Trigger finger release with hand surface landmark ratios: an anatomic and clinical study

Anatomic location of the first dorsal extensor compartment for surgical De-Quervain's tenosynovitis release: A cadaveric study

BACKGROUND

De-Quervain's tenosynovitis is a disorder arising from the compression and irritation of the first dorsal extensor compartment of the wrist. Patients who fail conservative treatment modalities are candidates for surgical release. However, risks with surgery include damage to the superficial radial nerve and an incomplete release due to inadequate dissection. Currently, there is a paucity of literature demonstrating the exact anatomic location of the first dorsal extensor compartment in reference to surface anatomy. Thus, this cadaveric study was performed to determine the exact location of the first extensor compartment and to devise a reliable surgical incision to prevent complications.

AIM

To describe the location of the first dorsal compartment in relation to bony surface landmarks to create replicable surgical incisions.

METHODS

Six cadaveric forearms, including four left and two right forearm specimens were dissected. Dissections were performed by a single fellowship trained upper extremity orthopaedic surgeon. Distance of the first dorsal compartment from landmarks such as Lister's tubercle, the wrist crease, and the radial styloid were calculated. Other variables studied included the presence of the superficial radial nerve overlying the first dorsal compartment, additional compartment sub-sheaths, number of abductor pollicis longus (APL) tendon slips, and the presence of a pseudo-retinaculum.

RESULTS

Distance from the radial most aspect of the wrist crease to the extensor retinaculum was 5.14 mm ± 0.80 mm. The distance from Lister's tubercle to the distal aspect of the extensor retinaculum was 13.37 mm ± 2.94 mm. Lister's tubercle to the start of the first dorsal compartment was 18.43 mm ± 2.01 mm. The radial styloid to the initial aspect of the extensor retinaculum measured 2.98 mm ± 0.99 mm. The retinaculum length longitudinally on average was 26.82 mm ± 3.34 mm. Four cadaveric forearms had separate extensor pollicis brevis compartments. The average number of APL tendon slips was three. A pseudo-retinaculum was present in four cadavers. Two cadavers had a superficial radial nerve that crossed over the first dorsal compartment and retinaculum proximally (7.03 mm and 13.36 mm).

CONCLUSION

An incision that measures 3 mm proximal from the radial styloid, 2 cm radial from Lister's tubercle, and 5 mm proximal from the radial wrist crease will safely place surgeons at the first dorsal compartment.

Identification of the length and location of the A1 pulley combining palpation technique with palm landmarks: a cadaveric study

Through anatomical morphology, to accumulate the relevant parameters of the A1 pulley of each adult finger. A total of 100 fingers were selected, dissected layer by layer, and the A1 pulley and neurovascular of each finger were observed. Measure the length of the A1 pulley, the distance between the needle knife insertion point and the proximal edge of A1 pulley, and the nerves and blood vessels on both sides. (1) The length of A1 pulleys of each finger is 6.18 ± 0.33 mm, 6.58 ± 0.73 mm, 5.98 ± 0.67 mm, 5.36 ± 1.08 mm, 5.63 ± 1.09 mm. (2) The distances between the needle knife entry point of each finger and the volar proper nerve of the ulnar finger are 7.00 ± 1.55 mm, 8.29 ± 1.46 mm, 5.10 ± 0.25 mm, 5.30 ± 0.24 mm, 0 mm; the distances from the volar proper nerve of the radial finger are 9.08 ± 0.87 mm, 4.70 ± 1.10 mm, 7.03 ± 0.72 mm, 6.81 ± 0.22 mm, 7.81 ± 0.57 mm. (3) The distances between the needle knife entry point of each finger and the proper volar artery of the ulnar finger are 10.40 ± 0.75 mm, 8.89 ± 0.53 mm, 6.35 ± 0.44 mm, 7.26 ± 0.16 mm, 0 mm, respectively; The distances from the volar proper artery of the radial finger are 8.75 ± 1.07 mm, 6.10 ± 0.35 mm, 11.44 ± 0.41 mm, 8.19 ± 0.60 mm, 9.78 ± 0.68 mm, respectively. The landmarks of the needle entry points are located at the position corresponding to the highest point of the metacarpal heads, except the tail finger. From the needle knife entry point to distal, cut the proximal edge of the A1 pulley longitudinally along the midline until the patient can flex autonomously, and pay attention to the distance between the two sides of 3.60-11.85 mm neurovascular bundle.

Ultrasound-guided percutaneous opening of the A1 pulley with surgical knife on anterograde versus retrograde approach: A comparative cadaver study (40 fingers)

OBJECTIVE

Trigger finger is one of the most common pathologies of the finger flexor mechanism. Previous studies have shown the value of ultrasound-guided percutaneous tenolysis. The aim of this study was to compare the efficacy and safety of anterograde versus retrograde percutaneous ultrasound-guided tenolysis.

MATERIALS AND METHODS

This was a comparative cadaver study performed between December 2021 and April 2022 in France, with 40 fresh cadaver fingers. Thumbs were excluded. A single surgeon performed 20 ultrasound-guided anterograde releases and 20 ultrasound-guided retrograde releases, using a second-generation minimally invasive surgical knife, and a multipurpose linear ultrasound transducer. The primary endpoint was the success of ultrasound-guided release, defined as complete opening of the A1 pulley along its entire length.

RESULTS

The success rate was 90% in the retrograde group and 95% in the anterograde group (non-significant difference: p = 0.56). There was no significant difference in superficial flexor tendon slip injuries or partial A2 pulley injuries. There were no neurovascular pedicle lesions.

CONCLUSION

The choice of anterograde or retrograde ultrasound-guided tenolysis should be left to the surgeon's discretion.

Is the Surface Anatomy of the Popliteal Crease Related to Lower Extremity Alignment or Knee Osseous Morphology? A Radiographic Study

Background and objectives: The popliteal crease varies among individuals, and there has been no prior study on this aspect. We assumed that it may be associated with lower extremity alignment and osseous morphology. To demonstrate this, we conducted a radiographic analysis. Materials and Methods: The study was conducted on 121 knees of 63 patients, whose popliteal creases were well distinguished on clinical photographs. PCOA was defined as the angle between the longitudinal axis of the lower leg and the popliteal crease. Through the radiologic examinations performed, the HKA, MPTA, mLDFA, JLCA, MFCA/TEA, and PCA/TEA were measured. Pearson correlation analysis and multiple linear regression analysis were performed on the PCOA and the six radiologic measurements to analyze the relationship. Results: Pearson correlation analysis found HKA had the highest coefficient at 0.568. In multiple linear regression, only HKA was associated, excluding all other measurements. Conclusions: Popliteal crease obliquity is significantly associated with coronal plane lower extremity alignment and exhibits a stronger correlation than with underlying knee osseous morphology. If future research is conducted based on this, popliteal crease could serve as a valuable clue for predicting lower extremity alignment and the risk of osteoarthritis development.

