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TRIGGER THUMB

Introduction

Trigger thumb, or stenosing tenosynovitis, occurs when the flexor tendons cannot pass through the A-1 pulley smoothly. Whether the pulley thickens, the tenosynovium thickens and/or the tendons deform and develop a "nodule," the result is the same: loss of smooth active flexion and extension in the digit. The digit can lock in flexion or extension or simply be difficult to move without significant pain.

Related Anatomy

  • Caused by anomalous anatomy, including abnormal lumbrical insertion and/or proximal decussation of flexor digitorum sublimis (FDS) tendon
  • Narrowing/thickening of FDS tendon sheath at the A1 pulley level
  • Histology shows non-inflammatory fibrosis; occasionally, chronic inflammatory cells are present

Relevant Basic Science

  • When tendon sheath becomes edematous, the sheath becomes fibrotic and may undergo cartilaginous metaplasia; the tendon becomes thinner and fibrotic

Incidence and Related Conditions

  • More common in women; pregnancy is a predisposing risk factor
  • Predisposing systemic conditions: rheumatoid arthritis, diabetes, gout, amyloidosis, mucopolysaccharidoses
  • Often comorbid with DeQuervain’s disease and carpal tunnel syndrome

Differential Diagnosis

  • DeQuervain’s disease
  • Dupuytren’s contracture
  • MP joint loose body/dislocation
  • Tendon sheath tumor
  • Intrinsic tendon injury on an irregular metacarpal head
  • Rheumatoid arthritis
ICD-10 Codes

  • TRIGGER THUMB

    Diagnostic Guide Name

    TRIGGER THUMB

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    TRIGGER THUMB M65.312M65.311 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Trigger Thumb with IP joint locked in flexion
    Trigger Thumb with IP joint locked in flexion
Symptoms
Pain at the base of the thumb near the MP joint
Clicking, catching, triggering or locking of thumb or finger with motion
Flexion or extension contracture due to a permanently locked trigger thumb
Typical History

A patient often notices a click in his or her thumb that eventually becomes painful.  The patient may eventually be unable to fully flex or extend the thumb without pulling the thumb with the other hand. In chronic cases, the trigger finger may become locked, resulting in fixed-joint contracture.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Trigger thumbs have normal X-rays
    Trigger thumbs have normal X-rays
Treatment Options
Treatment Goals

Treatment Goals

Goals

      •    Stop the pain, catching, and/or finger locking
      •    Return hand to normal active range of motion with a normal pain-free grip
      •    When making treatment recommendations, consider patients grade according to Green’s classification


Green’s Classification
       •    Grade I: Pain, history of catching, but no demonstrable trigger
       •    Grade II: Demonstrable catching, actively correctable
       •    Grade III: Demonstrable locking, passively correctable
       •    Grade IV: Fixed contracture

Conservative
  • Activity modification
  • Splinting
  • NSAIDS
  • Corticosteroid injections
Operative
  • Percutaneous release of A1 pulley (extra risk in the thumb)
  • Open release or excision of the A1 pulley
Treatment Photos and Diagrams
  • Trigger Thumb Incision
    Trigger Thumb Incision
  • Trigger Thumb Thickened A-1 pulley
    Trigger Thumb Thickened A-1 pulley
  • Trigger Thumb Thickened A-1 pulley cut edges (arrows)
    Trigger Thumb Thickened A-1 pulley cut edges (arrows)
  • Trigger Thumb - Arrow separates "Notta's" section proximally from normal FPL distal to A-1 constriction.
    Trigger Thumb - Arrow separates "Notta's" section proximally from normal FPL distal to A-1 constriction.
  • Trigger Thumb - IP Joint now extends easily.
    Trigger Thumb - IP Joint now extends easily.
  • Trigger Thumb - Wound closure
    Trigger Thumb - Wound closure

Work-up Comments

X-rays are sometimes needed to verify the existence of co-existing arthritis particularly in the PIP joint or for other special circumstances. 

Ultrasound can be used to verify the deformity of the flexor tendons, flexor tendon sheath, or volar plate but is not needed when making a routine diagnosis of trigger finger. When treating trigger fingers with a cortisone injection, ultrasound can be useful for guiding the needle.

MRI can be used to verify the changes of the flexor tendons, flexor tendon sheath, and the volar plate but is not needed when making a routine diagnosis of trigger finger. MRI can be helpful when associated lesions such as a tumor are present with a trigger finger and further evaluation is warranted.

CPT Codes for Treatment Options

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Common Procedure Name
Trigger finger release (trigger thumb release)
CPT Description
Tendon sheath incision trigger finger
CPT Code Number
26055
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Complications

Operative: infection, secondary adherence, scar tenderness, mild PIP joint contractures, neurovascular bundle injuries, ulnar drift of digit, bowstringing.

Outcomes
  • Conservative: short-term symptom relief; higher rates of long-term recurrence.
  • Operative: nearly all patients are satisfied with results.
Key Educational Points
  • The radial digital nerve of the thumb is at risk during trigger thumb release in adults and children because of its oblique orientation overlying the A1 pulley.
References

New Articles

  1. Guler F, Kose O, Ercan EC, et al.  Open versus percutaneous release for the treatment of trigger thumb. Orthopedics 2013;36(10):e1290-4. PMID: 24093706
  2. Patel RM, Chilelli BJ, Ivy AD, Kalainov DM. Hand surface landmarks and measurements in the treatment of trigger thumb. J Hand Surg Am2013;38(6):1166-71. PMID: 23591023

Reviews

  1. Vargas A, Chiapas-Gasca K, Hernández-Díaz C, et al. Clinical anatomy of the hand. Reumatol Clin2012;8(S2):25-32. PMID: 23219083
  2. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am2006;31(1):135-46 PMID: 16443118

Classics

  1. Woolf AE. Trigger Thumb. Proc R Soc Med 1921;14(Surg Sect):142. PMID: 19982073
  2. Hueston JT, Wilson WF, Soin K. Trigger thumb. Med J Aust 1973;2(23):1044-5. PMID: 4544198

Hand Therapy References

  1. Cannon, et al. (2001).  Diagnosis and Treatment Manual for Physicians and Therapists, Upper extremity Rehabilitation (4th ed).  The Hand Rehabilitation Center of Indiana.
  2. Mackin, Callahan, Skirven, Schneider, and Osterman, (2002). Rehabilitation of the Hand and Upper Extremity, 1, (5th ed). St Louis, MO: Mosby Year Book, Inc.
  3. Cooper, (2014). Fundamentals of Hand Therapy; Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, (2nd ed). Mosby, imprint of Elsevier Inc.
  4. Stanley and Tribuzi. (1992).  Concepts in Hand Rehabilitation.  F. A. Davis Company
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