SUBCUTANEOUS RELEASE OF TRIGGER THUMB AND FINGERS IN 210 FINGERS

J. TANAKA, M. MURAJI, H. NEGORO, H. YAMASHITA, T. NAKANO and K. NAKANO

From the Hyogo College of Medicine, Nishinomiya, Japan

Subcutaneous release of the tendon sheath has been performed in 210 trigger digits of 172 patients. The follow-up period ranged from 3 to 58 months, with an average of 24 months. Based on our points system, the overall results were as follows: excellent 64.3%, good 9.5’& fair S.l%, poor 18.1%. There were no infections, no injuries of nerves or vessels and no functional insufficiency. This subcutaneous procedure can be easily, quickly and safely performed by careful hand surgeons in the out-patient clinic. Journal of Hand Surgery (British Volume, 1990) 1.5B : 463-46.5

There are two kinds of operative procedure for trigger digits : one is to incise enough skin to do a wide resection of tendon sheath and the other is to insert a small scalpel through the skin and cut the tendon sheath subcutane- ously. The former procedure has been commonly per- formed throughout the world. In our department, subcutaneous release of the tendon sheath has been carried out for the last five years.

Material and method

Subcutaneous release of the tendon sheath has been performed in 210 digits of 172 patients (male : 49, female : 123) between August 1983 and December 1988. Their ages ranged from 5 to 80 years (average 48.6). The digits affected were :

Thumb 116 Index finger 7 Middle finger 57 Ring finger 26 Little finger 4

Operative technique

Under local anaesthesia, a fine sharp scalpel (used as a skin cutter for insertion of an angiocath, Fig. la) is inserted through the skin deep enough to reach the tendon sheath (Fig. lb). The tendon sheath is cut by moving this scalpel longitudinally together with the skin (Fig. lc). Adequate release of the tendon sheath can be shown by disappearance of the triggering on active movement of the digit. Under local anaesthesia, the patient can easily do this during the operation (Fig. Id). The skin wound is covered with a dry dressing which is usually removed after three days. The patient can use the fingers immediately after operation.

Results

The follow-up period ranged from 2 to 58 months (average 24 months) and post-operative function of

VOL. 15B No. 4 NOVEMBER 1990

Table l-Our method of evaluation

~

Evaluation

Excellent

Good

Fair

Poor

minor sym. 1 point <

,, 2 points <

,I 3 points <

minor or 4 points > major sym.

fingers was evaluated in terms of locking or snapping (major symptoms), swelling, tenderness, pain on move- ment and limitation of movement (minor symptoms). There formed the basis for a points system (Table 1).

The overall results were as follows: excellent 64.3x, good 9.5x, fair S.l%, poor 18.1%. The thumb did better than the fingers : excellent 80. I%, good 11.3x, fair 5. lx, poor 3.4% (Fig. 2).

In this series, there were no serious complications, such as infection, injury of nerves and vessels or functional impairment. Every patient could resume his work soon after the operation.

Discussion

Trigger digits are a relatively common affliction of the fifth and successive decades. If conservative treatment has failed, open surgical release is generally recom- mended. This is regarded as minor surgery but compli- cations are not rare ; scar tenderness, mild flexion deformity, infection, nerve injury, bowstringing and recurrence have all been reported. Subcutaneous release is easier and as safe as the conventional open method.

Open release was performed in the first 15 cases of

463

J. TANAKA, M. MURAJI, H. NEGOR, H. YAMASHITA, T. NAKANO AND K. NAKANO

Fig. I Operative technique. (a) A fine sharp scalpel (4.0 cm in length, 5 mm edged) (b) Insert it through the skin deep enough to reach the tendon sheath (c). Cut the tendon sheath by moving this scalpel together with the skin (d). Checking disappearance of snapping by asking the patient to move his thumb before concluding the operation.

subcutaneous release which had poor results in order to clarify the cause. Having examined these cases, several factors were thought to cause poor results. The first is insufficient release (eight cases), the second is that the sharp edge of the scalpel is not long enough to cut the thick tendon sheath (three cases), the third is injury to the tendon itself (two cases) and the fourth is adhesions between the superficialis and profundus tendons (two

Overall (N = 210) Excellent

Thumb (N= 116)

Good

??Fair

Finger (N = 94)

Poor

Fig. 2 Results in patients operated by subcutaneous release.

cases). Though it is not difficult to release the tendon sheath subcutaneously, one should remember the follow- ing points :

1. Acquire or refresh knowledge of the anatomy around the tendon sheath, particularly the close proximity of the nerves in the thumb.

2. Do not insert the scalpel too deep. 3. Move the scalpel along the line of the tendon. 4. During the operation, the patient should be asked to

move finger actively to make sure that the triggering has been cured.

We conclude that the indication for subcutaneous release is a patient with major symptoms which did not respond to conservative treatment, especially in the thumb which has only one flexor tendon.

The procedure is not suitable for children, because it is hard for them to keep still under local anaesthesia.

Conclusion

Subcutaneous release can be performed easily and safely by a careful hand surgeon in the out-patient clinic, taking

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SUBCUTANEOUS RELEASE OF TRIGGER DIGITS

only a short time. This procedure is recommended to be done first: if necessary, one can proceed later to conventional open resection of the tendon sheath.

The simy of the procedure is an advantage both to you and your patient.

References

LORTHIOIR, J. (1958). Surgical Treatment of Trigger-Finger By a Subcutaneous Method. Journal of Bone and Joint Surgery, 40A: 4: 793-795.

THORPE, A. P. (1988). Results of surgery for trigger finger. Journal of Hand Surgery, 13B: 2: 199-201.

BONNICI, A. V. and SPENCER, J. D. (1988). A survey of ‘trigger finger’ in adults. Journal of Hand Surgery, 13B: 2: 202-203.

DINHAM, J. M. and MEGGITT, B. F. (1974). Trigger thumbs in children. A review of the natural history and indications for treatment in 105 patients. Journal of Bone and Joint Surgery, 56B: 1: 153-155.

Accepted: 4 April, 1989 Dr Juichi Tanaka, Department of Orthopaedic Surgery, Hyogo College of Medicine, l-l, Mukogawa-cho, Nishinoqiya-shi, Hyogo, Japan 663.

HUESTON, J. T. and WILSON, W. F. (1972). The aetiology of trigger finger explained on the basis of intratendinous architecture. The Hand, 4: 3: 257- 260.

0 1990 The British Society for Surgery of the Hand

026&7681/90/0015+463/$10.00

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