and thumbs
This article reports our experience with the management of 93 consecutive patients with 108 trigger digits initially treated by triamcinolone acetonide injections into the flexor tendon sheath. It appears that two distinct clinical types of trigger digits exist—nodular and diffuse. Ninety—three percent (63/68) success was obtained in the nodular type compared with 48% (10/33) in the diffuse type (p < 0.05). We conclude that the patients with the nodular type should be offered a simple cortisone injection. Those patients seen initially with the diffuse type should probably be offered surgical decompression.
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Cited by (137)
Factors Influencing the Successful Treatment of Recurrent Trigger Finger With Repeated Corticosteroid Injections: A Prospective Cohort Study
2024, Journal of Hand SurgeryThe aim of this study was to determine the success rate, duration of disease control, and predictive factors of success of repeated corticosteroid injections for recurrent trigger finger.
This prospective cohort study involved patients who had recurrent trigger finger and a history of corticosteroid injections. A total 114 patients were treated with repeated corticosteroid injections and followed for 12 months. Data on demographic characteristics, comorbid conditions, and possible predictive factors for successful treatment from medical chart reviews and direct patient interviews were compared. Patients were classified into success or failure groups at one, three, six, and 12 months after the initial injection. The relationship between hypothesized predictors and success or failure after repeated corticosteroid injection was analyzed with multivariable logistic regression.
The overall success rates from repeated cortisone injections after one, three, six, and 12 months were 97.4%, 84.2%, 68.4%, and 49.1%, respectively. Multivariable logistic regression modeling revealed that a high grade of disease (grade III or IV based on the Quinnell system), a body mass index (BMI) ≥ 25 kg/m2, and a short symptom-free period (< six months) after a previous injection were strong predictors of symptom recurrence (odds ratio = 3.6 [95% CI 1.5–8.4], odds ratio = 2.5 [95% CI 1.1–5.9], and odds ratio = 1.8 [95% CI 1.1–3.0], respectively). The average success rates for patients at 1-year according to the number of risk factors were as follows: none of the three risk factors, 73.3%; one risk factor, 54.2% to 63.6% (54.2% for grade III–IV triggering, 63.6% for BMI ≥ 25 kg/m2 and 63.6% for < 6-month symptom-free period); two risk factors, 30% to 75% (30% for a combination of grade III–IV and BMI ≥ 25 kg/m2, 45.5% with grade II–IV and < 6-month period, and 75% with a combination of < 6-month period and BMI ≥ 25 kg/m2); and all three risk factors, 11.8%.
Repeated corticosteroid injections for recurrent trigger finger should be considered in patients who prefer nonsurgical treatment, especially in those without factors predictive of failure.
Prognostic II.
Adult presentation of locked ‘congenital’ trigger thumb: A case report
2023, International Journal of Surgery Case ReportsAlthough ‘congenital’ or paediatric trigger thumb is commonly seen in the paediatric age group, adult presentation is very rare. However it is crucial to acknowledge the occurrence of unusual manifestations of paediatric trigger thumbs, since paediatric trigger thumbs are considered a separate disease entity compared to the commonly seen stenosing tenosynovitis in adults.
We report a case of a 18-year-old young lady presenting with atraumatic locked trigger thumb, which was successfully treated surgically with intra-operative finding confirming abnormally thickened flexor pollicis longus tendon signifying a paediatric trigger thumb pathology.
Adult and paediatric trigger thumbs have different aetiology, with thickened A1 pulley and tendon sheath being the culprit in adults, whereas in paediatric thumbs thickened tendon nodules (Notta's node) are usually the causes of triggering.
This uncommon presentation in this case report is atypical in the age group presentation of paediatric trigger thumb, and should be distinguished from the usual trigger thumb pathology in adults. Although a transient period of extension lag in the early post-operative period may be evident, it can still be successfully treated with surgical release.
Trigger finger: Percutaneus ultrasound A1 pulley release
2023, Revue du Rhumatisme (Edition Francaise)Le doigt à ressaut est une pathologie fréquente dont la prise en charge a été révolutionnée par les progrès de l’échographie. Dans les formes résistantes au traitement médical de première intention (infiltrations cortisonées), les patients peuvent se voir proposer un traitement percutané, peu invasif et qui permet d’éviter un geste chirurgical classique dont les suites post-opératoires sont plus longues.
La section de poulie A1 peut être réalisée avec une aiguille intramusculaire (IM) de 21 gauges (G) ou un outil dédié (couteau). Ces 2 techniques ont démontré leur efficacité à court et moyen terme.
