Heather Benjamin: Thank you for joining us for our educational webinar: “What causes Trigger finger and how it’s treated?” Tonight’s speaker is Dr. James Cassandra, an orthopedic surgeon at OrthoNeuro.
Dr. Cassandra is a board-certified and fellowship-trained orthopedic surgeon specializing in hand and upper extremity conditions, as well as general orthopedics, fracture care, and trauma. He has been in practice for over 20 years.
Dr. James Cassandra: Thanks for coming. I appreciate it. I have a quick presentation. It’s a great topic. It’s very relevant. We see a lot of trigger digits, and it’s a condition that’s common. And we see patients every day with this problem.
So it’s a problem that is it’s gratifying to treat. There are great treatment options, and the trigger digit is something that we’ll talk more about tonight.
So, the bottom line is that trigger finger is a painful condition. It’s a condition that affects the hand, and it’s based on the anatomy. And the anatomy of the hand and forearm, all the muscles in the forearm, run down that tendon and run into the hand and to the end of the digits.
So those tendons, to function properly, have to go through a tunnel or a tight space. And that tunnel acts to restrain the tendons and allows you to make a full motion with your hand and prevents bowstringing. If we didn’t have the pulley system, you could bend your fingers, but you wouldn’t have complete motion.
And so having this anatomical system, it works well until it doesn’t. Or until there’s some type of pathology or inflammation, and what we see or call it stenosing tenosynovitis.
And that’s where there’s inflammation around the flexor tendons. And when that happens, the tendon doesn’t run smoothly through the tunnel, and there’s some swelling, and nodules can form, and that tendon gets stuck. And that’s essentially what a trigger finger is.
That finger gets stuck in a usually flexed position, gets stuck down, the patient can’t open it up, and they have to usually use their other hand to snap it open. And it’s painful.
This can happen for, you know, different reasons. In orthopedics, there are many things that we know, but with the human body, it’s still a great mystery. And the exact cause is unknown. But we know that there are associated conditions that affect the hand and can lead to a trigger digit, such as repetition and using the hand over and over in a strenuous manner, such as the weekend warrior that decides to paint their house, or a factory worker, or someone who knits continuously.
Those are common things that sometimes can lead to some irritation about that tendon. So strenuous, repetitive motion is one associated condition.
There are other medical conditions that can be associated with the trigger digit, most commonly diabetes, especially if the sugars aren’t well controlled. That can lead to conditions where there is more tenosynovitis in the tendon sheath. And if that happens, there’s a higher risk for that tendon just to get caught up and stuck.
Other medical conditions are gout, and rheumatoid arthritis can be classic for inflammation around tenosynovitis and tendons. The age group is usually between 40 and 60, where the acquired trigger digit can form or present.
And it can happen in an older age group. Younger, occasionally, but not as common. But most commonly if there is someone with poorly controlled rheumatoid arthritis, which isn’t as common nowadays, or more commonly diabetes, that’s heavy on their hand, it can lead to this trigger digit.
So, what happens is the pathophysiology—there is this pulley system that we talked about. That tendon should be nice and smooth and go through the pulley. That tendon enlarges and gets thicker, and its lining of it gets thicker, which we call it tenosynovium.
And then the pulley sheath itself, that also gets thicker. And, when those two things happen, it causes, number one, more friction. Number two, there’s more pressure. And number three, more fluid that forms in the tendon sheath.
That tendon sheath is a confined compartment, and there’s only so much space. So that confined compartment fills up, and it’s hard for that finger to move.
So that painful condition develops, and the fingers start to trigger. The good news about this is when coming in to see the doctor or hand surgeon, this is an easy diagnosis compared to some things that we have to diagnose or work up.
I think two things are key. Number one, we need a good history from the patient. You know, oftentimes if you listen to the patient, you can deduce what’s going on. And then, number two, a good physical exam to examine the trigger digit.
There are other conditions that can mimic trigger finger. So it’s important to make sure other conditions aren’t going on.
