Open Surgical Release of Stenosing Tenosynovitis (a.k.a. Trigger Finger)

Video Type: CVideo
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Author: James Kee
Published:
Specialties: Hand and Upper Extremities, Orthopedic Surgery
Schools: University of Arkansas for Medical Sciences
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Basic Info

Contributors: James Kee

In this video, we show the open surgical release of the A1 pulley to restore movement and alleviate triggering in a patient with stenosing tenosynovitis, or trigger finger.

DOI #: https://doi.org/10.17797/punju11l92

Advanced

Procedure

An oblique incision is made over the palmar surface of the metacarpal head. Careful blunt dissection is undertaken to expose the A1 pulley and the flexor tendon sheath. The A1pulley and the palmar pulley are released. The patient is then asked to actively demonstrate flexion and extension of the digit to confirm the resolution of the previously noted triggering. The wound is closed with nylon suture and sterile dressings are placed.

Indications

Stenosing tenosynovitis, or trigger digit, is most commonly caused by a size mismatch between the A1 pulley and the flexor tendons. The A1 pulley usually exhibits degeneration and hypertrophy. Patients often feel pain over the A1 pulley and associated clicking or locking of the digit or limited range of motion. Symptoms are often worse upon awakening in the morning of with prolonged gripping. The diagnosis of trigger digit is associated with female sex, diabetes, hypothyroidism, carpal tunnel syndrome, and Dupuytren�¢ï¿½ï¿½s disease.

Contraindications

No specific contraindications for this procedure exist. This procedure is typically nonmergent, so general contraindications for routine surgery apply.

Instrumentation

Setup

The patient is placed supine on the operating table, with a hand table attached. A tourniquet is placed on the upper arm to allow for clear visualization during dissection. Local anesthesia is injected in the skin before surgery. The procedure can be done with or without sedation but the patient ideally should be awake to perform active motion of the digit after release and prior to skin closure to ensure the triggering is alleviated. Rarely, surgical release of the more distal A3 pulley and/or resection of a single slip of the flexor digitorum superficialis (FDS) tendon is warranted in the case of persistent triggering after complete A1 pulley release.

Preoperative Workup

Trigger digit is usually a clinical diagnosis. Trigger digits may be associated with carpal tunnel syndrome and an investigation into a history of carpal tunnel syndrome symptoms is warranted. Corticosteroid injection in the area of the A1 pulley in the office may be considered as initial nonoperative treatment and is successful in alleviating symptoms in up to 85% of patients. Steroid injection in poorly controlled diabetic patients should be undertaken with extreme caution and will result in a transient increase in blood glucose levels which may be dangerous. Steroid injection has a lower success rate in diabetic patients than in nondiabetic patients. Rupture of the flexor tendons has been reported with multiple steroid injections for trigger digits and generally a maximum of two injections is recommended to avoid this complication.

Anatomy and Landmarks

The oblique incision shown here can be extended distally to expose the remaining pulleys in the case when simple A1 pulley release does not result in resolution of the triggering. Other incisions can also be used. A transverse skin incision in the distal palmar crease may be helpful if multiple trigger fingers are to be released. Digital nerves traveling longitudinally on either side of the flexor tendon sheath should be protected.

Advantages/Disadvantages

The major alternative to open A1 pulley release is percutaneous release, usually done with a hypodermic needle in the office setting. Open release allows for direct visualization of the tendons and pulley to ensure full pulley release. Open release is associated with slightly longer recovery time than percutaneous release. Percutaneous release is associated with incomplete pulley release and tendon lacerations.

Complications/Risks

Minimal risks of infection, incomplete release resulting in persistent triggering, wound dehiscence, delayed healing and scar tenderness are the most commonly encountered. The presence of a pre-existing flexion contracture of the proximal interphalangeal (PIP) joint can be difficult to correct with surgical release and postoperatively extension splinting of this joint may be required along with therapy to correct this. Severe pre-existing PIP flexion contractures may persist even after appropriate surgical release and splinting.

Disclosure of Conflicts

Minimal risks of infection, incomplete release resulting in persistent triggering, wound dehiscence, delayed healing and scar tenderness are the most commonly encountered. The presence of a pre-existing flexion contracture of the proximal interphalangeal (PIP) joint can be difficult to correct with surgical release and postoperatively extension splinting of this joint may be required along with therapy to correct this. Severe pre-existing PIP flexion contractures may persist even after appropriate surgical release and splinting.

Acknowledgements

None

References

Adams JE, Habbu R. Tendinopathies of the Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons. 2015;23(12):741-750. doi:10.5435/jaaos-d-14-00216.
Favre Y, Kinnen L. Resection of the Flexor Digitorum Superficialis for Trigger Finger With Proximal Interphalangeal Joint Positional Contracture. The Journal of Hand Surgery. 2012;37(11):2269-2272. doi:10.1016/j.jhsa.2012.07.026.
Fowler JR, Baratz ME. Percutaneous Trigger Finger Release. The Journal of Hand Surgery. 2013;38(10):2005-2008. doi:10.1016/j.jhsa.2013.03.001.
Makkouk AH, Oetgen ME, Swigart CR, Dodds SD. Trigger finger: etiology, evaluation, and treatment. Current Reviews in Musculoskeletal Medicine Curr Rev Musculoskelet Med. 2007;1(2):92-96. doi:10.1007/s12178-007-9012-1.
Schubert C, Hui-Chou HG, See AP, Deune EG. Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits. Hand. 2013;8(4):439-444. doi:10.1007/s11552-013-9541-6.
Wessel LE, Fufa DT, Boyer MI, Calfee RP. Epidemiology of Carpal Tunnel Syndrome in Patients With Single Versus Multiple Trigger Digits. The Journal of Hand Surgery. 2013;38(1):49-55. doi:10.1016/j.jhsa.2012.08.040.
Will R, Lubahn J. Complications of Open Trigger Finger Release. The Journal of Hand Surgery. 2010;35(4):594-596. doi:10.1016/j.jhsa.2009.12.040.

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