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TRIGGER FINGER

Introduction

Trigger finger, or stenosing tenosynovitis, occurs when the flexor tendons cannot pass through the A-1 pulley smoothly.  Whether the pulley thickens, the tenosynovium thickens and/or the tendons deform and develop a "nodule," the result is the same: loss of smooth active flexion and extension in the digit. The digit can lock in flexion or extension or simply be difficult to move without significant pain.

Related Anatomy

  • Caused by anomalous anatomy, including abnormal lumbrical insertion and/or proximal decussation of flexor digitorum sublimis (FDS) tendon
  • Narrowing/thickening of FDS tendon sheath at the A1 pulley level
  • Histology shows non-inflammatory fibrosis; occasionally, chronic inflammatory cells are present

Relevant Basic Science

  • When tendon sheath becomes edematous, the sheath becomes fibrotic and may undergo cartilaginous metaplasia; the tendon becomes thinner under the area of constriction and thickens proximal to the constriction. The swollen portion of the tendon is referred to as a nodule or "Notta's Node".

Incidence and Related Conditions

  • More common in women (2-6 times); pregnancy is a predisposing risk factor
  • Predisposing systemic conditions: rheumatoid arthritis, diabetes, gout, amyloidosis, mucopolysaccharidoses
  • Often comorbid with DeQuervain’s disease, carpal tunnel syndrome, and elbow tendinopathy
  • Repetitive trauma likely plays a central but not sole role in the etiology of the condition

Differential Diagnosis

  • DeQuervain’s disease
  • Dupuytren’s contracture
  • Metaphalangeal (MP) joint loose body/dislocation
  • Proximal interphalangeal (PIP) joint dislocation
  • Volar plate avulsion with entrapment
  • Tendon sheath tumor
  • Intrinsic tendon injury on an irregular metacarpal head
  • Rheumatoid arthritis
ICD-10 Codes

TRIGGER FINGER

Diagnostic Guide Name

TRIGGER FINGER

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
TRIGGER FINGER INDEX   M65.322 M65.321  
TRIGGER FINGER MIDDLE   M65.332 M65.331  
TRIGGER FINGER RING   M65.342 M65.341  
TRIGGER FINGER LITTLE   M65.352 M65.351  

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Trigger Finger Locked
    Trigger Finger Locked
  • Right Long Trigger Finger Exam - Examiner is palpating A-1 pulley while passively flexing and extending the finger. Palpation should reveal tenderness and/or crepitus as the flexor tendon moves through the A-1 pulley.
    Right Long Trigger Finger Exam - Examiner is palpating A-1 pulley while passively flexing and extending the finger. Palpation should reveal tenderness and/or crepitus as the flexor tendon moves through the A-1 pulley.
  • Trigger fingers also occur in children. Toddler with right ring chronic trigger finger locked in mild flexion.
    Trigger fingers also occur in children. Toddler with right ring chronic trigger finger locked in mild flexion.
Symptoms
Pain at the base of the thumb or finger near the MP joint
Clicking, catching or triggering of thumb or finger with motion
Typical History

A patient often notices a click in his or her finger that eventually becomes painful, and the patient may be unable to fully flex the finger. In chronic cases, the trigger finger may become locked, resulting in fixed-joint contracture.

Positive Tests, Exams or Signs
Treatment Options
Conservative

Conservative

  • Activity modification
  • Splinting
  • NSAIDS
  • Corticosteroid injections
Operative
  • Percutaneous release of A1 pulley For ASSH's Hand-e Surgical Video of open trigger finger release by Hammert:
  • Open release or excision of the A1 pulley For ASSH's Hand-e Surgical Video of trigger thumb release (min invasive) by Julka:
Treatment Photos and Diagrams
  • Trigger finger with small Dupuytren's cord superficial to A-1 pulley.
    Trigger finger with small Dupuytren's cord superficial to A-1 pulley.
  • Transverse incision for releasing index and long trigger fingers. Longitudinal incisions can also be used.
    Transverse incision for releasing index and long trigger fingers. Longitudinal incisions can also be used.
  • Blunt dissection used to expose A-1 pulley.
    Blunt dissection used to expose A-1 pulley.
  • Edge of A-1 exposed. Second arrow at fiber of palmar aponeurotic pulley (superficial intermetacarpal ligaments).
    Edge of A-1 exposed. Second arrow at fiber of palmar aponeurotic pulley (superficial intermetacarpal ligaments).
  • A-1 pulley exposed and neurovascular bundle visible.
    A-1 pulley exposed and neurovascular bundle visible.
  • Probe pulling FDS. Note erosions on FDS and tenosynovium evading tendon substance. PIP joint passively flexing after A-1 release.
    Probe pulling FDS. Note erosions on FDS and tenosynovium evading tendon substance. PIP joint passively flexing after A-1 release.
  • Tensynovium between FDS and FDP which sometimes thickens and requires excision to fully relieve catching and locking with active motion.
    Tensynovium between FDS and FDP which sometimes thickens and requires excision to fully relieve catching and locking with active motion.
  • Before closure active motion under local and sedation checking to verify complete release, no locking and full active range of motion.
    Before closure active motion under local and sedation checking to verify complete release, no locking and full active range of motion.
  • Transverse incision used to release index and long trigger fingers closed with simple sutures.
    Transverse incision used to release index and long trigger fingers closed with simple sutures.
CPT Codes for Treatment Options

