Trigger fingers and thumb: When to splint, inject, or operate Fifty trigger fingers were treated by splinting of the metacarpophalangeal of flexion for an average of 6 weeks (range, 3 to 9 weeks). injected with 0.5 ml of betamethasone 0.5 ml of lidocaine.
joint at 10 to 15 degrees
Another 50 trigger fingers were
sodium phosphate and acetate suspension (Celestone) and
All patients were followed up for a minimum of 1 year (range, 1 to 4 years).
Treatment was successful in 33 (66%) of the splinted digits and 42 (84%) of the injected digits. Fifty percent of the 10 splinted thumbs and 70% of the 40 splinted fingers had a successful outcome. Of the 17 unsuccessfully injections
and 2 required
treated digits in the splinted group, 15 were later cured with
surgery.
All of the 7 unsuccessfully
treated digits in the injected
group were cured with surgery.
Patients with marked triggering,
months’ duration,
involved digits had a higher rate of failure in both groups.
and multiple
Splinting offers an alternative
symptoms
of more than 6
for patients who have a strong objection to cortisone injection.
(J HAND SURC 1992;17A:llO-3.)
M. R. Patel,
MD,
and Lynn
Bassini,
C
ortisone injection of the involved flexor tendon sheath relieves symptoms in 67% to 94% of the injected digits.‘-* What can we do for patients with trigger fingers who do not want to use cortisone or injections? Evans et aL9 reported that splinting of the metacarpophalangeal joint in 0 degrees extension relieved the symptoms in 73% of the 55 digits in 44 nonrheumatoid patients. We report a comprehensive grading of trigger fingers and compare the results of splinting and cortisone injection in two groups of patients .
MA,
OTR.
Brooklyn,
N. Y.
Table I. Six stages of digital
stenosing
tenosynovitis
Stage
Finger movements
1 2 3 4
Normal Uneven Triggering = Clicking = Catching Locking of finger in flexion or extension unlocked by active finger movement
5
Locking of finger in flexion or extension by passive finger movement Locked finger in flexion or extension
6
unlocked
Each stage may be painless or painful
Patients
and methods
We divided trigger fingers into six stages, each with increasing grades of mechanical problems (Table I).
From the Hand Surgery Service, Division of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, N. Y., and Staten Island University Hospital, Staten Island, N. Y. Presented at the forty-fifth annual meeting of the American Society for Surgery of the Hand, Toronto, Ontario, Canada, Sept. 26, 1990. Received for publication May 10, 1991.
Feb. 18, 1991; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: M. R. Patel, M.D., 4901 Fort Hamilton Brooklyn, NY 11219. 3/I/31209
110
THE JOURNAL OF HAND SURGERY
Parkway,
Over a l-year period 50 consecutive trigger fingers were treated by splinting of the metacarpophalangeal joint in 10 to 15 degrees of flexion. The digit was immobilized with a Thermoplast splint (Johnson & Johnson, New Brunswick, N.J.) and Velcro hook and loop straps (Smalley & Bates, Nutley, N.J.). The proximal interphalangeal joint was left free for extrinsic tendon gliding ( Figs. 1 to 3). Two digits may be splinted together (Fig. 4). The patients were allowed to remove the splint for hygiene. Three patients wore splints for 3 weeks, 27 for 6 weeks, 19 for 9 weeks, and 1 for 12 weeks. All patients were followed up for at least 1 year. The results of treating 50 trigger fingers with splinting and 50 trigger fingers with cortisone injection were compared. All patients were followed up for at least 1
Vol. 17A, No. 1 January 1992
Trigger Jingers and thumb
Fig. 1. The metacarpophalangeal joint of the index finger is immobilized at 15 degrees of flexion. The splint extends to the proximal interphalangeal joint crease and allows some oiposition of the digit with the thumb.
Fig. 2. Splinting of the long and ring fingers is similar. The splint is molded with the fingers opposing the thumb. The splint extends to the proximal interphalangeal joint crease, allowing flexion of the proximal and distal interphalangeal joints.
111
112
The Journal of HAND SURGERY
Putel and Bassini
Fig. 3. Splinting of the small finger requires a small gutter splint around the hypothenar eminence.
