Trigger finger: injection or surgery?

Trigger finger is one of the commonest reasons an adult sees a hand surgeon, and one of the most satisfying to treat, because the problem is mechanical and the treatments address it directly. The question patients bring is nearly always the same: do I need the operation, or will an injection do? The answer depends on how long it has been going on, how bad it is, and a few things about you.

What is happening in the finger

The tendons that bend the fingers run through a series of fibrous tunnels, called pulleys, that hold them against the bone. The first of these sits at the base of the finger, in the palm. In trigger finger the tendon and its lining become inflamed and thickened, and a nodule forms that no longer glides freely through that first pulley. The finger bends normally, because the tendon is pulled through with force, but on straightening the nodule catches at the mouth of the tunnel — the finger sticks, then gives with a click. In advanced cases it locks in the bent position and has to be straightened with the other hand, or cannot be straightened at all.

It is commoner in women, most often between forty and sixty, in people with diabetes or rheumatoid arthritis, and in occupations and hobbies that involve repeated forceful gripping. The ring finger and thumb are the most frequently affected, and it is not unusual to have more than one.

The treatment ladder

Rest, and a splint at night In a mild, recent case — a finger that catches occasionally and is not yet painful — reducing the activity that provokes it and wearing a small splint that holds the finger straight overnight can be enough to let the inflammation settle. This is a reasonable first step for a few weeks where the symptoms are minor.

Steroid injection A small dose of corticosteroid is injected into the tendon sheath beside the nodule, in clinic, in a few minutes. It reduces the inflammation and swelling of the sheath so that the tendon glides again. The injection itself is briefly uncomfortable; the finger may be sore for a day or two and then improves over the following one to three weeks.

For a first episode in a single finger, an injection resolves the triggering in the majority of patients, and for many of them it does not come back. It is less reliable where the finger has been locking for a long time, where several fingers are involved, and in people with diabetes — in whom it both works less often and can raise blood sugar for a few days afterwards. A second injection is sometimes given if the first helped and the symptoms return; beyond that, repeated injections are not a good plan, because each one carries a small risk of weakening the tendon and the sheath.

Release The operation divides the first pulley so that the tendon and its nodule can pass freely. It takes fifteen to thirty minutes under local anaesthetic, as a day case, through a short incision in the palm at the base of the finger. You are awake, and you are asked to bend and straighten the finger during the operation so that I can confirm the catching has gone before the wound is closed. The finger moves normally from that moment. Dividing this one pulley does not compromise the tendon’s function; the other pulleys along the finger hold it in place.

When I recommend going straight to surgery

There are situations in which an injection is a delay rather than a treatment. A finger that is locked and cannot be straightened. Triggering that has been present for many months, where the nodule is large and firm. A recurrence after an injection that worked — the second injection is less likely to hold than the first. Several fingers affected in a patient with diabetes, where injections have a poor record. And any patient who has developed stiffness in the joint from holding the finger bent, because the sooner the finger is moving freely the sooner that stiffness resolves.

In those cases the release is the definitive treatment, and it is one of the most reliable operations in hand surgery.

What the release involves afterwards

The palm is dressed and you go home the same day with the finger free to move, and you are encouraged to move it. The dressing is reduced after a few days. Driving is usually possible after one to two days, once you can grip the wheel without discomfort. Desk work resumes in days; work involving a firm grip or tools takes two to three weeks. The scar in the palm is tender for a few weeks and settles.

The risks are low but worth knowing. The nerves that supply feeling to the sides of the finger run close to the pulley, so numbness from injury to one of them is the main specific risk, though uncommon. Some stiffness can follow and is treated with movement. Occasionally the triggering is not fully resolved or returns. Infection is uncommon.

In short

A first episode in one finger, not locked, without diabetes: an injection is a sensible first treatment and often the only one needed. A locked finger, a long-standing one, a recurrence, several fingers, or diabetes: the release is the better answer and there is little to gain from delay. Either way the decision is made at a consultation, with the finger in front of us, and takes a few minutes.

Dr. Papavasiliou sees hand patients in Nicosia and Limassol.