Sometimes the medical staff thinks it’s a trigger digit, but it could be the other side of the hand affected where the sagittal band rupture and then the extensor tendon triggers or catches. And it can present and look a little bit like a trigger digit, but the cause is totally different.
There could be Dupuytren’s, which causes a contracture of the joint from an injury or a tendon injury. All those conditions or diseases can present and sometimes make trigger finger a little more tricky to diagnose. But if you take time with the patient, with their history and a physical exam, it can diagnose trigger digit or trigger finger 100% of the time.
So, the symptoms we look for are, number one, pain at the A-one pulley or usually the palm. There can be swelling in that region of the hand.
Sometimes you feel a nodule that can develop. As the finger moves, you can see it stick. Sometimes it gets locked and then they have to unlock it. That’s what we call triggering, where we have to unlock it or release that lock position.
And then if it keeps locking, it can lead to a finger that has decreased motion or becomes stiff. So the problem is if there’s a trigger digit that goes on too long, it can lead to wear and tear on the tendon where it frays and can tear. Or, more commonly, the finger can become stiff, and contracture can develop if the patient’s not moving their finger through a full range of motion.
When patients come to the office, it’s nice to diagnose what it is. But the more important issue and factor is getting these conditions treated and resolution to the pain and suffering. So the first step: Ice, anti-inflammatories, massage—all can help on the hand.
If those aren’t helping, then we often talk about the next step. And the next step is a cortisone injection. This can be done in the office. Small injections are placed right into the palm.
Whichever finger is affected, we shoot it, put the medicine in and it goes down the tendon sheath, and that allows for that anti-inflammatory effect of the cortisone to take place. It causes that inflammation to go down, and the trigger digit can oftentimes resolve.
Therapy can be helpful, and some patients come in using splints. I think they may be beneficial at night. It won’t usually resolve it, but it might help at night to keep the hand in a more comfortable position and avoid waking up with the finger locked and very painful.
And then if, when a patient comes in, most times the injection can cure this. So I tell healthy patients that 80% of the time, the trigger digit can be cured by cortisone injection. This is done, and within seven days, it usually gets better.
But for the 20% of patients that it doesn’t cure or they don’t respond as well to the injection, then the next step is a small surgery. Surgery is an outpatient surgery.
It’s a quick procedure. It’s a gratifying procedure because we do this procedure under what we call MAC local, where the patient’s in a late twilight. The patients do not have to be intubated or put to sleep.
And then we numb up the hand, and then we free up the tendon. And oftentimes we can instruct the patient to move their hand, and we can see that motion correct itself and the lack of triggering. And so right away, it’s gratifying.
The outcomes are good. It’s a quick surgery it takes around 10-15 minutes. Patients go home, and healing times are around 10 to 14 days until the sutures come out.
With all surgeries, though, there are risks, and even though it’s an easy minor procedure, the risk we still have to keep in the back of our minds and take it seriously.
I think the biggest complication that could happen is infection. So keeping that hand protected after surgery, clean, and avoiding any contamination is crucial. Having patients optimize for surgery, especially if the patient is diabetic, means keeping the hemoglobin A1C at a nice level. And avoiding any risks, like smoking. Smoking makes healing harder.
And then protecting the hand. Therapy usually can be started at home and therapy can help get the motion back and also work out some of the tenderness that can sometimes occur with the scar.
So, overall, trigger digit is something that can happen. Most times it happens to the ring or long finger. The thumb is also common. The index and small fingers, it definitely can happen at those digits as well.
Diagnosis is easy, and treatment is straightforward. Most times improves with a cortisone injection or conservative care as opposed to surgical intervention. But when surgery is needed, the outcome is excellent, and patients do very well.
Heather Benjamin: It looks like we do have a few questions. I’ll start with one of the first that we got in. Do I have to have surgery to fix a trigger finger?
Dr. James Cassandra: I don’t think surgery is a must with a trigger digit. I think that a cortisone injection is my preferred first step. But after two injections, if that trigger digit doesn’t respond, then I think surgery is the next best option.
Two cortisone injections, and if there’s no relief, then surgery. Sometimes the one caveat is with diabetic patients, sometimes, the cortisone can bump sugar levels up in diabetic patients. And sometimes, the chance of full resolution with injection isn’t as high.
