TRIGGER FINGER AND

DIFFERENTIAL DIAGNOSES
CHRISTIAN DUMONTIER
CENTRE DE LA MAIN, URGENCES MAIN GUADELOUPE
With the help of Pr Le Viet and Dr Vuillemin

Is there something you are not aware of ?

EPIDEMIOLOGY

28 cases / 100,000 , a risk of 2,6% over a lifetime

3 females / 1 male
Mean age: 52-62 yrs (females are younger)
Risk factors: Diabetics ( 20%), Rheumatoid arthritis

PATHOPHYSIOLOGY

136

The Journal of Hand Surgery / Vol. 31A No. 1 January 2006

1st description Notta (1850)

Idiopathic
Inadaquation between flexor tendons and the pulley (A1)
Triggering in flexion or extension

Figure 1. The digital pulley system of the fingers.

cartilage. The A-1 pulley may triple in thickness as

the histologic inner gliding layer of the A-1 pulley
changes from the spindle-shaped fibroblasts and
ovoid cells normally seen to cells with chondrocyte
characteristics.
It has been proposed that tendovaginitis is a more
accurate term to describe the condition than tenosynovitis. This is because the pathologic inflammatory
changes are found in the retinacular sheath and peritendinous tissue rather than in the tenosynovium. The
2 terms continue to be used interchangeably in the
literature.

or of the thumb, splinting alone does n

the triggering. Splinting appears to be
option for patients with mild triggering
wish to undergo a steroid injection or as
to injection.

Ring finger and thumb most frequently, index and

auricular more rarely
Most often, many fingers are involved +++

Corticosteroid Injection
Long-acting corticosteroid injection is
in initial management of the symptom
digit. Injection of the involved flexor te
provides long-term relief of symptoms
92% of affected digits with up to 3 inje
tamethasone sodium phosphate is the
choice because it is water soluble, does
residue in the tendon sheath, is not kno
tenosynovitis, and it causes less fat ne
injection is placed in the tissue around

Conservative Treatment
Notta A. Recherches sur une affection particulire
des gaines tendineuses de la main. Arch
Activity modification, nonsteroidal anti-inflammaGen Med 1850;24:142.
tory drugs, splinting, steroid injection, and surgical
release all have been used in the management of

PATHOHYSIOLOGY
Friction between the
proximal edge of the
pulley and the tendon
during flexion
Cartilaginous metaplasia
of the inner layer
Thickening (x 3) of the
pulley
No real inflammation of
the sheath (but of peritendinous tissues)
Pulley

Tendon

STENOSING TENDINITIS

Thickening of the pulley is responsible for a tendon constriction (at

the finger, pulley thickness may vary from a normal 0,5mm thickness
up to 2 mm)

STENOSING TENDINITIS

Pulleys are made of three layers

External, vascularized, responsible for its nutrition
Internal, fibrocartilaginous for the gliding of the tendon
Intermediate, responsible for its resistance and which contains hormonal
receptors ( 30% of tendinitis and articular pain in patients treated with
Aromatase inhibitors or Tamoxifen)

CLINICAL
Pain at the base of the finger, at the
level of the pulley (more painful at
the thumb - Pruzansky, 1990)
Sometimes a painful bump can be
palpate (associated ganglion)
Fear to close or extend completemly
the finger
Triggering during flexion
Locking

Imaging technique ?: No, however a good

sonography is helpful for the diagnosis of patients
with purely painful or atypical presentations
Thickening of the pulley
Modification of the tendon

A true synovitis or an abnormality of the tendon is

observed in only 48 to 55% of cases

Hypertrophy of A1 pulley
(arrow) with doppler
hypervascularisation and hyper
signal with MRI

Sonographic findings:
hypervascularization (91%),
Fluid synovitis (55%), tendinosis
(48%), tendinosis with fluid
synovitis (39%)

MEDICAL TREATMENT ?
Activity modifications (???)
NSAId (???)
Splints:
10-15 MCP flexion, IP are not immobilized during 6 weeks - 65
% of patients improved at one-year ( Patel)
PIP at night
DIP during 6 weeks, resolution in over 50% of patients (Rodgers)
Rehabilitation ?: Less efficient (68,6%) than steroid injection
(97,4%) at 3 months [Salim. JHS 2012; 37(1):27-34]
Rodgers JA, McCarthy JA, Tiedeman JJ. Functional distal interphalangeal joint splinting for trigger
finger in laborers: a review and cadaver investigation. Orthopedics 1998;21:3059.
Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg [Am]
1992;17:11013

