Trigger Finger

Episode 32 - Trigger Finger

[00:00:00] Dr. Chehab: Welcome to IBJI's OrthoInform, where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoINFORM, our goal is to provide you with an in depth resource about common orthopedic procedures that we perform every day. Today, it's my pleasure to welcome Dr.

Ty Baxamusa, who will be speaking about a trigger finger. Ty, thanks for being here. Welcome to OrthoINFORM. , before we get started on trigger finger, , just give us a background of your education and your

[00:00:27] Dr. Baxamusa: training. Sure. Thank you very much for having me, Dr. Chehab. I originally started out as an economics major at Northwestern, but I fulfilled all the pre med requirements so then I went on to medical school at Northwestern and I was kind of deciding between neurosurgery and orthopedics and I actually had met Dr.

Goldstein who was The founder of IBJI who steered me into ortho. So, I then went on to Yale to do my orthopedic residency training. And I still like neurosurgery so the kind of mix of neurosurgery a little bit of plastics is hand and so then I went on to do hand and upper extremity training at the Indiana Hand Center.

After that I joined one of the, This is the group in Northern Illinois University where we were general orthopedic and team doctors for NIU. I was in practice, private practice with them, and then I came back to join Wayne and Illinois Bone and Joint back in 2003, so now I've Developed my practice more exclusively to hand and upper extremity from the shoulder to the fingertips And I actually am the division director of hand and upper extremity here at Illinois bone and joint also the chief of orthopedic hand and upper extremity at Advocate Lutheran General Trauma Center, which is a level one trauma center, and we're affiliated with the training program with University of Illinois at Chicago, the orthopedic residency program, where we train the orthopedic residents.

And you also are involved with the Chicago Society for Surgery of the Hand? Yes, that's an academic collection of the hand surgeons throughout the Chicagoland area. I got involved with that early when I came, , one of my mentors, Terry Light at Loyola, had suggested that, uh, I get involved with it and it was actually a lot of fun.

We, , basically meet people. Collegially up at the top of the Sears Tower discuss hand surgery cases get Speakers from around the country to speak and give grand rounds and I eventually moved up the ranks and now I'm past president of the CSSH

[00:02:17] Dr. Chehab: Great, and then you also do some examination for board candidates and for board recertification candidates.

[00:02:23] Dr. Baxamusa: Yes I recently started giving back to Back to the American Board of Orthopedic Surgery to train the new generation of orthopedic surgeons. So we're kind of making sure that there's quality control, getting these guys board certified and passing, the boards to make sure we get quality docs out there.

[00:02:38] Dr. Chehab: I don't think we all remember our written board exam, but I think we all remember our oral exam.

[00:02:44] Dr. Baxamusa: I'm actually one of the tougher oral examiners I've been told , on the reviews.

[00:02:48] Dr. Chehab: Okay. , you've been, , a tremendous partner and a trusted colleague and an outstanding surgeon. You've taken care of thousands of people with conditions of the hand.

So we're very pleased to have you here today to talk about trigger finger. And so first of all, what is trigger finger? When I hear the name trigger finger, I can't help but think of gangster, , but what is a trigger finger?

[00:03:07] Dr. Baxamusa: So a trigger finger is exactly, it's , the technical term is actually stenosing tendovaginitis or.

stenosing tenosynovitis, but it's technically a constriction of the tendon in the hand as it goes through a sheath. And so what ends up happening is that there's usually a little bit of swelling of the flexor tendon that develops and it gets stuck as you flex your fingers. So the classic line would be as if you're pulling the trigger of a gun and your finger gets caught as it's pulling that trigger.

So that's where I got the term trigger finger, but it really has nothing to do with the guns.

[00:03:42] Dr. Chehab: And that swelling is on the back. So on the palm of the hand or on the back of the hand?

[00:03:45] Dr. Baxamusa: On the palm of the hand, most commonly in the ring finger and in the thumb, but it can happen to any of the fingers.

[00:03:49] Dr. Chehab: Okay.