Identifying Palmar Skin Surface Landmark for Locating A2 Pulley during Cadaveric Dissection of the Hand

The A2 and A4 pulleys are fibro-osseous structures that support the flexor tendon function. Injury to these pulleys can result in bowstringing and limited tendon excursion. Thus, having an understanding of the skin surface landmark of the A2 pulley is crucial to safeguard it during hand surgery.

Methods

We performed cadaveric dissection of 62 hands. For 248 fingers, the measurement of distance A, which is half the distance between the palmar digital crease and proximal interphalangeal crease reflected in the palm, and distance B, which is the distance between the A2 pulley's starting point and the palmar digital crease, were taken by a caliber. Statistical analysis was performed using the paired sample t test to determine whether there was a significant difference between distances A and B.

Results

Our study revealed that there was no significant difference (p>0.05) between the measured starting point of the A2 pulley and its proposed surface landmark for the index, middle, and small fingers. Conversely, the ring finger showed a statistically significant difference of 1 mm more proximal.

Conclusions

By measuring the distance between the palmar digital crease and proximal interphalangeal crease and reflecting it proximally in the palms, one can anticipate the location of the A2 pulley's starting point for each digit, except for the ring finger. The ring finger's starting point is 1 mm more proximal than the other digits. Knowing the starting point of the A2 pulley will help hand surgeons limit incisions and avoid accidental injury during hand surgery.

Differential Pulley Release in Trigger Finger: A Prospective, Randomized Clinical Trial

BACKGROUND

The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release.

METHODS

This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded.

RESULTS

Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution.

CONCLUSIONS

These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone.

Single-Portal Antegrade Endoscopic Trigger Finger Release: Cadaveric and Clinical Outcomes

BACKGROUND

This study aimed to examine the relationship between anatomical surface landmarks in fresh frozen cadavers as related to in vivo endoscopic trigger finger release (ETFR) and present clinical outcomes after a single-portal antegrade ETFR technique.

METHODS

Endoscopic trigger finger release was performed on 40 cadaveric digits. Each digit was dissected and the following measurements were recorded: distance from palmar digital crease and A1 pulley, length of the A1 pulley, percentage of A1 pulley released, and injury to vulnerable anatomy. A retrospective chart review was performed on 48 patients (62 digits) treated with ETFR. Outcome measures included grip and pinch strength, range of motion, Disability of Arm, Shoulder, and Hand (DASH) questionnaires, and Visual Analog Scale (VAS) pain scores.

RESULTS

Release of the A1 pulley was achieved in 33 of the 40 cadaveric digits (83%) with an A2 pulley laceration rate of 25%. No flexor tendon or neurovascular injuries occurred. Gross grasp, lateral pinch, 3-jaw chuck, and precision pinch strength had 85%, 90%, 82%, and 90% recovery, respectively. At the final follow-up, average metacarpophalangeal joint, proximal interphalangeal joint, and distal interphalangeal joint range of motion were within the normal limits. Mean VAS scores decreased from 5.7 preoperatively to 1.0 postoperatively and mean DASH score at the final follow-up was 4.8.

CONCLUSIONS

With the use of anatomical surface landmarks, ETFR may be performed in an efficient and reproducible manner. Patients treated with ETFR had low complication rates, good functional recovery, and improved pain at short-term follow-up. Further study of long-term outcomes and cost-effectiveness of ETFR is warranted.

Sonographic Location of Distal A1 Pulley by Means of a Bony Acoustic Landmark on the Proximal Phalanx: An Anatomic Study

PURPOSE

To identify the anatomic relationship between the distal extent of the A1 pulley and the distalmost insertion point of the palmar plate into the base of the proximal phalanx at a metaphyseal bony ridge, the "P1 peak" (P1P), which is a bony acoustic landmark easily identifiable on sonography of the finger.

METHODS

We studied 48 fingers (no thumbs) from 12 fresh frozen cadavers with high-resolution ultrasound. A 20-gauge hypodermic needle was directed perpendicular to the long axis of the tendon sheath along a plumb line drawn at the level of the bony flare of the proximal metaphyseal-diaphyseal junction of the proximal phalanx, or the P1P, under high-resolution ultrasound guidance. Dissection was then performed, and the distance of the needle barrel and the actual distance of the P1P from the distal edge of the A1 pulley were recorded.

RESULTS

The study demonstrated that accurate placement of the needle within 1 mm of the actual P1P was possible using ultrasound guidance and that the P1P was within 1 mm of the distal edge of the actual A1 pulley in all specimens studied.

CONCLUSIONS

In all the specimens studied, we found that the P1P may be used as a clearly identifiable sonographic reference landmark to identify the distal extent of the A1 pulley.

CLINICAL RELEVANCE

Using the P1P landmark as a guide to judge the completeness of ultrasound-guided percutaneous trigger finger release may reduce the risks of incomplete distal release and inadvertent release of the A2 pulley.

Innervation of the lumbrical and interosseous muscles in hand: analysis of distribution of nerve fascicles and quantification of their surface projections

We aimed to determine the surface locations of the nerve fascicles that innervate the lumbricals and interossei, re-examine the branching pattern of the deep branch of the ulnar nerve (dUN), and provide a clear description of their course. Eleven fresh-frozen adult cadaver hands were investigated. Nerve fascicles that innervate the lumbricals, interossei, and surface landmarks including the distal wrist crease and 2-5 proximal finger creases were marked by radio opaque fibers and subjected to X-ray. We analyzed the images and set a quadrant-linked hand surface. Subsequently, we measured the lengths of both axes and the coordinates of the branch locations in the quadrant. The surface locations of branches that innervated the lumbricals and interossei were clearly quantified. The branches of dUN exhibited a 4-group distribution pattern. Novel methods for quantitatively locating the surface anatomy of these branches and demonstration of a 4-group branching pattern of the dUN were established.