STEROID INJECTIONS

CS + lidocaine > Lidocaine

(Cochrane 2009).
CS and NSAID showed no
improvement
Technique ? no known difference
on the efficacy

Figure 2. Intraoperative photographs of an open trigger digit release. (A)

exposure of the A-1 pulley a knife is used to incise the pulley longitudinall
pulley (check for any tightness of the palmar pulley of Manske and if so rele
FDS tendons may be performed to check that all triggering is gone.

be used to infiltrate the flexor tendon sheath with

corticosteroid and local anesthetic. Patients should be
warned that fat necrosis or skin depigmentation are

on the v
joint an

STEROID INJECTIONS: RESULTS

1 to 3 injections give 60 to 90% cure(57% according to
Fleisch in a meta-analysis)- The third injection has almost
0% chance of efficacy !
Less efficient in long-standing symptoms or if repeated
Few cases of tendinous necrosis, ruptures or infections
have been described

Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I
and II systematic review. J Am Acad Orthop Surg 2007;15:166171.

RESULTS OF CS INJECTIONS
577 fingers in 362 patients, 80% efficacy, most often after
a single injection (Schubert)
A single injection is as efficient as 2 at 6 weeks (Sheikh)
Good results usually are long-standing (8 years), Thumb
injections are more efficient (Castellanos)
Schubert C et al. Corticosteroid injection therapy for trigger finger or thumb: a retrospective
review of 577 digits. Hand (N Y). 2013 Dec;8(4):439-44.
Sheikh E et al. A prospective randomized trial comparing the effectiveness of one versus two
(staged) corticosteroid injections for the treatment of stenosing tenosynovitis. Hand (N Y). 2014
Sep;9(3):340-5.
Castellanos J et al. Long-term effectiveness of corticosteroid injections for trigger finger and
thumb. J Hand Surg Am. 2015 Jan;40(1):121-6.

IS CS INJECTION PAINFUL ?
Pain during injection was evaluated 4/10 and 2/10 the
other day.
More painful in patient(e)s who are afraid of suffering,
are catastrophists, depressed, or depend of the
physician (Julka). However these factors only explained
28% of the pain
CS injection on 1st phalanx would be less painful that at
the MP level (Pataradool)
Pataradool K, Buranapuntaruk T. Proximal phalanx injection for trigger finger: randomized
controlled trial. Hand Surg. 2011;16(3):313-7.
Julka A, Vranceanu AM, Shah AS, Peters F, Ring D. Predictors of pain during and the day after
corticosteroid injection for idiopathic trigger finger. J Hand Surg Am. 2012 Feb;37(2):237-42.

SHOULD STEROID INJECTION BE DONE UNDER SONOGRAPHIC CONTROL ?

Better precision
70% sheath injection vs 15% without control
No intra-tendinous injection vs 30% without control
Some claim a better efficiency, but recent studies are not
conclusive (Cecen)

Cecen GS, Gulabi D, Saglam F, Tanju NU, Bekler HI. Corticosteroid injection for trigger
finger: blinded or ultrasound-guided injection? Arch Orthop Trauma Surg. 2015 Jan;
135(1):125-31.

CS INJECTIONS IN DIABETICS ?

Injections are less efficient in diabetics (Baumgarten)

Blood glucose increases by 73% at D1 and of 26% at D5.
Elevation is more pronounced in type 1 diabetes (145% at
D1), without secondary effects observed (Stepan, Wang).

Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A
prospective, randomized, controlled double-blinded study. J Bone Joint Surg 2007;89A:2604 2611.
Stepan JG, London DA, Boyer MI, Calfee RP. Blood glucose levels in diabetic patients following
corticosteroid injections into the hand and wrist. J Hand Surg Am. 2014 Apr;39(4):706-12.
Wang AA, Hutchinson DT. The effect of corticosteroid injection for trigger finger on blood glucose level
in diabetic patients. J Hand Surg 2006;31A:979 981

ANATOMICAL LANDMARKS FOR INJECTIONS ?

140

The Journal of Hand Surgery / Vol. 31A No. 1 January 2006

favored the percutaneous technique with the benefits of

shorter procedure time (7 vs 11 min), shorter duration
of postoperative pain (3.1 vs 5.7 days), quicker recovery of full hand function (7 vs 18 days after the procedure), and faster return to work (3.9 vs 7.5 days).17

Scaphoid tubercle - middle of the

proximal digital crease
the auricular
Techniqueof
of Percutaneous
Release

Percutaneous release can be performed in the clinic

setting. Local anesthetic mixed with corticosteroid is
administered and the palmar base of the affected
finger is prepared sterilely. The patient is asked to
flex the affected digit actively. The surgeon then
hyperextends the finger. This brings the flexor tendon
sheath directly under the skin and allows the neurovascular bundles to displace to either side.
An 18-gauge needle or other device is inserted at the
proximal aspect of the A1 pulley. Care should be taken
to stay centered over the flexor tendon sheath to avoid
neurovascular structures and to enter the skin perpendicularly with the bevel of the needle parallel to the
tendon. Alternatively some investigators have advocated inserting the needle slightly more distally in the
middle of the pulley and then proceeding with release
proximally and distally (Fig. 4).
The proximal edge of the A-1 pulley is located near
the distal horizontal palmar crease for the small, ring,
and middle fingers. For the index finger it is located at
the proximal horizontal palmar crease. Release of the
ring and middle fingers is believed to be relatively safe.
Figure 4. Use of surface landmarks for percutaneous A-1
The oblique course of the flexor tendons and neurovaspulley release.
Index finger:of
at the
proximal palmar
crease at
Wilhelmi BJ, Mowlavi A, Neumeister
R, Lee
WP. Safe
treatment
trigger
finger
cular structures to MW,
the indexBueno
and small finger,
however,
a line connecting the radial border of the pisiform and the
18
pose
a
greater
challenge.
Wilhelmi
et
al
described
of the border
proximal digital
crease offor
the index finger.
with longitudinal and transverse
landmarks: an anatomic studycenter
of the
fingers
reliable landmarks for the small finger flexor tendon
Middle finger: at the distal palmar crease in the midaxis of the
percutaneous release. Plast
Reconstr
Surg
2003;112:993999.
sheath
in the area of the
A-1 pulley
as lying underneath
digit. Ring finger: at the distal palmar crease in the midaxis of
the digit. Small finger: at the distal palmar crease at a line
a line connecting the ulnar border of the scaphoid

Radials side of the pisiform - middle of

the proximal digital crease of the index
Over the distal palmar crease

Littlers landmarks (distance middle of the

pulp- PIP joint crease = d PIP joint crease,
A1 pulley)

SURGICAL TREATMENT
Ryzewicz and Moriatis Wolf / Trigger Digits

137

89 to 100% success rate at 10 years FU (= the

gold standard)
Ryzewicz and Moriatis Wolf / Trigger Digits

Section of A1 pulley (T1)

13

Increase work of flexion of the tendon by 10%

without clinical consequences
However A1 & A2 are separated anatomically
in only 50% of cases (by 0,4 to 4,1 mm)

Figure 2. Intraoperative photographs of an open trigger digit r

exposure
of the A-1
pulleyanesthetic.
a knife is used
to incise
the pulley l
Figure 2. Intraoperative photographs of an open trigger digit release.
(A) Injection
of local
(B) After
appropriate
pulley
(check
for
any
tightness
of
the
palmar
pulley
of
a
exposure of the A-1 pulley a knife is used to incise the pulley longitudinally. (C) Exposure shows complete release of theManske
A-1
FDS
tendons
may
be
performed
to
check
that
all
triggering
is
g
pulley (check for any tightness of the palmar pulley of Manske and if so release as well). (D) A traction tenolysis of the FDP and
FDS tendons may be performed to check that all triggering is gone.

If A2 is cut, it increases by 42% the work in

flexion, if A1 & A2 are cut, increase is 62%

be used to infiltrate the flexor tendon sheath with

and local
anesthetic.
Patientsthe
should
oncorticosteroid
the volar aspect
of the
hand overlying
MCPbe
be used to infiltrate the flexor tendon sheath with
corticosteroid and local anesthetic. Patients should be
warned
necrosis
or skin
are
joint
and that
A-1 fat
pulley
all have
beendepigmentation
described. Blunt
warned that fat necrosis or skin depigmentation are
potential iscomplications
of tosubcutaneous
injection.
dissection
continued down
the level of the
flexor
potential complications of subcutaneous injection.
Intrasheath
injections
generally
do not result
in comtendon
and the
A-1 pulley
is visualized
(Figs.
2A,
Intrasheath injections generally do not result in complications;
however,
tendon
rupture
has been re2B),
with care
taken to
protect
the neurovascular
plications; however, tendon rupture has been reported that
and is
the on
result
inadvertent
intratenbundles
arelikely
located
the of
radial
and ulnar
sides
ported and is likely the result of inadvertent intratendinous
injections
leading
to
collagen
necrosis.
of the tendon sheath. The radial neurovascular bundinousFigure
injections
leading to photographs
collagen necrosis.
2. Intraoperative
of an open trigger digit
release.
(A) Injection
of local
anesthetic.
(B)because
After appropria
dle
to the thumb
is most
at risk
for injury
it
Surgical
Considerations
exposure of the A-1 pulley a knife is used to incise the pulley
longitudinally.
(C)
Exposure
shows
complete
release
of
takes an oblique ulnar to radial course across the A-1the ASurgical
Considerations
of as
thewell).
A-1(D)
pulley
has been
usedoftothetreat
pulley
(check for any tightness of the palmar pulley of ManskeOpen
and ifrelease
so release
A traction
tenolysis
FDP an
bundle also is subcutaneous, averaging
FDS tendons
may
bepulley
performed
check
thattoalltreat
triggering pulley.
istrigger
gone. This
Open release
of the
A-1
has to
been
used
digits for more than 100 years. Some sur1.19
mm
deeptotoperform
the dermis
at A-1
the thumb
MCP
trigger digits for more than 100 years. Some surgeons
prefer
an open
pulley release
flexion
and may so
bethe
transected
a deep
geons prefer to perform an open A-1 pulley release
under crease,
local anesthetic
absence with
of triggering
skin
incision.
The
A-1
pulley
should
be
released
aspect of thebefore
hand overlying
used
to infiltrate
theabsence
flexor tendon
sheath with can on
under be
local
anesthetic
so the
of triggering
be the
seenvolar
intraoperatively
closure ofthe
theMC

Peterson WW, Manske PR, Bollinger BA, Lesker PA, McCarthy JA. Effect of pulley
excision on flexor tendon biomechanics. J Orthop Res 1986;4:96 101

Section of A1 & A2 pulleys is responsible for

bowstringing of the flexor tendons and loss of strength

144

ASSOCIATED DISEASES

The Journal of Hand Surgery / Vol. 31A No. 1 January 2006

digits may be the higher incidence of a diffuse inflammatory stenosis of the tendon sheath rather than
a focally nodular process.
Studies have reported poor glucose control in patients for several days after steroid injection for trigger fingers but none have documented the incidence,
extent, or management of such phenomena. Patients
should be advised of the possibility of increased
blood sugar levels after steroid treatment but the
presence of diabetes should not be considered a contraindication for flexor tendon sheath injection.
Diabetic hand complications are believed to be
primarily fibrosing processes related to the same
pathogenic mechanisms that induce other diabetic
complications. Hyperglycemia increases collagen
cross-linking while conferring a resistance to degradation, therefore causing collagen accumulation.
This could explain the predilection toward trigger
fingers in diabetic patients.

Amyloidosis: (associated synovectomy)

Rheumatoid arthritis. In contrast to idiopathic

trigger finger, triggering in rheumatoid patients is
referred to correctly as tenosynovitis. Rheumatoid
arthritis is a systemic disorder that affects the synovial tissues. The digital flexor tendon sheath is lined
with synovium. Inflammation of the tenosynovium
causes a mismatch between the size of the contents of
the sheath and the enclosing fibro-osseous canal,
producing symptoms that may resemble closely those
of idiopathic trigger finger. Such symptoms in a
patient with rheumatoid arthritis, however, require an
entirely different diagnostic and therapeutic approach
than that for idiopathic tendovaginitis.
Flexor tenosynovitis in the rheumatoid patient may
cause finger pain, swelling, triggering, limited motion, or rupture of the flexor tendon. The diagnosis is
characterized by digital triggering or stiffness with
palpable swelling on the volar aspect of the digit.
Passive range of motion in the finger that exceeds the
active range of motion is helpful for distinguishing
flexor tenosynovitis from articular pathology. Fixed
joint stiffness may develop in chronic cases, however, making the diagnosis of restricted flexor tendon
excursion as a consequence of diffuse tenosynovitis
more difficult.
The surgical treatment of rheumatoid flexor tenosynovitis is tenosynovectomy and preservation of the
annular pulleys, with selected cases requiring USSR
or excision of rheumatoid nodules from the tendon.
Although the condition may respond temporarily to
corticosteroid injection, early surgical intervention in
the form of flexor tenosynovectomy with decompression of the carpal tunnel is recommended by many
investigators to prevent flexor tendon rupture and
irreversible damage to the median nerve.26

Mucopolysaccharidosis: (A1 & A3 release, USSR)

Carpal tunnel: frequent association (40-63%)

Figure 7. The tendency toward ulnar drift of the flexor tendons after the A-1 pulley of the middle and ring fingers is
shown.

An A-1 pulley release in rheumatoid flexor tenosynovitis is not recommended. Despite pulley release, motion still may be limited by rheumatoid
nodules or diffuse flexor tenosynovium in the area of
one of the more distal pulleys. The division of the
A-1 pulley will increase the rheumatoid tendency for
digital ulnar drift (Fig. 7), with resultant increase in
the ulnar torque across the MCP joint.

Diabetes: more frequent, Injections less efficient,

desequilibrium of the diabetes, post-surgery sequelae
more frequent (Pain, sensibility of the incision site, PIP joint
flexum,)

Surgical Technique
Standard Bruner incisions are used to approach the
digital flexor tendon sheath. The more proximal aspect of the sheath is approached in the palm through
transverse incisions in the distal palmar crease. A
standard approach to the carpal tunnel is used to
expose the flexor tendons at this level if necessary.
The tendon sheath is opened proximal to the A-1
pulley and between the A-2 and A-4 pulleys. The
A-1, A-2, and A-4 pulleys all are preserved.
Diseased tenosynovium surrounding the tendon is
removed. Intratendinous nodules are excised care-

Rheumatoid arthritis: synovectomy WITH preservation of

pulleys to avoid ulnar drift +++

COMPLICATIONS OF SURGERY
1598 trigger fingers in 984 patients
66 patients (7%) had a complication
46 (3%) had persistent problem leading to rehabilitation or injection
30 (2%) had superficial infection
10 (0,6%) had a persisting triggering and 4 (0,3%) a recurrence
Diabetics had longer after care, more difficulties for healing and more
recurrences.
Associated Carpal tunnel release increases the post-operative disabling
period
Bruijnzeel H, Neuhaus V, Fostvedt S, Jupiter JB, Mudgal CS, Ring DC. Adverse
events of open A1 pulley release for idiopathic trigger finger. J Hand Surg Am. 2012
Aug;37(8):1650-6

COMPLICATIONS OF SURGERY
795 fingers in 543 patients
95 patients had complications (12%)
Persistant pain
Stiffness
Oedema
Superficial Infection
19 re-operations (2.4%)
Male sex, sedation or general anesthesia are indpendant risk factors

Everding NG, Bishop GB, Belyea CM, Soong MC. Risk factors for complications of
open trigger finger release. Hand (N Y). 2015 Jun;10(2):297-300.

OTHER TECHNIQUES

Per-cutaneous release (needle, tenotome,...)

Nerves are at 2-3 mm from the needle tip at the thumb
and index finger
Efficient but 100% of superficial tendon laceration
Painful tenosynovitis without triggering often occurs
after a percutaneous release

Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JC. Prospective randomized trial of open
versus percutaneous surgery for trigger digits. J Hand Surg 2001;26A:497500

OTHER TECHNIQUES - USSR

In case of flexum, long-standing

evolution, FDS fraying, reccurence,

A1 pulley sectioning may be

insufficient
Resection of the ulnar slip of the
superficialis
Le Viet D, Tsionos T, Bouloudenine M, Hannouche D. Trigger finger treatment by
ulnar superficialis slip resection (U.S.S.R.). J Hand Surg 2004;29B:368 373.

OTHER TECHNIQUES

Intra-tendinous resection of
the tendon thickening (nodule)
- Seradge et Kleinert

OTHER TECHNIQUES
A1 pulley sectioning under endocopy

Films Dr Desmoineaux

AT THE THUMB

2nd in frequency, very painful and disabling

CS injections are more efficient
If surgical treatment use either an anterior or a lateral approach (Lora)
Post-op surgical outcomes are usually simpler

AT THE THUMB

The radial collateral nerve is the

most at risk:
Superficial (1,9 mm) - palpable
Crosses the surgical incision
proximally +++
Release the A1 pulley on its radial
side to protect the oblique pulley,
the most important mechanically

AT THE THUMB

The proximal edge of T1 pulley is

locatede 0,3 mm proximal to the
proximal thumb crease
Collateral radial nerve was at 2,7
mm from T1 pulley
Collateral ulnar nerve was at 5,4
mm

Patel RM. Hand Surface Landmarks and Measurements in the Treatment of Trigger Thumb. J Hand Surg
2013;38A:11661171

TRIGGER FINGER IN CHILDREN

0,05% of children
90% involve the thumb which is locked in flexion (no
triggering)
During surgery, one should release more than the T1
pulley (usually the oblique pulley should be released)
Spontaneous appearence around the 6th month
< 50% of spontaneous cure (splinting and rehab have
both been proposed)
No sequelae after surgical release (even if realized lately)

The treatment of a congenital trigger finger as

opposed to a congenital trigger thumb in a child
differs in which of the following ways?
A. The surgical release of a trigger thumb is rarely necessary.
B. Surgical release of a trigger thumb usually requires
release of the A2 pulley.
C. A trigger thumb should be released at approximately 7
years of age compared to a trigger finger at approximately
1-2 years of age.
D. Trigger thumb almost never has a nodule of the tendon.
E. Release of a congenital trigger finger often requires more
than simple release of the A1 pulley.

Preferred Response: E

Discussion: Three recent publications clearly define the different findings and treatment
in the congenital trigger finger versus the congenital trigger thumb. . In the finger, the
surgi- cal release usually is more extensive than a simple A1 pulley release and very
often requires separation of anomalous slips of the flexor digitorum superficialis tendon.
Steenwerckx confirmed a clear difference between trigger thumbs and trig- ger finger.
Cardon similarly found that in a trigger finger, release of the A1 pulley alone is not
sufficient to correct the triggering and very often must include resection of one or both
slips of the superficialis tendon or an A3 pulley release. Tordai found that the operative
findings in the trigger finger almost never involved a nodule. Trigger thumbs usually do
need to be released, but it is common to see a nodule of the tendon and A2 pulley
release is not indicated; release of the A1 pulley is sufficient in the thumb. There is no
reason to wait till the age of 7 for release of a trigger thumb.

References:

Tordai, P and Engkvist, O. Trigger Fingers in Children. JHS 1990A; 24A: 11621165.

Steenwerckx, A, De Smet L, Fabry G. Congenital Trigger Digit. JHS 1996; 21A: 909
911.

Cardon, LJ, Ezaki MB, Carter PR. Trigger Finger in Children. JHS 1999; 24A: 1156
1161.

DIAGNOSTICS DIFFERENTIAL DIAGNOSIS OF TRIGGER FINGERS

A3 pulley triggering
Triggering of swan-neck deformity
MP joint triggering due to extensor tendons dislocation
Locked MP
A partially lacerated flexor tendon catches against the A1
pulley or the FDS decussation

A3 PULLEY TRIGGERING

Bowlings players
Pain and tenderness palmar to the PIP joint
Swelling within the flexor tendon adjacent to the PIP
joint
Triggering during flexion over 90, of the FDP +++

Rayan GM. Distal stenosing tenosynovitis. J Hand Surg 1990;15A:973975.

SWAN-NECK TRIGGERING

A swan-neck deformity may be:

asymptomatic- Triggered- Locked
in extension
Temporary locking of lateral
bands over the PIP joint with
triggering when attempting to
flex the finger
TTT : treatment of the cause of
swan-neck

A patient presents with difficulty

extending the middle and ring fingers of
her hand. The patient states that she
initially had some snapping of these
fingers and had trigger finger releases,
but still complains of difficulty extending
these fingers. If the fingers are first
passively extended, she can then
maintain that posture, as shown in
Figure C. Which of the following
explains her continued symptoms?

