|Year : 2014 | Volume
| Issue : 3 | Page : 173-176
Corticosteroid injection versus percutaneous release surgery in treatment of trigger fingers
Aref Hosseinian Amiri1, Fatemeh Shirani2, Mohammad Hosein Kariminasab3
1 Department of Rheumatology, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
2 Department of Rheumatology, Rasoul Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
3 Department of Orthopedic Surgery, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
|Date of Web Publication||11-Aug-2014|
Aref Hosseinian Amiri
Department of Rheumatology, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari
Source of Support: None, Conflict of Interest: None
Background: Trigger finger is a common problem encountered in rheumatologic practice that causes a triggering or locking that may produce an uncomfortable sensation. There are various methods of treatment ranging from conservative management to surgical release. Aim: To determine effectiveness of corticosteroid injection and percutaneous release in terms of symptomatic relief, patient satisfaction and complications. Materials and Methods: At this prospective study, 50 patients who presented with trigger finger Grade 2 and 3 were randomized into 2 groups. One group received corticosteroid injection and in the other group, percutaneous release was done. These patients were then assessed weekly over a period of 6 weeks and their progress noted. Results: Thirty cases (60%) were females and 20 (40%) were males. The age of patients at this study was 40-65 years (mean: 48). Twenty-three (46%) were manual workers, 17 (34%) were semi-professionals and 10 (20%) were housewives. Most of the patients had involvement of dominant hand (62%); non-dominant hand was involved in 38% of the cases. The most common presenting symptom was pain with triggering. In both groups, significant improvement in pain and triggering occurs in the first 2 weeks but there was improvement in pain and triggering in the corticosteroid group after 2 weeks. In terms of swelling of the digits, no difference was noted during the course of the treatment in the two groups. The corticosteroid group of patients had a complication rate of 6% while the percutaneous group had 18% complication rate. A total of 12 patients had recurrence (recurrence rate: 24%); 5 (41.6%) cases in the first or corticosteroid group and 7 (58.3%) cases in the surgery group. Conclusion: The group of patients treated with corticosteroid had better relief from pain and triggering and had a lower complication rate. Recurrence was equal in both the groups.
Keywords: Corticosteroid injection, surgery, trigger finger
|How to cite this article:|
Amiri AH, Shirani F, Kariminasab MH. Corticosteroid injection versus percutaneous release surgery in treatment of trigger fingers
. Indian J Pain 2014;28:173-6
|How to cite this URL:|
Amiri AH, Shirani F, Kariminasab MH. Corticosteroid injection versus percutaneous release surgery in treatment of trigger fingers
. Indian J Pain [serial online] 2014 [cited 2020 Feb 23];28:173-6. Available from: http://www.indianjpain.org/text.asp?2014/28/3/173/138455
| Introduction|| |
Inflammation of the tendon sheaths of the flexor tendons in the palm is extremely common but often unrecognized. Pain in the palm is felt on finger flexion, and in some cases may radiate to the proximal interphalengeal (PIP) and metacarpophalangeal (MCP) joints on the dorsal side. The diagnosis is made by palpation and identification of localized tenderness and swelling of the volar tendon sheaths. The middle and index fingers are most commonly involved, but the ring and little fingers can also be affected. Often a nodule composed of fibrous tissue can be palpated in the palm just proximal to the MCP joint on the volar side. The nodule interferes with the normal tendon gliding and can cause a triggering or locking (trigger finger), which may produce an uncomfortable sensation. Similar involvement can occur at the flexor tendon of the thumb. Volar tenosynovitis may be part of inflammatory conditions, such as rheumatoid arthritis, psoriatic arthritis or apatite crystal deposition disease. It is seen frequently in conjunction with osteoarthritis of the hands.  The most common cause of trigger finger is overuse trauma of the hands from gripping with increased pull on the flexor tendons. Injection of a long-acting steroid into the tendon sheath usually relieves the problem,  although surgery on the tendon sheath may be needed in unremitting cases. Infection of the tendon sheaths in the hand requires drainage and antibiotics. People with drug addictions and diabetes may be at increased risk for such infections. Pathogenesis of trigger finger is due to pathological disproportion between the volume of the retinacular sheath and its contents. This disproportion inhibits gliding of the tendon through A1 pulley.  Trigger fingers are graded according to severity. Commonly used classification is Quinnell grading [Table 1]. 