And then, , how do patients develop a trigger finger?

[00:03:53] Dr. Baxamusa: So that's a good question. We really, the majority of the patients are really idiopathic, meaning that it can happen. I actually had a trigger finger. I was trying to lose some weight and doing some pull ups and, , started developing a lot of inflammation and causing triggering of my index finger.

But we do see that there are some risk factors like diabetes, thyroid, other, uh, other medical comorbidities that can exist, but in the general cases, it's generally idiopathic. Comes out of nowhere. Out of nowhere.

[00:04:18] Dr. Chehab: Idiopathic means we're idiots and don't know how it happened, correct? That's right. Okay.

And then, , when people have the triggering, what are the symptoms that they experience? How do they, what do they feel? They feel a lot of pain or they just feel annoyance? What's the, what's their complaint? Generally,

[00:04:35] Dr. Baxamusa: we look for complaints of pain because there may be a little bit of annoyance, but if it's just an occasional annoyance, Many people will just kind of deal with it and, , think it's called a, quote, trick finger and just, it's a neat thing, but when it becomes painful or inhibits activities of daily living, that becomes a problem.

And we especially see that patients, , the trigger finger is most prominent at night. At night we sleep in a kind of flex posture, , the old fetal position and you clench your fist. So they'll wake up in the morning and all of a sudden find that they cannot. Straighten out that ring finger or they have to take their opposite hand and open up their finger.

That's a classic trigger finger

[00:05:09] Dr. Chehab: So their finger gets stuck bent in the trigger finger and then in order to straighten it out They have to either use their other hand or flick it forward and that's the triggering. That's a click of it.

[00:05:18] Dr. Baxamusa: That's correct Okay. Yeah,

[00:05:19] Dr. Chehab: and then When they what's the precipitating event that brings them into your office that nighttime pain that getting stuck?

the activities of daily living

[00:05:28] Dr. Baxamusa: Yeah, I think some people are actually quite, , to wake up in the morning and not be able to straighten out your finger, it can be quite alarming. And if somebody doesn't know what a trigger finger is, they're really freaked out and they come in and they're like, what's happening?

Is it a stroke or is it some sort of, , an unusual condition, and then, we explain this is probably the second most common procedure that I do , in surgery, and it's called a trigger finger. We go through , the handout, I've got a lot of educational handouts, websites on our Illinois Bone and Joint website that, that educates it, and then when they see this is a common condition, they're a little more relieved that, hey, there are things they can do to treat this.

[00:06:02] Dr. Chehab: So, do they come in normally with their finger bent and stuck, or are they coming in, , saying, Hey, every once in a while my finger gets stuck. How do you see the most common presentation?

[00:06:10] Dr. Baxamusa: So the most commonly, they're not locked. That's what I would call a lock trigger finger when they come in and they can't straighten it out.

And that's a pretty alarming thing because that can also cause finger contractures. So we really don't want to keep somebody in the locked position, and we'll kind of They'll jump on that pretty quickly, but what they'll usually say is it locks or it triggers on them, but they're able to straighten it out, but it's annoying.

, sometimes it's not even that bad. Sometimes they'll have that history, but when they come to the office they're opening and closing their fingers perfectly, and we actually have to examine. You put pressure directly over what's called the A1 pulley. And if you press on that and then ask them to flex, you can actually feel that little tendon gliding and actually getting stuck in that sheath, the little swollen tendon.

[00:06:51] Dr. Chehab: Where is the A1

[00:06:52] Dr. Baxamusa: pulley

[00:06:52] Dr. Chehab: on the

[00:06:53] Dr. Baxamusa: hand? So you look for what's called the distal palmar crease. So if you look in your hand, you'll see , the creases that we have, and there's a crease that's the furthest it's right. Kind of close to the fingers, closest to where the finger meets the hand at the metacarpophalangeal joint.

And that distal palmar crease correlates with where the A1 pulley is existing in that. And that's where the swollen tendon gets stuck. That is 99 percent of the time. That's the issue. There are some cases where the tendon may get stuck, what's called a camper's chiasm, or where the flexor tendon splits apart and the deep flexor goes through there.