Location and Extent of A1, A2 Release and Its Impact on Tendon Subluxation and Bowstringing-A Cadaveric Study

Surgical treatment of trigger finger involves release of A1 pulley. Some authors have theorized that the loss of A1 pulley can lead to ulnar subluxation of flexor tendons, which can be prevented by release of A1 pulley radially, even in a nonrheumatoid hand. However, there is no evidence in literature to either support or oppose this hypothesis. Occasionally, difficulty is encountered to precisely identify where A1 ends and A2 begins. While incomplete release of A1 can cause relapse of triggering, release of substantial A2 can cause bowstringing. Knowledge of the safe limit of concomitant A2 release is beneficial. The study was conducted in 12 cadaver upper extremity specimens. A1 pulleys of 48 fingers were divided at the radial (24 fingers) or ulnar (24 fingers) attachment. A 20lb traction force was applied on the flexor tendons. Any subluxation or bowstringing was noted. The experiment was repeated following serial release of the A2—initially 25%, followed by 50% and 100%. No bowstringing or subluxation was noted when A1 pulley was opened, either by radial or ulnar incision. The same was true for A1 + 25% A2 release. When A1 + 50% A2 pulley were released, bowstringing was observed in 3/48 fingers. When A1 + 100% of the A2 pulley were released, bowstringing occurred in all cases. The location of incision for release of the A1 pulley has no effect on bowstringing or tendon subluxation. Release of additional 25% of the A2 pulley can be performed safely, which corresponds to the level of palmar digital crease.

Comprehensive simulation on morphological and mechanical properties of trigger finger - A cadaveric model

Trigger finger has long been a common disorder in hand orthopedics. To clarify the unknown causative factors regarding the disease, numerous experiments were done on human cadavers, including tendon forces, tendon moment arm, mechanical properties of the pulley, gliding resistance, etc. However, most of these studies were conducted on normal fingers. As the etiology of trigger finger is still controversial on whether it is an outcome of tendon nodule or pulley scarring, in this study, a trigger finger model was built combining both the nodule created by silicone gel injection and pulley constriction by external compression. Indentation and gliding resistance tests were performed on cadaveric specimens to verify the model. Results showed that after silicone gel injection into the tendon, a significant increase in thickness was found. In addition, no significant difference was found in the toe region compressive modulus of the tendon after injection. Moreover, maximum, drop of gliding resistance and work of extension were all found to be significantly larger as the severity of triggering increased. Our results indicated we have developed a feasible cadaver model simulating trigger finger nodule which could be utilized for further experiments to elucidate other causative factors and biomechanical features of trigger finger in the future.

Identification of the location of the A1 pulley combining palpation technique with palm landmarks and percutaneous release of A1 pulley with a 19-gauge needle: A cadaveric study

The aims of this study were to identify the location of the A1 pulley combining palpation technique with superficial palm landmarks and to determine the efficacy and safety of A1 pulley percutaneous release with a 19-gauge needle. Fourteen fresh frozen cadaveric specimens were used: 56 fingers and 14 thumbs. The location of the A1 pulley was based on anatomical landmarks and was identified in all digits. Complete release of the A1 pulley occurred in 60 of the 70 digits (85.7%). The length of the A1 pulley in thumbs was 5.7 mm and in other fingers 4.5 mm. There were no signs of neurovascular bundle injuries. The mean distance between needle pathway and neurovascular bundle was 4.3 mm in the thumbs and 6.5 mm in the other fingers. There were no total flexor tendon injuries. The location of the A1 pulley can be predicted with success. Percutaneous release of the A1 pulley with a 19-gauge needle shows acceptable results in both safety and efficacy.

Surgery for trigger finger

BACKGROUND

Trigger finger is a common clinical disorder, characterised by pain and catching as the patient flexes and extends digits because of disproportion between the diameter of flexor tendons and the A1 pulley. The treatment approach may include non-surgical or surgical treatments. Currently there is no consensus about the best surgical treatment approach (open, percutaneous or endoscopic approaches).

OBJECTIVES

To evaluate the effectiveness and safety of different methods of surgical treatment for trigger finger (open, percutaneous or endoscopic approaches) in adults at any stage of the disease.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and LILACS up to August 2017.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed adults with trigger finger and compared any type of surgical treatment with each other or with any other non-surgical intervention. The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trial reports, extracted the data and assessed the risk of bias. Measures of treatment effect for dichotomous outcomes calculated risk ratios (RRs), and mean differences (MDs) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs). When possible, the data were pooled into meta-analysis using the random-effects model. GRADE was used to assess the quality of evidence for each outcome.

MAIN RESULTS

Fourteen trials were included, totalling 1260 participants, with 1361 trigger fingers. The age of participants included in the studies ranged from 16 to 88 years; and the majority of participants were women (approximately 70%). The average duration of symptoms ranged from three to 15 months, and the follow-up after the procedure ranged from eight weeks to 23 months.The studies reported nine types of comparisons: open surgery versus steroid injections (two studies); percutaneous surgery versus steroid injection (five studies); open surgery versus steroid injection plus ultrasound-guided hyaluronic acid injection (one study); percutaneous surgery plus steroid injection versus steroid injection (one study); percutaneous surgery versus open surgery (five studies); endoscopic surgery versus open surgery (one study); and three comparisons of types of incision for open surgery (transverse incision of the skin in the distal palmar crease, transverse incision of the skin about 2-3 mm distally from distal palmar crease, and longitudinal incision of the skin) (one study).Most studies had significant methodological flaws and were considered at high or unclear risk of selection bias, performance bias, detection bias and reporting bias. The primary comparison was open surgery versus steroid injections, because open surgery is the oldest and the most widely used treatment method and considered as standard surgery, whereas steroid injection is the least invasive control treatment method as reported in the studies in this review and is often used as first-line treatment in clinical practice.Compared with steroid injection, there was low-quality evidence that open surgery provides benefits with respect to less triggering recurrence, although it has the disadvantage of being more painful. Evidence was downgraded due to study design flaws and imprecision.Based on two trials (270 participants) from six up to 12 months, 50/130 (or 385 per 1000) individuals had recurrence of trigger finger in the steroid injection group compared with 8/140 (or 65 per 1000; range 35 to 127) in the open surgery group, RR 0.17 (95% CI 0.09 to 0.33), for an absolute risk difference that 29% fewer people had recurrence of symptoms with open surgery (60% fewer to 3% more individuals); relative change translates to improvement of 83% in the open surgery group (67% to 91% better).At one week, 9/49 (184 per 1000) people had pain on the palm of the hand in the steroid injection group compared with 38/56 (or 678 per 1000; ranging from 366 to 1000) in the open surgery group, RR 3.69 (95% CI 1.99 to 6.85), for an absolute risk difference that 49% more had pain with open surgery (33% to 66% more); relative change translates to worsening of 269% (585% to 99% worse) (one trial, 105 participants).Because of very low quality evidence from two trials we are uncertain whether open surgery improve resolution of trigger finger in the follow-up at six to 12 months, when compared with steroid injection (131/140 observed in the open surgery group compared with 80/130 in the control group; RR 1.48, 95% CI 0.79 to 2.76); evidence was downgraded due to study design flaws, inconsistency and imprecision. Low-quality evidence from two trials and few event rates (270 participants) from six up to 12 months of follow-up, we are uncertain whether open surgery increased the risk of adverse events (incidence of infection, tendon injury, flare, cutaneous discomfort and fat necrosis) (18/140 observed in the open surgery group compared with 17/130 in the control group; RR 1.02, 95% CI 0.57 to 1.84) and neurovascular injury (9/140 observed in the open surgery group compared with 4/130 in the control group; RR 2.17, 95% CI 0.7 to 6.77). Twelve participants (8 versus 4) did not complete the follow-up, and it was considered that they did not have a positive outcome in the data analysis. We are uncertain whether open surgery was more effective than steroid injection in improving hand function or participant satisfaction as studies did not report these outcomes.