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Common Procedure Name
Trigger finger release
CPT Description
Tendon sheath incision trigger finger
CPT Code Number
26055
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Hand Therapy
  • A silicone-based scar conformer
    A silicone-based scar conformer
  • Resting finger extension splint for progressive night extension
    Resting finger extension splint for progressive night extension
  • Reverse knuckle bender splint for Integrated dynamic PIP extension
    Reverse knuckle bender splint for Integrated dynamic PIP extension
Complications
  • Corticosteriod injections help trigger fingers 60% of the time with a 60% recurrence rate at one year. Steriod injection failure increases in young patients, diabetic patients and those with multiple triggers.
  • Operative: infection, secondary adherence, scar tenderness, mild PIP joint contractures, neurovascular bundle injuries, ulnar drift of digit, flexor tendon bowstringing.
Outcomes
  • Splinting reportly can eliminated triggering in 66% of patients after 1 year.
  • Steroid injection: success in 40-90% of patients but recurrence common.
  • A1 pulley release: elimination of triggering in >90% of patients.
Video
Trigger Finger
Chronic Right Long and Ring Finger Triggering
YouTube Video
Trigger Finger Adult
Key Educational Points
  • The pathologic mechanism of acquired trigger finger is characterized by fibrocartilage metaplasia. There is no synovial layer on the A-1 pulley.
References

New Articles

  1. Degreef I, Devlieger B, De Smet L. Primary ulnar superficial slip resection in complicated trigger finger. J Plast Surg Hand Surg 2014;48(5):340-3. PMID: 24679115
  2. Yang TH, Chen HC, Liu YC, et al. Clinical and pathological correlates of severity classifications in trigger fingers based on computer-aided image analysis. Biomed Eng Online 2014 ePub. PMID: 25055721
  3. Wolfe SW. Tendinopathy.  In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH,  eds. Green’s Operative Hand Surgery, sixth edition.  Philadelphia: Elsevier/Churchill Livingstone 2011;62:2071-2079.

Reviews

  1. Vargas A, Chiapas-Gasca K, Hernández-Díaz C, et al. Clinical anatomy of the hand. Reumatol Clin 2012;8(S2):25-32 PMID: 23219083
  2. Akhtar S, Bradley MJ, Quinton DN, Burke FD. Management and referral for trigger finger/thumb. BMJ 2005;331(7507):30-3. PMID: 15994689

Classics

  1. Notta A. Recherches sur une affection particuliere des gaines tendineuses de la main, caracterisee par le development d’une nodosite sur le trajet des tendons fleschisseurs des doigts et par l’empechement de leurs mouvements. Arch Gen Med 1850;24:142-61.
  2. Hueston JT, Wilson WF. The aetiology of trigger finger explained on the basis of intratendinous architecture. Hand1972 Oct;4(3):257-60. PMID: 5083965
  3. Fahey JJ, Bollinger JA. Trigger-finger in adults and children. J Bone Joint Surg Am 1954 Dec;36(6):1200-18. PMID: 13211713
  4. Sampson SP, Badalamente MA, Hurst LC, Seidman J. Pathobiology of the human trigger ànger. J Hand Surg 1991;16A:714-21.

Hand Therapy References

  1. Cannon, et al. (2001).  Diagnosis and Treatment Manual for Physicians and Therapists, Upper extremity Rehabilitation (4th ed).  The Hand Rehabilitation Center of Indiana.
  2. Mackin, Callahan, Skirven, Schneider, and Osterman, (2002). Rehabilitation of the Hand and Upper Extremity, 1, (5th ed). St Louis, MO: Mosby Year Book, Inc.
  3. Cooper, (2014). Fundamentals of Hand Therapy; Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, (2nd ed). Mosby, imprint of Elsevier Inc.
  4. Stanley and Tribuzi. (1992).  Concepts in Hand Rehabilitation.  F. A. Davis Company