A patient presents with difficulty extending the middle and ring fingers of
her hand. The patient states that she initially had some snapping of these
fingers and had trigger finger releases, but still complains of difficulty
extending these fingers. If the fingers are first passively extended, she
can then maintain that posture, as shown in Figure C. Which of the
following explains her continued symptoms?

A. Residual stenosis of the flexor tendon sheath at the A-1

pulleys
B. C7 radiculopathy
C. Rupture of the extensor tendons
D. Ulnar subluxation of the extensor tendons at the MCP
E. Partial posterior interosseous nerve palsy

A patient presents with difficulty extending the middle and ring fingers of her hand. The patient
states that she initially had some snapping of these fingers and had trigger finger releases, but still
complains of difficulty extending these fingers. If the fingers are first passively extended, she can
then main- tain that posture, as shown in Figure C. Which of the following explains her continued
symptoms?
A.

Residual stenosis of the flexor tendon sheath at the A-1 pulleys

B.

C7 radiculopathy

C.

Rupture of the extensor tendons

D.

Ulnar subluxation of the extensor tendons at the MCP

E.

Partial posterior interosseous nerve palsy

Preferred Response: D
Discussion: This patient has ulnar subluxation of the extensor tendons. The tendons may
sometimes snap as they sublux and relocate. The photographs demonstrate good extension at the
PIP joints which rules out trigger fingers. She is able to maintain finger extension after passively
extending the fingers, ruling out a posterior interosseous nerve syndrome, C7 radiculopathy, and
extensor tendon rupture. The dorsal view photograph demonstrates ulnar subluxation of the extensor
tendons and ulnar deviation of the middle finger. Extensor tendon subluxation may be associated
with an underlying arthropathy, such as rheumatoid arthritis or SLE; therefore, a rheumatologic
evaluation should be considered.

SAGITTAL BAND AND MP CAPSULAR LESIONS

Contusion wait and see policy
Capsular/lgts rupture mostly
surgical repair
Sagittal band rupture active
conservative treatment most often if
seen early
Type I: contusion without a tear
Type II: subluxation (maintain
contact with metacarpal head)
Type III: dislocation
Rayan, G.M., Murray, D. Classification and treatment of closed sagittal band injuries. J Hand Surg [Am].
1994; 19(4):590-4.

SAGITTAL BAND RUPTURES

Frequent. Could be:
Congenital (Vara-lopez, Z.Chir
1983),
Spontaneous (Ishizuki JHS 1990),
Spastic, Elderly (Harvey JHS1980)
Traumatic (punch or forceful
torsion)
141 traumatic ruptures
published in 2005, with 71%
being on the middle finger

PREDISPOSITION ?

Predisposition ? [Shinohara, 2005]

Prominent metacarpal head, radial
sagittal band longer and thinner,
[Wheeldon, 1954; Kettelkampf,
1971; Rayan, 1994]
Lax patients
At least 50% of fibers ruptured in
order to produce a dislocation

Shinohara et al. Extensor mechanism laxity at the MP

joint as identified by a new provocative test: J Hand
Surg 2005; 30B: 79-82

ANATOMICAL VARIATIONS
Ulnar-sided pain can be seen in
ulnar sagittal band rupture but the
tendon never subluxates [Koniuch,
JHS 1987]
Both at index and little finger, both
tendons can dislocate on the same
side or on either side of the joint
[Le Viet, ACMMS 1991; Van
Meirhaeghe, JHSB 1989]

HOW TO MAKE THE DIAGNOSIS ?

Few clinical signs:

Oedema, pain
Snapping during flexion/extension
in type II and III
Some active extension deficit from
MP flexion in type III
Tendon dislocation is only seen in
the most severe injuries

IMAGING TECHNIQUES
Imaging technique:
Sonography ?
MRI: Good definition
with sensibility 0,9
for the visualization
of sagittal bands
[Drap, Radiology
1994]

Kichouh M, De Maeseneer M, Jager T, Marcelis S, Van Hedent E, Van Roy P, De Mey J. Ultrasound findings in injuries of dorsal
extensor hood: correlation with MR and follow-up findings. Eur J Radiol. 2011 Feb;77(2):249-53.