AUTHORS' CONCLUSIONS

Low-quality evidence indicates that, compared with steroid injection, open surgical treatment in people with trigger finger, may result in a less recurrence rate from six up to 12 months following the treatment, although it increases the incidence of pain during the first follow-up week. We are uncertain about the effect of open surgery with regard to the resolution rate in follow-up at six to 12 months, compared with steroid injections, due high heterogeneity and few events occurred in the trials; we are uncertain too about the risk of adverse events and neurovascular injury because of a few events occurred in the studies. Hand function or participant satisfaction were not reported.

The Safety of Percutaneous Trigger Digit Release Increased by Neurovascular Displacement with Local Hydraulic Dilatation: An Anatomical and Clinical Study

Background

Although percutaneous trigger digit release is common, controversy exists regarding its safety. The purpose of this study was to evaluate the feasibility and safety of the neurovascular displacement by local hydraulic dilatation (LHD) during percutaneous trigger digit release.

Material/Methods

Ten cadaver hands with 50 digits were dissected in this anatomical study. The distance between bilateral neurovascular bundles in each digit was measured before LHD and after LHD. The difference between the measured data before LHD and those after LHD in the same digit was compared to assess the feasibility of the neurovascular displacement by LHD. A further 81 patients with 106 trigger digits were treated by percutaneous release with neurovascular displacement by LHD in our clinical series. All patients were followed for 12 months. During the follow-up period, the presence of any postoperative complication and patient satisfaction were recorded.

Results

In our anatomical study, there was a statistically significant difference (p<0.05) comparing the average distance of bilateral neurovascular bundles before LHD with that after LHD. In the current series, no complications, such as digital neurovascular injury or recurrence of trigger, were encountered. On subjective assessment, 80/81 patients (98.8%) with 105/106 digits (99.1%) were graded as satisfactory with complete resolution of symptoms by percutaneous release under LHD.

Conclusions

Based on our study anatomical and clinical results, the neurovascular displacement by LHD may be a feasible adjunctive technique that may play a role in increasing the safety of percutaneous trigger digit release.

The Relationship Between the Intercrease Line and the A1 Digital Pulley: A Cadaveric Study

BACKGROUND

Accurate identification of surface anatomy is critical to identify the location of the A1 pulley. The intercrease line (ICL) describes a transverse line between the radial edge of the proximal palmar crease and the ulnar edge of the distal palmar crease. We hypothesize that this easily identifiable surface landmark approximates the location of the A1 pulley.

METHODS

The ICL was marked on 7 cadaver hands. We marked a point proximal to the proximal digital crease (PDC) equal to the distance between each digit's proximal interphalangeal crease (PIC) and PDC (the PIC/PDC point). We calculated the distance between PIC/PDC points and proximal edge of the A1 pulleys.

RESULTS

The ICL was proximal to A1 in all digits. The PIC/PDC point was distal to A1 in the ring finger, and proximal to A1 in the index, middle, and small fingers. The PIC/PDC point was closer to the A1 pulley than the ICL in the middle and ring fingers.

CONCLUSIONS

Despite less accuracy than the PIC/PDC point at approximating the location of the A1 pulley, the ICL is reliably proximal to the A1 pulley.

Short-term Versus Long-term Outcomes After Open or Percutaneous Release for Trigger Thumb

Good outcomes have been reported after both open and percutaneous surgery to release trigger thumb. This study evaluated short-term and long-term outcomes after treatment of trigger thumb with open or percutaneous release. A total of 126 trigger thumbs in 107 patients were reviewed from 2009 to 2012. Short-term (3 months) and long-term results (2 years) and complications of open release (58 digits) and percutaneous release (68 digits) were recorded and compared. Short-term complications included pain occurring in 9 digits (15.5%) in the open release group and in 2 digits (2.9%) in the percutaneous release group and scarring in 4 digits (6.9%) only in the open release group. Long-term complications included pain in 13 digits (19.1%) in the percutaneous release group and in 4 digits (6.9%) in the open release group; in addition, recurrent triggering occurred in 6 digits (8.8%) in the percutaneous release group and in 2 digits (3.4%) in the open release group. Pain and patient satisfaction were significantly better in the percutaneous release group in the short term, but they were better in the open release group in the long term. Although percutaneous release for trigger thumb is a safe and quick procedure, with good short-term outcomes, open release may provide better long-term outcomes. [Orthopedics. 2017; 40(1):e131-e135.].

Evaluation of Percutaneous First Annular Pulley Release: Efficacy and Complications in a Perfused Cadaveric Study

PURPOSE

Trigger finger is the most common entrapment tendinopathy, with a lifetime risk of 2% to 3%. Open surgical release of the flexor tendon sheath is a commonly performed procedure associated with a high rate of success. Despite reported success rates of over 94%, percutaneous trigger finger release (PFTR) remains a controversial procedure because of the risk of iatrogenic digital neurovascular injury. This study aimed to evaluate the safety and efficacy of traditional percutaneous and ultrasound (US)-guided first annular (A1) pulley releases performed on a perfused cadaveric model.

METHODS

First annular pulley releases were performed percutaneously using an 18-gauge needle in 155 digits (124 fingers and 31 thumbs) of un-embalmed cadavers with restored perfusion. A total of 45 digits were completed with US guidance and 110 digits were completed without it. Each digit was dissected and assessed regarding the amount of release as well as neurovascular, flexor tendon, and A2 pulley injury.