But those are less common. It's usually the A1 pulley.

[00:07:31] Dr. Chehab: Okay. So now, On the exam, you're feeling the swollen tendon near the A1 pulley, or the patient may be able to demonstrate the trigger finger. What are some other possible diagnoses that can cause similar symptoms, or is this basically, that's what it is?

[00:07:46] Dr. Baxamusa: No, there's, so one of the things that oftentimes gets confused with trigger finger, there's a term, it's a very benign, but Common condition called Dupuytren's disease and what that is instead of triggering it actually develops a slow progressive contracture Usually more often in older patients over the age of 50 and 60 and it's a lot of times familial But what that is not really triggering and it's usually not painful, but it's a cord that It exists in the palm with a slow progressive contracture.

One of the big things that I think you need to really diagnose with the trigger finger and make sure that it's separate. We said triggers on the palm side of the hand. There's an injury on the back of the hand called a radial sagittal band rupture. And if that happens, oftentimes that'll happen, sometimes as simple as like flicking a coin or flicking a fly, but usually that happens where there's a rain that holds the sagittal Extensor tendon in place if it ruptures the extensor tendon, dislocates or dislocates, and that can simulate a trigger finger.

[00:08:46] Dr. Chehab: Okay, so dupuytren's contractures and the extensor mechanism on the knuckle side of the hand can seem like a trigger finger. Yes. The Dupuytren's can bend the finger and the extensor hood injury can flick , and cause these sharp snaps in the hand, but they're distinctly different from trigger finger.

Very

[00:09:03] Dr. Baxamusa: different. The extensor tendon injury, when the extensor tendon subluxates or dislocates, the finger can actually get stuck and simulate a trigger finger.

[00:09:12] Dr. Chehab: Yeah.

[00:09:12] Dr. Baxamusa: But you actually can passively look at it and examine and you notice that. The pathology is on the back of the hand, so if you give, say, an extensor tendon subluxation or dislocation, a trigger finger injection, no benefit.

You're not going to

[00:09:24] Dr. Chehab: help him out very much. Alright. And are any x rays, CTs, MRIs needed for your diagnosis of a trigger finger?

[00:09:30] Dr. Baxamusa: A simple trigger finger doesn't really require it, but I do like to get x rays because I'm looking at other pathology. I'm not needing the x ray to diagnose a trigger finger.

What I'm looking at the x ray for is any incidental findings. I'm looking for arthritis in the joints or, um, Take for instance a prior history of fracture or some altered abnormality. So that's really, I'm looking more for the x ray to rule out any associated symptoms rather than rule in the trigger.

[00:09:54] Dr. Chehab: Okay, so the patients come to your office, they've complained about their finger getting stuck in the middle of the night or they have this annoyance with their hand, pain associated, it's in the palm side. Not to be confused with the Dupuytren's contracture or Dupuytren's disease and not to be confused with an extensor subluxation around the knuckles.

Um, and so now let's talk about some of the treatments and let's start with the non operative treatments that are available for trigger finger.

[00:10:20] Dr. Baxamusa: Yeah, , non operatively, a lot of this is, we try to figure out what's the inciting factor. We talked about idiopathic, but I forgot to mention that a lot of times this is associated with activity.

So Like yours. Mine, with pulling and lifting weights. I know my son makes fun of me for wearing gloves in the gym, but Yeah, as you get older, I think you need a little bit of padding. So I have no, no shame, I wear gloves. And now it's a little bit of extra padding, triggering went away.

Same way I get older patients that maybe say use a cane or a walker and they're putting a lot of pressure. And as we get older, the fat shifts, it gets to places we don't want it. It goes away from places we do want it. So again, putting a little bit of padding like a glove will help, uh, give some cushion and prevent the trigger finger.

Sometimes anti inflammatories or even topical anti inflammatories like Naperson's a nice non invasive treatment.

