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Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint.

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.

A case of multiple trigger fingers is presented in a 56-year-old diabetic woman who refused operative management which is the main stay of treatment. Both hands were involved; three on the left and two on the left. The thumb was spared. She was therefore managed conservatively with corticosteroid infiltration at the A1 pulley which had to be repeated but with long term satisfactory result.

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.

Trigger finger is a common well recognized condition and involves the flexor tendons at the A1 pulley in the palm. Triggering of the extensor tendons is a very rare clinical entity. We report a rare case of extensor triggering of little finger caused by constriction of the extensor digiti minimi by a markedly thickened extensor retinaculum (ER) at the wrist, well delineated dynamically by real-time high-resolution ultrasound. The patient underwent release of thickened ER and was asymptomatic immediately.Il dito a scatto è una condizione frequente, ben riconosciuta, che coinvolge i tendini flessori a livello della puleggia A1. A livello dei tendini estensori è un’entit□ clinica molto rara. Riportiamo un raro caso di dito a scatto dell’estensore del mignolo causato da un marcato ispessimento del retinacolo degli estensori (ER) a livello del polso, ben evidenziato con ecografia dinamicamente ad alta risoluzione. Il paziente è stato sottoposto a intervento con resezione dell’ER ispessito con conseguente, completa, risoluzione della patologia.

Producción Científica, Resumen: Objetivos: La tenosinovitis estenosante de los flexores de la mano es una patología muy frecuente en el ámbito laboral. Se han descrito distintos tratamientos de tipo conservador, aunque el tratamiento definitivo de los casos que no responden a otros tratamientos es quirúrgico, siendo la técnica abierta y la liberación percutánea las dos técnicas de elección. Esta última ha obtenido resultados superiores de satisfacción aunque la ausencia de visualización incrementa las lesiones neurovasculares y el riesgo de apertura incompleta de la polea, por ello es necesario establecer puntos de referencia anatómicos para realizar una correcta liberación. Material y método: Se realizó un estudio experimental en cinco manos de cadáver en el Departamento de Anatomía de la Universidad de Valladolid. Se realizaron mediciones de las longitudes de los dedos y de la polea. Se registró la posición de la aguja y de cada uno de los dedos al realizar la polectomía percutánea y se comprobó si la sección de la polea A1 fue completa, si existió alguna laceración de los tendones o si se produjo una lesión iatrógena del paquete neurovascular o de la polea A2. Resultados: Para establecer el punto de entrada de la aguja intramuscular se tomó como referencia la intersección entre el eje del dedo y el surco dígito-palmar. En el caso del tercer y cuarto dedo la entrada fue en el punto de la intersección, mientras que en el resto se desplazó 1-1,5 mm en dirección medial. El ángulo de entrada de la aguja intramuscular en el plano anterior osciló entre 0-30 grados en función del dígito, mientras que en el plano lateral fue siempre 0 excepto en el cuarto dedo que corresponde a un valor de -60 grados respecto al eje palmar. No se observó ninguna lesión iatrógena de los tendones flexores, del paquete neurovascular o de la polea A2. La apertura fue completa en todos los dedos salvo en un caso del segundo dedo. Conclusión: La tenolisis percutánea de la polea A1 es una alternativa a la liberación abierta tradicional, aunque existe controversia debido a la relación riesgo-beneficio. El conocimiento de las referencias anatómicas así como la posición exacta del dígito y de los instrumentos utilizados ayudan a evitar la liberación incompleta de la polea, los problemas neurovasculares y la lesión de estructuras adyacente. En el presente estudio anatómico se ha comprobado que es una técnica segura ya que no ha ocurrido ninguna lesión iatrógena y fiable, que se ha conseguido una liberación completa en todos los casos salvo uno.

Long standing trigger finger, often present for 6 months to years before consulting, can result in a lack of extension, which is often painful and may persist after section of the A1 pulley. The ulnar superficial slip resection (USSR) was introduced by Le Viet to address this problem. It is hypothesised that primary section of the A1 pulley with USSR resolves both extension lack and pain in longstanding trigger fingers with a painful extension lack. This retrospective study reviewed the results of primary USSR for longstanding trigger fingers (6 months or more) with painful extension lack in 18 patients. Locking was resolved and full extension was acquired in all cases (100%). Satisfaction rate was high (89%) and disability returned to normal after surgery. In two patients, satisfaction was low due to residual loss of flexion as a result of osteoarthritis and cold intolerance in another. It is concluded that the USSR procedure is a valuable primary surgical option in complicated trigger finger with painful extension lack caused by flexor tendon tendinosis.

