Hand CASE 15
CASE 15
A 54-year-old female comes to your office with a chief complaint of a painful left palm. When further questioned, she mentioned that she has difficulty moving her
finger first thing in the morning and occasionally finds that the finger catches, and she has difficulty opening the palm. Review of systems is negative and the patient reports that she is in otherwise good health. This has been going on the past 6 to 8 weeks.
The mostly likely diagnosis is:
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Osteoarthritis of PIP and DIP
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Trigger finger
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Carpal tunnel syndrome
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Work-related pain in the left hand
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None of the above
Discussion
The correct answer is (B). Trigger fingers are commonly seen in patients over the age of 35 to 40 years. There is no data to show that it is related to hand dominance. However, the ring finger appears to be the most commonly affected. Symptoms can vary, and trigger fingers have been classified into different types. Some patients present with difficulty with flexion, whereas others may present with classic triggering where the finger gets stuck in the bent position and the patient has to straighten it. Morning stiffness is a common form of presentation.
The patient tells you that while this does not affect her functional activity she finds it to be painful in the mornings. However, she is not interested in having any kind of invasive intervention.
The choice of treatment that you could offer her at this point in time would include which of the following?
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Periodic observation
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Splinting
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Local steroid injection
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Percutaneous ultrasound guided release of the A1 pulley
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Open release of A1 pulley
Discussion
The correct answer is either (A) or (B). This patient does not appear to have any functional issues and finds this to be more of a nuisance and uncomfortable first thing in the morning. She is also not interested in having invasive intervention. Therefore, options which include a steroid injection or release of the A1 pulley be it
percutaneous or open are incorrect responses to this question. Since the patient has minimal functional issues, periodic observation in this situation is entirely reasonable. On the other hand, if the patient is willing to try a splint, there is some data to show that splinting in patients such as this can be effective up to 50% of the time. In most instances, the patients are asked to wear a splint at night. However, if their occupation allows it, wearing a splint over a few weeks for most of the day is also known to have some degree of success.
The patient returns 3 months later and now has pronounced triggering with the patient being able to demonstrate full composite fist in the office but, when trying to open the fingers, the ring finger remains stuck in the bent position. It requires considerable effort to straighten it and is accompanied by severe pain.
The most appropriate form of treatment at this point in time would be which of the following?
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Percutaneous release of the A1 pulley
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Ultrasound guided release of the A1 pulley
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Open release of the A1 pulley
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Steroid injection at the level of the A1 pulley
Discussion
The correct answer is (D). In patients who are willing to accept a steroid injection it is certainly reasonable to inject the vicinity of the A1 pulley with steroid. Data suggests that there is no superiority of any one steroid preparation over the other. Numerous methods of steroid instillation have been described. However, none of these methods have been shown to be superior to the other. Simple instillation of the steroid preparation at the level of the A1 pulley is successful in over 75% of the patients. However, the duration of symptom relief is unpredictable. The patient should be cautioned about the possibility of increasing pain for the first day or two after steroid instillation. They should also be informed about the pharmacokinetics of mechanism of action. Most patients notice gradual relief of symptoms over a period of a few weeks. It is now accepted that recurrence of symptoms despite two successful attempts at steroid instillation are best treated by surgical release of the A1 pulley, which has a lasting relief from symptoms of triggering.
Objectives: Did you learn...?
Describe the clinical presentation of trigger finger?
Perform Nonoperative management in trigger finger? Select invasive treatment options?