[00:11:11] Dr. Chehab: Okay. And then, so oral anti inflammatories and then some mechanical cushioning of the hand in order to prevent or even treat the trigger finger while it's happening, if you can identify a cause based on.

And then what are some of the more invasive but non operative measures you can do for trigger fingers?

[00:11:28] Dr. Baxamusa: , I really do like a cortisone injection. There's a cortisone injection and, , it's really directly, , injected right into the A1 pulley of, or the area of pathology. And I like it because it can be both diagnostic and therapeutic, meaning that if I give the, if I suspect a cortisone, I mean suspect a trigger and we tried initial conservative treatment and we still have the symptoms.

Giving the cortisone does confirm the diagnosis as well as possibly eliminate the entire condition. Usually the studies will show about a 50 50 chance of success with one cortisone shot. A lot of times we'll even require a second cortisone shot. If after a couple of cortisone shots you keep getting recurrence, then I think we go to surgery.

But I would almost say that virtually every one of my patients I would at least offer one cortisone shot before the surgery. Going on to surgery,

[00:12:16] Dr. Chehab: is there such thing as too many cortisone shots in the hand?

[00:12:19] Dr. Baxamusa: Absolutely. There is a, there's a kind of a diminishing returns. That's where we find actually after a couple of cortisone shots, if it's going to a couple, two shots, two, two, I, sometimes you'll twist my arm and I'll do three.

 But what ends up happening is that cortisone does have a weaken weakening of the tissues. So I've seen, unfortunately, there was a. well intentioned doctor who just didn't want to take time off. And she had her partner, uh, inject her multiple times, meaning about a dozen. And it actually ruptured the tendon.

And that's irreversible at that point.

[00:12:49] Dr. Chehab: Yeah. No flexor tendon rupture where you can't bend your hand is a big deal. And the repairs are difficult and the recovery is even more difficult. Yes. Okay. So obviously that's an outcome we'd want to avoid. So maybe a couple of injections with cortisone, if the anti inflammatories and the mechanical cushioning, , Strategies aren't particularly working or effective for resolving the trigger finger.

Um, but let's say we've had a patient with a couple cortisone shots. They continue to have the annoyance and the pain from the triggering. It hasn't cured the problem. So, what are next steps? So what are your options at this point?

[00:13:21] Dr. Baxamusa: So generally at that point, I forgot to mention, I also sometimes use occupational therapy.

They can use modalities like ultrasound, sometimes splinting at night. But if we've made the decision that at this point all conservative measures have failed, we talk about surgery. And with surgery, it's generally a very simple outpatient surgery, oftentimes done under local anesthesia. If the patient is a little nervous.

Because we do have to use a tourniquet, sometimes we'll have an anesthesiologist present give him a little cocktail, kind of like a colonoscopy or a sedative.

[00:13:52] Dr. Chehab: So you're awake, breathing on your own, getting some numbing medicine in your hand, and maybe a little bit of this, , medicine to make you not care about anything in the world.

 If you're applying a tourniquet to the hand.

[00:14:03] Dr. Baxamusa: Exactly.

[00:14:04] Dr. Chehab: Okay. Exactly. Okay. And so what, the day of surgery doesn't sound like, what's, I'm really trying to ask, what's the day of surgery like? It doesn't sound like it's a big deal. They just kind of come in , and usually as an outpatient, I assume.

[00:14:14] Dr. Baxamusa: So correct.

It's an outpatient surgery. We generally like to do it in our surgery center because it's a little bit better controlled setting. We do the hospital, but it's sometimes, the hospital I kind of reserve for patients, really sick patients. And this is. , it's pretty much an outpatient procedure.

As a matter of fact, back in the 90s when I was in residency, we were actually doing some techniques where we were even trying to use a needle or do this percutaneously using the bevel of a needle like a knife and doing these percutaneously.

[00:14:40] Dr. Chehab: Doing that in the office? In the

[00:14:41] Dr. Baxamusa: office.

[00:14:42] Dr. Chehab: And why did that fall out of favor?

I assume they There was some injuries to the tendon.

