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PurposeThe purpose of this study was to determine whether extremities undergoing carpal tunnel release (CTR) have an increased rate of trigger finger (TF) compared with conservatively managed carpal tunnel syndrome.MethodsData were collected from the Humana Insurance Database, and subjects were chosen on the basis of a history of CTR with propensity matching performed to develop a nonsurgical cohort. Following propensity matching, 16,768 patients were identified and equally split between surgical and nonsurgical treatments. Demographic information and medical comorbidities were recorded. Univariate and multivariate analyses were performed to identify risk factors for the development of TF within 6 months of carpal tunnel syndrome diagnosis.ResultsPatients in the surgical cohort were more likely to develop TF than those in the nonsurgical cohort whether in the ipsilateral or contralateral extremity. Whether managed surgically or nonsurgically, extremities with carpal tunnel syndrome demonstrated an increased prevalence of TF than their contralateral, unaffected extremity.ConclusionsSurgeons should be aware of the association of TF and CTR both during the presurgical and postsurgical evaluations as they might impact patient management. With knowledge of these data, surgeons may be more attuned to detecting an early TF during the postsurgical period and offer more aggressive treatment of TF pathology during CTR.Type of study/level of evidencePrognostic III.

Resumen Antecedentes y objetivo Las infiltraciones de corticoides son efectivas en el tratamiento de los dedos en gatillo pero el dolor percibido por el paciente durante la inyeccion es un efecto acompanante siempre presente. El objetivo de este estudio fue evaluar la efectividad y el dolor percibido durante una infiltracion corticoidea depositada fuera de la vaina tendinosa utilizando la tecnica comisural dorsal. Material y metodo Se incluyeron 126 pacientes consecutivos. Se realizo una infiltracion esteroidea subcutanea (fuera de la vaina) a traves de la comisura dorsal. En los casos en que los signos o sintomas persistieron, se ofrecio una segunda infiltracion. Se registro el dolor percibido durante la infiltracion mediante la escala visual analogica, el cuestionario DASH antes del tratamiento y al final de seguimiento, la tasa de exito y las complicaciones. Resultados Fueron 86 mujeres y 40 hombres con una edad media de 61 anos. La puntuacion media del dolor durante la infiltracion fue de 3,8. Doce pacientes se perdieron durante el seguimiento. El exito global fue del 68% y el exito tras una unica inyeccion fue del 54%. El mejor resultado se obtuvo en el dedo anular. Los pacientes que no habian sido operados previamente del sindrome del tunel carpiano respondieron mejor. No se objetivaron complicaciones. Conclusiones La infiltracion esteroidea fuera de la vaina tendinosa y utilizando la tecnica comisural dorsal es efectiva y segura en el tratamiento de los dedos en resorte. Parece ser menos dolorosa que los resultados publicados para la tecnica palmar sobre la linea media, aunque esto debe evaluarse en un estudio disenado para ello.

The interventional use of sonography is growing fast, and percutaneous sonographically guided release is more and more used as minimally invasive treatment of carpal tunnel syndrome as well as trigger finger digit. The benefits of these procedures seem promising in clinical studies, but biomechanical studies comparing these procedures with open classical surgery are scarce. Minimally invasive releases of carpal tunnel and trigger finger could limit the phenomenon of tendon bowstringing observed after open surgery. A new model is presented to compare the biomechanical effects of open and sono-guided carpal tunnel and trigger finger releases.

Summary Purpose Recently, local anaesthesia has become popular among hand surgeons. We hypothesized that using the “wide awake local anaesthesia no tourniquet” (WALANT) approach would result in lower global costs and in an increase in the operating room (OR)’s efficiency. Methods All cases of carpal tunnel (CTR) and trigger finger releases (TFR) performed over 2016 and 2017 were divided into four groups, following which the anaesthesia method was used. Total OR occupation time, surgical time and the “all but surgery” time were analysed. A common minimum bill per anaesthesia was generated. Results WALANT or local anaesthesia and tourniquet increase the OR's throughput by having shorter operation room occupation times than other methods (17.5–33%). Costs of the two procedures are reduced by 21–31% when using local anaesthesia methods. Conclusion Preferring those techniques for CTR and TFR has a notable beneficial impact on the costs and on the OR's efficiency. This effect is more evident on short surgical procedures. LOE Level of evidence III, economic analysis.

Background Trigger finger or stenosing tenosynovitis is a disproportion between the volume of the tendon sheath and its contents. This disproportion prevents gliding of the tendon as it moves freely through the annular pulley. The technique of percutaneous release of the annular pulley for trigger finger has been described well in the literature, which has undergone several modifications, like use of hypodermic needle, tenotome or specially designed knives. Method We performed percutaneous trigger finger release using a 20-gauge hypodermic needle to know the outcome and efficacy of the technique post release. A Prospective cohort study was conducted in 80 consecutive trigger fingers of 67 patients who were treated by percutaneous release using 20-gauge hypodermic needle. Quinell’s grading system was used to quantify severity of triggering and pain was assessed using visual analogue scale (VAS) before and after the procedure. Patients were evaluated based on these two parameters at timely interval and final outcome was assessed at the end of one year. Results Out of 80 digits treated, most of the subjects were in the age group 40–50 years (39.07%). Most common grade of trigger finger observed was Grade 3 (60%) followed by Grade 4 (30%) with VAS score of 8 (46%) followed by VAS score of 7 (24%) before release. At a year follow-up 95% of patients improved to grade 0 and mean VAS score was 0.44. Three patients developed scar tenderness, which gradually subsided by analgesics and physiotherapy with no other major complications. Conclusion Our technique of percutaneous release of trigger digit with 20 G needle is effective and can be performed safely with ease. It is cost efficient and has a short learning curve with great acceptance being an outpatient procedure.

A locked metacarpophalangeal joint (LMCP) is a rare condition often confused with trigger finger. Its causes are numerous and typically divided into two broad categories: acquired LMCP in younger patients, and degenerative LMCP in older patients. This pathology usually affects only one MCP. Even though several external reduction techniques have been described, the main risk of non-surgical reduction treatment is recurrence. Thus, its management is most often surgical. We report the case of a 60-year-old woman with 3 simultaneous LMCP (3rd, 4th, and 5th rays of the left hand) due to degenerative metacarpal heads. Surgical treatment was performed and found that locking was due to entrapment of the radial collateral ligament on metacarpal head osteophytes. Full extension was regained at the end of the surgery. The follow-up was uneventful, no recurrence occurred. This case highlights the need for careful examination to prevent medical and surgical wandering for a rare but well-described and easy to treat condition.