RESULTS

Overall, 114 A1 pulleys were completely released (74%). There were 38 partial releases (24%) and 3 complete misses (2%). No significant flexor tendon injury was seen. Longitudinal scoring of the flexor tendon was found in 35 fingers (23%). There were no lacerations to digital nerves and one ulnar digital artery was partially lacerated (1%) in a middle finger with a partial flexion contracture that prevented appropriate hyperextension. The ultrasound-assisted and blind PTFR techniques had similar complete pulley release and injury rates.

CONCLUSIONS

Both traditional and US-assisted percutaneous release of the A1 pulley can be performed for all fingers. Perfusion of cadaver digits enhances surgical simulation and evaluation of PTFR beyond those of previous cadaveric studies. The addition of vascular flow to the digits during percutaneous release allows for Doppler flow assessment of the neurovascular bundle and evaluation of vascular injury.

CLINICAL RELEVANCE

Our cadaveric data align with those of published clinical investigations for percutaneous A1 pulley release.

Ultrasound-Guided Interventional Procedures of the Wrist and Hand: Anatomy, Indications, and Techniques

Acute and chronic wrist and hand conditions are commonly seen by neuromuscular and musculoskeletal specialists. High-frequency diagnostic ultrasonography (US) has facilitated advances in the diagnosis and interventional management of wrist and hand disorders. US provides excellent soft tissue resolution, accessibility, portability, lack of ionizing radiation, and the ability to dynamically assess disorders and precisely guide interventional procedures. This article review the relevant anatomy, indications, and interventional techniques for common disorders of the wrist and hand, including radiocarpal joint arthritis, scaphotrapeziotrapezoidal joint arthritis, trapeziometacarpal joint arthritis, phalangeal joint arthritis, first dorsal compartment tenosynovitis, ganglion cysts, and stenosing tenosynovitis.

Percutaneous Trigger Release in Non-Triggering Digits: Infiltration of Normal Saline into Tendon Substance to Induce Triggering

Percutaneous trigger release is recognized as an effective minimally invasive procedure with a low complication rate. One prerequisite for percutaneous trigger release is a trigger of Quinnell Type II or higher; that is, a digit that is actively triggering. We describe an additional step in percutaneous trigger release, which enables the surgeon to perform the procedure in digits that are not actively triggering at the point of surgery. This step involves the infiltration of normal saline into the tendon substance distal to the A1 pulley in order to induce triggering.

Development of a three-dimensional hand model using 3D stereophotogrammetry: Evaluation of landmark reproducibility

BACKGROUND

Using three-dimensional (3D) photography, exact images of the human body can be produced. Over the last few years, this technique is mainly being developed in the field of maxillofacial reconstructive surgery, creating fusion images with computed tomography (CT) data for accurate planning and prediction of treatment outcome. However, in hand surgery, 3D photography is not yet being used in clinical settings.

METHODS

The aim of this study was to develop a valid method for imaging the hand using 3D stereophotogrammetry. The reproducibility of 30 soft tissue landmarks was determined using 3D stereophotogrammetric images. Analysis was performed by two observers on 20 3D photographs. Reproducibility and reliability of the landmark identification were determined using statistical analysis.

RESULTS

The intra- and interobserver reproducibility of the landmarks were high. This study showed a high reliability coefficient for intraobserver (1.00) and interobserver reliability (0.99). Identification of the landmarks on the palmar aspect of individual fingers was more precise than the identification of landmarks of the thumb.

CONCLUSIONS

This study shows that 3D photography can safely produce accurate and reproducible images of the hand, which makes the technique a reliable method for soft tissue analysis. 3D images can be a helpful tool in pre- and postoperative evaluation of reconstructive trauma surgery, in aesthetic surgery of the hand, and for educational purposes. The use in everyday practice of hand surgery and the concept of fusing 3D photography images with radiologic images of the interior hand structures needs to be further explored.

A study of 60 patients with percutaneous trigger finger releases: clinical and ultrasonographic findings

We present the clinical results and ultrasonographic findings of 61 trigger digits treated with percutaneous A1 pulley release. An endoscopic carpal tunnel knife was used for the release in the outpatient department. The mean follow-up period was 3.5 months. A total of 55 digits (90%) had complete relief of their triggering postoperatively. Six digits (10%) had Grade 2 triggering clinically in the early postoperative period.The complications included six cases of insufficient release (10%), scar sensitivity in one patient, short-term hypoaesthesia in three digits (5%), and flexor tendon laceration noted on postoperative ultrasonography in eight digits (13%). No neurovascular damage was noted on the postoperative ultrasonography. Ultrasonograpy provides information about tendon laceration and changes in thickness of the pulleys and confirm A1 pulley release after surgery, but it does not alter clinical decision-making. We believe that pre- and postoperative ultrasonograpy does not need to be included as a routine examination.

Hand surface landmarks and measurements in the treatment of trigger thumb

PURPOSE

To determine hand surface landmarks and measurements that may be useful in localizing the A1 pulley and digital neurovascular structures in the treatment of trigger thumb.

METHODS

We highlighted 4 surface landmarks in 20 adult cadaveric hands: the radial border of the index finger, the ulnar border of the thumb, the thumb interphalangeal joint flexion creases, and the thumb metacarpophalangeal joint creases. We injected the radial arteries with red latex and dissected the thumbs.

RESULTS

The proximal margin of the A1 pulley was located an average of 0.3 mm proximal (range, 3.2 mm proximal to 2.3 mm distal) to the most proximal metacarpophalangeal joint flexion crease. The ratio of measurements from the thumb tip to the midpoint of the interphalangeal joint flexion creases and from this point to the proximal margin of the A1 pulley averaged 1.1:1. The radial digital nerve crossed obliquely over the flexor pollicis longus tendon and approached the proximal margin of the A1 pulley at a mean distance of 2.7 mm (range, 0-12.9 mm). The ulnar digital nerve was located deep to intersecting lines drawn along the radial border of the index finger and the ulnar border of the thumb and coursed parallel to the A1 pulley at a mean distance of 5.4 mm (range, 0-11.1 mm). At the level of the A1 pulley, the digital arteries were positioned dorsal to the digital nerves, and both nerves were located 1.0 to 4.2 mm from the skin surface.

CONCLUSIONS

The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures.