[00:14:46] Dr. Baxamusa: It basically it's a blind technique. Now, you now, I think 30 years later, we do have ultrasound and you could look at it, but still you're using it's kind of taking multiple passes with the needle. And so you're basically scraping, , scraping until you cut.

This is, , in the surgery center, it honestly, my tourniquet times are about two to three minutes. So it's a 15 blade, which is, , 7 and you make a little incision and you've, you protect the nerves and you incise the pathology. So. And the pathology is the tendon or the A1 pulley?

So it's the A1 pulley and the tendon. So the A1 pulley actually, Thickens and it becomes almost, , there's, it's what's called mucoid degeneration. And basically what we find is that instead of a normal sheath or what I like to say is like a, , the best analogy I give for trigger finger is it's like a string gliding through a straw and that should normally glide through.

And now imagine somebody tied some knots on that string. Now it gets stuck in the straw. So there is some swelling of the tendon itself, but like you said, we can't really. , tendons, zone 2 flexor tendons, leave them alone. We don't want to touch the tendons, so what we do is we make the straw bigger.

And the pathology in the straw is that mucoid degeneration, that, that flexible sheath is not so flexible. It actually gets very thick and stenotic or thickened , and narrowed. So you, so the

[00:16:04] Dr. Chehab: surgery is a release of that A1 pulley, which is the straw. The tendon goes through that. It's not a long straw, it's a very

[00:16:11] Dr. Baxamusa: short straw, correct?

Exactly.

[00:16:13] Dr. Chehab: Okay.

[00:16:14] Dr. Baxamusa: And we actually like to move the patient right away because that straw will reform. That pulley reforms at about six weeks. So what we do is immediately, intraoperatively, and I like, and that's why we keep the patient, , pre op. Pretty much awake during the surgery. I want to see them move and make sure that the triggering is resolved and they've got full range of motion.

So

[00:16:34] Dr. Chehab: the tendon's gliding easily and the swollen part of the tendon is not getting stuck and they won't pull any other place along

[00:16:42] Dr. Baxamusa: where the

[00:16:42] Dr. Chehab: tendon goes. Okay. Let's walk through the recovery. It sounds like it's a relatively rapid recovery. Let's talk about maybe the first week, the first month, the first three months.

[00:16:51] Dr. Baxamusa: Perfect. So it generally, , scars take up to six months or so to heal. to heal, , with the collagen remodeling and the soreness. So, we'll see patients, , complain of minor soreness into the palm, even up to six months, but the restrictions themselves are really for the first couple of weeks while the stitches are in place.

That's the most critical time. You don't want to get it wet or dirty, so we'll curtail their activities not a whole A lot of forceful gripping for the first few weeks. The immediately after surgery, again, I encourage people, if they want to play the guitar or piano or use their fingers for typing, writing, texting, that's excellent.

The more they move it, the better. We start beginning that on day zero. We usually bring the patient back about five to seven days, take the big bulky dressing and that bulky dressing is kind of analogous to like the boxing pre wrap, , what you'd put under a boxing glove. And we take that down and then just go to a simple bandaid.

And then the stitches come out usually at about 10 to 14 days.

[00:17:44] Dr. Chehab: Okay. So it sounds like a relatively straightforward recovery where movement is encouraged early. And then, , the wound care is relatively straightforward with the removal of the surgical dressing at about five days and then really just a Band Aid for coverage.

And then just trying to obviously keep it clean. You don't want dirt and germs and everything like that around the incision site. , and then enter any other, parts of the recovery is occupational therapy typically recommended or a patient's basically able to do their own therapy. They're able to quote walk it off with their hand.

They're able to move their hand and do their own rehab.

[00:18:16] Dr. Baxamusa: So the key is the patient really needs to be able to do their own rehab and do a lot of it at home. When we use occupational therapy, it's only once or twice a week just to monitor their progress or to teach them and push them along, but.

, the key is having a patient doing this every day at home. Okay.

[00:18:31] Dr. Chehab: , that's not a routine part of the recovery. There's really not a heck of a lot of a need for an occupational therapist to get involved there. Do you usually get one involved?