Closed rupture of thumb flexor tendon pulleys is rare. No standardized surgical management has yet been defined, in contrast to the situation when reconstruction of pulleys of the long fingers is required. We describe a case of rupture of the three pulleys of the thumb that probably occurred after violent thumb grasp during delivery in absence of any other trauma. We reconstructed only the A1 pulley using an extensor retinaculum graft in the absence of remnants of the native pulleys. An extensor retinaculum strip was harvested via a transverse incision on the dorsum of the wrist at the level of the fourth extensor compartment. The graft was inserted in the proximal third of the proximal phalanx and fixed with two anchors positioned at both edges. At one year postoperatively, the result was satisfactory: pain had disappeared, active and passive thumb motion was complete, grip strength on the operated from 15 kg preoperatively to 26 kg postoperatively and thumb mobility evaluated with Kapandji score improved from 8/10 to 10/10. Guidelines for conservative or surgical management of closed ruptures of long finger pulleys are available, but not for thumb pulleys. The anatomical and biomechanical studies on FPL function motivated us to reconstruct only the complex A1-Av pulley, but the exact location of the reconstructed pulley was not clear. The biomechanical work Meyer zu Reckendorf et al. and Roloff et al. have similar conclusions that the new pulley should be placed in front of the proximal third of the proximal phalanx. Guelmi et al. reconstructed an A1-oblique complex using a modified Lister technique. Lister described satisfactory reconstruction of the A2 and A4 long finger pulleys using free grafts of the extensor retinaculum. Moutet considered that use of a synovialized tissue such as the extensor retinaculum was better than that of a tissue without any synovial layer and Bouyer et al. reported a series of 38 rock climbers who underwent successful pulley reconstructions using the extensor retinaculum. Thus, we chose an extensor retinaculum graft and, as no remnant of the old pulleys remained, we fixed the graft using anchors; this is effectively the Lister approach. Surgery is essential when the goal is recovering thumb mobility and eliminating bowstringing. Reconstruction of a single A1-Av pulley is sufficient; remnants of the native pulleys do not seem to be necessary and the extensor retinaculum remains the graft of choice.

Background Trigger finger is thought to be caused by aseptic inflammation of the A1 pulley and subsequent thickening and narrowing of the fibrous sheath. Acupotomy has been an important treatment for trigger finger. But an updated systematic review about this issue has not yet been released. This systematic review protocol is aimed at providing a higher quality method used to evaluate the efficacy and safety of acupotomy treatment for trigger finger. Methods The following databases will be searched from the study inception to July 2019: the Cochrane Central Register of Controlled Trials (Cochrane Library), MEDLINE, EMBASE, PubMed, China National Knowledge Infrastructure, Wan-Fang Data, and Chinese Biomedical Literature Database. All English or Chinese randomized controlled trials related to acupotomy for trigger finger will be included. Two reviewers will independently perform the processes of study inclusion, data extraction, and quality assessment. The primary outcome will be assessed by improvement of the pain symptoms and finger activity. Secondary outcomes will be assessed through Safety assessment. Meta-analysis will be completed by RevMan V.5.3 software. Results This systematic review will provide an assessment of the current state of acupotomy for trigger finger, aiming to show the efficacy and safety of treatment. Conclusion This systematic review will re-evaluate a higher-quality systematic review to obtain a relatively convincing conclusion that finds acupotomy to be a better choice for trigger finger patients. Prospero registration number CRD42018118663.

Background: Stenosing tenosynovitis or trigger finger is a common condition affecting finger function, which can lead to disability in hand function. Treatment in form of conservative can be helpful in early stages, however later stages and chronic triggering needs release of A1 pulley either by open or percutaneous methods. The aim of this study was to find the results of percutaneous release of trigger finger with 18 guage needle.Methods: 43 digits in 36 patients were enrolled for this prospective study in a district level hospital over a 2 year period. Release was done under local anaesthesia using 18 guage needle percutaneously. Follow up was done upto 6 months. Final scoring was done at 6 months using Quinell’s criteria.Results: We had 81.39% (35 out of 43) excellent to good results. 19.61% (8) needed open release. We had no neurovascular injury or infection in our series.Conclusions: Percutaneous release by 18 guage needle is safe and effective treatment for trigger finger without much complication.

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.

Introduction: Congenital trigger thumb is an uncommon anamoly of children. Its management is controversial, ranging from observation to extensive surgical release. We report a case of delayed presentation of bilateral trigger thumb along with a brief review of past literature. Case Report: A six year old girl presented with fixed flexion deformity of interphalangeal joints of both thumbs and Notta’s nodules. It is diagnosed as trigger thumb and release of bilateral A1pulleys is done. But we found another constricting annular pulley just distal to A1. Only after splitting the distal pulley, we could get complete extension of interphalangeal joints. At two years follow-up, the child is free of complications. Conclusion: Splitting of A1 pulley alone may not be sufficient in few cases of trigger thumb. Keywords: Congenital trigger thumb, bilateral trigger thumb and variable pulley of thumb.

