How should trigger finger be managed?

Trigger Finger Management

Begin with corticosteroid injection as first-line treatment for trigger finger, reserving open surgical A1 pulley release for cases that fail conservative management or present with fixed flexion deformity. 1, 2, 3

Initial Conservative Management (First 3 Months)

Corticosteroid Injection - Primary Treatment

• Corticosteroid injection is the preferred initial intervention, particularly effective in non-diabetic patients 2, 4
• Inject into the tendon sheath at the A1 pulley level to reduce inflammation and narrowing 1
• Success rates are substantial, though recurrence occurs in approximately 385 per 1000 patients (38.5%) within 6-12 months 3
• Can be repeated if initial injection provides temporary relief 5

Splinting - Alternative Conservative Option

• Splinting is appropriate for patients who wish to avoid corticosteroid injection 4
• Immobilize the affected finger in extension to prevent triggering during flexor tendon gliding 1, 2
• Continue for several weeks with activity modification 2
• Less effective than injection but avoids pharmacologic intervention 5

Activity Modification

• Reduce repetitive gripping and forceful hand activities that exacerbate symptoms 1
• Educate patients on avoiding positions that trigger locking 5

Surgical Intervention - Definitive Treatment

Indications for Surgery

• Proceed directly to surgery if patient presents with fixed flexion deformity or inability to flex the finger due to pain intensity and functional disability 5
• Failure of conservative treatment after 3 months 2, 5
• Recurrent triggering after multiple steroid injections 3
• Patient preference for definitive treatment 4

Open A1 Pulley Release - Gold Standard

• Open surgical release is the definitive treatment with 90-100% success rates 4
• Perform under local anesthesia to allow immediate intraoperative confirmation of release 4
• Make 1-1.5 cm incision on volar hand just proximal to A1 pulley in skin crease to minimize scarring 4
• Release A1 pulley longitudinally at least to level of A2 pulley 4
• For thumb trigger finger, identify and protect the radial digital nerve which courses directly over the A1 pulley 4
• Patient actively flexes and extends finger intraoperatively to confirm complete release 4

Percutaneous Release - Alternative Surgical Approach

• Percutaneous needle release of A1 pulley is an option 2, 4
• No difference in recurrence rates compared to open release (RR 1.48,95% CI 0.79-2.76) 3
• Open release provides better visualization and may be safer regarding neurovascular injury 4
• Consider percutaneous approach for experienced surgeons in selected cases 2

Comparative Effectiveness: Surgery vs. Injection

Recurrence Rates

• Open surgery dramatically reduces recurrence compared to steroid injection: 65 per 1000 (6.5%) with surgery versus 385 per 1000 (38.5%) with injection at 6-12 months, representing 83% improvement (RR 0.17,95% CI 0.09-0.33) 3
• Absolute risk reduction of 29% fewer people with recurrence after surgery 3

Pain Profile

• Surgery causes more immediate postoperative pain: 678 per 1000 (67.8%) with surgery versus 184 per 1000 (18.4%) with injection at one week (RR 3.69,95% CI 1.99-6.85) 3
• This represents 49% more patients experiencing palmar pain with surgery in the first week 3
• Pain is temporary and resolves as surgical site heals 4

Complications

• Minor complications occur in 9.6-28% of open releases (stiffness, swelling, persistent pain) 4
• Major complications occur in 2.4-3% (synovial fistula, PIP joint arthrofibrosis) 4
• Neurovascular injury risk is low: 9/140 (6.4%) with surgery versus 4/130 (3.1%) with injection (RR 2.17,95% CI 0.7-6.77) 3
• Male gender, sedation, and general anesthesia may increase complication risk 4

Management of Persistent Triggering After A1 Release

• If triggering persists despite A1 pulley release, excise a slip of flexor digitorum superficialis (FDS) 2
• This is reserved for refractory cases with continued symptoms after primary release 2
• Also indicated for patients with persistent flexion contracture after A1 release 2

Common Pitfalls

• Avoid delaying surgery in patients with fixed flexion deformity - these patients benefit from earlier surgical intervention rather than prolonged conservative management 5
• Do not perform percutaneous release without adequate experience - open release provides superior visualization and safety 4
• Ensure complete A1 pulley release to at least A2 level - incomplete release leads to persistent triggering 4
• Protect neurovascular structures, especially radial digital nerve in thumb - this nerve courses directly over the A1 pulley 4