Trigger Finger - Stephen Powell, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today we're interviewing Dr. Stephen Powell. Dr. Powell finished his medical school training at Indiana University. He then went on to complete an orthopaedic residence at the University Hospitals of Indiana University. He then completed two fellowships, one an Arthritis Fellowship in Denver, and another Fellowship in Hand Surgery in Indianapolis, Indiana. Today we're going to be talking about a very common condition called "trigger digit" which occurs in the thumb and all fingers of the hand. Good afternoon, Dr. Powell.

Dr. Stephen Powell: Hello, Randy.

Dr. Sechrest: Thanks for joining us. This condition is one of the most common conditions that most orthopaedic surgeons, hand surgeons, see on a daily basis. Can you describe what a trigger finger really is?

Dr. Stephen Powell: A trigger finger is a locking or snapping of the finger when the patient makes a fist with the finger or straightens it out. It can be either, it can be both, and the cause of the trigger finger is a locking of the tendon as it traverses or passes through the tunnel; there is a tunnel that is designed to hold that tendon system close to the finger as the finger bends so the tendon doesn't move away from the bones as you move the finger. Sometimes that tunnel is too tight, and is usually too tight only at one spot and that's down at the base of the finger down in here. I tell patients it's sort of like a train trying to go through the tunnel and the stack is too big and so it just doesn't quite make it. So what happens is the patient will notice typically an early case of some snapping. There may be some soreness in the palm and in the finger, and some clicking of the finger. That may be variable from day to day, from hour to hour, typically it's worse in the morning when they first get up and, in the early period of this condition, then it may or may not progress from just a clicking to a locking where the finger will actually be unable to be straightened out unless the patient takes their other hand and straightens the finger out by the other hand.

Dr. Sechrest: Does that hurt when they do that?

Dr. Stephen Powell: Frequently that hurts more often than not, that hurts, and that's called a 'locking'. Locking can be even to the point where you have to push very hard to get it straight or to bend it down.

Dr. Sechrest: So we'd feel sort of a click if we moved back and forth in the early stages, and then it might actually get stuck.

Dr. Stephen Powell: That's correct. And that can happen in the fingers or the thumb.

Dr. Sechrest: It's interesting about your analogy. I usually tell people, but I'm a big fisherman, so I'll usually tell them it's like a split-shot going through the eyes on a fishing rod. If you can imagine pulling the split-shot back and it's sort of snapping back and through, so most of the folks I see, they seem to get that. What causes this? Why do you get it?

Dr. Stephen Powell: That's a good question in most cases. It's an inflammatory condition. There's a definite thickening of this ligament structure that begins the tunnel. The tendons are pretty much unrestricted as they come past the proximal palm in this area out to the area where the tunnel starts, and at that point, the leading edge of that tunnel has a definite circular structure that will start to thicken if it's inflamed. What causes the inflammation? Most times we don't now. It probably doesn't have much to do with what you're doing with your hands. It could be related to injury. Some people will have an injury of some sort, fracture perhaps in that area, or a crush injury, or some post-injury scarring will cause thickening of that ligament. But whatever causes it, the ligament will start to become inflamed. Press on the tendon, and if you think about the tendon being underneath an area of pressure, you'll start to get a little indentation in that. So it's a valley with a mountain on either side, and those mountains can't go through where the valley is sitting most of the time. So the inflammation is of uncertain etiology in most patients. There are some conditions that can cause it that we know are associated with it. Diabetes is particularly a problem. Many patients will have every finger and both thumbs operated on at some time who are diabetic, because of locking of their fingers and they don't respond as well to the other things that we will talk about for treatment.

Dr. Sechrest: So it's really the first part of the problem is the pulley, not the tendon?

Dr. Stephen Powell: That's correct.

Dr. Sechrest: And then the tendon gets involved after the pulley begins to affect the tendon.

Dr. Stephen Powell: Yes.

Dr. Sechrest: Which are the most common fingers? Are there more common ones than others?

Dr. Stephen Powell: The middle two fingers are the most typical of trigger fingers.

Dr. Sechrest: So the long finger and the ring finger?

Dr. Stephen Powell: Yes.

Dr. Sechrest: And then what about the thumb?

Dr. Stephen Powell: The thumb is very common. Any finger can have it but those are the two most common.

Dr. Sechrest: If I heard you right, this is not today considered necessarily a repetitive motion injury.
Dr. Stephen Powell: That's correct.

Dr. Sechrest: So it's more related to other disease processes.

Dr. Stephen Powell: That's correct.

Dr. Sechrest: You mentioned diabetes. Is there any other disease process that trigger finger is related to?

Dr. Stephen Powell: Rheumatoid arthritis is a very common cause. Any type of systemic arthritis, which causes inflammation of the linings of the tendons, can cause trigger fingers and trigger thumbs.

Dr. Sechrest: So I think you've probably covered most of this anyway and, that is, if I'm a patient and I'm having these clicking sensations, what else do I feel? What should I look for to make this diagnosis on myself, for example?