The first annular (A1) pulley is an important structure of the hand, providing a biomechanical support to the metacarpophalangeal joint and maintaining joint stability and flexor tendon alignment. Albeit uncommon, disruption of this pulley can result in dislocation or ulnar drift of the digit, particularly pronounced in patients with rheumatoid arthritis. Despite this, the A1 pulley is commonly divided without reconstruction in trigger finger. Several annular pulley reconstructive techniques have been developed to preserve its function. However, development of recurrent triggering has been observed due to fibrosis, largely due to inadequate release of the pulley. We have developed a technique to increase the volume within the flexor sheath while preserving the A1 pulley by way of stepwise lengthening. This has enabled an increase in the diameter of the pulley to 4 times its original size. A prospective study was performed comprising 10 trigger finger releases with stepwise lengthening of the A1 pulley. In all patients, there were no complications, and good hand function was achieved with no recurrence of triggering at 6 weeks of follow-up. This technique can thus safely achieve trigger release without sacrifice of the function of the A1 pulley.

The objective of the study was to assess the safety, the efficacy, and the result of percutaneous A1 pulley release, using the tip of a 20-G hypodermic needle; the study included 17 patients with 27 trigger digits (18 grade IIIA, 8 grade IIIB, and 1 grade IV). All the patients were assessed by the total range of motion of the affected digit, the visual analog scale score, and the Disability of Arm Shoulder Hand score, before and after the procedure and during the follow-up at 2, 6, 12, and 24 weeks, and then every 3 months, and the improvement was assessed by one sample t test. Sixteen patients with 26 trigger digits (95.4%) showed complete relief of symptoms with no recurrence and a statistically significant improvement in the range of motion, the visual analog scale score, and the Disability of Arm Shoulder Hand score with a P-value

Trigger digit is recognized as thickening and constriction of the flexor tendon sheath at the base of digits. This study investigates the correlation between the severity grading of trigger digits and clinical findings from high-frequency ultrasonography. We measured and compared thicknesses, areas and pathological changes of the flexor digit tendons among total, contracture and noncontracture trigger digits and noninvolved contralateral digits. Forty-seven patients with 55 idiopathic trigger digits (36 contracture and 19 noncontracture) and 55 noninvolved contralateral digits were examined using high-frequency ultrasonography. The thickness of the flexor tendons was measured in a longitudinal plane at the A1 pulley: Inlet (metacarpal head-neck junction), Outlet (proximal phalangeal base-shaft junction) and Interpulley (middle of Inlet and Outlet). The cross-sectional and extratendinous tissue areas of the flexor tendons in a transverse plane at the point of Interpulley were measured. Pathological changes including irregular internal echotextures, fluid collection, dominant A1 pulley and abnormal metacarpophalangeal joint were analyzed. All thicknesses and areas of total and contracture trigger digits were significantly greater than those of noninvolved contralateral digits (p0.05), whereas no significant difference was observed in noncontracture trigger digits. The pathological changes were all significantly different from noninvolved contralateral digits in total, contracture and noncontracture trigger digits (p0.05). In contracture and noncontracture trigger digits, there were significant differences only in the thickness of the Inlet and the pathological change of the dominant A1 pulley (p0.05). In conclusion, the results of the ultrasonographic measurements and findings provided evidence of Notta's node and correlated with clinical findings and severity grades.

It has been suggested that the increased frequency of trigger finger (TF) after carpal tunnel release (CTR) may be caused by the volar migration of the flexor tendons at the wrist altering the tendon biomechanics at the A1 pulley. This hypothesis has not been validated. We performed pre- and post-operative ultrasonography (USG) on the affected wrists of 92 patients who underwent CTR. Pre-operative USG was performed in neutral with no tendon loading; post-operative USG was performed in neutral unloaded and in various positions of wrist flexion whilst loading the flexor tendons with gripping.The mean volar migration of the flexor tendons after CTR was 2.2 (SD 0.4) mm in the unloaded neutral position. It was 1.8 (SD 0.4) mm in patients who did not develop TF and 2.5 (SD 0.5) mm in those who did ( p = 0.0067). In loaded wrist flexion, the mean volar migration of flexor tendons after CTR in patients who did not develop TF and those who did was 2.1 and 3.0 mm in 0° flexion; 3.2 and 3.9 mm in 15° flexion; 4.3 and 5.1 mm in 30° flexion; and 4.9 and 5.8 mm in 45° flexion, respectively. There were significant differences between patients with and without TF at each flexion angle.Our data indicate that patients with greater volar migration of the flexor tendons after CTR are more likely to develop TF. This conclusion supports the hypothesis that the occurrence of TF after CTR may be caused by the bowstringing effects of the flexor tendons.

