Trigger finger (or thumb) is the term for a specific catching or locking of a finger when a fist is made. Often it requires using your other hand to unlock the finger, and it is generally painful. Sometimes the locking is worse in the mornings or after prolonged or repeated manual activity. It can occur on any digit, and it is not unusual to have multiple trigger digits. Trigger digit is common in certain diseases, such as Rheumatoid Arthritis. The tendons that bend the fingers (flexor tendons) have a thickened area called a nodule. This is not present in everyone, and tends to be hereditary. The tendon glides through a tunnel called a tendon sheath, which holds the tendon down next to the bone. There is a thick edge of the sheath in the palm, and when the finger is bent, the nodule catches on the sheath. Catching generally occurs when the patient bends the finger, but not when the physician bends it during the examination.

Symptoms: Usually there is swelling along the finger, and pain with flexion of the finger, although there can be painless locking or catching when the finger is bent. It can feel like one of the finger joints is locking or dislocating, although this is not the case. Because the tendons go through the carpal tunnel, swollen and inflamed tendons can cause numbness in the fingers through irritation of the nerve (see Carpal Tunnel Syndrome). It is important that the triggering be treated even if painless, because tendon damage can occur if left untreated.

Treatment Options:

Activity modification can reduce irritation to the tendons that bend the fingers. Any repeated grasping or fine manipulation can cause inflammation of the tendons. Padded gloves (e.g. weight lifting gloves) can reduce trauma to the tendons. Stopping frequently to perform tendon gliding exercises can reduce tendon irritation. Avoiding prolonged activity without a rest can make symptoms worse.

Splints can be useful, although there is little solid research to support the use of splints. Wrist braces, commonly used for carpal tunnel syndrome can aggravate trigger finger if the splint extends too far into the palm, causing pressure on the flexor tendons.

Anti-inflammatory medications, such as ibuprofen, Aleve or prescription medications can reduce pain.

Corticosteroid injections successfully treat the problem nearly 90% of the time, although the success rate is slightly lower in diabetic patients. If triggering does not resolve within three weeks of the injection, a second injection is done. If the triggering does not resolve with that, surgery is generally indicated. Very little corticosteroid is used, and it generally does not affect the blood sugar level in diabetic patients, even with multiple simultaneous injections. The injection lasts about six months, and although triggering can recur years after a successful injection, most often it never recurs. Additional injections can be done intermittently if the injections demonstrate temporary success (four months or more). If multiple injections are required at regular intervals, surgical release is often a better option. Each finger must be injected separately, so hand therapy can be helpful for multiple trigger digits, when the patient does not want to undergo five or six injections at once.

Surgical Trigger Finger Release: This is done as an outpatient procedure in a surgery center. It is done with Bier block anesthesia, which affords painless surgery, but allows movement of the finger after the tourniquet is released and the anesthetic is gone. The patient is asked to make a fist after release of the sheath, to show that the finger is no longer locking. This allows confirmation that a complete release has been performed. In some cases there is abnormal thickening of the normal tissue that surrounds the tendon, and this must be removed. This can result in reactive swelling around the tendon, which generally resolves within three months. A soft dressing is placed on the hand, and removed two days later. The sutures are removed in 10-12 days. Activities are allowed as tolerated by the patient. Occasionally, therapy is required after surgery to reduce scar formation and improve strength and range of motion. Despite successful surgical release, care should be taken to avoid future tendon trauma or irritation.

Carpal tunnel syndrome is the term for compression of the median nerve through the carpal tunnel in the wrist and hand.

Symptoms: Numbness in the thumb, index and middle fingers. There may be some numbness in the ring and little fingers as well, but it is less common. Numbness can occur during sleep or during activities, often because of holding the wrist in a flexed position, cutting off the blood flow to the nerve. Numbness often occurs gradually and can be present for years before it is noticed. Pain in the hand and wrist, which again occurs during sleep or activities. Not everyone has pain.

Nerve Studies are done if surgery is contemplated. They will reveal the severity of the nerve compression, show other areas of nerve compression that can cause similar symptoms (the forearm or the neck), and assess any nerve damage. The degree of nerve damage is relevant since the worse the nerve starts out, the longer it takes to recover after surgery. Nerve compression, which has been present for years or is severe, can take 12-18 months to improve after surgery.

