Article

How Many Trigger Fingers Resolve Spontaneously Without Any Treatment?

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Abstract

Introduction: There is very little information in the literature evaluating the natural history of adult trigger fingers and their rate of spontaneous resolution over time. Methods: A consecutive case series of patients with trigger finger was generated. For each patient, we recorded whether the patient's disease resolved from either no treatment versus active treatment options and over what time period. Results: Three hundred forty-three patients with trigger finger were included in the study. Fifty-two percent of patients resolved without any treatment whatsoever after waiting a mean (and median) of 8 months from initial consultation. The thumb was the most frequent digit to resolve without treatment (72%). Conclusions: We found that just over half of patients with trigger fingers who are referred to our office resolve spontaneously without any intervention.

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... The improvement with time observed in the sham group can be explained by the natural course of TF. McKee et al 26 reported that TF spontaneously resolved in over half of 343 patients without any intervention after a mean period of 8 months from the initial consultation, implying that inflammation may be the major cause of TF symptoms. In addition, because this trial included only patients with grade II TF according to the Quinnell classification, the symptoms of TF may be caused by inflammation inside the tendon sheath rather than mechanical locking that occurs during tendon gliding. ...
Article
Objectives: To determine the efficacy of extracorporeal shock wave therapy (ESWT) and to determine the ideal energy flux density of wide-focused ESWT in the treatment of trigger finger (TF). Design: Double-blinded, randomized, controlled trial. Setting: A university hospital PARTICIPANTS: A total of 60 patients with grade II TF according to the Quinnell classification were randomly and evenly allocated to three treatment groups. Interventions: Thee treatment groups included a high-energy ESWT (HS) group (energy flux density of 0.01 mJ/mm2, 5.8 bar, 1500 impulses, once per week for 4 wk), a low-energy ESWT (LS) group (energy flux density of 0.006 mJ/mm2, 3 bar, 1500 impulses, once per week for 4 wk), and a sham intervention group (sham group). All participants received 6 months of follow-up after intervention when only painkillers were allowed as concomitant treatment. Outcome measures: Clinical outcomes were followed at baseline and 1, 3, and 6 months after intervention, including pain score, frequency of triggering (FT), severity of triggering (ST), functional impact of triggering (FIT), and quick Disabilities of the Arm, Shoulder, and Hand (qDASH) questionnaire. Results: All groups showed significant improvements from baseline in all clinical parameters, except for FIT, at the sixth month following interventions. However, the HS group demonstrated a higher magnitude of improvement than the LS and sham groups. In addition, the HS group reported significantly lower pain (p = .01) and lower qDASH (p = .008) than the sham group at the sixth month following interventions. No adverse effects were reported in both HS and LS groups within 6 mo of follow-up. Conclusion: Wide-focused ESWT is a safe and effective but dose-dependent alternative facilitating pain relief and functional improvement in the treatment of grade II TF according to the Quinnell classification.
... 34 Observation is another option as one retrospective case series by a hand surgeon found that 52% of patients had complete resolution of trigger finger within an average time of 8 months without splinting or corticosteroid injection. 35 Avoidance of suspected causative activities is often recommended, but whether it hastens resolution beyond simple observation is unknown. ...
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Trigger finger is a common condition usually curable by a safe, simple corticosteroid injection. Trigger finger results from a stenotic A1 pulley that has lost its gliding surface producing friction and nodular change in the tendon. This results in pain and tenderness to palpation of the A1 pulley, progressing to catching and then locking. Splinting for 6 to 9 weeks produces gradual improvement in most patients as does a quick steroid injection with the latter resulting in resolution of pain in days and resolution of catching or locking in a few weeks. Percutaneous or open release should be reserved for injection failures particularly those at high risk for continued injection failure including diabetics and those with multiple trigger fingers. We present a step-by-step method for injection with illustrations to encourage primary care providers to offer this easily performed procedure to their patients.
... They defined three clinical grades of symptoms as follows. Grade I was considered a simple tenosynovitis with tenderness and pain but [19] reported that greater than half of non-dialysis patients (52%) exhibited spontaneous resolution without any surgical intervention. Spontaneous resolution is rare in TF in dialysis patients. ...
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Abstract We introduced criteria for the clinical diagnosis of dialysis-related amyloidosis (DRA) from the Amyloidosis Research Group study supported by a Grant-in-Aid from the Ministry of Health, Labour and Welfare of Japan. DRA exhibits various kinds of bone articular lesions, such as carpal tunnel syndrome, trigger finger, destructive spondyloarthropathy, spinal canal stenosis, and joint pains. These bone articular lesions, excluding destructive spondyloarthropathy, are observed in non-dialysis patients or dialysis patients without DRA. We carefully compared these lesions between DRA and non-DRA patients and summarized the differences between them. The incidence age, male to female ratio, and coincidence rate were distinct between these groups of patients. Biopsies from bone articular lesions are invasive and burdensome for dialysis patients; therefore, a precise clinical diagnosis is required for DRA. We discussed the validity and availability of our proposed criteria.