WOS: 000417251000015 PubMed: 28454779 The main complaints in extensor tendon dislocations are pain, swelling, sense of discomfort, snapping and difficulty in writing and forceful flexion. However, congenital extensor tendon subluxations may present with triggering of the fingers due to tendon dislocations. Unnecessary Al pulley release may be performed for pseudotriggerring with unsuccessful results. Here, we report an unusual case of congenital extensor tendon subluxation of multiple digits with triggering of the left little finger and aim to attract notice to pseudotriggering of the digits due to tendon dislocations. An extensor hood reconstruction performed by an extensor digitorum communis tendon slip which is passed beneath the deep inter metacarpal ligament is a successful choice of treatment for these patients. (C) 2017 Turkish Association of Orthopaedics and Traumatology. Publishing services by Elsevier B.V.

Background: We report a variant of paediatric trigger thumb which is locked in extension rather than flexion. Methods: Eleven children with 14 trigger thumbs (three bilateral) locked in extension were reviewed retrospectively over a 12-year period. The number of flexed trigger thumbs encountered over this period was established from the operating room database. Results: All children were treated with release of the A1 pulley. Nine children achieved a full range of motion at the interphalangeal joint. One child with bilateral extended trigger thumbs required bilateral dorsal capsulotomy and another child developed temporary mild triggering in flexion. Conclusions: Approximately 1% of trigger thumbs treated operatively at this institution presented as the extended variant. Trigger thumb locked in extension should be considered in a child presenting with inability to flex the thumb.

Developmental trigger thumb, although uncommon, can be easily identifiable in the pediatric outpatient visit. Patients often present with their thumb locked in flexion and a firm nodule at the base of the thumb. The thumb is usually passively correctable and nonpainful. It is important to examine the opposite thumb as bilateral trigger thumbs occur at a rate of 25% to 30%. Nonsurgical options have been proposed in the past including watchful waiting, extension exercises, splinting, and steroid injections with mixed results. Surgical intervention is indicated when there is painful triggering or the thumb is not passively correctable. Surgical treatment is an outpatient procedure that involves releasing the thumb flexor tendon from a small fibrous sheath called the A1 pulley. The overall recurrence rate after surgery is 1.4%. Our recommendation is for early referral to a pediatric orthopedic surgeon to evaluate for the need for surgical intervention. [ Pediatr Ann . 2016;45(4):e135–e138.]

Purpose The anatomical arrangement of the thumb pulley system continues to be revised through ongoing investigative research, changing our previous assumptions. This study demonstrates the components and anatomical features of this pulley system in an effort to improve surgical outcomes and to clarify current misconceptions. Methods Researchers procured 75 hand specimens from 41 adult cadavers through our institution's anatomical donations program. Dissections of the thumb and thenar compartment identified the various pulleys. A detailed analysis of the thumb pulleys was performed through various measurements. Results Four different pulley categories were identified: type I (n = 5), type II (n = 29), type III (n = 29), and type IV (n = 12). The variable annular pulley was present in 70 of 75 hands (93%) in 1 of 3 arrangements: transverse, oblique, or fused with the A1 pulley. Conclusions The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3. Along with the A1 pulley, the additional variable annular pulley might contribute to stenosis in trigger thumb. This might necessitate a more extensive surgical incision and its partial release to relieve triggering. Clinical relevance Understanding the anatomical configuration of the thumb pulley system will aid in the surgical attempt to resolve triggering while avoiding complications such as bowstringing of the flexor pollicis longus tendon and iatrogenic nerve injury.

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.

Decreasing rupture rates after flexor tendon repair is accomplished by increasing the strength of the repair and by decreasing the forces across tendons during rehabilitation. The authors sought to determine whether A1 pulley release affects work of flexion after a zone 2 flexor tendon repair.Four fresh-frozen cadaveric hands were thawed to room temperature. The flexor digitorum profundus and flexor pollicis longus tendons were tested in a tensile testing machine. In hands 1 and 2, work of flexion of uninjured tendons was evaluated through the sequential division of the A1 pulley, starting with either the proximal 50 percent or the distal 50 percent of the pulley. In hands 3 and 4, zone 2 flexor digitorum profundus lacerations were created and repaired using a modified Kessler technique; then, sequential division of the A1 pulley was performed. Force-excursion curves were generated and used to calculate work of flexion. Analysis of variance was performed for multigroup comparisons, and t tests were performed for pairwise comparisons. Values of p0.05 were considered statistically significant.In uninjured tendons, work of flexion decreased with sequential division of the A1 pulley. After tendon repair, work of flexion increased significantly from baseline in all digits. A1 pulley release after flexor tendon repair produced significant decreases in work of flexion in all digits.A1 pulley release effectively decreases work of flexion after flexor tendon repair. Release performed at the time of tendon repair may decrease the forces across tendons in the postoperative period.

