Case Report
A case of Multiple Bilateral Trigger Digits: Injection or Surgery?
1Paul D Nesbitt, 1Wiqqas Jamil, 1Prashant Jesudason, 1Lindsay Muir
- 1Department of Orthopaedics and Trauma, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD
- Submitted:
December 10, 2012
- Accepted:
January 6, 2013
- Published:
May 18, 2013
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Trigger finger is one of the most common problems presenting to hand clinics in the UK [1]. Characterised by catching or locking on extension of the flexed digit it can affect all the digits in the hand [3] with the ring, thumb and middle finger most frequently affected [1, 5] . The incidence of multiple digits being affected is between 20% [5] and 24% [6], with a higher Incidence in Diabetes Mellitus sufferers [5]. The most successful methods used to treat trigger finger are corticosteroid injection and surgical release [1, 11]. We report an extreme case of a patient with eight trigger digits in whom corticosteroid injection had previously failed, review the literature and advocate the use of surgical release as an earlier treatment option in those patients with multiply involved digits.
Introduction
Trigger finger is one of the most common problems presenting to hand clinics in the UK [1] with a quoted incidence of 28 cases per 100,000 per year [2]. Characterized by clicking, catching or locking on flexion and extension it can affect all the digits in the hand [3]. Occurring 6 times more commonly in females than males [4], the incidence of multiple digits being affected is between 20% [5] and 24% [6].The highest incidence is between the ages of 55 and 65. The lifetime risk of developing trigger finger has been reported at 2-3% [5], with the incidence in Diabetes mellitus sufferers rising to between 10 and 15% [5, 7]. Congenital and familial associations have also been found as well as links with trauma [7, 9].
Trigger finger is caused by a thickening of the flexor tendon sheath which occurs as a reaction to traumatic and compressive force created through movement of the fingers [5]. The first annular pulley is the most commonly affected area due its location, subjecting it to the highest forces in both a normal and power grip [5]. The thickened sheath impinges on the tendon during flexion and extension [3], leading to inflammation and loss of the normal spiral arrangement of the collagen fibers within. This causes them to bunch and form a nodule, which catches on the pulley proximally as the digit flexes [10]. It is this catching, and sometimes locking of the proximal end of the tendon that causes the symptoms. The ring, thumb and middle finger are the most frequently affected digits [1, 5].
The most successful methods used to treat trigger finger are corticosteroid injection and surgical release [1, 11]. Corticosteroid injection is first line method used due to its ease of administration. Normally injected into or around the tendon sheath [12] results have been good in patients with a single digit affected and duration of symptoms less than six months, with success in up to 93% [11, 13, 14, 15]. Complications include dermal or subcutaneous atrophy, skin hypo pigmentation, infection and in one rare case tendon rupture [5]. Complication rates for this method are very low, with two studies quoting none from over 100 fingers [10, 13].
Surgery has widely been used as the second line treatment after injections of corticosteroid. The main aim of surgery is to divide the annular pulley at the point of entrapment, although some studies have found that total division is not necessary for resolution of symptoms [16]. The major benefits of surgery over corticosteroid injection are lower rate of recurrence and in most, complete resolution of symptoms [10, 17]. Complications from surgery include scar tenderness, pain at the flexor tendon sheath, parasthesia and infection [5, 17]. Complication rates can be high, with one study quoting them at 35% [18]. In more recent studies however, rates have been quoted between 0 [11] and 5% [17].
Case Report
A fifty seven year old male, right hand dominant, non diabetic, milk man presented to clinic with a three year history of triggering affecting multiple digits in both the left and right hands. This had initially started in the right hand, with the left hand becoming affected in the following months. He had presented to our clinic through his General Practitioner due to symptoms affecting his work. There were no associated co-morbidities and no significant family or past medical history.
Examination on presentation revealed mild thickening of the flexor tendons in both palms. There were palpable nodules in the left middle finger, right middle, ring and little fingers. There was impaired power grip bilaterally. In the left hand, grade two triggering was found in the index ring and little fingers, with grade three triggering in the middle finger. In the right hand grade two triggering was found in the second and fourth digits with grade three in the third and fifth digits (Quinn ell Classification). Due to the above he had found difficulty releasing his grip of milk bottles and had knocked a number over when placing them onto the ground.
Plain radiographs of both hands showed no abnormalities, and ultrasound scans of the flexor tendons bilaterally were normal. Previous treatment with two courses of steroid injections to all eight digits had been unsuccessful.
In the case of our patient, release of all eight trigger digits proved successful, and follow up at three months has seen complete resolution of his symptoms with no pain, parasthesiae or restriction in daily activities.
Discussion
In the treatment of trigger finger, corticosteroid injections have been shown to have an efficacy of up to 93% [13, 14, 15]. This method of treatment has widely been used as the first line over surgery due to its ease of administration and favorable side effect profile. In patients with multiple triggering however, lower efficacy rates have been reported [13, 14] with one study quoting successful results in less than 50 per cent [11]. This point is reinforced by our case above and the two cases reported in the literature [19] in which corticosteroid injection was ineffective in all digits. Other factors decreasing the efficacy of injection therapy are greater duration of symptoms, younger patients and diabetes mellitus [5, 10, 11, 14, 15]. Corticosteroid injections are also less likely to be effective if they have been tried before [14, 15].
The recurrence rates in patients in whom corticosteroid injections are used are high at up to 56 per cent [20, 21]. In patients with multiple digits, all of whom have had duration of symptoms over six months, and many with diabetes [19], this is likely to be even higher [8]. Surgery carries the benefits of definitive treatment in up to 99% of patients [10] and in most, complete resolution of symptoms [17]. One study has also reported that patients found surgery less painful than injection therapy, with two thirds of participants saying they would consider surgical treatment sooner if they needed treatment again [15]. Additionally, the first injection is unsuccessful in 37.5% to 75% [17] of patients, with up to two further injections required to reach optimum success rates [10, 11]. This is time consuming for the patient, and with each injection the chances of success is decreased [13, 14, 15]. Although widely regarded to be higher than in injection therapy, complication rates from surgery are low, with one study quoting none in a group of 34 patients’ [15]. Most however quote rates of around 5 percent [17], with only one study in 1988 quoting an unusually high complication rate of 35 percent [18].
Conclusion
In the case presented, injection therapy failed on multiple attempts to resolve symptoms. Studies have shown that in patients with multiply affected digits surgical treatment has a higher rate of success [13], is likely to relieve symptoms faster and is less painful [9]. Although surgery does involve a higher rate of complication than injection therapy [14], we would advocate its use earlier based on our review of the current literature and our experience in this case.
Author’s Contributions
PDN prepared the manuscript.
WJ did the literature search and helped in preparation of manuscript
PJ did the literature search and helped in preparation of manuscript
LM preparation of manuscript
Conflict of interest
The authors declare that there are no conflicts of interests
Ethical consideration
Written consent was obtained from the patient for publication of this case report
Funding
None declared
Acknowledgement
Previous presentation at the british Orthopedic Trainee association National Meeting 2011.
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