Trigger finger is a frequent pathology whose management has been revolutionized by the progress of ultrasound. In forms that are resistant to first-line medical treatment (cortisone injection), patients may be offered percutaneous treatment, which is minimally invasive and avoids a conventional surgical procedure with longer post-operative effects.
A1 pulley sectioning can be performed with a 21-gauge intramuscular (IM) needle or a dedicated tool (knife). These 2 techniques have demonstrated their effectiveness in the short and medium term.
Treatment of trigger finger by section of the A1 pulley with a needle under ultrasound guidance: prospective observational study
2022, Revue du Rhumatisme (Edition Francaise)L’objectif de ce travail est d’évaluer l’efficacité et la tolérance de la section de poulie A1 à l’aiguille sous contrôle échographique dans les doigts à ressaut symptomatiques.
Tous les patients inclus ont bénéficié d’une libération de poulie A1 à l’aiguille sous contrôle échographique. L’aiguille utilisée était une intramusculaire de 21 gauges (G). Le stade Quinnell (1–4), le QuickDASH (0–100) et l’EVA douleurs (0–10 mm) ont été recueillis à l’inclusion. Le critère de jugement principal était la disparition du ressaut à 6 mois (M6).
Quatre-vingt-quatre patients (105 doigts traités) ont été inclus. L’âge moyen était de 63,3 ± 10,7 ans. Avant traitement, l’EVA douleur moyenne était de 5,8 ± 2,6 mm et le QuickDASH moyen de 44,3 ± 19,1. À M6, la disparition du ressaut était obtenue pour 85 des 91 doigts réévalués (93,4 %), et pour 85,7 % à 12 mois. La diminution à M6 de l’EVA douleur et du QuickDASH était respectivement de 4,1 ± 3,1 (p < 0,001) et de 36,1 ± 20,7 (p < 0,001), et 90 % des patients étaient satisfaits ou très satisfaits à M6. La durée d’évolution ancienne était significativement associée à la persistance du ressaut à M6. Les complications étaient peu fréquentes et mineures. Une ténosynovite apparaissait dans 5,7 % des cas, pour qui une infiltration dans un second temps d’un corticostéroïde dans la gaine du fléchisseur permettait une évolution rapidement favorable.
Le traitement du doigt à ressaut par libération de la poulie A1 à l’aiguille sous contrôle échographique apparaît comme une technique percutanée peu invasive, rapide, efficace et avec une bonne tolérance jusqu’à 12 mois.
Treatment of Trigger finger by ultrasound-guided needle release of a1 pulley: A series of 105 cases
2022, Joint Bone SpineWe aimed to evaluate the efficacy and tolerance of A1 pulley release using the needle technique, under ultrasound guidance, in patients with symptomatic trigger finger.
All patients with symptomatic trigger finger underwent A1 pulley release using an intramuscular 21 gauge (G) needle. Quinnell grade (I-IV), Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score (0–100) and pain score on a visual analog scale (VAS: 0–10 mm) were recorded at inclusion. The primary endpoint was complete resolution of the trigger finger at 6 months.
Eighty-four patients totaling 105 treated digits were included. Mean age was 63.3 ± 10.7 years. Prior to treatment, mean VAS pain score was 5.8 ± 2.6 mm, and mean QuickDASH score was 44.3 ± 19.1. At 6 months, disappearance of symptoms was achieved in 85 of 91 digits with follow-up (93.4%), and in 85.7% at 12 months. The absolute reduction in VAS pain and QuickDASH scores at 6 months was respectively 4.1 ± 3.1 (P < 0.001) and 36.1 ± 20.7 (P < 0.001), and 90% of patients reported being satisfied or very satisfied at 6 months. Long duration of symptoms was significantly associated with persistent trigger finger at 6 months after intervention. Complications were rare and minor. Tenosynovitis occurred in 5.7% of cases, for which a corticosteroid injection into the tendon sheath rapidly led to favorable resolution.
Treatment of trigger finger by release of the A1 pulley under ultrasound guidance using the needle technique is a mildly invasive technique that yields rapid and effective symptom resolution with good tolerance up to 12 months.
Determinants of Therapeutic Success of Corticoids Injections in Trigger Finger Syndrome
2022, Reumatologia ClinicaEl dedo en resorte es un motivo de consulta frecuente en el que las infiltraciones de corticoides juegan un papel terapéutico relevante en los grados de severidad intermedios cuando el tratamiento conservador no ha funcionado. Sin embargo, no existen criterios que permitan seleccionar qué pacientes se beneficiarán más de este procedimiento. El objetivo de nuestro estudio es identificar los condicionantes de éxito terapéutico de las infiltraciones de corticoides en estos pacientes.