Introduction Epinephrine and sodium bicarbonate (NaHCO3) used in wide-awake local anesthesia no tourniquet (WALANT) affect many areas such as hemostasis, injection pain, anesthetic effect and others. However, few clinical trials have focused on injection pain and the duration of anesthetic effect, and no prospective studies have reported the benefits of WALANT post operation. This study compared WALANT with conventional local anesthesia with tourniquet in minor hand surgeries, and aimed to answer following questions: (1) Does WALANT have enough benefits for injection pain and duration of anesthetic effect?; (2) How does WALANT affect postoperative management (such as postoperative pain and use of analgesics)?; (3) How satisfied are the patients with the surgery? Hypothesis We hypothesized that WALANT had advantages in injection pain, duration of anesthetic effect, and postoperative management compared to conventional local anesthesia. Materials and methods The present study is designed as a randomized prospective one center study. This study included 185 patients who received surgical treatment for the diagnosis of carpal tunnel syndrome, trigger finger, or de Quervain's disease between 2017 and 2019. We randomly allocated the patients to either the WALANT group or the conventional group. We inquired and recorded patients’ injection pain, duration of anesthetic effect, postoperative pain, the use of analgesics, and satisfaction with the surgery. Results The injection pain was significantly lower in the WALANT group in all procedures (p Discussion Our study showed better results in WALANT than in the conventional method, with no tourniquet pain, lower injection pains, longer anesthetic duration, and less postoperative pain. It provided patients with great satisfaction. In addition, WALANT has the potential benefits of no time limit due to tourniquet pain and long anesthetic effect. Therefore, WALANT is comfortable and cost effective, and could be a good alternative to conventional local lidocaine anesthesia. Level of evidence II.

Background Corticosteroid injection is an effective treatment for trigger digits but the pain during the injection is an ever-present side effect. Since the palmar skin has a high density of sensitive receptors, injecting through dorsal skin could be less painful. Our aim was to assess whether a dorsal technique through the dorsal web is safe for extra-sheath injection of trigger fingers and thumb. Material and method This is an anatomical study in sixteen cadaveric hands. An injection through the dorsal web was performed on each digit. After careful resection of the palmar skin, the distance between the needle and the main anatomical structures was measured. The risk of major injury was considered high when the mean distance from the needle to the neurovascular bundle was below one millimeter. Results The mean distance from the needle to the neurovascular bundle was 1.77 mm. Two neurovascular injuries in 112 injections were observed, one nerve and one artery. The safest digit was the thumb while the most dangerous was the index finger. At the ring finger, the technique was safer when it was carried out from the dorso-radial. Conclusions A subcutaneous injection near the flexor tendon sheath can be carried out through the dorsal web with a low, but present, risk of neurovascular injury. It could be useful for injection in the treatment of trigger finger and trigger thumb but it should be assessed in a clinical study.

Design: This is a prospective cohort study. Introduction: Evidence is emerging that advanced practice hand therapy clinics improve patient outcomes. Purpose of the Study: The aim of this study was to evaluate an advanced practice hand therapy model of care for patients with chronic hand conditions on surgical outpatient waiting lists at eight Australian public hospitals. Methods: Nonurgent and semiurgent patients were screened and treated, as required, by an advanced practice hand therapist and then discharged from the surgical outpatient waiting list as appropriate. Outcomes included patient safety, impact on the waiting list, patient satisfaction, and patients' perception of change as measured by Global Rating of Change (GROC). The GROC score was also compared across diagnoses. The relationship between the waiting time and need for surgical review during hand therapy treatment was also assessed. As appropriate, T-tests and analysis of variance were used for statistical analyses. Results: A total of 37.2% of patients who commenced hand therapy were removed or discharged from the surgical outpatient waiting lists. Of the subset of patients who completed hand therapy (n = 1116), 28.4% were discharged without requiring surgical follow-up. A further 7.53% requested return to the waiting list despite discharge being recommended. The model of care was safe, and patient satisfaction was above 90%. The mean GROC score was +2.09 (±3.58) but varied across diagnoses with trigger finger or trigger thumb showing the greatest improvement (+4.21 ± 2.92, P

Purpose To determine the risk for infection in trigger finger release surgery after preoperative corticosteroid injection. Methods We retrospectively evaluated all patients undergoing trigger finger release by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, trigger finger(s) operated on, presence of a prior corticosteroid injection, date of most recent corticosteroid injection, postoperative signs of infection, and need for surgery owing to deep infection. Superficial infection was defined per Centers for Disease Control criteria. Deep infection was defined as the need for surgery related to a surgical site infection. Results In this cohort of 2,480 fingers in 1,857 patients undergoing trigger release surgery, 53 (2.1%) developed an infection (41 superficial [1.7%] and 12 deep [0.5%]). Before surgery, 1,137 fingers had no corticosteroid injection. These patients developed 1 deep (0.1%) and 17 superficial (1.5%) infections. In contrast, 1,343 fingers had been given a corticosteroid injection before surgery. These patients developed 11 deep (0.8%) and 24 superficial (1.8%) infections. Median time from corticosteroid injection to trigger release surgery was shorter for fingers that developed a deep infection (63 days) compared with those that developed no infection (183 days). The risk for developing a deep infection in patients who were operated on within 90 days of an injection (8 infections in 395 fingers) was increased compared with patients who were operated on greater than 90 days after an injection (3 infections in 948 fingers). Conclusions Preoperative corticosteroid injections are associated with a small but statistically significantly increased rate of deep infection after trigger finger release surgery. The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period. Type of study/level of evidence Therapeutic IV.

Hypothesis To evaluate benefits for the patient and the economic impact for the implementation of a wide awake local anesthesia no tourniquet (WALANT) hand surgery compared to traditional major outpatient circuit. Methods A prospective cohort study was planned comparing 150 cases of ambulatory hand surgery (carpal tunnel and trigger finger) using WALANT technique intervention out from the operating room; with another 150 which underwent intervention, outpatient setting, with preoperative evaluation, sedation and tourniquet, in the operation room (OR). Preoperative, intraoperative and postoperative pain was monitored, as well as the use of analgesics after the surgery. The resources used and costs were evaluated. Satisfaction was evaluated using a specific survey. Results The pain during the surgery was equivalent for both groups and was significantly lower postoperatively for the WALANT group, with less need for the use of analgesics. Satisfaction was greater for the local anesthesia group. The use of personnel resources and hospital material was less for the WALANT group, with total saving calculated by 1,019€ per patient. Summary Procedures such as carpal tunnel surgery and trigger finger surgery can be safely performed using wide awake surgery. Patient satisfaction is higher to conventional procedure in the OR. Pain control is excellent, especially during the postoperative period. WALANT technique for hand surgery represents a benefit for the patient in comfort, timeliness and no need for a preoperative evaluation or blood test. In addition, it represents a significant savings in hospital resources.

Introduction Trigger finger (TF) is a frequent pathology depending on several factors. The objective of this study was to assess the relationship between multiple TF and systemic or musculoskeletal disorders in a sample of young patients. Material and method A retrospective study was performed of all patients with TF operated in our hospital between 2011 and 2015. Multiple or single TF diagnosis and pathologies such as diabetes mellitus (DM), thyroid dysfunction, carpal tunnel syndrome (CTS), epicondylalgia or DeQuervain's disease were collected. Statistical results included a bivariate analysis and a multiple logistic regression. Results Two hundred and seventy-nine patients with a mean age of 48.45 years were included. The dominant hand was affected in 217 cases. There were 59 patients with multiple TF, 21 DM, 55 STC, 16 epicondylalgia and 14 DeQuervains. Prevalence of CTS was 19.7%, significantly higher than the general population (2%–4%). No statistical differences were found in age, sex, hypothyroidism, epicondylalgia or DeQuervain in the multiple TF group. Bivariate analysis detected that DM and CTS patients in the multiple TF group was significantly higher than in the single TF group (p = 0.007, p Conclusions Diabetes, CTS and dominant side are independently associated with multiple TF in young patients.

Diabetics have a much greater prevalence of trigger finger than nondiabetics and are more likely to have severe symptoms. Diabetic trigger finger may be more accurately described on a spectrum of diabetic hand pathology alongside carpal tunnel syndrome and cheiroarthropathy. Recent publications have called into question the current treatment algorithm for diabetic trigger finger. Although some evidence supports the use of corticosteroid injections, a recent cost analysis reported that immediate surgical release of the A1 pulley in the clinic is the most cost-effective management of diabetic trigger finger. In addition to traditional treatment with injection and open release, percutaneous release with or without simultaneous corticosteroid injection has shown promising results and may have a role in patient care. The appropriate treatment algorithm in terms of efficacy, safety, and cost remains controversial.

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.

Objectives To determine the efficacy of extracorporeal shockwave therapy (ESWT) and to determine the ideal energy flux density of wide-focused ESWT in the treatment of trigger finger (TF). Design Double-blind randomized controlled trial. Setting A university hospital. Participants A total of 60 patients (N=60) with grade II TF according to the Quinnell classification were randomly and evenly allocated to 3 treatment groups. Interventions Three treatment groups included a high-energy ESWT (HS) group (energy flux density of 0.01 mJ/mm2, 5.8 bar, 1500 impulses, once per week for 4wk), a low-energy ESWT (LS) group (energy flux density of 0.006 mJ/mm2, 3 bar, 1500 impulses, once per week for 4wk), and a sham intervention group (sham group). All participants received 6 months of follow-up after intervention when only painkillers were allowed as concomitant treatment. Main Outcome Measures Clinical outcomes were followed at baseline and 1, 3, and 6 months after intervention, including pain score, frequency of triggering, severity of triggering, functional impact of triggering, and quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH). Results All groups showed significant improvements from baseline in all clinical parameters, except for functional impact of triggering, 6 months after the interventions. However, the HS group demonstrated a higher magnitude of improvement than the LS and sham groups. In addition, the HS group reported significantly lower pain (P=.01) and lower qDASH (P=.008) than the sham group 6 months after the interventions. No adverse effects were reported in the HS and LS groups within 6 months of follow-up. Conclusions Wide-focused ESWT is a safe and effective but dose-dependent alternative facilitating pain relief and functional improvement in the treatment of grade II TF according to the Quinnell classification.

To define the role of the flexor tendons in trigger finger, a high-resolution ultrasound examination was performed in 20 trigger fingers and 20 normal contralateral digits in three digital postures: full extension, mid-flexion and near-full flexion. Precise measurements of diameter and cross-sectional area of the combined tendon mass were recorded at five clearly defined locations: summit of the metacarpal head, proximal lip of the proximal phalanx (PP) and at 1/8, 1/4 and 1/2 length of the PP. In the normal tendons, there was an anatomical thickening, not previously appreciated at 1/4 length PP, in the region of the FDS bifurcation. This anatomical region moved proximally on finger flexion to the A1 pulley. In trigger fingers, the flexor tendons had greater diameter (sagittal view) and cross-sectional area than the normal side at all locations (p 0.01, p 0.001), with an even greater increase in diameter in the FDS bifurcation area (p 0.001). Trigger fingers also had thicker A1 pulleys (p 0.001). Triggering occurs on flexing the finger when the enlarged combined flexor tendon mass at the specific anatomical region of the FDS bifurcation impacts on the thickened A1 pulley, resisting its excursion.

Aims We aimed to: (i) estimate the prevalence of Dupuytren's disease, trigger finger, carpal tunnel syndrome and frozen shoulder; (ii) assess stiffness of the hand, shoulder and back; and (iii) explore the association of joint stiffness with both long-term HbA 1c and collagen advanced glycation end-products (AGEs) in long-term type 1 diabetes mellitus (T1DM). Methods Patients with T1DM from 1970 or earlier attending a specialized diabetes center were included in this cross-sectional controlled study. We collected HbA 1 /HbA 1c measurements from 1980 to 2015 and data on hand and shoulder diagnoses and joint stiffness through interviews, charts, and standardized examination. Skin biopsies were analyzed for collagen AGEs by liquid chromatography-mass spectrometry. Results Lifetime prevalence of hand and shoulder diagnoses in the diabetes group (n=102) ranged from 37%–76% (frozen shoulder) versus 11%–15% in controls (n=73) (p 1c (odds ratio 2.01 [95% CI 1.10–3.7]) and the AGEs methyl-glyoxal-lysine-dimer (odds ratio 1.68 [95% CI 1.03–2.73]) and pentosidine (odds ratio 1.81 [95% CI 1.04–3.16]). Conclusions Patients with T1DM >45years had a very high prevalence of hand and shoulder diagnoses versus controls. Joint stiffness was associated with collagen AGEs. However, joint biopsies and prospective studies must explore this association further.

Purpose To quantify the long-term success of repeat injections for trigger fingers and to identify predictors of treatment outcomes. Methods This retrospective case series analyzed 292 repeat corticosteroid injections for trigger fingers administered by hand surgeons at a single tertiary center between January 2010 and January 2013. One hundred eighty-seven patients (64%) were female, 139 patients (48%) had multiple trigger fingers, and 63 patients (22%) were diabetic. The primary outcome, treatment failure, was defined as receiving a subsequent injection or surgical treatment. Patients without either documented failure or a return office visit in 2015 or 2016 were surveyed by telephone to determine if they had required subsequent treatment. Kaplan-Meier analyses with log-rank testing assessed the median time to treatment failure and the effect of demographic and disease-specific characteristics on injection success rate and predictors of injection outcome (success vs failure) were assessed with multivariable logistic regression. Results Second injections provided long-term treatment success in 39% (111 of 285) of trigger fingers with 86 receiving an additional injection and 108 ultimately undergoing surgical release. Thirty-nine percent (24 of 62) of third injections resulted in long-term success, with 22 receiving an additional injection, and 23 ultimately undergoing surgery. Median times-to-failure for second and third injections were 371 and 407 days, respectively. Success curves did not differ significantly according to any patient or disease factor. Logistic regression identified that advancing patient age and injection for trigger thumb were associated with success of second injections. Conclusions Thirty-nine percent of second and third corticosteroid injections for trigger finger yield long-term relief. Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief. Repeat injections of trigger fingers should be considered in patients who prefer nonsurgical treatment. Type of study/level of evidence Therapeutic IV.

A thorough understanding of the swing phases and mechanisms of injury in golf allows accurate diagnosis, treatment, and future prevention of injuries. Recommended initial treatment starts with cessation of practice to rest the wrist, a splint or orthotic brace, and nonsteroidal antiinflammatory drug medication with corticosteroid injection and swing modification. Pisiform excision is the best treatment of the most severe chronic cases of pisiform ligament complex syndrome. Delayed diagnosis of hook of hamate fracture may lead to complications, including flexor tendon rupture. Prompt surgical resection is recommended to hasten return to sport and to prevent further complications.

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.

Background Intravenous regional anesthesia (Bier block) and monitored anesthesia care (MAC) with local anesthesia injection are routinely used for minor hand procedures. This study evaluates differences in post-operative pain control, PACU medication consumption, and duration of patient care. Methods Patients between 18 and 89 years of age who had trigger finger or carpal tunnel release performed were evaluated over a one year period. Demographics, pain score on arrival to PACU, highest Visual Analog Score (VAS), and pain score at discharge were evaluated alongside surgery, anesthesia, and tourniquet times. Results The average age was 58.8 and was significantly different between Bier and Local/MAC groups (P = 0.0217). There were 106 carpal tunnel releases and 34 trigger finger releases. Median time in surgery was 18 min for the Bier group and 15 min for the MAC group and statistically different (p = 0.0095). Median tourniquet time was 24.5 min for the Bier group and 14 min for the MAC group which was statistically significant (p = 0.0001). Median immediate post-operative pain score was significantly different between Bier and MAC groups (0 IQR:2 vs. 0 IQR:0), p = 0.0076). Discharge pain score was significantly higher for Bier block group than MAC group (0 IQR:3 vs. 0 IQR:0, p = 0.0001). Postoperative pain presence was less likely with Local MAC than Bier block (OR 0.197, 95%CI: 0.067, 0.578). Conclusion The likelihood of a zero pain score was greater in the Local/MAC group than the Bier block group. Tourniquet times did not affect pain scores in either group. Surgical procedures and anesthesia care times were shorter in the Local/MAC group.

Purpose As health care costs continue to rise, providers must increasingly identify and implement cost-effective practice measures without sacrificing quality of care. Corticosteroid injections are an established treatment for trigger finger; however, numerous clinical trials have documented the limited efficacy of these injections in the diabetic population. Furthermore, the most cost-effective treatment strategy for diabetic trigger finger has not been determined. The purpose of this study was to perform a decision analysis to identify the least costly strategy for effective treatment of diabetic trigger finger using existing evidence in the literature. Methods Four treatment strategies for diabetic trigger finger were identified: (1) 1 steroid injection followed by surgical release, (2) 2 steroid injections followed by surgical release, (3) immediate surgical release in the operating room, and (4) immediate surgical release in the clinic. A literature review was conducted to determine success rates of the different treatment strategies. Costing analysis was performed using our institutional reimbursement from Medicare. One-way sensitivity and threshold analysis was utilized to determine the least costly treatment strategy. Results The least costly treatment strategy was immediate surgical release in the clinic. In patients with insulin-dependent diabetes mellitus, this strategy results in a 32% and a 39% cost reduction when compared with treatment with 1 or 2 corticosteroid injections, respectively. For 1 or 2 corticosteroid injections to be the most cost-effective strategy, injection failure rates would need to be less than 36% and 34%, respectively. The overall cost of care for immediate surgical release in the clinic was $642. Conclusions Diabetic trigger finger is a common problem faced by hand surgeons, with a variety of acceptable treatment algorithms. Management of diabetic trigger finger with immediate surgical release in the clinic is the most cost-effective treatment strategy, assuming a corticosteroid injection failure rate of at least 34%. Type of study/level of evidence Economic/decision III.

Background Epidemiologic studies have consistently demonstrated a strong positive association between repetition and “occupational overuse syndromes” (OOS). The repetitive nature of painting then can predispose many people to these disorders. Objective The purpose of this study was to conduct an electromyographic analysis (EMG) comparing a right angle handle paint applicator with a commonly used, equal quality standard handle paint brush. Method A randomized cross over repeated measures design was implemented where 30 volunteers were randomly given a paint brush handle type while muscle activity (EMG) was recorded from eight upper limb muscles groups. Subjects were their own controls returning within one week to perform the same painting activity with the other paint brush handle type. ANOVA with repeated measures was used to analyze the EMG data among muscles between the two painting trials. Results EMG analysis revealed that there was no difference in EMG activity or median frequency between the two types of paint brush handles in the eight muscles studied (p > 0.05). Conclusion A right angle handle has no added ergonomic advantage in modifying muscle activity or decreasing muscle fatigue over a commonly used standard handle paint brush in people without injury. It was suggested that the right angle style brush may not prevent OOSs from occurring, although there still could be a decrease risk of injury based on the posture used when gripping the brush handle. It must be emphasized, however, that this study's results cannot be extrapolated to people who already have an OOS and need a device to prevent further injury and pain. Further study is needed.

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.

The purpose was to identify the A1 pulley's exact location and thickness by comparing measurements from a clinical high-frequency ultrasound scanner system (CHUS), a customized high-frequency ultrasound imaging research system (HURS) and a digital caliper. Ten cadaveric hands were used. We explored the pulley by layers, inserted guide pins and scanned it with the CHUS. After identifying the pulley, we measured each long finger's thickness using the CHUS and excised the pulley to measure its thickness with a digital caliper and the HURS. The thin hypo-echoic layer was revealed to be the synovial fluid space, and the pulley appears hyper-echoic regardless of scan direction. We also defined the pulley's boundaries. Moreover, the CHUS provided a significantly lower measurement of the pulley's thickness than the digital caliper and HURS. Likewise, based on the digital caliper's measurement, the HURS had significantly lower mean absolute and relative errors than the CHUS.

Clinical results of a percutaneous needle trigger digit release (PNTDR) technique using a 25-gauge needle with corticosteroid infiltration are reported. This prospective study assessed 52 digits that underwent PNTDR. Experimental results were compared with those of a control group with only steroid injection. Patients who underwent PNTDR were divided into diabetic and nondiabetic groups, and assessed after 1 week, and 1, 2, 3, and 6 months post surgery. The quick disability of the arm, shoulder, and hand (QuickDASH) questionnaire and visual analog scale (VAS) score for pain were completed both before and after surgery. PNTDR showed better statistical results than the control group. At final follow-up, 94% of patients were rated as excellent or good, recurrence was observed in 3 digits, and QuickDASH and VAS score significantly decreased. This technique was equally effective in patients with moderate or well-controlled diabetes with favorable results.

Introduction Epinephrine and sodium bicarbonate (NaHCO3) used in wide-awake local anesthesia no tourniquet (WALANT) affect many areas such as hemostasis, injection pain, anesthetic effect and others. However, few clinical trials have focused on injection pain and the duration of anesthetic effect, and no prospective studies have reported the benefits of WALANT post operation. This study compared WALANT with conventional local anesthesia with tourniquet in minor hand surgeries, and aimed to answer following questions: (1) Does WALANT have enough benefits for injection pain and duration of anesthetic effect? (2) How does WALANT affect postoperative management (such as postoperative pain and use of analgesics)? (3) How satisfied are the patients with the surgery? Hypothesis We hypothesized that WALANT had advantages in injection pain, duration of anesthetic effect, and postoperative management compared to conventional local anesthesia. Materials and methods The present study is designed as a randomized prospective one center study. This study included 185 patients who received surgical treatment for the diagnosis of carpal tunnel syndrome, trigger finger, or de Quervain's disease between 2017 and 2019. We randomly allocated the patients to either the WALANT group or the conventional group. We inquired and recorded patients’ injection pain, duration of anesthetic effect, postoperative pain, the use of analgesics, and satisfaction with the surgery. Results The injection pain was significantly lower in the WALANT group in all procedures (p Discussion Our study showed better results in WALANT than in the conventional method, with no tourniquet pain, lower injection pains, longer anesthetic duration, and less postoperative pain. It provided patients with great satisfaction. In addition, WALANT has the potential benefits of no time limit due to tourniquet pain and long anesthetic effect. Therefore, WALANT is comfortable and cost effective, and could be a good alternative to conventional local lidocaine anesthesia. Level of evidence II.

Pediatric trigger thumb presents not at birth but early in childhood. Most evidence suggests that it is caused by a developmental size mismatch between the flexor pollicis longus tendon and its sheath. Patients generally present with the thumb interphalangeal joint locked in flexion. Surgical reviews report near universally excellent outcomes after open release of the A1 pulley. However, recent reports indicate that there may be a role for nonsurgical treatment for families that are willing to wait several years for possible spontaneous resolution of the deformity. Triggering in digits other than the thumb in children is generally associated with an underlying diagnosis including anatomic abnormalities of the tendons, and metabolic, inflammatory, and infectious etiologies. Although some have advocated nonsurgical treatment, surgery is often necessary to address the underlying anatomic etiology. More extensive surgery beyond simple A1 pulley release is often required, including release of the A3 pulley and resection of a slip of the flexor digitorum superficialis tendon.

ResumenLa diabetes es una de las enfermedades con mayor prevalencia y repercusión sociosanitaria, no solo por su elevada frecuencia, sino también por el impacto de las complicaciones crónicas de la enfermedad y el papel que desempeña como factor de riesgo en la afección cardiovascular. Sin embargo, la diabetes también puede involucrar al sistema musculoesquelético y a los tejidos blandos de forma muy diversa, siendo la mano una de las regiones más afectadas. De hecho, se estima que el 40% de los pacientes diabéticos tienen problemas significativos de la mano que requieren una atención médica.En el presente artículo se revisan las principales enfermedades de la mano que van asociadas a la diabetes, haciendo especial hincapié en el tratamiento y el pronóstico de cada una de ellas.AbstractDiabetes is one of the most prevalent diseases with significant health and social repercussions, not only due to its high frequency, but also due to the impact of chronic disease complications, as well as its role as a risk factor in cardiovascular disease. However, diabetes can also involve the musculoskeletal system and soft tissues in very different ways, with the hand being one of the most affected regions. In fact, it is estimated that 40% of diabetic patients have significant hand problems that require medical attention.In the present article, the main pathologies of the hand that are associated with diabetes are reviewed, with particular emphasis on their treatment and prognosis.

Trigger fingers are common tendinopathies representing a stenosing flexor tenosynovitis of the fingers. Adult trigger finger can be treated nonsurgically using activity modification, splinting, and/or corticosteroid injections. Surgical treatment options include percutaneous A1 pulley release and open A1 pulley release. Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or patients with persistent flexion contracture. Pediatric trigger thumb is treated with open A1 pulley release. Pediatric trigger finger is treated with release of the A1 pulley with excision of a slip or all of the flexor digitorum superficialis if triggering persists.

Purpose To determine short- and long-term success rates of a single corticosteroid injection for de Quervain tendinopathy while identifying prognostic indicators for symptom recurrence and repeat intervention. Methods Fifty consecutive patients with de Quervain tendinopathy treated with corticosteroid injections (lidocaine plus triamcinolone acetonide or dexamethasone) were prospectively enrolled. Patients with inflammatory arthritis, carpometacarpal osteoarthritis, or a previous distal radius fracture affecting the symptomatic wrist were excluded. Demographic data and information on existing comorbidities were recorded. Patients were seen in clinic at 6 weeks after injection and contacted at 3, 6, 9, and 12 months following injection to determine symptom recurrence and further intervention. Medical records were also reviewed for this purpose. Kaplan-Meier survival analysis and Cox regression modeling were used to estimate recurrence rates and identify predictors of symptom recurrence and repeat intervention. Results Fifty wrists in 50 patients (average age, 49 y) were included. One patient was lost to follow-up. Eighty-two percent of patients had resolved symptoms 6 weeks after a steroid injection. Twenty-four patients had a recurrence of symptoms at a median of 84 days after the injection. Eleven patients underwent additional intervention (7 surgical releases and 4 repeat injections) at a median of 129 days (range, 42–365) after the injection. Estimated freedom from symptom recurrence was 52% at 6 and 12 months. Estimated freedom from repeat intervention was 81% at 6 months and 77% at 12 months. Two of 3 patients with a history of trigger finger required subsequent de Quervain surgery. Conclusions We demonstrated that a single cortisone injection was effective in alleviating symptoms of de Quervain tendinopathy in 82% of patients and that over half remained symptom-free for at least 12 months. All patients with recurring symptoms developed them within the first 6 months. Type of study/level of evidence Prognostic IV.

Background: Rotator cuff disease is a common condition in the general population, but relatively little is known about its associated risk factors. Materials and methods: We have undertaken a large case-control study using The Health Improvement Network database to assess and to quantify the relative contributions of some constitutional and environmental risk factors for rotator cuff disease in the community. Our data set included 5000 patients with rotator cuff disease who were individually matched with a single control by age, sex, and general practice (primary care practice). Results: The median age at diagnosis was 55 years (interquartile range, 44-65 years). Multivariate analysis showed that the risk factors associated with rotator cuff disease were Achilles tendinitis (odds ratio [OR] ¼ 1.78), trigger finger (OR ¼ 1.99), lateral epicondylitis (OR ¼ 1.71), and carpal tunnel syndrome (OR ¼ 1.55). Oral corticosteroid therapy (OR ¼ 2.03), oral antidiabetic use (OR ¼ 1.66), insulin use (OR ¼ 1.77), and ‘‘overweight’’ body mass index of 25.1 to 30 (OR ¼ 1.15) were also significantly associated. Current or previous smoking history, body mass index of greater than 30, any alcohol intake, medial epicondylitis, de Quervain syndrome, cubital tunnel syndrome, and rheumatoid arthritis were not found to be associated with rotator cuff disease. Conclusions: We have identified a number of comorbidities and risk factors for rotator cuff disease. These include lateral epicondylitis, carpal tunnel syndrome, trigger finger, Achilles tendinitis, oral corticosteroid use, and diabetes mellitus. The findings should alert the clinician to comorbid pathologic processes and guide future research into the etiology of this condition. Level of evidence: Level III, Case-Control Design, Epidemiology Study. 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.

Hand and wrist problems are frequently the cause of patients' complaints in the primary care setting. Common problems include hand numbness, pain, loss of motion, or unexplained masses in the hand. Many problems can be successfully managed or treated with nonoperative measures. This article focuses on commonly encountered causes of chronic hand pain.

This study investigated the sonographic appearance of the pulley and flexor tendon in idiopathic trigger finger in correlation with the contracture of the interphalangeal (IP) joint in the thumb or proximal IP (PIP) joint in the other digits. Sonographic measurements using axial images were performed in 177 affected digits including 17 thumbs and 34 other digits judged to have IP or PIP joint contracture and 77 contralateral control digits. The A1 pulley of the contracture group was significantly thicker than that of the non-contracture group in all digits, whereas the flexor tendon was thicker only in digits other than the thumb. In the analysis using calculated cut-off values, A1 pulley thickening in the thumb and A1 pulley and flexor tendon thickening in the other digits showed statistically significant correlations with IP or PIP joint contracture. This study sonographically confirmed previous reports showing that enlargement of the flexor tendons contribute to the pathogenesis of PIP joint contracture.

Introduction With local anesthesia and new ultrasound-guided percutaneous procedures, it is now more often possible to perform hand surgery in minimal settings. Indeed, the authors argue that most hand surgery procedures could be performed in office surgeries. They have reported morbidities in a continuous series of 921 ultrasound-assisted hand procedures performed under local anesthesia in a clinic setting. Method Over a period of 3.5 years, 921 in-office procedures (635 patients) were performed using specific ultrasound-guided techniques (previously published) under local anesthesia. We included 265 trigger fingers, 418 carpal tunnel releases, 25 de Quervain releases and 202 Dupuytren contractures, 3 lateral epicondylitis, 8 flexor tendon sheath ganglions. Exclusion criteria for office surgery were: – ASA (American Society of Anesthesiologists) grade 3 or higher; – allergic history (latex, xylocaine?); – age over 85. Asepsis was achieved with a preoperative iodine shower and a 5-step antiseptic skin preparation. Fasting was forbidden and disease-modifying treatments, including anticoagulants, taken as usual. The WALANT technique was used for local anesthesia. All procedures were performed percutaneously under ultrasound guidance. Surgical blades were proscribed, only a 18 gauge needle was used for skin incision. All the instruments were thinner than 1.5 mm, non-disposable and cost less than 50? Bandages were removed by the patient the day after surgery. Morbidities were reported systematically: – before surgery, during local anesthesia (vagal faintness, panic attack); – during surgery (pain, excessive bleeding, faintness, mild heart attack); – after surgery (infection, Sudeck's disease, hematoma, scarring problem). Individual procedure efficacy was assessed in previous studies and not included in this series. Results Preoperative: – 18 vagal faintness, including 5 syncopes with spontaneous resolution; – no panick attack. Operative: – no pain felt; – no excessive bleeding, no specific hemostasis procedure needed; – no heart attack. Postoperative: – 1 infection in a trigger finger requiring re-operation; – 19 Sudeck's disease; – 10 mild hematoma after carpal tunnel release with spontaneous resolution. Conclusion The combination of the WALANT technique and ultrasound-assisted procedures provides an original approach that can be used in a clinic setting. Three vagal faintness (without syncope) was observed in the last 400 patients. The morbidities reported were at least equivalent to those published in standard operating theatre procedures; only one patient was re-operated (case of infection). Hand surgery can be performed in good conditions as in-office surgery using local anesthesia and ultrasound guidance.

Introduction/Background Trigger finger is a common cause of hand pain and disability and an A1-pulley dividing, percutaneous release is a definitive treatment for advanced stage disease. High-resolution, musculoskeletal ultrasonography provides clear visualization of the A1-pulley and flexor tendon, however, the evidence to support ultrasonographic guidance of this procedure is scarce. This study aim to evaluate the results of ultrasound (US)-guided, percutaneous, needle technique, annular, A1-pulley release for trigger finger (TF); specifically identifying whether this minimally-invasive procedure had low complication rates and enables early functional recovery. Material and method Single center, prospective cohort study of consecutive patients who were > 20 years of age, had grade II TF or higher for at least 4 months, and were unresponsive to conservative treatment. Patients with chronic connective tissue disease, rheumatoid arthritis, previous TF surgery, pregnancy, or bleeding risks were excluded. The procedure was an US-guided percutaneous A1-pulley release using needle technique. Outcome measures at 1 week post-surgery included; recovery time, pain level and duration, use of analgesic medications, time to normal activity of affected TF, and subject satisfaction for cosmesis and overall results. Surgical complications were monitored for 6 months. Results Thirty-nine fingers from 33 patients who received US-guided, percutaneous, A1-pulley release using needle technique were included in the analysis. Mean operative time was 6.17 (SD = 1.70) minutes. Median postoperative pain duration, use of analgesic medications, and recovery time to normal activity were 1.0 (IQR = 0–2), 0.5 day (IQR = 0.5–1), and 2 days (IQR = 1–2), respectively. Mean subject satisfaction scores for wound appearance and overall treatment were 9.87 and 9.61, respectively. Only one patient had an incomplete release and no severe complication were observed. Conclusion US-guided, percutaneous, A1-pulley release with needle technique was an effective treatment for TF, with high levels of overall satisfaction and no significant complications.

Stenosing tenosynovitis of the fingers and thumb is one of the most common causes of hand pain and disability. Corticosteroid injection is the mainstay in initial management but the pain during the injection is an always-present side effect. The purpose of this study was to assess the effectiveness, safety and perceived pain during a subcutaneous corticosteroid injection for trigger finger and thumb performed through the dorsal skin. A total of 63 consecutive patients diagnosed of trigger finger or thumb were included in this study. They were 43 women and 20 men with a mean age of 61 years. A subcutaneous corticosteroid injection was performed through the dorsal web. In cases where triggering was not completely solved, a second injection was offered. Demographic data, DASH questionnaire, VAS for pain during the injection, success rate and complications were collected and analyzed. The mean DASH questionnaire was 48 points at diagnosis and 8.6 points at final follow-up. The mean VAS for pain during the injection was 3.84 and it was considered mild by most patients. Six patients were lost to follow-up. The success rate after a single injection was 31/57 (54.4 %). The overall success rate was 39/57 (68.4 %). The best result was achieved on the middle finger (19/22; 86 %), followed by the ring finger (10/12; 83 %). No complications were noted. No differences in the success rate between the diabetic and non-diabetic sample were found. The overall success rate of trigger fingers injections through the palmar skin has been reported between 47 % and 92 %. In our series, injecting subcutaneously through the dorsal skin, the overall success rate at final follow-up was 39/57 (68.4 %) what is consistent with the published data. The mean reported VAS for pain during a palmar injection has been reported to be 5.32 points. In our series, the perceived pain during the injection was 3.84 points. A prospective randomized study would be necessary to assess these differences. The subcutaneous corticosteroid injection through the dorsal web for trigger finger and thumb is safe and effective. It seems to be less painful than the reported scores for the palmar midline technique although it should be assessed in a prospective randomized study.

Purpose To help strategize efforts to optimize value (relative improvement in health for resources invested), we analyzed the factors associated with the cost of care and use of resources for painful, nontraumatic conditions of the upper extremity. Methods The following were the most common upper extremity diagnoses in the Truven Health MarketScan database: shoulder pain and rotator cuff tendinopathy, shoulder stiffness, shoulder arthritis, lateral epicondylitis, hand arthritis, trigger finger, wrist pain, and hand pain. Multivariable generalized linear regression models were constructed accounting for sex, age, employment status, enrollment year, payer type, emergency room visit, joint injection, magnetic resonance imaging (MRI), physical or occupational therapy, outpatient and inpatient surgery, and insurance type. In addition, we assessed the use of the following 4 diagnostic and treatment interventions: joint injection, surgery, MRI, and physical or occupational therapy. Results Inpatient and outpatient surgery are the largest contributors to the total amount paid for most diagnoses. Older patients had more injections for the majority of conditions. Conclusions Efforts to improve the value of care for nontraumatic upper extremity pain can focus on the relative benefits of surgery compared with other treatments and interventions to lower the costs of surgery (eg, office surgery and limited draping for minor hand surgery). Type of study/level of evidence Economic II.

Purpose Shared decision making is an approach where physicians and patients collaborate to make decisions based on patient values. This requires eliciting patients’ preferences for each treatment attribute before making decisions; a structured process for preference elicitation does not exist in hand surgery. We tested the feasibility and usability of a ranking tool to elicit patient preferences for the treatment of trigger finger. We hypothesized that the tool would be usable and feasible at the point of care. Methods Thirty patients with a trigger finger without prior treatment were recruited from a hand surgery clinic. A preference elicitation tool was created that presented 3 treatment options (surgical release, injection, and therapy and orthosis) and described attributes of each treatment extracted from literature review (eg, success rate, complications). We presented these attributes to patients using the tool and patients ranked the relative importance (preference) of these attributes to aid in their decision making. The System Usability Scale and tool completion time were used to evaluate usability and feasibility, respectively. Results The tool demonstrated excellent usability (System Usability Scale: 88.7). The mean completion time was 3.05 minutes. Five (16.7%) patients chose surgery, 20 (66.7%) chose an injection, and 5 (16.7%) chose therapy and orthosis. Patients ranked treatment success and cost as the most and least important attributes, respectively. Twenty-nine (96.7%) patients were very to extremely satisfied with the tool. Conclusions A preference elicitation tool for patients to rank treatment attributes by relative importance is feasible and usable at the point of care. A structured process for preference elicitation ensures that patients understand the trade-offs between choices and can assist physicians in aligning treatment decisions with patient preferences. Clinical relevance A ranking tool is a simple, structured process physicians can use to elicit preferences during shared decision making and highlight trade-offs between treatment options to inform treatment choices.

Study design Retrospective cohort comparison. Introduction Using acetic acid iontophoresis (AAI) as a treatment modality significantly improved the functionality of hand in patients with recalcitrant scarring. Methods Open trigger finger release patients followed up exclusively at a hand clinic between 2009 and 2011 were analyzed. Group I recovered optimal total active range of motion (TAM) after 14 standard of care (SOC) therapy sessions but Group II (10 digits) could only reach optimal recovery after 7 additional AAI sessions. Results After SOC therapy, Group I's TAM recovery plateaued at 245 and Group II's at 219 (p Discussion Clinical studies suggest that AAI can modify collagen structure in scars. AAI could be a novel non-surgical treatment for restoring functionality to areas affected by difficult, recalcitrant scars. Conclusion AAI significantly improved the TAM of hand surgical patients who could not recover optimally with SOC therapy alone. Level of evidence Level 3.

Study design: Retrospective cohort study. Purpose: To measure the impact of initial treatment by a hand therapist of people referred to a hand surgeon for common hand conditions. Methods: This retrospective cohort study included 224 patients with Carpal Tunnel Syndrome, Trigger Finger/Thumb, de Quervain’s tenosynovitis, and trapeziometacarpal osteoarthrosis. All were invited to attend for assessment and non-operative treatment and were followed up for at least one year. Between groups comparisons for who attended (N ¼ 164) and those who did not (N ¼ 60) were conducted. Results: 40.8% of the non-operative treatment group and 65% of the no treatment group underwent surgery, which was statistically significant (p ¼ 0.02). Univariate analysis found that the variable “attending non-operative treatment” was able to predict those who did not have surgery (p ¼ 0.02). Multivariate analysis using logistic regression also showed that this was the only significant predictor of not progressing to surgery (p ¼ 0.001). Conclusions: Assessment and treatment by a non-operative provider were associated with a decrease in the rate of operative treatment. Prospective, randomized studies could help determine if this observed difference is related to the treatment approach. Level of evidence: 2C

The smooth gliding of the normal human digital flexor is maintained by synovial fluid lubrication and lubricants bound to the tendon surface. This system can be disrupted by degenerative conditions such as trigger finger, or by trauma. The resistance to tendon gliding after surgical repair of the lacerated digital flexor tendon relates to location of suture knots, exposure of suture materials, and type of surgical repair and materials. Restoration of a functioning gliding surface after injury can be helped by using low-friction, high-strength suture designs, therapy that enables gliding, and the addition of lubricants to the tendon surface.

This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys, sesamoid bones), flexor tenosynovitis, de Quervain's syndrome, Dupuytren's contracture, some hand deformities in rheumatoid arthritis, the carpal tunnel syndrome and the ulnar nerve compression at Guyon's canal. Some important syndromes and structures have not been included but such are the nature of these seminars. Rather than being complete, we aim at creating a system in which clinical cases are used to highlight the pertinent anatomy and, in the most important part of the seminar, these pertinent items are demonstrated by cross examination of participants and teachers. Self learning is critical for generating interest and expanding knowledge of clinical anatomy. Just look at your own hand in various positions, move it, feel it, feel also your forearms while you move the fingers, do this repeatedly and inquisitively and after a few tries you will have developed not only a taste, but also a lifelong interest in clinical anatomy.

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.

Purpose Open release of the A1 pulley is a widely known procedure for the treatment of trigger finger. A subset of patients presents with both trigger finger and a positional contracture of the proximal interphalangeal (PIP) joint. These patients usually have a long history of trigger finger or have already undergone a surgical release of the annular pulley. This study is a retrospective review of the outcomes of resection of the flexor digitorum superficialis (FDS) for patients whose trigger finger was associated with a positional contracture of the PIP joint. Methods Thirty-six patients (39 fingers) were treated by resection of the FDS after section of the A1 pulley. The mean age of the patients was 63 years (range, 45–90 y). Seven patients (19 %) had previously undergone an open release of the A1 pulley and had developed a positional contracture of the PIP joint 2 to 5 months afterward. We performed a retrospective review with a mean follow-up of 30 months (range, 12–60 mo). No patient was lost to follow-up. The active range of motion was recorded at the PIP joint before and after surgery. Results The mean preoperative positional contracture of the PIP joint was 24° (range, 15°–30°). The mean postoperative positional contracture of the PIP joint was 4° (range, 0°–10°). The most commonly affected digit was the middle finger (26 fingers, 67%). In 28 fingers (72%), full extension was achieved following only the surgical procedure. The remaining 11 fingers (28%) had a postoperative residual positional contracture (range, 5°–10°). However, all fingers achieved a full range of motion after physical therapy and an injection of betamethasone. All of the resected tendons had histological damage. Conclusions This technique is a useful treatment for selected patients whose trigger finger is associated with a positional contracture. Type of study/level of evidence Therapeutic IV.

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. Type of study/level of evidence Therapeutic I.

Purpose: To evaluate the use of orthotic devices (splints) in an attempt to resolve trigger finger. Methods: Data were extracted from 46 charts during a five-year period from January 2005 to December 2010. At ten weeks, patients were seen for follow-up assessment of pain and stage of stenosing tenosynovitis (SST). One-year follow-up was performed to determine if the patients required further surgical intervention or steroid injection. The data were analyzed to determine the efficacy of orthosis intervention. Results: Mean pain score preorthotic is 5.63 and postorthotic is 1.20. Mean SST score preorthotic is 3.93 and postorthotic is 1.21. There was an 87% (40 patients) success rate with the orthotic intervention; 4.3% (two patients) had surgery and 8.5% (four patients) received a steroid injection in the year after orthotic application. Conclusion: This study demonstrated the efficacy of orthoses for the reduction of pain and SST score for patients who have trigger finger. Level of Evidence 3.