Trigger Finger Release
When the flexor tendons of the hand thicken or become inflamed, stenosing flexor tenosynovitis of the hand (also known as trigger finger) develops. Dr. Asif Ilyas demonstrates on a cadaver how to perform the most standard trigger finger release, releasing the A1 pulley and then decompressing or releasing the flexor tendon.
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My name is Asif Ilyas. I'm a professor of orthopedic surgery and the program director of hand surgery at the Rothman Institute at Thomas Jefferson University in Philadelphia. Today we're going to be doing a trigger finger release surgery. Trigger fingers - also more technically known as stenosing flexor tenosynovitis of the hand - is a very common condition where patients develop painful triggering of the fingers. It's a product of thickening and/or inflammation of the flexor tendon as it travels through the pulley system of the hand. There's a number of ways to perform this surgery, and I'll be using the most standard technique, which is a standard open approach to the trigger digit where we release the A1 pulley and subsequently decompress or release the flexor tendon. During the procedure, I'll go through some of the tips and tricks and some of the nuances and also some advantages and disadvantages of doing this surgery either awake or asleep relative to your patient.
So we'll be doing a trigger finger release procedure. Now, the A1 pulley is what we're releasing, and they're typically more proximal than people often realize. And the way you tell is you can flex up your fingers, and you'll see what is called the distal palmar crease right there. And at that crease is where the A1 pulleys lie; they're not here, and they're not there. It's really more kind of midsection - right where the fingers bend. You can often feel them in a - in a very symptomatic trigger digit, or again, stenosing flexor tenosynovitis. You'll see swelling in the area. So there's a number of ways to - to place these incisions. You can place the longitudinal incision directly over top of it like so. Some will advocated for trying to find a - a standard palmar crease like here and trying to blend the incision into the crease. That's perfectly reasonable as well. And some will say place it more proximally over that distal palmar crease. All those techniques are perfectly appropriate. I tend to place them directly over the sheath to give me maximum exposure as placing them in some of the different creases can sometimes move you away from where you want to get - where you - where you need to get to in terms of the A1 pulley.
Incision is a standard incision, directly over top. I generally perform these surgeries under just a local anesthetic; I do not anesthetize my patients for this. I do that for two reasons. One is I don't think it's necessary to put a patient through anesthesia or sedation for this procedure; it's a very simple procedure - a local injection of a local anesthetic, and I use 1% lidocaine with epinephrine along with 1 cc of bicarb. And what that bicarb does is really buffer the acidity of the lidocaine, making it much more tolerant - tolerable - and does - you don't get that burning sensation that you often will get otherwise. And also probably the most important reason why I want my patients awake for this procedure is I want to be able to test them when I'm done to confirm that we have successfully released their trigger digit.
Once exposed, the A1 pulley is released, and it releases longitudinally to the axis of the flexor tendon. The question that often comes up, how far to take the release, and I would recommend taking it to at least the level of the A2 pulley if not including some of the A2 pulley. I use the rule of thumb to get to approximately the base of the finger. That often takes me into the A2 pulley area. Now, when in doubt, my patients aren't asleep, so once I do my release, I'll just have them move and confirm that it's released. But if not, I come in with my scissors - don't slide - I just took the area up to that point - up to that level here to con - to confirm release. You'll see complete decompression of the tendon distally, and we're - we will do the same proximally. We're going to the same thing proximally - just spreading - nothing more. And then once I'm satisfied, I come in with my scissor and do the same thing, and that will result in complete decompression of the tendon.
Again, the way that I check is I have the patient move the finger. Another thing that I can do is I can actually place a retractor into the sheath and pull the tendon out and complete - and confirm complete release. You shows - you might even get a bit of bowstringing to further confirm. This will also help you see if there's any area of constriction. If there's extensive tenosynovitis, it can be elevated off and sharply removed as well if necessary. We'll often see tenosynovitis in certain conditions such as diabetes and hypothyroidism, and they can be a cause of some of the trouble, and it can be trabeated away.
Once satisfied with the release, the wound is washed and closed. I'll typically close these incisions with two 4-0 nylon or equivalent mattress sutures. I'll ask the patient to leave the sutures in place for about 10 days, plus or minus a couple of days. They'll return at that point, and the suture will be removed. I'll then apply a dressing for them today. I like them to leave that dressing on and dry for 2 days. After 2 days, they're able to remove the dressing and shower and wash normally. I asked them in addition to that, starting in 2 days, to clean the incision twice a day with some rubbing alcohol, on volar glabrous skin and then just apply a Band-Aid. I encourage early motion with this. The more the better. I don't typically have to prescribe any physical therapy, but occasionally if a patient is stiff or sore a week, then therapy by all means can be initiated.
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