CLINICAL RELEVANCE

Awareness of topographical landmarks in localizing the A1 pulley and digital neurovascular structures and the relationships between the digital neurovascular structures and the A1 pulley may improve the safety and efficacy of trigger thumb treatment.

The little finger ulnar palmar digital artery perforator flap: anatomical basis

PURPOSE

The aim of this study was to explore the cutaneous vascularization of the hypothenar region and investigate the anatomical basis for perforator propeller flaps for coverage of the flexor aspect of the little finger.

METHODS

The area between the pisiform and the base of the little finger was studied in 14 hands of fresh cadavers injected with red latex. An oval flap 1.5 cm large was raised along the axis between these two points. Perforators going into the flap were dissected up to their origin from the ulnar palmar digital artery of the little finger, and their distance from the proximal edge of the A1 pulley was recorded.

RESULTS

The mean number of perforator arteries entering the flap was 5.8 (range 4-8). A constant sizeable perforator was identified within 0.7 cm from the proximal margin of the A1 pulley in all 14 specimens. In the majority of cases (64 %), the most distal perforator was located at this level. Dissection of the flap was carried out suprafascially on the most distal perforator and 180° rotation allowed the flap to reach the flexor surface of the fifth finger. The donor site was closed primarily.

CONCLUSION

Distal perforators of the ulnar palmar digital artery of the little finger are constantly found. Our anatomical findings support the possibility of raising a propeller perforator flap from the hypothenar region for coverage of the flexor aspect of the little finger. Its clinical application could provide a quick and straightforward single-stage option with a negligible donor-site morbidity for reconstruction of such defects.

Percutaneous release of the A1 pulley: a cadaver study

PURPOSE

Percutaneous release of the A1 pulley has been used for treatment of trigger fingers with success. However, lack of direct visualization raises concerns about the completeness of the release and about potential injury to the tendons or neurovascular structures. The purpose of this study was to assess the efficacy and safety of percutaneous release of the A1 pulley in a cadaveric model using a commonly available instrument, a #15 scalpel blade.

METHODS

Fourteen fresh frozen cadaveric hands (54 fingers, thumbs excluded) were used. Landmarks were established for the A1 pulley based upon cutaneous features. Percutaneous release was performed using a #15 blade. The specimens were then dissected and examined for any tendon or neurovascular injury, and completeness of A1 pulley release was evaluated.

RESULTS

There were 39 (72%) complete releases of the A1 pulley with 14 partial and 1 missed (failed) release. There was a 22% incidence of release of the proximal edge of the A2 pulley. However, there was no case of release of more than 25% of the A2 pulley length, nor was bowstringing of flexor tendons seen in these specimens. Eleven digits showed longitudinal scoring of the flexor tendons and 3 had partial tendon lacerations. No neurovascular injuries were noted.

CONCLUSIONS

Percutaneous release of the A1 pulley using a #15 blade was associated with good efficacy and an acceptable margin of safety in this series.

CLINICAL RELEVANCE

Percutaneous release of trigger digits may assume a greater role in the treatment of patients with trigger finger because of cost containment pressures. The data from this study suggest that the technique used in this study is both safe and effective. With use of proper anatomical guidelines, risk to neurovascular structures is low, although longitudinal scoring of the tendon can occur.

Steroid injection versus NSAID injection for trigger finger: a comparative study of early outcomes

PURPOSE

Stenosing tenosynovitis of the flexor tendon sheath of the digits of the hand results from a discrepancy between the diameter of the flexor tendon and its sheath at the A1 pulley. The treatment options for trigger digits include oral nonsteroidal anti-inflammatory drugs (NSAIDs) and local NSAID applications, splintage, steroid injection, and percutaneous and open release of the A1 pulley. Injectable NSAID is used intramuscularly and locally in other sites. The hypothesis is that an injectable NSAID is as effective as the traditionally used steroid injection in the treatment of trigger digit, based on Quinnell grading, and that the treatment works as well in patients with diabetes as in those without diabetes.

METHODS

In this prospective, randomized, double-blinded controlled study for trigger digits, we injected diclofenac sodium locally in one group (NSAID group) and triamcinolone acetonide in another (corticosteroid group). A total of 100 patients (50 patients in each group) were followed up and assessed 3 weeks and 3 months after the injection.

RESULTS

At the end of the follow-up, 35 patients (70%) in the corticosteroid group and 28 patients (53%) in the NSAID group had complete symptomatic resolution. There was no difference between the response of patients with and without diabetes. There was no significant difference found in Quinnell score between treatments at 3 months, although at 3 weeks, the patients who received steroid had significantly better Quinnell scores.

CONCLUSIONS

We concluded that, although steroids gave quicker relief, NSAID injections are equally effective at 3 months in the treatment of trigger digits. We were unable to detect a statistically significant difference in the response of patients with and without diabetes to either treatment.

Surface markers for locating the pulleys and flexor tendon anatomy in the palm and fingers with reference to minimally invasive incisions

PURPOSE

Palm and finger pulley anatomy has been well described in relation to osseous structures. The goal of this study was to describe skin surface markers that locate the underlying flexor tendon and pulley system. We describe the anatomic detail of these structures and provide a guide for the surgeon for making small incisions. Using this approach, extensile exposure can be avoided, and the integrity of the complex pulley system is maintained.

METHODS

We dissected 12 palms and 48 fingers in 12 cadaver hands. We marked the palm and finger creases with methylene blue before dissection. We removed palm skin, finger skin, and subcutaneous tissue over the flexor tendon sheath and retained a 2-mm strip of each skin crease in its native position. We divided the palm and palmar surface of the fingers into 4 distinct zones and measured the location of the proximal and distal extent of each pulley and the tendon anatomy relative to the proximal and distal skin crease.

RESULTS

We documented the location of the proximal and distal extent of the annular and cruciate pulleys as well as the decussation of the flexor digitorum superficialis (FDS) tendon and Camper chiasm. The results allow us to establish a relationship between the skin creases and underlying anatomy by dividing the palm and finger into 4 zones. In zone A, in the palm, the A2 pulley is located in the distal third and the FDS decussation is at the proximal extent of the A2 pulley. Zone B is in the proximal phalanx and A2 lies in the proximal third of this zone, whereas the Camper chiasm lies in the middle third. Zone C is in the middle phalanx and A4 and the insertion of FDS lie in the middle third of this zone. Zone D lies in the distal phalanx and the flexor digitorum profundus tendon inserts into the middle third of this zone.

CONCLUSIONS

Skin creases can be used as surface markers to accurately locate the underlying pulley and tendon system and plan for limited incisions.

