Trigger finger (stenosing flexor tenosynovitis)
- Philip E Blazar, MD
Philip E Blazar, MD
- Assistant Professor of Orthopedic Surgery
- Harvard Medical School
- Rohit Aggarwal, MD, MSc
Rohit Aggarwal, MD, MSc
- Assistant Professor of Medicine, Division of Rheumatology and Clinical Immunology
- University of Pittsburgh
Trigger finger (also called stenosing flexor tenosynovitis) is caused by a disparity in the size of the flexor tendons and the surrounding retinacular pulley system at the first annular (A1) pulley (figure 1) which overlies the metacarpophalangeal (MCP) joint (figure 2). The flexor tendon catches when it attempts to glide through a relatively stenotic sheath, resulting in an inability to smoothly flex or extend the finger. In severe cases, the finger may become locked in flexion or extension, requiring passive manipulation of the finger to achieve normal motion. The cause of trigger finger is most frequently unclear, although patients often attribute it to overuse or repetitive movements. (See "Musculoskeletal complications in diabetes mellitus", section on 'Flexor tenosynovitis'.)
The pathogenesis, clinical manifestations, diagnosis and treatment of trigger finger are discussed here. The anatomy of the finger flexion and pulley system is reviewed separately. (See "Finger and thumb anatomy", section on 'Finger flexion and pulley system'.)
Trigger finger is one of the most common causes of hand pain in adults. The reported prevalence is roughly 2 percent in the general population, and is more common among women than men in the fifth or sixth decade of life . It can occur in one or many fingers in each hand and can be bilateral. The prevalence of trigger finger is also higher among patients with diabetes mellitus, rheumatoid arthritis, or conditions that cause systemic deposition of protein such as amyloidosis [1,2]. Trigger finger is occasionally observed in children . (See "Mucopolysaccharidoses: Complications", section on 'Carpal tunnel syndrome'.)
The majority of trigger fingers are idiopathic . Symptoms usually begin spontaneously, without a prior history of trauma or change in activity level. There are some observational reports suggesting an association with occupational or repetitive activities, but this is somewhat controversial .
The main histopathological change is fibrocartilaginous metaplasia of the ligamentous layer of the tendon sheath at the first annular (A1) pulley with secondary reduction in the cross-sectional area of the fibro-osseous canal [1,4]. Functional impairment in finger flexion and extension is primarily a result of mechanical impingement leading to tendon entrapment.
Subscribers log in hereLiterature review current through: Sep 2017. | This topic last updated: Jul 11, 2017.References
- Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger thumb). J Occup Environ Med 2000; 42:526.
- Saldana MJ. Trigger digits: diagnosis and treatment. J Am Acad Orthop Surg 2001; 9:246.
- McAuliffe JA. Tendon disorders of the hand and wrist. J Hand Surg Am 2010; 35:846.
- Sbernardori MC, Bandiera P. Histopathology of the A1 pulley in adult trigger fingers. J Hand Surg Eur Vol 2007; 32:556.
- Katzman BM, Steinberg DR, Bozentka DJ, et al. Utility of obtaining radiographs in patients with trigger finger. Am J Orthop (Belle Mead NJ) 1999; 28:703.
- Kameyama M, Meguro S, Funae O, et al. The presence of limited joint mobility is significantly associated with multiple digit involvement by stenosing flexor tenosynovitis in diabetics. J Rheumatol 2009; 36:1686.
- Doumas C, Vazirani RM, Clifford PD, Owens P. Acute calcific periarthritis of the hand and wrist: a series and review of the literature. Emerg Radiol 2007; 14:199.
- Colbourn J, Heath N, Manary S, Pacifico D. Effectiveness of splinting for the treatment of trigger finger. J Hand Ther 2008; 21:336.
- Makkouk AH, Oetgen ME, Swigart CR, Dodds SD. Trigger finger: etiology, evaluation, and treatment. Curr Rev Musculoskelet Med 2008; 1:92.
- Rodgers JA, McCarthy JA, Tiedeman JJ. Functional distal interphalangeal joint splinting for trigger finger in laborers: a review and cadaver investigation. Orthopedics 1998; 21:305.
- Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg Am 1992; 17:110.
- Rozental TD, Zurakowski D, Blazar PE. Trigger finger: prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg Am 2008; 90:1665.
- Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint Surg Am 2007; 89:2604.
- Anderson B, Kaye S. Treatment of flexor tenosynovitis of the hand ('trigger finger') with corticosteroids. A prospective study of the response to local injection. Arch Intern Med 1991; 151:153.
- Wojahn RD, Foeger NC, Gelberman RH, Calfee RP. Long-term outcomes following a single corticosteroid injection for trigger finger. J Bone Joint Surg Am 2014; 96:1849.
- Murphy D, Failla JM, Koniuch MP. Steroid versus placebo injection for trigger finger. J Hand Surg Am 1995; 20:628.
- Lambert MA, Morton RJ, Sloan JP. Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb. J Hand Surg Br 1992; 17:69.
- Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom-de Jong B. Corticosteroid injection for trigger finger in adults. Cochrane Database Syst Rev 2009; :CD005617.
- Peters-Veluthamaningal C, Winters JC, Groenier KH, Jong BM. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. Ann Rheum Dis 2008; 67:1262.
- Baek GH, Kim JH, Chung MS, et al. The natural history of pediatric trigger thumb. J Bone Joint Surg Am 2008; 90:980.
- Mishra SR, Gaur AK, Choudhary MM, Ramesh J. Percutaneous A1 pulley release by the tip of a 20-g hypodermic needle before open surgical procedure in trigger finger management. Tech Hand Up Extrem Surg 2013; 17:112.
- Fowler JR, Baratz ME. Percutaneous trigger finger release. J Hand Surg Am 2013; 38:2005.
- Wang J, Zhao JG, Liang CC. Percutaneous release, open surgery, or corticosteroid injection, which is the best treatment method for trigger digits? Clin Orthop Relat Res 2013; 471:1879.
- Bain GI, Wallwork NA. Percutaneous A1 Pulley Release a Clinical Study. Hand Surg 1999; 4:45.
- Turowski GA, Zdankiewicz PD, Thomson JG. The results of surgical treatment of trigger finger. J Hand Surg Am 1997; 22:145.
- Guler F, Kose O, Ercan EC, et al. Open versus percutaneous release for the treatment of trigger thumb. Orthopedics 2013; 36:e1290.
- Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am 2006; 31:135.
- Stahl S, Kanter Y, Karnielli E. Outcome of trigger finger treatment in diabetes. J Diabetes Complications 1997; 11:287.
- Werner BC, Boatright JD, Chhabra AB, Dacus AR. Trigger digit release: rates of surgery and complications as indicated by a United States Medicare database. J Hand Surg Eur Vol 2016; 41:970.
- Huang HK, Wang JP, Wang ST, et al. Outcomes and complications after percutaneous release for trigger digits in diabetic and non-diabetic patients. J Hand Surg Eur Vol 2015; 40:735.
- DIFFERENTIAL DIAGNOSIS
- Dupuytren’s contracture
- Diabetic cheiroarthropathy
- Metacarpophalangeal joint sprain
- Infection within the tendon sheath
- Calcific peritendinitis or periarthritis
- Tenosynovitis (non-infectious)
- Overall approach
- Acute symptoms
- Persistent symptoms
- - Glucocorticoid injection
- - Surgery
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS