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Persistent Trigger Finger Due to Tendon Subluxation
CASE REPOSITORY
Persistent Trigger Finger Due to Tendon Subluxation Ronald K. Akiki, BS,* Loree K. Kalliainen, MD, MA†
We report the case of an adult patient with persistence of triggering after A1 pulley division in the ring finger, which was caused by flexor digitorum superficialis tendon subluxation. This resolved after longitudinal flexor digitorum superficialis tendon separation. (J Hand Surg Am. 2020;-(-):1.e1-e3. Copyright Ó 2020 by the American Society for Surgery of the Hand. All rights reserved.) Key words FDS, hand, subluxation, trigger finger.
P
ATIENTS WITH TRIGGER FINGER present with locking and clicking of the affected finger(s), sometimes with decreased active range of motion. Trigger finger, also known as stenosing flexor tenosynovitis, has a 2% prevalence. It is more common in patients with diabetes, amyloidosis, and rheumatoid arthritis.1 Most cases involve a single digit; the thumb, middle, and ring fingers are the most commonly affected, but multiple digits can be affected simultaneously.2 Occupation and daily repetitive tasks were associated with the occurrence of trigger finger in some studies, whereas no associations have been found in others.1 Treatment includes the placement of an orthosis, steroid injections, and operative release. Surgical failures are common in children, but success approaches 100% in adults.3,4
CASE REPORT A 49-year-old man presented to the clinic with symptoms of left ring finger triggering. The patient From the *The Warren Alpert School of Brown University and the †Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, RI. Received for publication January 11, 2020; accepted in revised form August 12, 2020. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Loree K. Kalliainen, MD, MA, Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, 235 Plain Street, Providence, RI 02905; e-mail: [email protected]. 0363-5023/20/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2020.08.003
had fallen onto the hand about 2 years previously and had since had daily triggering of the left ring finger for which he refused steroid injections. He had normal extension of the thumb, index, middle, and little fingers. The patient had no other major medical conditions such as diabetes or hypothyroidism. A left ring finger trigger release under local anesthesia was planned and consent was signed. The surgeon injected 5 mL lidocaine with epinephrine and plain bupivacaine into the palm around the planned incision site. A longitudinal incision was made over the A1 pulley of the left ring finger. Blunt and sharp dissection was performed to access the tendon sheath. The neurovascular bundles were retracted. A longitudinal incision was made in the sheath, and the A1 pulley was divided through its extent. Synovium and a redundant portion of the sheath were excised. The patient was asked to flex and extend the fingers forcefully. There was palpable and visible snapping in the palm. By exploring the tendons more proximally, the flexor digitorum superficialis (FDS) was seen to be subluxating radial to the flexor digitorum profundus (FDP). The chiasm in the superficialis was distal (beneath the A2 pulley). To centralize the superficialis tendon over the FDP, the surgeon split the tendon longitudinally into the midpalm. The tendon lay in a more normal position, and with gentle range of motion, it did not subluxate. A synovial biopsy was sent for pathology. The tendons appeared otherwise normal, although when the FDS tendon was split, there appeared to be a layer of
Ó 2020 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
PERSISTENT TRIGGER FINGER
FIGURE 1: A Digit in extension. B Digit in flexion with snapping subluxation. C Digit in extension after separation of FDS tendon slips. D Digit in flexion after separation of FDS tendon slips.
scar in the middle of its substance. There were no masses on or in the sheath. The wound was irrigated and closed, and a well-padded plaster dorsal blocking orthosis was applied. The pathology report results showed normal synovium. There were no complications. At the 2-month postoperative visit, the patient had no further left ring finger triggering, with normal motion and hand strength.
direction with release of one-third of the proximal A2 pulley. They performed this procedure in 2 pediatric patients with persistent triggering after A1 pulley release, resulting in complete and immediate recovery. In this case report, and similar to Tordai and Engkvist’s study,5 proximal separation of the FDS tendon was performed in an adult patient because the persistent triggering observed during surgery resulted from subluxation of the FDS tendon to the radial side of FDP (Fig. 1). Gently separating the 2 arms of the FDS tendon proximally to allow the FDS to drape over the FDP led to complete and immediate recovery of normal active motion. The etiology of this unusual occurrence is less likely an inability of the tendons to slide beneath the
DISCUSSION Persistent triggering with no period of improvement after A1 pulley release is rare. Hypotheses to explain the persistence of triggering have not been proposed. Tordai and Engkvist5 recommended separating the terminal divisions of the FDS tendon in a proximal J Hand Surg Am.
r
Vol. -, - 2020
PERSISTENT TRIGGER FINGER
ACKNOWLEDGMENT The authors would like to acknowledge the contributions of Julia Lerner, CMI, for the creation of the illustrations used in this publication.
A1 pulley, as is the usual cause of triggering, and more likely congenital in nature. In this patient, the FDS chiasm was more distal in relation to the FDP (closer to the A2 pulley) relative to its usual location at the A1 pulley. The flexion force exerted by the asymmetrically placed FDS tendon appeared to cause radial FDS tendon subluxation leading to the symptoms. Abnormalities of the FDS chiasm may be a reason for the failure of trigger release in non-thumb digits, as in pediatric patients previously reported in the literature.5 We report a case of persistent triggering in an adult patient caused by FDS tendon subluxation, which resolved after an open A1 pulley release and FDS tendon separation.
J Hand Surg Am.
1.e3
REFERENCES 1. Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger thumb). J Occup Environ Med. 2000;42(5):526e545. 2. Saldana MJ. Trigger digits: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(4):246e252. 3. Shah AS, Bae DS. Management of pediatric trigger thumb and trigger finger. J Am Acad Orthop Surg. 2012;20(4):206e213. 4. Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg Am. 1999;24(6):1156e1161. 5. Tordai P, Engkvist O. Trigger fingers in children. J Hand Surg Am. 1999;24(6):1162e1165.
r
Vol. -, - 2020
Persistent Trigger Finger Due to Tendon Subluxation Ronald K. Akiki, BS,* Loree K. Kalliainen, MD, MA†
We report the case of an adult patient with persistence of triggering after A1 pulley division in the ring finger, which was caused by flexor digitorum superficialis tendon subluxation. This resolved after longitudinal flexor digitorum superficialis tendon separation. (J Hand Surg Am. 2020;-(-):1.e1-e3. Copyright Ó 2020 by the American Society for Surgery of the Hand. All rights reserved.) Key words FDS, hand, subluxation, trigger finger.
P
ATIENTS WITH TRIGGER FINGER present with locking and clicking of the affected finger(s), sometimes with decreased active range of motion. Trigger finger, also known as stenosing flexor tenosynovitis, has a 2% prevalence. It is more common in patients with diabetes, amyloidosis, and rheumatoid arthritis.1 Most cases involve a single digit; the thumb, middle, and ring fingers are the most commonly affected, but multiple digits can be affected simultaneously.2 Occupation and daily repetitive tasks were associated with the occurrence of trigger finger in some studies, whereas no associations have been found in others.1 Treatment includes the placement of an orthosis, steroid injections, and operative release. Surgical failures are common in children, but success approaches 100% in adults.3,4
CASE REPORT A 49-year-old man presented to the clinic with symptoms of left ring finger triggering. The patient From the *The Warren Alpert School of Brown University and the †Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, RI. Received for publication January 11, 2020; accepted in revised form August 12, 2020. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Loree K. Kalliainen, MD, MA, Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, 235 Plain Street, Providence, RI 02905; e-mail: [email protected]. 0363-5023/20/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2020.08.003
had fallen onto the hand about 2 years previously and had since had daily triggering of the left ring finger for which he refused steroid injections. He had normal extension of the thumb, index, middle, and little fingers. The patient had no other major medical conditions such as diabetes or hypothyroidism. A left ring finger trigger release under local anesthesia was planned and consent was signed. The surgeon injected 5 mL lidocaine with epinephrine and plain bupivacaine into the palm around the planned incision site. A longitudinal incision was made over the A1 pulley of the left ring finger. Blunt and sharp dissection was performed to access the tendon sheath. The neurovascular bundles were retracted. A longitudinal incision was made in the sheath, and the A1 pulley was divided through its extent. Synovium and a redundant portion of the sheath were excised. The patient was asked to flex and extend the fingers forcefully. There was palpable and visible snapping in the palm. By exploring the tendons more proximally, the flexor digitorum superficialis (FDS) was seen to be subluxating radial to the flexor digitorum profundus (FDP). The chiasm in the superficialis was distal (beneath the A2 pulley). To centralize the superficialis tendon over the FDP, the surgeon split the tendon longitudinally into the midpalm. The tendon lay in a more normal position, and with gentle range of motion, it did not subluxate. A synovial biopsy was sent for pathology. The tendons appeared otherwise normal, although when the FDS tendon was split, there appeared to be a layer of
Ó 2020 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
PERSISTENT TRIGGER FINGER
FIGURE 1: A Digit in extension. B Digit in flexion with snapping subluxation. C Digit in extension after separation of FDS tendon slips. D Digit in flexion after separation of FDS tendon slips.
scar in the middle of its substance. There were no masses on or in the sheath. The wound was irrigated and closed, and a well-padded plaster dorsal blocking orthosis was applied. The pathology report results showed normal synovium. There were no complications. At the 2-month postoperative visit, the patient had no further left ring finger triggering, with normal motion and hand strength.
direction with release of one-third of the proximal A2 pulley. They performed this procedure in 2 pediatric patients with persistent triggering after A1 pulley release, resulting in complete and immediate recovery. In this case report, and similar to Tordai and Engkvist’s study,5 proximal separation of the FDS tendon was performed in an adult patient because the persistent triggering observed during surgery resulted from subluxation of the FDS tendon to the radial side of FDP (Fig. 1). Gently separating the 2 arms of the FDS tendon proximally to allow the FDS to drape over the FDP led to complete and immediate recovery of normal active motion. The etiology of this unusual occurrence is less likely an inability of the tendons to slide beneath the
DISCUSSION Persistent triggering with no period of improvement after A1 pulley release is rare. Hypotheses to explain the persistence of triggering have not been proposed. Tordai and Engkvist5 recommended separating the terminal divisions of the FDS tendon in a proximal J Hand Surg Am.
r
Vol. -, - 2020
PERSISTENT TRIGGER FINGER
ACKNOWLEDGMENT The authors would like to acknowledge the contributions of Julia Lerner, CMI, for the creation of the illustrations used in this publication.
A1 pulley, as is the usual cause of triggering, and more likely congenital in nature. In this patient, the FDS chiasm was more distal in relation to the FDP (closer to the A2 pulley) relative to its usual location at the A1 pulley. The flexion force exerted by the asymmetrically placed FDS tendon appeared to cause radial FDS tendon subluxation leading to the symptoms. Abnormalities of the FDS chiasm may be a reason for the failure of trigger release in non-thumb digits, as in pediatric patients previously reported in the literature.5 We report a case of persistent triggering in an adult patient caused by FDS tendon subluxation, which resolved after an open A1 pulley release and FDS tendon separation.
J Hand Surg Am.
1.e3
REFERENCES 1. Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger thumb). J Occup Environ Med. 2000;42(5):526e545. 2. Saldana MJ. Trigger digits: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(4):246e252. 3. Shah AS, Bae DS. Management of pediatric trigger thumb and trigger finger. J Am Acad Orthop Surg. 2012;20(4):206e213. 4. Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg Am. 1999;24(6):1156e1161. 5. Tordai P, Engkvist O. Trigger fingers in children. J Hand Surg Am. 1999;24(6):1162e1165.
r
Vol. -, - 2020