Objective: The aim of this study was to determine the efficacy of sonographically guided intra-flexoral sheath corticosteroid injection in the treatment of trigger thumb.Methods: This study included 112 trigger thumbs of 104 patients (7 males, 97 females; mean age: 52.11 years) studied prospectively from 2009 to 2011. All patients experienced pain, tenderness, discomfort and/or triggering with flexion/extension of the thumb and palpable nodules at the level of the A1 pulley. Ultrasonographically guided corticosteroid injection was performed on all affected thumbs. Thumb improvement was evaluated using the Quinnell grading system and patients were followed up for one year.Results: All 112 thumbs received one ultrasonographically guided corticosteroid injection. Fifteen thumbs (13.4%) needed re-injection and/or surgery during their one year follow-up. Eight (53.3%) of these 15 cases, had a pre-treatment Quinnell Grade of 4, six (40%) thumbs were Grade 3 and one (6.7%) was Grade 2. Twelve were re-injected, two underwent surgery without re-injection and one underwent surgery after showing no improvement following re-injection. There was a significant reduction in the post-injection Quinnell grade (p, Amaç: Bu çalışmanın amacı tetik parmak tedavisinde ultrason eşliğinde fleksör kılıf içi kortikosteroid enjeksiyonunun etkinliğini saptamaktı.Çalışma planı: Çalışmaya 2009-2011 yılları arasında prospektif olarak incelenen 104 hastanın (7 erkek, 97 kadın; ortalama yaş: 52.11) 112 tetik parmağı dahil edildi. Hastaların tamamında ağrı, hassasiyet, rahatsızlık ve/veya başparmağın fleksiyon veya ekstansiyonunda tetikleme şikayeti mevcuttu. A1 pulley seviyesinde nodüller palpe edilebiliyordu. Etkilenen tüm başparmaklara ultrason kılavuzluğunda kortikosteroid enjeksiyonu yapıldı. Bir yıl boyunca takip edilen hastaların başparmaklarındaki iyileşme Quinnell derecelendirme sistemine göre değerlendirildi. Bulgular: Yüz on iki parmağın tamamına ultrasonografi kılavuzluğunda kortikosteroid enjeksiyonu bir kez yapıldı. Bir yıllık takiplerinde on beş başparmağa (%13.4) tekrar enjeksiyon ve/veya cerrahi yapılması gerekti. Tedavi öncesi Quinnell sınıflamasına göre bu 15 parmağın 8'i (%53.3) 4. derece, 6'sı (%40) 3. derece ve biri (%6.7) 2. derece idi. On ikisine tekrar enjeksiyon yapılırken, ikisine cerrahi girişim uygulandı. Bir parmakta da enjeksiyon sonrası iyileşme görülmemesi üzerine cerrahi gerçekleştirildi. Enjeksiyon sonrası Quinnell derecelerinde anlamlı şekilde düşüş gözlendi (p

Tendon injuries are the second most common hand injuries in orthopedic patients. Tendon adhesions are one of the most concerning complications after surgical repair of the flexor tendon injury, particularly in zone II, which extends from the A1 pulley to the distal insertion of the Flexor Digitorum Superficialis (FDS) tendon in the finger [1,2].

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.

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.

Purpose: The purpose of this study was to compare the results of blind versus ultrasonography-guided percutaneous A1 pulley release for treatment of trigger finger. Methods: This prospective study included 21 patients (25 fingers) who underwent blind release and 20 patients (23 fingers) who underwent ultrasonography-guided release. The visual analog scale (VAS) score, proximal interphalangeal joint contracture, complications, and patient satisfaction were compared between the groups. Results: At the final follow-up, triggering had disappeared in all patients who underwent ultrasonography-guided release, whereas three patients who underwent blind release required revision surgery for postoperative triggering. No complications were observed. VAS score was significantly different between groups at 2 and 4 weeks postoperatively. All patients who underwent ultrasonography-guided release were satisfied, whereas three patients who underwent blind release were not satisfied. Conclusion: Ultrasonography-guided percutaneous A1 pulley release for treatment of trigger finger reduces postoperative pain and complications, such as incomplete release, compared with a blind procedure.

Purpose Pediatric trigger thumb is regarded as an acquired condition characterized by flexion deformity of the interphalangeal joint of the thumb. However, the exact etiology and pathoanatomy of this condition remain unknown. The purpose of this study was to evaluate cross-sectional configurations of the flexor pollicis longus (FPL) tendon and the area under the A1 pulley quantitatively using ultrasonography. Methods In this study we enrolled 43 patients, 23 boys and 20 girls, with unilateral pediatric trigger thumb. We measured the anteroposterior (AP) diameter, radioulnar diameter, and cross-sectional area of the FPL tendon at the level of the greatest AP diameter of the FPL tendon proximal to the A1 pulley and those of the inner dimensions of the A1 pulley using ultrasonography. The measurements were repeated on the contralateral side. Average age at the time of the measurements was 32 months. Results Average AP and radioulnar measurements of the FPL tendon were 13% and 55% larger than those of the inner dimensions of the A1 pulley in the trigger thumb. The average AP measurement in the area under the A1 pulley was notably larger in the trigger thumb than on the normal side. Conclusions Using ultrasonographic measurements, we were able to identify enlargement of the FPL tendon proximal to the A1 pulley in the symptomatic thumb, compared with the area under the A1 pulley in the symptomatic thumb or FPL tendon on the contralateral side. Developmental mismatch between the FPL tendon and the area under the A1 pulley is a possible cause of pediatric trigger thumb. Type of study/level of evidence Diagnostic IV.