Diseñamos un estudio prospectivo longitudinal basado en práctica clínica habitual con pacientes adultos, con diagnóstico clínico de dedo en resorte grado II o III, a quienes se les realizó una infiltración de 20 mg de acetato de triamcinolona. Las variables desenlace fueron el alcanzar un grado Quinnell I o reducir en al menos una categoría la severidad del cuadro clínico, 2 meses después del procedimiento. Para determinar los condicionantes del alcance de los objetivos se realizó una modelización predictiva de regresión logística binaria utilizando aquellas variables que tuvieron una satisfactoria correlación univariante.
Se incluyeron 74 pacientes a lo largo de 3 años, 42 de los cuales (61,8%) tenían un grado Quinnell III. Tras la infiltración, 22 (32,4%) alcanzaron la resolución completa y 50 (73,5%), la resolución parcial. Las variables engrosamiento tendinoso (HR: 10,72; IC 95%: 2,88-39,93; p < 0,001) y tiempo de evolución (HR: 1,23; IC 95%: 1,02-1,49; p = 0,027) demostraron ser condicionantes predictoras del éxito terapéutico en la resolución completa. Para la modelización para resolución parcial las mismas variables demostraron ser condicionantes predictoras (HR: 5,57; IC 95%: 1,38-22,41; p = 0,016 y HR: 1,18; IC 95% 0,99-1,41; p = 0,051, respectivamente). El engrosamiento de la polea no demostró capacidad predictiva en ninguno de los 2 modelos.
Nuestros resultados indican que la demostración de engrosamiento del aparato flexor del dedo es el principal condicionante del éxito de las infiltraciones de corticoides en esta afección. Esto concuerda con los hallazgos histológicos de especímenes obtenidos tanto de tejido tenosinovial y de poleas. En los primeros se demuestra, además de un infiltrado de características inflamatorias la presencia de células condrocitoides productoras de ácido hialurónico. Si bien el éxito terapéutico de las infiltraciones en estudios previos alcanza el 70%, la tasa de recidiva es semejante a los 12 meses. La selección de pacientes con engrosamiento tendinoso asegura el éxito terapéutico a corto plazo, podría reducir la recidiva a largo plazo, y evitar el retraso de la cirugía de liberación.
Trigger finger is a frequent complaint in which corticosteroid infiltrations play a relevant therapeutic role in intermediate degrees of severity when conservative treatment has not worked. However, there are no criteria to select which patients will benefit most from this procedure. The present study aimed to identify the factors leading to the therapeutic success of corticosteroid infiltration in these patients.
We designed a prospective longitudinal study based on routine clinical practice with adult patients with a clinical diagnosis of trigger finger grade II or III on the Quinnell scale, who underwent an infiltration of 20 mg of triamcinolone acetate. The outcome variables were to achieve a Quinnell grade I or reduce the severity of the symptoms by at least one category two months after the procedure. To identify the determinants of complete or partial therapeutic success, binary logistic regression predictive modelling was performed using those variables that had a satisfactory univariate correlation.
74 patients were included over three years, 42 of whom (61.8%) were classified as Quinnell grade III. After infiltration, 22 (32.4%) achieved complete resolution and 50 (73.5%) partial resolution. The variables tendon thickening (HR 10.72; 95%CI 2.88-39.93; P<.001) and progression time (HR 1.23; 95%CI 1.02-1.49; P=.027) proved to be predictors of therapeutic success in complete resolution. For the modelling for partial resolution, the same variables proved to be determining predictors (HR 5.57; 95%CI 1.38-22.41; P=.016 and HR 1.18; 95%CI .99-1.41; P=.051, respectively). Pulley thickening did not demonstrate predictive ability in either model.
Our results indicate that the demonstration of finger flexor apparatus thickening is the main determining factor for the success of corticosteroid infiltrations in this pathology. This is in agreement with the histological findings of specimens obtained from both tenosynovial and pulley tissue. In the former, in addition to an infiltrate of inflammatory characteristics, the presence of chondrocytoid cells producing hyaluronic acid is demonstrated. Although the therapeutic success of infiltrations in previous studies reaches 70%, the recurrence rate is similar after 12 months. The selection of patients with tendon thickening ensures therapeutic success in the short term, could reduce recurrence in the long term, and avoid delay in release surgery.
- 1
From the Division of Plastic Surgery, Toronto Western Hospital, and the University of Toronto, Toronto, Ont., Canada.