What is the recommended treatment for trigger finger with tenosynovitis?

Treatment of Trigger Finger with Tenosynovitis

Corticosteroid injection into the tendon sheath is the recommended first-line treatment for trigger finger with tenosynovitis, with success rates being high for immediate symptom control. 1, 2

Diagnostic Confirmation

• Trigger finger presents with thickening of the flexor tendon sheath and A1 pulley with small volume fluid and hyperemia, consistent with tenosynovitis as seen in your case 1
• Diagnosis is primarily clinical with localized tenderness over the first dorsal compartment and pain that worsens with thumb and wrist movements 1

Treatment Algorithm

First-Line Management

• Conservative approaches:
  • Relative rest and activity modification to decrease repetitive loading of the damaged tendons 1
  • Thumb spica splint to immobilize the affected digit, reducing tension on affected tendons 1
  • NSAIDs can provide short-term pain relief but do not alter long-term outcomes 1

Second-Line Management (Recommended)

• Corticosteroid injection:
  • Local injection of triamcinolone acetonide into the tendon sheath is the most effective non-surgical intervention 2
  • Initial dose: 2.5 mg to 5 mg for smaller joints like fingers 2
  • A single local injection is frequently sufficient, but several injections may be needed for adequate relief of symptoms 2
  • Strict aseptic technique is mandatory when administering the injection 2
  • Ensure the injection is made into the tendon sheath rather than the tendon substance to prevent tendon damage 2

Third-Line Management

• Surgical intervention:
  • Reserved for patients who have failed 3-6 months of conservative therapy including corticosteroid injections 1
  • Surgical release of the A1 pulley provides high success rates 1, 3
  • Options include:
    • Percutaneous A1 pulley release 3
    • Open A1 pulley release 3
    • Excision of a slip of the flexor digitorum superficialis (reserved for patients with persistent triggering despite A1 release) 3

Evidence on Treatment Efficacy

• Approximately 80% of patients with tenosynovitis will fully recover within 3-6 months with appropriate conservative management 1
• Studies show that as many as 85% of triggering fingers can be treated successfully with corticosteroid injections 4
• A single injection approach is recommended initially, with a second injection given only in cases of recurrence or failure 5
• Patients with diabetes may have a higher rate of surgical intervention after corticosteroid injection failure 5

Important Considerations and Potential Complications

• Avoid injecting the corticosteroid directly into the tendon substance, which can weaken the tendon and predispose to rupture 1
• Subcutaneous atrophy is a potential complication of steroid injection if not properly administered 6
• Careful technique should be employed to avoid the possibility of entering a blood vessel or introducing infection 2
• Premature return to aggravating activities before adequate healing can lead to recurrence 1
• If an excessive amount of synovial fluid is present, some (but not all) should be aspirated to aid in pain relief and prevent undue dilution of the steroid 2

Follow-up Recommendations

• Monitor response to treatment and consider a second injection if symptoms persist after 6 weeks 5
• Surgical consultation should be considered if conservative measures fail after 3-6 months 1
• High baseline disability scores may predict earlier treatment failure and need for surgical intervention 5