Purpose We aimed to report by light microscopy the normal histology of the A1 pulley, describe the histologic abnormalities of A1 pulleys in trigger digits, and look for possible correlations between these findings and the severity of the disease. Methods In a series of 104 trigger digits operated on in 80 adult patients, the A1 pulleys were removed and histologically studied. The findings were compared with 55 normal A1 pulleys obtained from fresh-frozen cadaveric specimens. Results The normal A1 pulley was composed of 3 layers: layer I, an inner, avascular, concave unicellular or bicellular gliding layer containing cartilage-like cells; layer II, a middle layer, also avascular, characterized by spindle-shaped fibroblasts; and layer III, an outer, richly vascularized layer, continuous with the membranous tendons sheath. We used a 3-grade classification, increasing in severity, to describe the histologic abnormalities observed in trigger digit A1 pulleys. Mild abnormalities (grade 1) were those with a fibrocartilaginous gliding surface almost intact. The margin between the fibrocartilaginous and membranous portions of the pulley was well delineated. In moderate abnormalities (grade 2), the avascular fibrocartilaginous gliding surface appeared fissured and thinner. The inner layer (I) was interrupted and replaced by fibrous tissue, with fissures that did not cross through the middle layer (II). A mild vascular network hyperplasia was observed in the outer layer (III), which began to invade the fibrocartilage. In severe abnormalities (grade 3), the fibrocartilaginous gliding surface was thin, discontinuous, or even completely destroyed. The vascular network hyperplasia became excessive and reached the synovial space of the flexor tendon sheath. The histologic features were correlated with the severity of the clinical symptoms (p Conclusions The histologic abnormalities observed in the A1 pulley of trigger digits are characteristic and not related to inflammation. As the trigger digit worsens, the gliding surface begins to wear and is gradually replaced by a secondary invasive hyperplasia from the outer layer. These abnormalities could be caused by a modification or an increase of the mechanical stresses along the flexor tendons.

Objective. The purpose of this study was to describe the sonographic appearance of the first annular (A1) pulley–flexor tendon complex in patients with trigger fingers. Methods. Thirty-three trigger fingers in 33 patients were examined with a 7- to 15-MHz probe. A control group consisted of 20 patients without trigger fingers. The study included systematic measurement of the thickness of the A1 pulley and a power Doppler assessment of the pulleys, tendons, and tendon sheaths. Results. Thickening and hypoechogenicity of the A1 pulley were found in all patients with trigger fingers. Measurements of A1 pulley thickness were significantly different (P < .0001) between the groups without trigger fingers (mean, 0.5 mm; range, 0.4–0.6 mm) and with trigger fingers (mean, 1.8 mm; range, 1.1–2.9 mm). Hypervascularization of the A1 pulley on power Doppler imaging was found in 91% of the trigger fingers but was never found in the healthy control group. Flexor tendinosis was found in 48% of the trigger fingers; tenosynovitis was found in 55%; and both were found in 39%. In the control group, tenosynovitis and tendinosis were not found. Conclusions. Thickening and hypervascularization of the A1 pulley are the hallmarks of trigger fingers on sonography. Other frequently observed features include distal flexor tendinosis and tenosynovitis. Key words: finger; power Doppler sonography; sonography.

A prospective study was performed in 19 patients with trigger thumbs to define the anatomy of the A1 pulley of the thumb in this condition and to evaluate biomechanical parameters of the thumb after complete division of the A1 pulley. Pre- and postoperatively, flexion of the interphalangeal and metacarpophalangeal joints, key pinch strength and tip pinch strength were measured and compared with these measurements on the contralateral thumb. We identified three types of A1 pulley. The clinical data showed that there is no deficit with respect to motion and strength of the thumb after completely sectioning any of the three types of A1 pulley.

Trigger finger is a common finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. Although it can occur in anyone, it is seen more frequently in the diabetic population and in women, typically in the fifth to sixth decade of life. The diagnosis is usually fairly straightforward, as most patients complain of clicking or locking of the finger, but other pathological processes such as fracture, tumor, or other traumatic soft tissue injuries must be excluded. Treatment modalities, including splinting, corticosteroid injection, or surgical release, are very effective and are tailored to the severity and duration of symptoms.