[00:18:37] Dr. Baxamusa: Yes and no. It really depends on what the patient presents with preoperatively.

We talked about some patients that are, present with a locked finger. There's also some patients that have this trigger that's been going on for several months and they've Avoided activities. So they didn't, , nobody wants to have the pain. So you curtail your activities and you don't do the full motion that can lead to stiffness in the joint.

So what we find is that even once we release the trigger, we need to work with therapy to work through the stiffness of the joint.

[00:19:04] Dr. Chehab: Got it. Okay. Normal function, when do patients have normal function of their hand? You said about six weeks for all the scarring to resolve. But they're probably functioning normally even before that.

[00:19:14] Dr. Baxamusa: So I've had patients who are actually professional athletes or professional musicians. I actually had one guy Who is a guitarist and we released it and he was back to playing guitar like that was his therapy and even recorded a CD I think weeks after the surgery. Awesome. Yeah. That's great. Now what are some potential complications of trigger finger surgery?

So anytime you have surgery, risks of infection, that's the major thing that I'm worried about and that's why, , I've now been doing this almost 25 years and unfortunately you will see some complications here and there. And so I think a lot of it, we educate patients properly that, , take proper precautions.

Like we don't want to see somebody digging ditches or playing with manure or things, , With their, uh, with their immediate post operative wound, uh, but I think , if we really follow the directions and we're, educated on both, , pre and post operative, usually it's smooth sailing.

[00:20:08] Dr. Chehab: Okay. , in summary, trigger finger is usually done in, as an outpatient, in an outpatient Center, surgical center. Not an in office procedure though that has been tried previously and there are probably some places that may still try and do something like that. It's a very quick procedure and it's one that has a reliable result that ultimately is a rapid recovery.

And a resolution of the triggering. Is it a permanent resolution? Do you have recurrence with triggering in the same hand or is that rare for that to occur? So

[00:20:40] Dr. Baxamusa: it's rare to get a recurrence. There are some times that patients, and it's again looking at the preoperatively, who is predisposed to a recurrence.

If you've released that A1 pulley completely and you've tested it intraoperatively, That's pretty much the cure. However, there are a couple of types of subset of patients. We talked about diabetics. Yes, there's also rheumatoid arthritis and those patients sometimes require a different where you resect a portion of the flexor tendon Exactly.

[00:21:07] Dr. Chehab: Okay. And now, do you see any advances on the horizon for the prevention or treatment of trigger finger? Technique wise or medication or enzymatic?

[00:21:18] Dr. Baxamusa: So not so much the enzyme because the enzyme, like we've used in collagenase for dupatrans, you have to be very careful that you don't get that next to the flexor tendon.

You want to dissolve, say, Or, and another one is the, actual palmar fascia but you don't want to dissolve tendons. So, the enzymes I think are a little bit less common for that. There's been a lot of tools to try to do these percutaneously and the interesting thing is again, a lot of the development that we've done for a simple surgery has Can make this a little slicker maybe take your tourniquet time from three minutes down to two minutes Right, but for what additional cost so

[00:21:55] Dr. Chehab: it's already a really good procedure Yeah, really predictable results with a simple algorithm that works.

And so why complicate it further?

[00:22:02] Dr. Baxamusa: Correct,

[00:22:03] Dr. Chehab: correct. Okay. Well listen, Before we wrap up our discussion about Triggerfinger, my co host Corey Lehman asked a great question and I'm going to ask it to you. So what are things that you do to help you move better, live better?

[00:22:16] Dr. Baxamusa: So it's interesting, as I'm getting older, it's uh, I've followed more of a principle of eat less, move more.

I think that's really what's helping me a little bit.

[00:22:28] Dr. Chehab: , listen, my guest today is Dr. Ty Baxamusa. Thank you so much for joining us today on OrthoInform.

[00:22:34] Dr. Baxamusa: Thank you. Thanks very much. I really appreciate it. It's a lot of fun.