CONSERVATIVE TREATMENT

May be tried in early (< D 15) and

moderate injuries
4-5 weeks of palmar splint
Place the MP joint in the position in
which the tendon relocates
spontaneously ( 20)

Catalano LW 3rd, Gupta S, Ragland R 3rd, Glickel SZ, Johnson C, Barron OA. Closed
treatment of non rheumatoid extensor tendon dislocations at the metacarpophalangeal joint.
J Hand Surg [Am]. 2006 Feb;31(2):242-5.

SURGICAL TREATMENT

Can maintain, not attain

Many techniques proposed
I prefer Michons technique using a
radial slip of the extensor passed
around the collateral ligament

A 78-year-old female presents

with a one-week history of limited
function of her left hand. This
video demonstrates her clinical
exam. Radiographs are seen.

The most likely cause of

this clinical entity is:

A. Stenosing tenovaginitis
B. Radial sagittal band rupture
C. Collateral ligament entrapment on an osteophyte
D. Fibrosis of the palmar fascia
E. Volar MP dislocation

Preferred response: C (Collateral ligament entrapment on an osteophyte )

Discussion:

The clinical entity shown is a locked MCP joint of the long finger. This occurs when a
collateral ligament becomes entrapped on a marginal osteophyte, especially in older
patients. Alternatively, in younger patients, a prominent metacarpal head condyle can
restrict collateral ligament excursion. In both scenarios, the MCP joint extension is
constrained, but the flexor apparatus is unimpeded.

As seen in this case, the patient presented with a flexion deformity of the MCP joint
with normal PIP and DIP function. This helps distinguish this entity from a trigger finger,
where full active PIP and DIP extension would not be possible. A radial sagittal band
rupture will result in extensor subluxation and a flexed MP joint with PIP/DIP extension,
but the extensor hood appears centralized at the MCP joint in this case. Dupuytrens
disease (palmar fibromatosis) with pretendinous involvement can yield a similar clinical
exam as shown, but would not occur acutely over a weeks time. The radiographs
demonstrate marginal degenerative osteophytes of the MCP joint (best appreciated on
the lateral view in this case) and the MCP joint is congruent (i.e., no dislocation).

The closed reduction maneuver involves insufflating the joint with sterile saline or
lidocaine, MCP flexion with digital deviation stress and rotation (unlocks the entrapped
ligament), and then MCP extension.

LOCKING MP - A RARE DISEASE

Poirier ( 1889 , Arch gn med )

Langeskiold ( 1950 , Acta Chir scand ) :
2 cases
Locking of active AND passive
extension of the MP joint, without pain,
with normal mobility of PIP and DIP
joints

Thomsen L, Roulot E, Barbato B, Dumontier C. Locked metacarpophalangeal joint of long fingers:

classification, definition and treatment based on 15 cases and literature review. Chir Main. 2011 Sep;
30(4):269-75

OUR EXPERIENCE
5
5

15 patients, 1997 to 2007, 9

,6

47 years old ( 27-76)

No attempt at reduction
Painful : 13 cases
Locked in Flexion : 11 cases : 30 , 1 case : 40
Locked in Extension : 3 cas
Surgical treatment: 10 volar approaches, 5 radial approaches
1 year FU: 13 are cured with normal motion, 1 painful 1 loss to FU

LOCKING IN FLEXION

9 cases out of 12: accessory radial

collateral ligament, osteophyte,
prominent condyle,
TTT: resection of the abutting part

LOCKING IN FLEXION

3 other cases:
2 cases : osteophytes, no
ligamentous injury
1 case : osteochondromatosis

LOCKING IN EXTENSION

3 cases:
Volar accessory ligament incarceration which had to be resected

OUR CLASSIFICATION - 3 TYPES OF LOCKING

In flexion:
Incarcration of radial (> ulnar) collateral ligament over a
bony abnormality of the metacarpal head
Idiopathic (young, index)
Degenerative = osteophyte
others: Acromegalia (Y.Tani, skel radio, 1999) , achondroplasia
(Y.Hamada , JHS , 2007) , fracture (F.Shuind , JHS , 1993) , Malunion, bony
tumor

OUR CLASSIFICATION - 3 TYPES OF LOCKING

In extension
Volar accessory ligament incarceration
In Flexion/Extension: Foreign body
Flexion (R.Honner, JBJS, 1969)
Extension (Mriaux , rev rhum, 1984)

Choukran