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Trigger Finger / Thumb M65.30 727.03

 
ICD-9 Classification / Treatment
Etiology / Natural History Associated Injuries / Differential Diagnosis
Anatomy Complications
Clinical Evaluation Follow-up Care
Xray / Diagnositc Tests Review References

synonyms: trigger finger, stenosing tenosynovitis, stenosing tendovaginitis, tendon entrapement.

Trigger Finger ICD-10

Trigger Finger ICD-9

  • 727.03 (trigger finger)
  • 756.8(other congenital musculoskeletal anomalies of muscle, tendon, fascia)

Trigger Finger Etiology / Epidemiology / Natural History

  • Thickening of flexor tendon synovial sheath prevents tendon gliding.
  • Associated with rheumatoid arthritis, diabetes, heavy lifting/gripping occupations.
  • Female > male.

Trigger Finger Anatomy

  • Involves the A1 pulley, lies over the distal aspect of the metacarpal, just proximal to the MCP joint. 
  • Significant risks with the percutaneous technique- especially if you are releasing a trigger thumb, and the consensus appears to favor not doing the thumb percutaneously. 
  • The radial digital nerve to the thumb is only 2mm from the pulley, and hence at significant risk. (Carozella J, J Hand Surg 1989;14A:198)

Trigger Finger Clinical Evaluation

  • Palpable nondule a base o MCP pain.

Trigger Finger Xray / Diagnositc Tests

Trigger Finger Classification / Treatment

  • MCP joint extension splinting (66% relief) (Patel MR,J Hand Surg 1992;17A:110)
  • Flexor sheath steriod injection (84% relief) (Patel MR,J Hand Surg 1992;17A:110).
  • Percutaneous release (Maneerit J, J Hand Surg 2003;28Br:586).
  • Pediatric trigger thumb: developmental, not congential. Stretching and extension splinting indicated if patients is <2 years old. >3years old = release of the proximal annula pully. (Tan AH, JPO 2002;11B:25), (Slakey JB, JBJS 1996;78Br:481).

Trigger Finger Injection Technique

  • prep and drape in standard sterile fashion
  • Prepare 1ml Celestone (6mg) and 1ml 1%Lidocaine in 5ml syringe.
  • Use 25-gauge needle
  • Place needle in the base of the MCP flexor crease in the midline angled slightly proximally down to bone
  • Needle is withdrawn slightly and injection is performed after an aspiration to confirm needle is not intravascular. Firm resistance indicates needle is intratendinous and should be adjusted slightly.
  • Entire 2ml should be able to be injected and the finger tip pulp should appear "full" indicated injection was within flexor sheath.

Trigger Finger Open Release Technique

  • Prep and drape in standard sterile fashion.
  • Local anesthetic injected into skin and flexor sheath.
  • Longitudinal incision over A1 pully between the distal transverse palmar crease and the base of the finger flexion crease.
  • Blunt dissection under loop magnification down to A1 pulley. A1 pulley is clearely visualized and NV bundles protected.
  • A1 pulley is sharply released with #15 blade starting proximally just proximal to the base of the finger flexion crease which ensures the A2 pulley is preserved.
  • Tendons are pulled from the sheath and inspected. Full triggerless motion is verified.
  • Irrigation.
  • Close skin

Trigger Thumb Release Technique

  • CPT: 26055 (tendon sheath incision)
  • Prep and drape in standard sterile fashion.
  • Local anesthetic injected into skin and flexor sheath.
  • Radially based V shaped flap incision centered over the thumb A1 pulley ath the MP crease. Ensure thumb MCP joint is in slight flexion during incision to decrease risk of injury to radial digital nerve.
  • Blunt dissection under loop magnification down to A1 pulley. A1 pulley is clearely visualized and NV bundles protected.
  • A1 pulley is sharply released with #15 blade starting proximally just proximal to the base of the finger flexion crease which ensures the A2 pulley is preserved.
  • Tendons are pulled from the sheath and inspected. Full triggerless motion is verified.
  • Irrigation.
  • Close skin

Trigger Finger Associated Injuries / Differential Diagnosis

Trigger Finger Release Complications

  • incomplete cure
  • digitial nerve injury
  • A2 pulley release with bowstringing (Heithoff SJ, J Hand Surg 1988;13A:567)
  • stiffness
  • wound maceration
  • vascular injury
  • tendon laceration

Trigger Finger Follow-up Care

Trigger Finger Review References

  1. Fleisch SB, JAAOS 2007;15:166
  2. Saldana MJ, JAAOS 2001;9:246
  3. Pope DF, Wolfe SW: Safety and efficacy of percutaneous trigger finger release.  J Hand Surg Am 1995; 20:280-283.
  4. Bain GI, Turnbull J, Charles MN, Roth JH, Richards RS: Percutaneous A1 pully release: A cadaveric study.  J Hand Surg Am 1995; 20: 781-784.
  5. Lane LB: Commentary: Percutaneous release of the first annular pulley. J Hand Surg Am 1995; 20:785-6.

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