Dr. Stephen Powell: The tenderness in the palm over that inflamed ligament is probably the most common thing as well as the feeling of something moving underneath, you can feel the bump popping over your tendon sheath when your finger is straightening and bending. So that's probably the biggest thing. There are obviously other causes of snapping fingers, and patients typically will say, "I am feeling my knuckle pop" when they're doing that, and it's not in fact their knuckle, it's their tendon, but it could be something else popping in the knuckle, particularly after an injury, and that can cause problems.

Dr. Sechrest: So just because you've got popping in the fingers doesn't necessarily make it clear that it's a trigger finger.

Dr. Stephen Powell: That's right. There is also a popping that can happen on the other side of the hand and people will get confused when that tendon pops.

Dr. Sechrest: Yeah, it's always amazing to me because I'll almost come down to arguments with patients who just can't believe that the popping is coming from here. They just say, "No, it's here," and then you inject it and all of the sudden goes away and then they're convinced. So let's go back to diagnosis. If I'm a patient and I suspect that I've got trigger finger, and I show up in your office, how do you make the diagnosis?

Dr. Stephen Powell: It's a pretty simple diagnosis to make once you exclude the other causes of popping of the finger such as degenerative changes or injury to the other parts of the finger, the knuckles and the tendon on the top of the finger, the most common cause is trigger finger; and that is by taking a history, finding out what the patient is telling you particularly that it may be variable, worse in the morning, or that they can't straighten their finger out at all. Every time they bend it, it snaps. Whatever the history, that's very important. The typical physical finding is the tenderness that usually is present at the first pulley, the first part of that tunnel, and the nodule in the tendon, the bump in the tendon that you can feel moving back and forth and the patient showing you what happens.

Dr. Sechrest: Now do you do any special tests? Is this something that you would routinely get x-rays on? Does it require any more aggressive testing than just a physical exam?

Dr. Stephen Powell: If there is nothing else that I'm thinking about, which there typically is not, I wouldn't order x-rays or other tests, no.

Dr. Sechrest: So what do you tell that patient? I mean, what do we do to start treatment?

Dr. Stephen Powell: In the early cases, the patients have just had it, the people have had it perhaps 2, 3, 4 weeks, a couple of months, I would offer them an injection of some cortisone, corticosteroid synthetic type of medication, injection directly into the sheath either directly over the tunnel or in the side of the finger to go backwards in a small amount, just a very tiny needle injected there. Then have them make sure they don't get stiff, use their hand, kind of protect for a few days after the injection, but otherwise use it normally. Then I tell patients that we can go up to 3 injections. That's not in stone, but that's a good guideline to make sure that you're not damaging other tissues because cortisone is not great for your body overall. We'll go up to 3 injections. If they don't get any improvement at all after the first injection it's probably not going to be beneficial the second time. But if they get a step-wise improvement, I might do a second or a third. Typically in early cases you'll do an injection and that takes care of the problem completely. So that's the early cases. For somebody that's been doing it for years, and particularly if they're locking, if they actually have true locking of their finger, injections are not likely to offer them benefit, but I'll offer them a choice where they have a trial of an injection or not, but I can pretty much tell those patients they're going to probably require surgery. If the injections don't make the early patients well over a period of time, they're no longer early patients, and they'll get tired of it and they want it released, then we'll talk about a surgical release. You can also do some splinting of the finger. If people can wear a splint in their activities, splinting the middle joint of the finger, the proximal interphalangeal joint of the finger temporarily for during activities, can sometimes calm down the inflammation as well.

Dr. Sechrest: If that doesn't work and you proceed to surgery, tell us a little bit about that operation.

Dr. Stephen Powell: It's a pretty straightforward operation, typically done under local anesthesia. I prefer it to be done under local anesthesia because the patient can then show me when I'm done that they're not clicking any more. You don't like to have the patient wake up from a general anesthetic that maybe had a trigger finger released while you're doing another part of the body and you have them wake up and they're still clicking. So you want to make sure that the operation is finished and that's the best way. So I make a little incision in one of the creases of the palm, you have the creases at the end of your palm over the A1 pulleys as we call them; and we'll just make a small incision under local anesthesia, put a little tourniquet up on their forearm typically so they don't bleed a lot and we can see what we're doing, and incise that ligament; usually for an area of about three-quarters of an inch with a knife, watch that tendon ride through that area, ask the patient if they feel clicking. Typically they won't, sometimes there is a little more work to do, sometimes the tendon is degenerative and you need to do some things to the tendon, that's not common. When you're finished, you sew the patient up with a few stitches, put a light dressing on, and then after 2 or 3 days take the dressing off and make sure that they are moving their fingers from the early postoperative period so they don't get stiff. That's the most important thing after, besides taking care of their wound, is making sure that they keep their fingers moving.

Dr. Sechrest: Is this something you do in the office? Or is this something you do in the Surgery Center? Is it simple enough to do in the office?