There are various methods of treatment, including conservative treatment (consisting of massage, ice, NSAIDs and splinting), corticosteroid injection, percutaneous release and open release. Surgical release is recommended if non-operative treatment fails. It is postulated that 85% of trigger fingers respond well to conservative treatment. The success of the treatment is dependent on the duration of complaint, severity of triggering and type of triggering. 
| Materials and Methods|| |
This prospective randomized study was performed at the TOOBA referral rheumatology clinic of Mazandaran University of Medical Sciences during 2 years from January 2011 to December 2013. We compared the effectiveness of corticosteroid injection and percutaneous release in terms of symptomatic relief, patient satisfaction and complications. Patients who presented with Grade 2 and Grade 3 trigger fingers were randomized into 2 groups. Randomization was done by adding together the birth year of the patient and dividing it by 2. Those with even numbers were allocated to the corticosteroid group and the odd numbers to the percutaneous group. All the patients were explained the nature of the study and a written consent was taken. Thumbs were excluded from the study because in our center, they are usually treated by open release. This is due to the proximity of radial digital nerve to the A1 pulley making it susceptible to damage in a percutaneous release. The patients were followed-up weekly for 6 consecutive weeks. Patients in the surgery group were referred to the orthopedic clinic and percutaneous release was performed for them, while patients in the other group were injected 1 mL of triamcinolone mixed with 1 mL of 1% lignocaine (corticosteroid treatment) into the tendon sheath and around the nodule. Analgesia is given for 3 days. The patients were advised to return immediately if there were any signs that indicated infection. These patients were assessed weekly in the clinic for 6 weeks and were observed for any improvement in the grade of triggering, swelling, pain and patients' satisfaction. Pain was assessed with the visual analog scale.
Statistical analysis was performed using Stats View. Descriptive statistical analysis was used to analyze demographic data. Paired t-test was used to measure the weekly progress in the corticosteroid and percutaneous groups in terms of symptom relief, patient satisfaction and complications. Unpaired t-test was used to compare the effectiveness of treatment between both the groups. A P-value < 0.01 was considered to be significant.
| Results|| |
In this study, 50 patients referred to TOOBA referral rheumatology clinic of Mazandaran University of Medical Sciences during 2 years from January 2011 to December 2013 were randomized into two groups - corticosteroid group and percutaneous release group. A total of 25 patients received corticosteroid injections and 25 patients underwent percutaneous release. Thirty cases (60%) were females and 20 (40%) were males. The age of the patients at this study was 40-65 years (mean: 48). Twenty-three (46%) were manual workers, 17 (34%) were semi-professionals and 10 cases (20%) were housewives. Most of the patients had involvement of dominant hand (62%), while non-dominant hand was involved in 38%. The ring finger was most commonly affected (40%). There were 9 (18%) index fingers, 26 (52%) middle fingers, 10 (20%) ring fingers and 5 (10%) small fingers involved. The patients presented with symptoms of locking, triggering, pain, palpable nodule, swelling or a combination of these. All of them had the nodular type of trigger finger.
In 26 (56%) patients, this was the first episode of triggering, while 14 (28%) and 10 (10%) presented with second and third recurrence. Thumb was excluded from this study for reasons noted earlier. The most common presenting complaint in our patients was pain with triggering in 38 (76%), followed by triggering alone in 7 (14%) and pain alone in 5 (10%) patients. In both the groups, a significant improvement in pain occurred in the first 2 weeks but a better improvement of pain and triggering was observed in the corticosteroid group after 2 weeks. Triggering was assessed according to the grading described by Quinnell grading system. In terms of swelling of the digits, no difference was noted during the course of the treatment in the two groups. The corticosteroid group of patients had a complication rate of 6% (3 patients claimed numbness and skin atrophy or hypopigmentation over distal phalanx after corticosteroid injection). The second group (percutaneous group) had a complication rate of 18% (8 patients developed stiffness of digit, which responded to aggressive physiotherapy and 1 patient developed bowstringing of tendon). A total of 12 patients had recurrence (recurrence rate: 24%); 5 (41.6%) cases in the first or corticosteroid group and 7 (58.3%) cases in the surgery group. This occurred at 2 to 9 months after the primary procedure. They were treated successfully with open release.
| Discussion|| |
Trigger finger is one of the most common causes of pain in the hand that cause painful clicking and locking of the digits in flexion. This condition is caused by a thickening of the A1 retinacular pulley in the palm. According to the study by Bonnici and Spencer, the thumb is the most commonly affected digit, followed by the ring and long fingers.  In our study, the most commonly involved finger was the middle finger and the other most common affected fingers were ring, index and small fingers. Early clicking is felt as a snapping sensation during digital motion and is frequently worse on awakening. As the condition progresses, the digital range of motion can be reduced and secondary PIP joint contractures develop. The final stage is a locked trigger finger that cannot be straightened actively. Trigger fingers are most often found in middle-aged individuals. According to the study by Marks and Gunther, triggering of the thumb is four times more prevalent in women than in men.  In our study, triggering was observed in 30 females (60%) and 20 males (40%).