Fig. 4. Two fingers may be splinted together.
year. Thirty-seven digits were injected once, 13 digits were injected twice, and no digits were injected three or more times. The average age of the patients treated with splints was 60 years, and the average age of those who received
injections was 61, The male/female ratio was 14: 36 in the splinted group and 18 : 32 in the injected group. Trigger fingers occurred in the right hand in 30 digits and in the dominant hand in 48 digits in the splinted group. Trigger fingers occurred in the right hand in 32
Vol. 17A, No. 1 January 1992
digits and in the dominant injected group.
Trigger fingers and rhllmb
hand in 48 digits in the
Results Treatment was considered to have failed if it was followed by pain, clicking, or locking that required further treatment with injection or surgery. If patients had minimal pain or uneven movements that did not interfere with hand function and required no further treatment or if they were free of symptoms, treatment was considered successful. Thirty-three (66%) of the splinted digits and 42 (84%) of the injected digits had successful outcomes. Thumbs treated with a splint had the poorest outcomes; treatment of only 5 of the 10 splinted thumbs was successful. When thumbs were excluded, 70% of the 40 splinted digits had successful outcomes. In the injected group, the success rate was 92% for the thumb and 82% for the four fingers. The results that follow are analyzed for the index, long, ring, and small fingers only, as splinting succeeds in only 50% of the trigger thumbs and injections are successful in 92% of the thumbs. Of the 12 unsuccessfully treated digits in the splinted group, 10 were cured with injections and 2 with surgery. All of the 7 unsuccessfully treated digits in the injected group were cured with surgery. Splinting was successful in 77% of the patients whose symptoms had been present 6 months or less and in 44% of those with symptoms of more than 6 months’ duration. Injection was successful in 84% of the patients whose symptoms had been present 6 months or less, and in 71% of those with symptoms of more than 6 months’ duration. Two or more digits had a poorer result in both the splinted and the injected groups. All triple and quadruple digits treated with splinting failed. Thirteen splinted digits in which treatment failed were in stages 2, 3, and 4. Seven of the injected digits in which treatment failed were in stage 3. Recurrence within 1 year occurred in six digits (12%) in the splinted group.
Discussion Our classification (Table I) is based on the report of Quinnel” and modified by Evans et a1.9 and Newport et al.’ Evans et a1.9 reported satisfactory results with splinting of trigger fingers for 3 to 6 weeks. In this study, one third of the digits treated with satisfactory results needed splinting for more than 6 weeks. Patients tolerated and complied with splinting better when the
113
metacarpophalangeal joint was immobilized in 10 to 15 degrees of flexion rather than 0 as recommended by Evans et al. Our recommended protocol for trigger fingers is as follows: 1. Splinting. Splinting is most successful in trigger fingers involving index, long, ring, and small fingers in all stages, with the exception of locked fingers that cannot be passively unlocked. Patients are given a choice between splinting and injections. Patients who do not want to undergo splinting and patients who do not respond to splinting are treated with up to 3 cortisone injections at 2-week intervals. Patients who do not respond to injections are treated with surgery. 2. Injections. Trigger thumbs are treated with injections in all stages because the results of splinting are poorest injection
in the thumbs.
Patients
are then treated
who do not respond
to
with surgery.
3. Surgery.
We do not splint or inject digits locked in flexion (stage 6); they are treated with surgery. REFERENCES V. Treatment of trigger fingers. Acta I. Kohnd-Sorenson Orthop Stand 1970;41:428-32. 2. Rhoades CE, Gelberman RH. Manjarris JF. Stenosing tenosynovitis of the fingers and thumb: results of a prospective trial of steroid injection and splinting. Clin Orthop 1984;190:236-8. 3. Fauno P, Anderson HJ, Simonson 0. A long-term followup of the effect of repeated corticosteroid injections for stenosing tenosynovitis. J HAND SURG 1989;14B:242-3. 4. Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J HAND SURG 1990: 15A:74850. 5. Freiberg A, Mulholland RS, Levine R. Nonoperative treatment of trigger fingers and thumbs. J HAND SURG 1989;14A:553-8. 6. Clark DD, Ricker JH, MacCollum MS. The efficacy of local steroid injection in the treatment of stenosing tenovaginitis. Plast Reconstr Surg 1973;5 1: 179-80. 7. Howard LD. Pratt DR, Bunnell S. The use of compound F (hydrocortisone) in operative and nonoperative conditions of the hand. J Bone Joint Surg 1953;35A:9941002. 8. Marks M, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J HAND SURG 1989;14A:722-7. 9. Evans RB, Hunter JM, Burkhalter WE. Conservative management of trigger finger; a new approach. J Hand Ther 1988;2:59-68. 10. Quinnell RC. Conservative management of trigger finger. Practitioner 1980:224:187-90.
joint at 10 to 15 degrees
Another 50 trigger fingers were
sodium phosphate and acetate suspension (Celestone) and
All patients were followed up for a minimum of 1 year (range, 1 to 4 years).