CLINICAL RELEVANCE

These anatomic descriptions can aid surgeons in preoperative planning and may also help minimize the required exposure for flexor tendon repair and other surgery in the fingers and palm.

Transverse anatomic landmarks for the A1 pulley of the thumb

BACKGROUND

Triggering of the thumb is a common entity resulting in pain and disability. Operative management requires accurate knowledge of the pulley system for proper release of the A1 pulley. The purpose of this study was to predict the location of the A1 pulley with surface anatomic landmarks while avoiding injury to the neurovascular bundles and the critical oblique pulley.

METHODS

Thirteen fresh cadaveric thumbs were dissected while the volar digital creases of the thumb served as our potential anatomic landmarks for the A1 pulley. These included the distal crease and the two identifiable proximal creases. Measurements from the proximal edge of the A1 pulley to the surface landmarks were obtained. The pulley system was also inspected for variability, and the length of the A1 pulley was measured.

RESULTS

Of the three volar creases in the thumb, the proximal-proximal crease (PPC) corresponded anatomically to the A1 pulley and demonstrated minimal variability compared to the other landmarks. It measured 0.10 ± 0.15 cm distal to the proximal edge of the A1 pulley. The average length of the thumb A1 pulley measured 0.61 ± 0.17 cm. Therefore, the distal edge of the A1 pulley is predicted to be located 0.51 cm distal to the PPC.

CONCLUSIONS

Hand surface landmarks can be used reliably to predict the location of the thumb A1 pulley, thus avoiding injury to adjacent structures such as the critical oblique pulley.

TRANSDERMAL ANAESTHESIA FOR PERCUTANEOUS TRIGGER FINGER RELEASE

The purpose of this study was to evaluate the safety and efficiency of transdermal anaesthesia using eutectic mixture of lidocaine and prilocaine (EMLA) in patients undergoing percutaneous trigger finger release and to compare it with lidocaine infiltration.

In this prospective, randomised study percutaneous release of the A1 annular pulley was performed to treat stenosing tenosynovitis (trigger finger syndrome) in 50 patients (50 fingers). The procedure was performed either under transdermal anaesthesia using EMLA applied transcutaneously 120 minutes prior to the operation (Group A, n = 25) or using local infiltration anaesthesia using lidocaine (Group B, n = 25). Pain experienced during administration of anaesthesia and during the operation was assessed using a 10-point Visual Analogue Pain Scale (VAPS), while all patients rated the effectiveness of anaesthesia with a 5-point scale.

There were no significant differences between the two groups in the VAPS during the operation (1.33 ± 0.52 versus 1.59 ± 0.87) and the satisfaction scores (4.6 ± 0.2 versus 4.4 ± 0.3). The VAPS score during the administration of anaesthesia was statistically significantly less in the EMLA group (0 versus 5.96 ± 2.41). All patients were satisfied with the final result of the operation.

Percutaneous trigger finger release can be performed as an office procedure with the use of EMLA avoiding the use of injectable local infiltration anaesthesia.

Anatomical study of the A1 pulley: length and location by means of cutaneous landmarks on the palmar surface

PURPOSE

The objectives of this study were to evaluate palmar surface parameters to identify the exact location of the proximal edge of the flexor tendon A1 pulley relative to the digital palmar crease of the index, middle, ring, and little fingers and to evaluate the length of this pulley.

METHODS

We studied 280 fingers on 70 hands from 35 fresh human cadavers, initially by measuring the distance between the digital-palmar and proximal interphalangeal creases (measure A), followed by dissection of the fingers and measurement of the distance between the proximal edge of the A1 pulley and the digital-palmar crease (measure B) and the length of the A1 pulley (measure C). We carried out statistical analysis using Hotelling's multivariate T(2)-test and the paired-samples t-test.

RESULTS

We found no statistically significant difference between measures A and B in each finger (p > .05). The mean lengths, in tenths of millimeters, were as follows: measure A: index finger 22.0 mm, middle finger 24.4 mm, ring finger 22.0 mm, and little finger 17.9 mm; measure B: index finger 21.9 mm, middle finger 24.2 mm, ring finger 22.3 mm, and little finger 18.1 mm. The average lengths of the A1 pulley were: index finger 9.8 mm, middle finger 10.7 mm, ring finger 9.6 mm, and little finger 8.1 mm.

CONCLUSIONS

The distance between the digital-palmar and proximal interphalangeal creases may be used as a cutaneous landmark on the palmar surface for the exact location of the proximal edge of the A1 pulley in the palm of the hand, thereby ensuring greater safety in surgical procedures such as percutaneous release of trigger finger.

Liberação percutânea do dedo em gatilho com micro bisturi oftalmológico vitreorretiniano de lâmina 19

OBJETIVO: Desenvolver uma nova técnica de liberação percutânea do dedo em gatilho, usando microbisturi oftalmológico vitreorretiniano (MVR) de lâmina 19. MÉTODO: O tratamento conservador do dedo em gatilho inclui, com frequência, injeção local de esteroide. Esse método apresenta alta taxa de falha, sendo necessárias injeções repetitivas. Quando o tratamento conservador falha, recomenda-se a liberação a céu aberto da polia A1. Foram relatados vários métodos que empregam diversos instrumentos. Usamos um microbisturi oftalmológico vitreorretiniano (MVR, de microvitreoretinal blade) de lâmina 19 na liberação percutânea do dedo em gatilho. RESULTADOS: Liberamos 50 dedos em gatilho por via percutânea com essa lâmina. CONCLUSÃO: Foram obtidos resultados satisfatórios em 45 deles (90%). Nivel de Evidência VI, série de casos.

Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique

OBJECTIVE

The purpose of this study was to define in volunteers a safe area for performing a percutaneous intrasheath first annular (A1) pulley release under ultrasonographic guidance in cadavers for the treatment of trigger fingers.

METHODS

First, in 100 fingers of 10 volunteers, we used Doppler ultrasonography to determine the limits of the sectors enclosing structures at risk (arteries and tendons). From the synovial sheath's most volar point, we determined the relative position of the arterial walls and the distance to the flexor tendons. A scatterplot overlay of the arterial positions was digitally analyzed for determining the limits of the safe area. Second, we released the A1 pulley in 46 fingers from 5 cadavers, directing the edge of the cutting device toward our safe area from an intrasheath instrument position. The precision, safety, and efficacy of the release were evaluated by surgical exposure of the A1 and A2 pulleys and the neurovascular bundles.