Secondary triggering is seen in association with diseases such as rheumatoid arthritis, diabetes and gout. In this type, trigger fingers are often multiple and can coexist with other stenosing tendinopathies such as de Quervain's disease or carpal tunnel syndrome.  Non-operative treatment of trigger finger consists primarily of splinting and local steroid injections. Splinting is most effective at night to prevent the digit from locking. In adults, injection of steroids into the tendon sheath has been shown to be quite effective.  When non-operative treatments fail to give lasting relief, surgery has to be performed, which consists of longitudinal division of the A1 pulley at the level of the metacarpal head. It is a simple procedure that yields reliable and permanent results with few complications.  The decision of the mode of treatment depends on the grade of the trigger finger and duration of symptoms.  Saldana outlined treatment of trigger fingers according to grades of severity.  It is generally agreed that according to the staging system of Quinnell, grade 0 and grade 1 trigger fingers require only physiotherapy and NSAIDs and in cases of failure to response to treatment, corticosteroid injection at the trigger point. In cases of grade 4, triggering is usually resistant to conservative treatment and requires surgical release. However, the management of grade 2 and grade 3 trigger fingers is still a subject of debate. According to the study of Howard et al. in 1953, use of steroid injections has been reported with varying degrees of success.  Many other studies have demonstrated 92% good results ,,, in all grades of trigger fingers treated with corticosteroid injections. This treatment avoids complications of surgical release, which include digital nerve injury, A2 pulley injury with subsequent bowstringing of the tendons, stiffness and sympathetic dystrophy. ,,
According to the study by Lorthloir, percutaneous release of a trigger finger had no complications with the use of a fine tenotome.  In the study by Ha et al., a percutaneous technique with a specially designed knife was used in 185 patients with grade 3 and 4 triggering. Majority of the patients (173) achieved satisfactory results. Eleven patients had persistent triggering and one had persistent pain at the release site. No significant complications were noted.  A similar result was also obtained by Lyu.  According to the study by Sorbie, regardless of the technique used for the percutaneous release, there are some precautions that need to be taken when carrying out such procedures in order to avoid damaging the digital nerves. He suggested that percutaneous release could induce painful tenosynovitis with resultant painful finger flexion for several months if corticosteroid is not used with initial local anesthesia.  The study by Singh et al. supports the use of corticosteroid injection in treating grade 2 and grade 3 trigger fingers. Both the use of corticosteroid and percutaneous release yielded almost similar results, but the corticosteroid group was associated with fewer complications. 
| Conclusion|| |
Trigger finger is a common disease that causes pain in the hands of workers. The most commonly affected finger is the middle finger. The group of patients treated with corticosteroid had better relief from pain and triggering. Both methods of treatment eventually gave similar results in the first 2 weeks of treatment but the corticosteroid group had better results after few weeks. The percutaneous release group had a higher complication rate and recurrence rate was equal in both the groups.
| References|| |
|1.||Anderson B, Kaye S. Treatment of flexor tenosynovitis of the hand ("trigger finger") with corticosteroids. A prospective study of the response to local injection. Arch Intern Med 1991;151:153-6. |
|2.||Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med Rehabil 2006;85:36-43. |
|3.||Quinnell RC. Conservative management of trigger finger. Practitioner 1980;224:187-90. |
|4.||Saldana MD. Trigger digits: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:246-52. |
|5.||Bonnici AV, Spencer JD. A survey of 'trigger finger' in adults, J Hand Surg Br 1988;13:202-3. |
|6.||Marks MR, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J Hand Surg Am 1989;14:722-7. |
|7.||Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J Hand Surg Am 1990;15:748-50. |
|8.||Murphy D, Failla JM, Koniuch MP. Steroid versus placebo injection for trigger finger. J Hand Surg Am 1995;20:628-31. |
|9.||Patel MR, Bassini L. Trigger fingers and thumb: When to splint, inject, or operate. J Hand Surg Am 1992;17:110-3. |
|10.||Kolind-Sørensen V. Treatment of trigger fingers. Acta Orthop Scand 1970;41:428-32. |
|11.||Saldana MJ. Percutaneous trigger finger release. Atlas Hand Clin 1999;4:23-37. |
|12.||Howard LD Jr, Pratt DR, Bunnell S. The use of compound F (hydrocortone) in operative and non-operative conditions of the hand. J Bone Joint Surg Am 1953;35:994-1002. |
|13.||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 Relat Res 1984;190:236-8. |
|14.||Carrozzella J, Stern PJ, Von Kuster LC. Transection of radial digital nerve of the thumb during trigger release. J Hand Surg Am 1989;14:198-200. |
|15.||Heithoff SJ, Millender LH, Helman J. Bowstringing as a complication of trigger finger release. J Hand Surg Am 1988;13:567-70. |
|16.||Thorpe AP. Results of surgery for trigger finger. J Hand Surg Br 1988;13:199-201. |
|17.||Lorthioir J Jr. Surgical treatment of trigger-finger by a subcutaneous method. J Bone Joint Surg Am 1958;40:793-5. |
|18.||Ha KI, Park MJ, Ha CW. Percutaneous release of trigger digit. J Bone Joint Surg Br 2001;83:75-3. |
|19.||Lyu SR. Closed division of the flexor tendon sheath for trigger finger. J Bone Joint Surg Br 1992;74:418-20. |
|20.||Sorbie C. Percutaneous release of trigger finger. Orthop Thoroface 2001;328-1. |
|21.||Singh V, Chong S, Marriapan S. Trigger finger: Comparative study between corticosteroid injection and percutaneous release. Internet J Orthop Surg 2005;3. |