Surgery is indicated when nerve studies indicate nerve compression at the carpal tunnel, if non-operative treatments fail, if numbness is present all the time, or if nerve studies indicate nerve damage.

Treatment Options:

Activity modification is appropriate if the symptoms are caused by specific activities. Common aggravating factors include driving, vibration (air or power tools), repeated or prolonged grasping or fine motor activity (e.g. sewing, painting, gardening, etc.). Antivibration gloves can be helpful, and weight-lifting gloves can be an inexpensive substitute. Inflammation and swelling of the tendons that bend the fingers can cause nerve irritation because the tendons pass through the carpal tunnel. Splints (wrist braces) can be used to hold the wrist in a better position, reducing irritation to the nerve.

Anti-inflammatory medications, such as Ibuprofen or Aleve, or even prescription medications can reduce pain.

Corticosteroid medications can be utilized, although it is more appropriate to inject them into the carpal tunnel than to take oral steroids, which affect other areas of the body. Although injections can help the symptoms, they generally do not treat the carpal tunnel syndrome, and symptoms usually recur.

Hand Therapy is quite useful, especially for early or mild nerve compression. Oftentimes symptoms will resolve for several years. Generally, therapy is done three times weekly for a period of four weeks. If there is no improvement, nerve studies are the next step.

Surgical carpal tunnel release
This is done as an outpatient procedure in a surgery center. The surgery is usually done through a 1 inch incision in the palm, requiring three stitches which are removed in 10-12 days. The soft dressing is removed in two days, and the patient can resume any activities they choose, so long as they keep the incision clean. Most patients do not require anything further, although sometimes therapy is required post-operatively to reduce scar tissue and improve strength. In patients who have nerve damage, there can be some increased burning and stinging pain which occurs about a month after surgery and continues for about four or more months. This is related to improved blood flow to the nerve, and is similar to the pain you feel when your leg tingles after it falls asleep and "comes back to life."

When carpal tunnel symptoms occur without evidence of nerve compression by nerve studies, the cause is often related to tendonitis involving the flexor tendons of the fingers. Surgical release of the carpal tunnel for symptoms caused by tendonitis is less successful than for traditional carpal tunnel syndrome.

Recurrent Carpal Tunnel Syndrome
It is rare to need repeat surgery after a successful release, although there can be scarring around the nerve that can cause symptoms to recur. Repeat release for scar tissue is successful about half of the time, and generally only for a short time. Generally, a corticosteroid injection into the carpal tunnel is done before considering surgery. Often that is all that is required, and can be repeated as needed. If there is no improvement with injection, repeat surgery is not likely to improve symptoms.

Arthroscopic surgery allows us to examine the inside of the wrist through small incisions in the skin. It is useful for treating injuries from fractures to ligament tears and arthritis. Its greatest advantage is the ability to examine the wrist joint without disrupting supporting structures, thus providing more rapid recovery with minimal complications. We receive referrals from orthopaedic surgeons all across the ArkLaTex for repair of these injuries.

Triangular Fibrocartilage Complex (TFCC) injuries are one of the most common conditions treated arthroscopically. This often occurs from a twisting injury to the wrist or from a fall on the extended wrist. Pain occurs with wrist rotation or with lifting objects away from the body. After surgical repair the wrist and elbow are immobilized for four weeks to prevent forearm rotation. Typically therapy is required for 3 months after cast removal.

Ganglion cysts may be treated arthroscopically, allowing examination of the wrist joint to look for any injury or abnormality. If there is no indication of abnormality in the wrist, the cyst may be excised through a traditional incision rather than arthroscopically.

Ligament tears between the wrist bones are not well visualized with x-ray or MRI but are readily identified with arthroscopy. If the injury is not severe, the bones may be realigned and pinned together with aid of the arthroscope, avoiding a large open incision. A cast is placed to immobilize the wrist for 8 weeks, at which time the pins are removed and therapy is begun.

Arthritis can be treat many ways, but early or limited arthritis symptoms can be improved with arthroscopy. Often arthritis that is not apparent on x-ray or MRI is identified with arthroscopy.

The Center for Hand Surgery is the doctor's office. Dr. Ritter is a surgeon who specializes in the hand. She operates at hospitals and surgery centers. Not all visits to see the doctor require surgery.