The purpose of our study was to review the clinical features and determine the results following surgical excision of a flexor tendon sheath ganglion. A retrospective analysis of 24 consecutive patients (25 ganglions) who underwent excision of a painful flexor tendon sheath ganglion by the same surgeon was performed. The patient's medical and operative records were reviewed. Each patient was invited to return for an evaluation, which consisted of a clinical interview, completion of a questionnaire, and physical examination. Those patients that were unable to return underwent a detailed telephone interview. Sixteen patients returned for a clinical evaluation, while eight patients underwent a telephone interview. There were 15 women and nine men, with an average age of 43 years (range, 21–68 years). The dominant hand was involved in 15 patients. The long finger was most commonly involved (11 cases). The ganglion arose from the A1 pulley in 13 cases, between the A1 and A2 pulleys in three cases, and from the A2 pulley in nine cases. At an average follow-up of 18.5 months (range, 5–38 months), all of the patients were satisfied with their final result. No patient developed a recurrence and all returned to their previous functional level. There were two minor complications that resolved uneventfully; one patient experienced mild incisional tenderness, while an additional patient experienced transient digital nerve paresthesias. We conclude that surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath.

Purpose. To evaluate the condition of the tendons and neurovascular bundles after percutaneous release for trigger finger of the middle, ring, and little fingers. Methods. 30 women and 13 men aged 20 to 55 (mean, 40) years underwent percutaneous release of the A1 pulley using a 18-gauge needle for 43 trigger fingers of the middle, ring, or little finger unresponsive to conservative treatment. 19 trigger fingers were grade II and 24 were grade III. Open exploration was performed to evaluate the condition of the tendons and neurovascular bundles after percutaneous release. Results. Incomplete release of the A1 pulley was noted in 3 fingers, which occurred during the early study period. Superficial flexor tendon laceration was noted in 6 fingers but this did not interfere with tendon function. No injury to the A2 pulley, nerve, or artery of any finger was noted. Conclusion. Percutaneous release of trigger fingers is quick, safe, and effective.

A 39-year-old woman sustained a small wound on the palm of her right hand, which quickly healed naturally; however, a month later pain and limited range of motion were noted in her right finger. Surgery revealed the radial half of the flexor digitorum superficialis (FDS) tendon was ruptured and formed a flap, which hooked at the entrance of the A1 pulley. The proximal stump was sutured to the remaining ulnar (normal) side of the FDS tendon. Locking occurs between the tendon flap and the tendon sheath; therefore, when there is no fibrous tendon sheath near the partially ruptured tendon, locking will not occur.

A retrospective trial of percutaneous release for 40 trigger thumbs in 33 children under different types of anesthesia (general versus local) at a mean age of 2.5 years was conducted between February 1989 and March 2003. Based on the tolerance of the child and parents, 20 children were processed using local anesthesia at our office and 13 children were given general anesthesia. We recommend special manipulation to ensure complete release of the A1 pulley when general anesthesia is necessary. Of the 26 trigger thumbs in the local anesthesia group, 23 were successfully released. Only one patient in the general anesthesia group had an unsatisfactory outcome. Percutaneous surgery achieved a 90% successful release rate for trigger thumb in children, without recurrence. There was no statistical difference in the release of trigger thumbs with these two anesthetic procedures ( p = 0.66). Overall, 37 trigger thumbs achieved full extension and flexion without any residual deformity following percutaneous release. Our results suggest that percutaneous release for trigger thumb is satisfactory, no matter which method of anesthesia is used.

Although trigger finger occurs mostly due to a problem at the A1 pulley various other causes have also been reported. We present three patients with different tumors at the carpal tunnel as a cause of triggering. All patients were treated with local excision., Tetik parmak genellikle A1 pulley seviyesindeki sorun nedeni ile ortaya çıksa da, literatürde farklı nedenler de bildirilmiştir. Çalışmamızda, tetiklenme nedeni olarak karpal tünel seviyesinde tümör saptanan ve bu tümörlerin lokal eksizyonu ile tedavi edilen üç hastayı sunuyoruz.

We describe a rare experience with the treatment of a patient with finger flexion contracture caused by muscular involvement of sarcoidosis, who had been misdiagnosed as having a trigger finger and underwent surgical release of the A1 pulley of her little finger. This report serves as a reminder that muscular involvement of sarcoidosis can cause finger flexion contractures.

Background: Trigger finger is a rare condition in children and it is even more uncommon in the 5th finger. The etiology of Trigger finger includes congenital cases, which are the most common and usually affects the thumb; posttraumatic cases, more frequent after penetrating injury; and tumoral cases. Methods: In this paper, we report a post-traumatic trigger finger on a 2-year-old girl who was seen in our clinic complaining of triggering in her small left finger, following a slight contusion. As far as we know there is no previous report of this condition involving the fifth finger in toddlers. Conclusions: The natural history of pediatric trigger finger is poorly characterized due to the small number of retrospective cases series available. Based on our experience, the methodology to be followed would be, after a thorough history and after ruling out concomitant pathology, if a congenital trigger finger in a child come into our clinic, the most successful resolution is release of the A1 pulley.