Dr. Stephen Powell: I suppose you could do it in the office. There are people who have done the office procedure where they make a small incision in the ligament with a hypodermic needle or some variant of a small scalpel like that; do a puncture wound, basically, in the office. I personally like to make sure that I'm not damaging the tendon and I like to make sure that I have the nerves, which are on both sides of the ligament out of the way, particularly near the thumb where one nerve crosses right over the ligament. So my preference is to do it in the Surgery Center.

Dr. Sechrest: Now is this something that, once you've done this surgery, can this recur?

Dr. Stephen Powell: I have not seen it recur. I suppose it could. I've seen people who have had clicking of their finger maybe from another part of the tendon or other part of the finger afterwards that you have to investigate later, but that's a very, very small percentage of patients.

Dr. Sechrest: Is there any downside to cutting that tendon, I mean, or the pulley system. I'm assuming there is a downside to cutting the tendon obviously. But if you cut the pulley, is there any downside, do they notice any difference after that pulley's gone?

Dr. Stephen Powell: Once things are healed up, the loss of the pulley isn't a problem. The pulleys are very important, but that first pulley is not a problem to be without.

Dr. Sechrest: You mentioned that 3 or 4 days you're back to relative normal activity, or how long does it take?

Dr. Stephen Powell: Well, your hand is sore and you have stitches in, and you have to care for the wound, not get it wet, not abuse your hand during that period, and make sure that your fingers are moving. Make sure, particularly, that you're getting full flexion and that you're getting full extension. A lot of people will say they're moving their fingers and they don't get their finger straight in the joint, it might get a little stuck down because they're not moving it. So there is some rehab that they need to do themselves, no physical therapy typically, but it's sore. Once the stitches come out, the soreness tends to go away fairly quickly. Usually 2 or 3 weeks after the sutures come out they're using their hand pretty normally with a gradual increase in their use after the stitches come out.

Dr. Sechrest: Now, complications. There are always complications with any procedure. What do you worry about with this procedure?

Dr. Stephen Powell: I don't worry about it too much, but I am concerned about the things that can happen. It's rare to have problems with it except for the stiffness issues if people aren't following my postoperative plan or if they had some stiffness of their joint before they started. And that is stiffness. Infections are almost unheard of, it happens occasionally, but stiffness is the biggest problem that they have. Rarely will people have a tender scar. There are, as I mentioned, nerves that are right next to the tendon sheath, that we have to incise, and those, if you're not careful, can be injured. So, if they're done properly, the trigger finger releases shouldn't be a problem in that regard.

Dr. Sechrest: If I'm a physician or if I'm a patient looking for a surgeon to do this procedure, should I seek out a hand surgeon? Is this something that most general surgeons can do? Is this something a general practitioner does or an orthopaedic surgeon? Who should I seek out to do this procedure?

Dr. Stephen Powell: I think any orthopaedic surgeon, certainly a hand surgeon, a plastic surgeon trained in hand surgery, and there are general surgeons who are trained in hand surgery, that's not the majority, can certainly do that operation. You don't require a hand specialist to do a trigger finger.

Dr. Sechrest: Anything that you would advise patients who think they might have this disease process, how would you advise them to proceed?

Dr. Stephen Powell: Well, obviously if they have a problem, that they think is a problem for them, the proper procedure is to go to a physician who knows what that area of the body is all about. So, you're in an orthopaedic surgeon's office or hand surgeon's office probably and what you're concerned about, whether you're going to go see that person or not, is this a problem that I'm going to have problems with if I don't address it. In early cases, it's probably a nuisance. When it starts to lock then it gets to be a little bit of a problem with developing stiffness of the joint. There is the joint in the middle of the finger, which is really prone to get stiff if doesn't straight out all the time, and you can end up with a stiff finger, and some of the people don't even notice that they're not straightening out all the time. So, if your finger is moving fairly freely, and you can see that it's moving from a full straight to a full bent position and maybe you're having a little snapping, then it's just a matter of the nuisance factor, if it bothers you enough, to go see the physician. If you're actually having stiffness and you can't bend that finger down or straighten it up particularly all the way, that probably needs to be looked at.

Dr. Sechrest: So more likely to cause permanent restrictions or permanent damage.

Dr. Stephen Powell: It certainly can.

Dr. Sechrest: Well, it's been a fascinating discussion. Can you think of anything we haven't covered about either trigger thumb or trigger finger that patients need to know?

Dr. Stephen Powell: The typical trigger finger I think we've covered. There are other things that we have to worry about with rheumatoid arthritis; they might require a different operation, which is really a technical issue. Sometimes you work on the tendon as opposed to the tendon sheath. There are a lot of things we could talk about trigger finger, as simple as it might seem, but the 95% of the patients who have a classic trigger finger, I think we've covered that pretty well.

Dr. Sechrest: Okay. Well, thank you.

Dr. Stephen Powell: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.