So if there’s any loss of motion, stiffness, concerns about sugar levels, and bumping that up, then sometimes surgery could be a consideration before two injections.
Heather Benjamin: And, then, how many cortisone injections can I have?
Dr. James Cassandra: Usually I say two, but that’s not a steadfast rule and it depends on how long relief is. So if I had a patient who had one injection and it helped a little bit; then they had another injection 6 to 8 weeks later, and it helped a little bit, but came back within six weeks—I’d recommend surgery.
If someone had an injection that helped for a year, then it came back, and then they had another injection that helped for two years, and it came back—I think that patient, if they wanted to try to avoid surgery, an injection can be done.
It doesn’t mean that it would resolve it forever. Life gets in the way of surgery sometimes, and we understand that. So the injection in that case could be a good option.
Heather Benjamin: And is physical therapy painful for a trigger finger?
Dr. James Cassandra: I think therapy for a trigger finger progresses quickly. And everyone’s different with pain. But for the average patient, I would say that compared to some other conditions we treat, it advances quickly with lower pain compared to some other things.
Heather Benjamin: And then I have a follow-up question to the cortisone shots question, and that is, “Does diabetes preclude more than two cortisone shots?”
Dr. James Cassandra: It doesn’t. But if it doesn’t improve, I think I think surgery would be a good option. I try not to set things in stone. Every patient is different with the conditions they’re going through and where they’re at in life.
So we have to talk about the risk and benefits. And so I wouldn’t say it precludes it, but it probably would push that patient down more of a surgical route.
Heather Benjamin: And then, “If my finger is locked, can you get it unlocked?”
Dr. James Cassandra: Yeah, surgery is effective in getting that trigger digit unlocked, and we see that happen right away in the operative suite.
The bigger deal is if it’s been locked for a long time, sometimes a contracture of the joint can develop. And if that happens, then even though the tendons are free, the joint still has to be worked out, where that tightness can develop through other structures such as a capsule or a tendon component.
That’s why it’s important to get these trigger fingers treated and that motion back. Because if that motion isn’t full, or it’s restricted, for a month or two months, it can lead to these contractures that become more complicated to treat.
Heather Benjamin: And then, how effective is therapy in curing the issue at hand?
Dr. James Cassandra: I think therapy can help. I wouldn’t say it usually cures trigger digit. I would say it’s marginally effective in curing it. I think the bigger options are cortisone injections and surgery.
Heather Benjamin: How common is trigger digit?
Dr. James Cassandra: It’s very common. You know, as a hand surgeon, we see multiple cases every day.
Heather Benjamin: And then are Oval-8 splints worthwhile?
Dr. James Cassandra: I think they’re okay. It gives the finger time to rest. It may help prevent the finger from getting caught or locked up. But I think splinting can help try to cool it down. It doesn’t always resolve it, though.
Heather Benjamin: And then, “Will trigger finger come back if I have surgery?”
Dr. James Cassandra: Can trigger finger come back after surgery? It’s not common, but it’s possible. And there are sometimes conditions when there’s a lot of inflammation around the tendons. This is when it’s most common.
And even though we free up here that A1 pulley, we call it, and it’s down in this region of the palm. So if someone has surgery, that’s freed up, but they have a lot of inflammation. I see every now and then that the tendon can trigger and get caught up at the A3 pulley.
And sometimes that has to be addressed. It’s not very common, but it’s something that we have to watch for. When we do surgery, our outcome, we like to have it taken care of forever. That’s the goal.
Heather Benjamin: When should I see a specialist for trigger finger?
Dr. James Cassandra: I would give it a week or two. And if it’s not getting better, I think that’s a good time.
Heather Benjamin: Looks like there are no more questions for this evening. Thank you for participating in tonight’s webinar. Thank you so much, Dr. Cassandra, for presenting tonight.
If you have more questions about trigger finger, be sure to contact OrthoNeuro today! We have several locations within Columbus, OH for your convenience. Schedule your appointment online today!