We evaluated trigger fingers ultrasonographically and clarified differences between fingers with and without continuous locking or snapping symptoms according to the thicknesses of the A1 pulley, flexor tendon and volar plate.We evaluated 26 trigger fingers, divided into two groups: Group 1, 14 fingers with locking or snapping; and Group 2, 12 fingers without such symptoms. We also evaluated 26 contralateral fingers as controls (Control 1 and 2 groups). We compared each group to the respective control group according to thickness of the A1 pulley and volar plate, and cross-sectional area of the flexor tendon. In addition, nine fingers with locking or snapping and treated using corticosteroid injection were evaluated according to symptoms and sonographic findings 3-4 weeks after treatment.Thickness of the A1 pulley and cross-sectional area of the flexor tendon were greater in both Groups 1 and 2 than in controls. Thickness of the volar plate was greater in Group 1 than in Control 1, although no significant difference was seen between Group 2 and Control 2. In Group 1, eight of the nine fingers showed an alleviation of locking or snapping symptoms with corticosteroid injection, and sonographic findings showed that thickness of the volar plate was significantly decreased with corticosteroid injection, in addition to reduced thickness of the A1 pulley.In addition to thickening of the A1 pulley, thickening of the volar plate may represent an important contributor to continuous snapping or locking symptoms.

We aimed to investigate the relationship between the pulley-tendon complexes and the severity of trigger finger. The thickness of the A1 and A2 pulleys, and the cross-sectional area of the flexor tendon under the pulleys, were prospectively assessed using 17 MHz high-resolution ultrasonography, in 20 patients with trigger finger (31 fingers). A control group comprised 15 asymptomatic fingers. The thickness of the A1 pulley and the proximal part of the A2 pulley, and the cross-sectional area of the flexor tendon under the A2 pulley, were significantly increased in the patient group. Clinical grade was significantly correlated with the thickness of the A1 pulley, the thickness of the proximal part of the A2 pulley, and the cross-sectional area of the flexor tendon under the proximal part of the A2 pulley. This study confirmed that the thickness of the A2 pulley and flexor tendon under the A2 pulley seems to be related to the severity of trigger finger. Level of evidences: Level III

conventional treatment for trigger digits.1 Although minimally invasive techniques have been developed in various areas of orthopaedic surgery,2–4 percutaneous release of the A1 pulley remains controversial owing to the risk of neurovascular injuries.5 New instruments such as the hypodermic needle, tenotome, blade, and specially designed knives and needle knives have been developed.6–11 A cadaveric study has shown that percutaneous release of the A1 pulley can be safely and effectively performed with low risk for neurovascular structures.12 In a meta-analysis of randomised controlled trials comparing percutaneous release with open surgery Commentary: Percutaneous release of the A1 pulley using a modified Kirschner wire: a cadaveric study

PURPOSE. To evaluate the outcome of percutaneous release of the A1 pulley in 40 cadaveric fingers using a modified Kirschner wire. METHODS. A 2.5-mm-diameter Kirschner wire measuring >12 cm in length was used. One end of the wire was sharpened into a 'J' shape using a grinder. The J-shaped tip featured a blunt, elongated lower tip, a sharp J-shaped curve, and a blunt upper tip. Completeness of A1 pulley release and injuries to the A2 pulley, flexor tendon, and neurovascular structures were evaluated in 40 cadaveric fingers. RESULTS. Complete release of the A1 pulley was achieved in 8 index, 7 middle, 8 ring, and 8 little fingers, whereas incomplete release of the distal part was noted in 2 index, 2 middle, 2 ring, and one little fingers; release was missed in one middle and one little fingers. Injury to the A2 pulley was noted in 2 index fingers; the injury was minimal and limited to the proximal 2 mm of the A2 pulley. There was no flexor tendon or digital nerve injury in any finger. CONCLUSION. Percutaneous release of the A1 pulley using a modified Kirschner wire achieved complete release in 78% of cadaveric fingers, which is comparable to that using a specially manufactured push knife.

Four fresh-frozen arms were biomechanically tested to determine the effect of the route of tendon transfer (dorsal vs volar) and the site of digital tendon insertion (A1 pulley, A2 pulley, proximal phalanx, or lateral band/extensor mechanism) on restoring metacarpophalangeal joint flexion and interphalangeal joint extension. A volar carpal canal route of tendon transfer appears to be more mechanically efficient than a dorsal intermetacarpal route. A lateral band insertion provides a small but significant increase in proximal interphalangeal and distal interphalangeal joint extension. (J Hand Surg 1999;24A:609–613. Copyright © 1999 by the American Society for Surgery of the Hand.)