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Trigger finger is a common condition affecting the hand. Therapeutic variability surrounds the management of trigger finger, especially in the mild cases. The aim of this study was to survey secondary care surgeons to describe the current management of trigger fingers. The steering group developed a survey for hand surgeons. Following piloting, the survey was distributed to hand surgeons in the United Kingdom and The Netherlands. A total of 713 plastic surgeons and orthopaedic surgeons were invited to participate in the online survey and 440 (62%) surgeons completed the survey. In both mild and moderate cases of trigger finger, steroid injection was the preferred treatment option. Open surgery was the treatment of choice for severe cases. However, there was variation in delivery of care, including type and dosage of steroid, site of injection, interval between injections, maximum number of injections, type of incision and treatment of patients with diabetes or rheumatoid arthritis. This highlights the need for a better evidence base for the treatment of trigger fingers.
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ZUSAMMENFASSUNG Erkrankungen des Bewegungsapparats gehören zu den häufigsten Vorstellungsgründen in einer Hausarztpraxis. Wichtig ist in dem Zusammenhang ein frühzeitiges Erkennen und präventives Vorgehen zum Erhalt der Lebensqualität und Vermeidung von Morbidität. Ein Diabetes mellitus stellt für einige Erkrankungen einen wichtigen prädiktiven sowie verlaufsbestimmenden Faktor dar. Dieser Artikel zielt darauf ab, Ihnen das Wissen über die Erkrankungen und ihre Entstehung, praktische diagnostische Möglichkeiten sowie Therapieoptionen zu vermitteln und soll damit eine individuelle Behandlungsstrategie ermöglichen.
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Background: Evidence-based practices in medicine are linked with a higher quality of care and lower health care cost. For trigger finger, identifying patient factors associated with nonadherence to evidence-based practices will aid physicians in treatment decisions. The objectives were to (1) determine patient factors associated with treatment nonadherence, (2) examine the success rates of steroid injections, and (3) evaluate the economic consequences of nonadherence to treatment recommendations. Methods: The authors used data from the Clinformatics DataMart database from 2010 to 2017 to conduct a population-based analysis of patients with single-digit trigger finger. The authors calculated rates of steroid injection success and examined associations between injection success and patient factors using chi-square tests. In addition, the authors analyzed differences in the cost to the insurer, the cost to the patient, and total cost. Results: A total of 29,722 patients were included in this analysis. Injection success rates were similar for diabetic (72 percent) and nondiabetic patients (73 percent), women (73 percent), and men (73 percent). Nonetheless, diabetics (OR, 1.4; 95 percent CI, 1.4 to 1.5; p < 0.001) and women (OR, 1.2; 95 percent CI, 1.1 to 1.2; p < 0.001) were significantly more likely to receive nonadherent treatment. In total, $23 million (U.S. dollars) were spent on nonadherent trigger finger care. Conclusions: Diabetics and women have increased odds of having surgery without a prior steroid injection, despite similar success rates of steroid injections compared to nondiabetics and men. Because performing surgical release before any steroid injections may represent a higher cost treatment option, providers should provide steroid injections before surgery for all patients regardless of diabetes status or sex to minimize overtreatment. Clinical question/level of evidence: Risk, III.
Article
Trigger finger (TF) is one of the most common causes of hand disability. Immobilization of TF with a joint-blocking orthosis has been demonstrated to effectively relieve pain and improve function. The efficacy of steroid injections for TF varies based on the number of affected digits and the clinical severity of the condition. Up to three repeat steroid injections are effective in most patients. When conservative interventions are unsuccessful, open surgical release of the A1 pulley effectively alleviates the subjective and objective manifestations of TF and currently remains the benchmark procedure for addressing TF. Although several studies have emerged suggesting that a percutaneous approach may result in improved outcomes, this technique demands a learning curve that may predispose patients to higher risk of procedure-related complications. There is no role for preoperative antibiotics in patients who undergo elective soft-tissue procedures of the hand. WALANT anesthesia has gained popularity because it has been associated with improved patient outcomes and a clear cost savings; however, proper patient selection is critical. Similar to other soft-tissue hand procedures, TF surgery rarely necessitates a postoperative opioid prescription.