Treatment was successful in 33 (66%) of the splinted digits and 42 (84%) of the injected digits. Fifty percent of the 10 splinted thumbs and 70% of the 40 splinted fingers had a successful outcome. Of the 17 unsuccessfully injections
and 2 required
treated digits in the splinted group, 15 were later cured with
surgery.
All of the 7 unsuccessfully
treated digits in the injected
group were cured with surgery.
Patients with marked triggering,
months’ duration,
involved digits had a higher rate of failure in both groups.
and multiple
Splinting offers an alternative
symptoms
of more than 6
for patients who have a strong objection to cortisone injection.
(J HAND SURC 1992;17A:llO-3.)
M. R. Patel,
MD,
and Lynn
Bassini,
C
ortisone injection of the involved flexor tendon sheath relieves symptoms in 67% to 94% of the injected digits.‘-* What can we do for patients with trigger fingers who do not want to use cortisone or injections? Evans et aL9 reported that splinting of the metacarpophalangeal joint in 0 degrees extension relieved the symptoms in 73% of the 55 digits in 44 nonrheumatoid patients. We report a comprehensive grading of trigger fingers and compare the results of splinting and cortisone injection in two groups of patients .
MA,
OTR.
Brooklyn,
N. Y.
Table I. Six stages of digital
stenosing
tenosynovitis
Stage
Finger movements
1 2 3 4
Normal Uneven Triggering = Clicking = Catching Locking of finger in flexion or extension unlocked by active finger movement
5
Locking of finger in flexion or extension by passive finger movement Locked finger in flexion or extension
6
unlocked
Each stage may be painless or painful
Patients
and methods
We divided trigger fingers into six stages, each with increasing grades of mechanical problems (Table I).
From the Hand Surgery Service, Division of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, N. Y., and Staten Island University Hospital, Staten Island, N. Y. Presented at the forty-fifth annual meeting of the American Society for Surgery of the Hand, Toronto, Ontario, Canada, Sept. 26, 1990. Received for publication May 10, 1991.
Feb. 18, 1991; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: M. R. Patel, M.D., 4901 Fort Hamilton Brooklyn, NY 11219. 3/I/31209
110
THE JOURNAL OF HAND SURGERY
Parkway,
Over a l-year period 50 consecutive trigger fingers were treated by splinting of the metacarpophalangeal joint in 10 to 15 degrees of flexion. The digit was immobilized with a Thermoplast splint (Johnson & Johnson, New Brunswick, N.J.) and Velcro hook and loop straps (Smalley & Bates, Nutley, N.J.). The proximal interphalangeal joint was left free for extrinsic tendon gliding ( Figs. 1 to 3). Two digits may be splinted together (Fig. 4). The patients were allowed to remove the splint for hygiene. Three patients wore splints for 3 weeks, 27 for 6 weeks, 19 for 9 weeks, and 1 for 12 weeks. All patients were followed up for at least 1 year. The results of treating 50 trigger fingers with splinting and 50 trigger fingers with cortisone injection were compared. All patients were followed up for at least 1
Vol. 17A, No. 1 January 1992
Trigger Jingers and thumb
Fig. 1. The metacarpophalangeal joint of the index finger is immobilized at 15 degrees of flexion. The splint extends to the proximal interphalangeal joint crease and allows some oiposition of the digit with the thumb.
Fig. 2. Splinting of the long and ring fingers is similar. The splint is molded with the fingers opposing the thumb. The splint extends to the proximal interphalangeal joint crease, allowing flexion of the proximal and distal interphalangeal joints.
111
112
The Journal of HAND SURGERY
Putel and Bassini
Fig. 3. Splinting of the small finger requires a small gutter splint around the hypothenar eminence.
Fig. 4. Two fingers may be splinted together.
year. Thirty-seven digits were injected once, 13 digits were injected twice, and no digits were injected three or more times. The average age of the patients treated with splints was 60 years, and the average age of those who received
injections was 61, The male/female ratio was 14: 36 in the splinted group and 18 : 32 in the injected group. Trigger fingers occurred in the right hand in 30 digits and in the dominant hand in 48 digits in the splinted group. Trigger fingers occurred in the right hand in 32
Vol. 17A, No. 1 January 1992
digits and in the dominant injected group.