RESULTS

In our volunteers, we observed a volar safe area from +6.1° to +180°. Surgical precision was good in the cadavers, with no injuries to adjacent structures, a complete release in 44 fingers (95.7%), and an incomplete release of less than 1.6 mm in 2 fingers.

CONCLUSIONS

This study determined a safe volar area for aiming surgical instruments from an intrasheath position for percutaneous ultrasonographically guided A1 pulley release. The technique can be performed safely in all fingers, but we suggest being cautious in the thumb and converting the surgery to an open procedure if ultrasonographic visualization is not optimal.

Sonographically guided percutaneous first annular pulley release: cadaveric safety study of needle and knife techniques

OBJECTIVE

The purpose of this study was to assess the safety of sonographically guided percutaneous finger and thumb first annular (A1) pulley releases performed using needle and hook knife techniques in an unembalmed cadaveric model.

METHODS

A single operator completed 50 (40 fingers and 10 thumbs) sonographically guided percutaneous A1 pulley releases in unembalmed cadavers using previously described needle and hook knife techniques and simulated local anesthesia. Half of the fingers and thumbs were completed with each technique. An experienced observer blinded to the technique dissected each specimen and assessed for neurovascular, flexor tendon, and A2 pulley injury. Completeness of release was also recorded as a secondary outcome.

RESULTS

No neurovascular or A2 pulley injury occurred in any digit, regardless of technique. No significant flexor tendon injury was seen in any digit, although minor surface scratches were visualized in 3 cases (6%; 2 knife and 1 needle). The hook knife technique was significantly more likely to result in a complete pulley release compared to the needle technique (22 of 25 [88%] versus 8 of 25 [32%]; P < .001).

CONCLUSIONS

Sonographically guided percutaneous A1 pulley releases can be performed safely using previously described needle and hook knife techniques. The safety margin for thumb releases is less than that for finger releases, particularly with respect to the radial digital nerve. These cadaveric data support recently published clinical investigations recommending consideration of sonographically guided percutaneous A1 pulley release in the management of patients with a disabling trigger finger.

Anatomic outcome of percutaneous release among patients with trigger finger

PURPOSE

To investigate the adequacy and safety of percutaneous trigger finger release on symptomatic patients.

METHODS

Two orthopedic non-hand surgeons performed percutaneous A1 pulley release on the thumb, index, middle, and ring fingers with the use of a 19-gauge needle in 25 fingers of 24 patients. Open inspection was then performed to determine the extent of release and any injury to the surrounding anatomic structures.

RESULTS

Triggering was eliminated in all fingers. Of the 25 A1 pulleys, 19 were partially released; only 6 were completely released. Noted injury included only superficial abrasions in 15 tendons. None of the patients had injury to the digital artery or nerve.

CONCLUSIONS

In the percutaneous release of trigger fingers, complete anatomic release of the A1 pulley is not always adequately achieved, even though clinically patients experience relief of triggering. It is a safe procedure for the thumb, index, middle, and ring fingers as long as the recommended technique is observed.

Ultrasound-guided first annular pulley injection for trigger finger

OBJECTIVE

The purpose of this study was to develop an ultrasound-guided first annular (A1) pulley injection technique for trigger finger with documentation of outcomes at 1 year.

METHODS

We performed a short-axis injection into a triangle bordered by the A1 pulley, the flexor digitorum superficialis and profundus tendons and volar plate, and the distal metacarpal bone with a 10-mg median dose of triamcinolone acetonide and 2% lidocaine. This was a prospective study of 50 of 52 consecutive trigger fingers from 24 patients recruited from a physical medicine and rehabilitation private practice.

RESULTS

All patients were available for follow-up, with 94% (47 of 50) of fingers having complete resolution of symptoms at 6 months, 90% (37 of 41) at 1 year, 65% (17 of 26) at 18 months, and 71% (12 of 17) at 3 years after a single injection.

CONCLUSIONS

Our ultrasound-guided A1 pulley injection technique is a highly effective and minimally invasive treatment option for trigger finger with a 90% success rate at 1 year for complete resolution of symptoms after a single injection. Assuming similar patient populations, our results were statistically significant (P < .01) compared with the 56% to 57% success rates recently reported for blind injections.

Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial

A prospective randomized trial for release of the first annular pulley (A-1 pulley) in trigger fingers with a percutaneous technique versus the open surgical technique is presented. Thirty-six patients were randomized to either open (n = 16) or percutaneous (#15 blade; n = 20) release of the A-1 pulley. All patients were evaluated for grip strength, active range of motion of the proximal interphalangeal joint, and residual pain at 1 and 12 weeks after release. Furthermore, the operation time was assessed, and the costs were calculated. Overall, 100% success in terms of grip strength, active range of motion of the proximal interphalangeal joint, and residual pain was obtained in both groups. Mean operation time was significantly longer with the open technique. Because of lower costs and quicker procedure with equal functional outcome when compared with open surgery, we recommend the percutaneous technique using a #15 blade for trigger finger release.

Study to outline the efficacy and illustrate techniques for steroid injection for trigger finger and thumb

AIM

To outline the efficacy of a steroid injection in treating trigger finger. Our study defines the anatomy of the A1 pulley, and suggests methods for simple and safe flexor sheath injection for trigger finger and thumb.

METHOD

Systematic review of published literature on trigger finger and thumb and its treatment, particularly steroid injection. The use of the knowledge of the superficial landmarks of the A1 pulley with the techniques described were combined to provide a comprehensive guide to injecting steroids in patients with trigger finger and thumb.

RESULTS

Several studies are outlined, which provided evidence to suggest that a steroid injection into the flexor sheath of the affected digit is successful in treating most of the patients. Methods of identifying the superficial landmarks of the A1 pulley and of approaching the pulley without injury to surrounding structures are also outlined in the literature. Two different techniques used to infiltrate the flexor sheath were described.

CONCLUSION

Steroid injection in the flexor sheath at the level of the A1 pulley is an effective method of treating patients with trigger finger and should be considered as the preferred treatment. Specific anatomical landmarks and methods allow the procedure to be carried out without fear of inadvertent damage to surrounding structures.

Percutaneous trigger finger release: the 'lift-cut' technique

One hundred and eighty patients with 240 trigger digits were treated by percutaneous release using a 'lift-cut' technique. All patients were reviewed at 3 months following release. Overall, 94% achieved an excellent or good result. Ten patients experienced recurrent symptoms and required a subsequent open release. There was no clinical evidence of digital nerve or flexor tendon injury. We recommend this technique as a safe and effective outpatient procedure.