Article
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Pediatric trigger thumb is due to deformed flexion of the interphalangeal joint. We previously reported that pediatric trigger thumb can spontaneously resolve in > 60% of patients at the median follow-up of 48 months. The purpose of this study was to determine whether there were any more cases of resolution with a follow-up of more than 5 years and whether any residual deformities remain, and so to confirm the natural history of pediatric trigger thumb. We prospectively followed 87 thumbs in 67 patients with pediatric trigger thumb and these patients didn't receive any treatment such as passive stretching, splinting or surgery. The date of the first visit ranged from April 1994 to March 2005. The patients were evaluated every six-months prior to resolution and annually after resolution. The median duration of follow-up was 87.3 months (range, 60 to 156 months). Of the 87 trigger thumbs, 66 (75.9%) resolved spontaneously. The median time from the initial visit to resolution was 49.0 months (95% confidence interval, 41.1 to 56.9). There were no residual deformities that resolved beyond 48 months. Although complete resolution did not occur in the remaining 21 thumbs, the flexion deformities did improve in all 21 thumbs. There were no other differences between the two groups besides the average duration of follow-up. There was no difference in resolution based on gender. Pediatric trigger thumb can spontaneously resolve in > 75% of the cases after a follow-up period of at least 5 years. An operation may be delayed or avoided in the majority of cases. This may help both the families and the surgeons make decisions regarding the proper treatment of pediatric trigger thumb.
Article
: The purpose of this study is to report the natural history of pediatric trigger thumb with locked interphalangeal joint, the efficacy of a splint for this condition, and the outcome of late surgery. : Medical records of 64 patients were retrospectively reviewed. Patients were treated with a coil splint when parents and patients accepted; otherwise, regular observation was conducted. Splint application and/or observation were terminated either when the patient gained full range of active motion without snapping, or underwent surgical intervention. : In splint group, 92% of the patients experienced complete symptom relief in 22 months, whereas 60% resolved completely in 59 months in observation group. The differences were statistically significant. One thumb in a patient with bilateral involvement remained locked while the other completely resolved. The rest of the patients also showed improved symptom from locking to snapping. Four patients with residual snapping underwent surgery at the age of 8 years and above without any deformity and complication. : Splint was efficient in shortening the time for symptom relief; however, the natural history revealed the self-limiting nature of this condition. Late surgery was safe and effective for residual snapping and can be presented as one treatment option to the patients and families, combined with conservative treatment. : Level III-retrospective comparative study.
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A controlled double-blind prospective study of injection of methylprednisolone acetate plus local anaesthetic against a control injection of a local anaesthetic in the treatment of trigger finger and thumb has shown a 60% success rate for the steroid injection against 16% for the control group (p less than 0.05). This is the first controlled trial of local steroid therapy in this condition.
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The ability of a single injection of steroid and lidocaine to bring about cure of primary trigger finger was determined and compared with a control placebo injection of only lidocaine. Twenty-four patients were randomized to the therapeutic or control group and were followed prospectively. One physician administered the injection, another the clinical examination after injection, and a third evaluated the results blindly. Patients were not told to which group they were assigned. Nine of the 14 patients in the steroid group versus two of the ten patients in the placebo group were cured of trigger finger at final follow-up examination. After injection, seven patients had immediate but temporary relief of triggering because of flexor sheath distention. One injection cured 64% [corrected] of patients with primary trigger finger with no side effect and is the recommended nonsurgical treatment.
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30 consecutive adult patients presenting with trigger thumb (31 thumbs) were entered prospectively into a study to determine the natural history of the condition. Five patients insisted on treatment and could not be followed to resolution, but the rest resolved spontaneously after an average duration of symptoms of 6.8 months (range 2-15). There was a small but non-functional reduction in movement of the thumb in some of the patients: six lost an average of 7 degrees of abduction and ten had an average loss of opposition of 1.4 (Kapandji grade). The remaining patients made a full recovery.
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Conservative treatment was performed for 60 trigger thumbs (19 right, 17 left, 12 bilateral) in 48 children (19 boys, 29 girls); the age at initial diagnosis ranged from 0 to 48 months old (mean 26 months). In this approach, only passive exercise of the affected thumb was performed by the mother. As a result, two patients (two thumbs) dropped out of treatment. Fifty-six thumbs out of 58 showed a satisfactory result (96%). Sixteen thumbs (in stage 2) and eight thumbs (in stage 3) showed completely recovery. Four thumbs (in stage 3) have not yet improved. In conclusion, we suggest that conservative treatment is effective for trigger thumbs in stage 2, while surgical therapy was thought to be indicated for stage 3 before the age of 3 years to avoid flexion deformity.
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Stenosing tenosynovitis, or trigger finger, is an entity seen commonly by hand surgeons. This problem generally is caused by a size mismatch between the flexor tendon and the first annular (A-1) pulley. Conservative management includes splinting, corticosteroid injection, and other adjuvant modalities. Surgical treatment consists of release of the A-1 pulley by open or percutaneous techniques. Complications are rare but include bowstringing, digital nerve injury, and continued triggering. Some patients require more extensive procedures to reduce the size of the flexor tendon. Comorbid conditions affect how trigger finger is treated. Patients with rheumatoid arthritis require tenosynovectomy instead of A-1 pulley release. In children trigger thumb resolves reliably with A-1 pulley release but other digits may require more extensive surgery. In diabetic patients trigger finger often is less responsive to conservative measures. An understanding of the pathomechanics, risk factors, and varied treatments for trigger finger is essential for appropriate care.
  • Wolfe S