Trigger fingers and rhllmb
hand in 48 digits in the
Results Treatment was considered to have failed if it was followed by pain, clicking, or locking that required further treatment with injection or surgery. If patients had minimal pain or uneven movements that did not interfere with hand function and required no further treatment or if they were free of symptoms, treatment was considered successful. Thirty-three (66%) of the splinted digits and 42 (84%) of the injected digits had successful outcomes. Thumbs treated with a splint had the poorest outcomes; treatment of only 5 of the 10 splinted thumbs was successful. When thumbs were excluded, 70% of the 40 splinted digits had successful outcomes. In the injected group, the success rate was 92% for the thumb and 82% for the four fingers. The results that follow are analyzed for the index, long, ring, and small fingers only, as splinting succeeds in only 50% of the trigger thumbs and injections are successful in 92% of the thumbs. Of the 12 unsuccessfully treated digits in the splinted group, 10 were cured with injections and 2 with surgery. All of the 7 unsuccessfully treated digits in the injected group were cured with surgery. Splinting was successful in 77% of the patients whose symptoms had been present 6 months or less and in 44% of those with symptoms of more than 6 months’ duration. Injection was successful in 84% of the patients whose symptoms had been present 6 months or less, and in 71% of those with symptoms of more than 6 months’ duration. Two or more digits had a poorer result in both the splinted and the injected groups. All triple and quadruple digits treated with splinting failed. Thirteen splinted digits in which treatment failed were in stages 2, 3, and 4. Seven of the injected digits in which treatment failed were in stage 3. Recurrence within 1 year occurred in six digits (12%) in the splinted group.
Discussion Our classification (Table I) is based on the report of Quinnel” and modified by Evans et a1.9 and Newport et al.’ Evans et a1.9 reported satisfactory results with splinting of trigger fingers for 3 to 6 weeks. In this study, one third of the digits treated with satisfactory results needed splinting for more than 6 weeks. Patients tolerated and complied with splinting better when the
113
metacarpophalangeal joint was immobilized in 10 to 15 degrees of flexion rather than 0 as recommended by Evans et al. Our recommended protocol for trigger fingers is as follows: 1. Splinting. Splinting is most successful in trigger fingers involving index, long, ring, and small fingers in all stages, with the exception of locked fingers that cannot be passively unlocked. Patients are given a choice between splinting and injections. Patients who do not want to undergo splinting and patients who do not respond to splinting are treated with up to 3 cortisone injections at 2-week intervals. Patients who do not respond to injections are treated with surgery. 2. Injections. Trigger thumbs are treated with injections in all stages because the results of splinting are poorest injection
in the thumbs.
Patients
are then treated
who do not respond
to
with surgery.
3. Surgery.
We do not splint or inject digits locked in flexion (stage 6); they are treated with surgery. REFERENCES V. Treatment of trigger fingers. Acta I. Kohnd-Sorenson Orthop Stand 1970;41:428-32. 2. Rhoades CE, Gelberman RH. Manjarris JF. Stenosing tenosynovitis of the fingers and thumb: results of a prospective trial of steroid injection and splinting. Clin Orthop 1984;190:236-8. 3. Fauno P, Anderson HJ, Simonson 0. A long-term followup of the effect of repeated corticosteroid injections for stenosing tenosynovitis. J HAND SURG 1989;14B:242-3. 4. Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J HAND SURG 1990: 15A:74850. 5. Freiberg A, Mulholland RS, Levine R. Nonoperative treatment of trigger fingers and thumbs. J HAND SURG 1989;14A:553-8. 6. Clark DD, Ricker JH, MacCollum MS. The efficacy of local steroid injection in the treatment of stenosing tenovaginitis. Plast Reconstr Surg 1973;5 1: 179-80. 7. Howard LD. Pratt DR, Bunnell S. The use of compound F (hydrocortisone) in operative and nonoperative conditions of the hand. J Bone Joint Surg 1953;35A:9941002. 8. Marks M, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J HAND SURG 1989;14A:722-7. 9. Evans RB, Hunter JM, Burkhalter WE. Conservative management of trigger finger; a new approach. J Hand Ther 1988;2:59-68. 10. Quinnell RC. Conservative management of trigger finger. Practitioner 1980:224:187-90.
