#23 How to Inject Steroids for Trigger Finger Release TUTORIAL7th February 2012
Facelift SurgeryInjecting steroids to release the trigger finger video tutorial for general practitioners and the medically qualified individuals. Plastic surgeon Adrian Richards describes the causes and symptoms of Trigger finger and demonstrates how to inject the trigger finger with steroids to improve it by reducing the swelling in the tendons without resorting to surgery. For more information on Minor surgery training courses for GPs led by Mr. Adrian Richards of Aurora clinics, please call our FREE office number: 0800 3285743
Hi guys. My name is Adrian Richards. I’m a plastic surgeon and the Surgical Director of Aurora Clinics based here in the UK. In this short video – it’s one of a series we’re doing – I’m going to be talking about trigger finger, why you get it, and how you do an injection to help improve it. Now, the injection technique is obviously only for medical professionals, so don’t be tempted to even consider doing the injection at home on your own.
So, trigger finger, what is it? Well, essentially it’s a swelling of the tendons in the fingers, and because the tendons are held in tight sheaths, when you get a swelling, you get a sort of locking of the tendon in the opening of the sheath.
Ring finger is the most commonly effected. We always think that the middle finger is our power finger, but in fact the most power comes from the ring finger. When you bend your fingers, the ring finger is actually one of the longest fingers and the first one to take all the power.
This sheath in the fingers lies . . . this is called the distal palmar crease here. There’s basically a tunnel which comes all the way along here. Now, the tunnel has got lots of different pulleys, which is quite complicated, but basically the one you’re interested in is the A1 pulley. So we’ve got A1 going to A5, but A1 is the most towards your brain side pulley. It’s here, and then we’ve got a tendon which comes in here, and when the tendon gets a swelling on it, the knobble on the tendon will not go through the mouth of the pulley.
So what tends to happen is at night you bend your fingers. Your fingers are all bent at night. You get more swelling everywhere. You get swelling in your eyes, so you get puffy eyes in the morning. No different from your tendon. Everything gets a bit more swollen. Your finger’s bent. You get swollen in there. So first thing in the morning the tendon is swollen, and it won’t go through the mouth of the A1 pulley. So what tends to happen is the fingers are bent like that. It’s called trigger finger because you can sometimes straighten it yourself, from pulling the tendons, or some people actually have to physically straighten their fingers. Or in really severe cases, the tendon can get locked because that nodule won’t go through. So the tendons like that, and it’s called a trigger finger because you have to sort of trigger it to get that nodule to go through the finger.
So our aim of the treatment is to inject local anaesthetic and steroids around this knobble here to reduce the swelling on the outside of the tendon. So the swelling is caused by sinovium, which is on the outside of the tendon, and that’s what we want to reduce and by reducing that, we’re going to let the tendon slip simply in and out of that tendon sheath.
Trigger fingers can occur in any of the fingers. The most common is the ring. It can occur in the thumb, and I am going to now show you how to do a steroid injection to help trigger fingers.
So what I’m going to do, we couldn’t get anyone in the office to have a hand injection, so I’m doing it on our trusty model hand here. So I’m going to try and get the steroids around the tendon. It doesn’t actually have to be within the flexor sheath in the A1 pulley, because you can get these ganglions if you go through there. So I’m going to aim to get the steroid just around the nodule.
So the first thing to do, no touch technique, so I’m going to clean the area. Unfortunately, I’ll clean my marks off as well. But there you go. I wouldn’t normally need marks. Feel for the tendon nodule. Get the patient to move the finger up and down, and you feel the nodule moving up and down. It’s important to check that there is a nodule, because one of the other things that can give the appearance of trigger finger is subluxation of the extensor tendon on the back of the proximal phalangeal joint here. So just look for any clicking here, and make sure that you have got a nodule which moves when the patient moves.
Put your finger on it, locate the spot, and then with the numbers of the syringe up, bevel of the needle up, just pop through like that. Ideally, with the finger slightly bent. So the patient has got their finger bent. It’s difficult to do that, but I will try. Pop through, bevel up, pop through, through the skin, through the subcutaneous tissue, on top of the tendon. Now you might actually be on the tendon there. So if you ask the patient to straighten up their finger, that pulls the tendon away and you should be able to inject really, really easily. If there’s any resistance, stop injection. You should be able to inject really easily into that sheath. And then let’s direct on there, out we come.
Always with any type of hand surgery, same with facial surgery, hand up or head up. The higher above your heart it is the less arterial pressure you’re going to have, the less bleeding or swelling. Hand up, pressure on the area where it is direct for a couple of minutes. And then I always ask my patients to bend and straighten the fingers because that disperses the local anaesthetic and the steroids through the sheath. So a good old bend there. Okay.
Now the triggering will pretty much go or the patient will definitely feel much more comfortable pretty much immediately for the next hour, relief in the pain. But triggering may continue for a few days because what we’re trying to do is the steroid is reducing the sinovium around the tendon, and that’s going to take a little bit of time to work.
Really, really effective treatment. You can do it with any of the digits. Slightly different position, which I’ll show you in a minute, for each of the different pulleys. Probably I would only recommend a maximum of three times, really, for trigger finger release. If it keeps coming back after three times, really perhaps surgery is the best option. And the surgery is a very simple procedure performed under a local anaesthetic and just releases the pulley.
So, now I’m just going to show you the different sites to inject for each of the different digits. I’d just like to say thank you to my children. They’ve lent me their special pen set today. So thanks very much to all of them, and I’m going back to school with all my different colours. So, the flexor retinaculum, the A1 pulley is this red area here. The green line here, that’s the distal palmar crease, the proximal palmar crease. There are normally two creases in the thumb – the proximal one and the distal one.
So what you’re trying to do is get just before the crease, just before the A1 pulley. So in the little finger, you inject slightly distal to the crease and again, ring finger, slightly distal to the crease. In the middle finger, it’s between this crease, the distal palmar crease and the proximal palmar crease there, and the same for the index finger. For the index finger, remember all the tendons are coming from the carpal tunnel there, so they’re angling that way. So in the index finger the tendon is more this way. It’s more ulnar, more towards the little finger than you would think. In the thumb, you tend to inject just proximal to the, proximal thenar crease here, but interestingly again, remember the tendons are coming from the carpal tunnel so they’re going that way. So they’re much more around, much more towards the back of the hand than you would think. So you can either rotate the thumb and go in that way, or some people actually do the injections from that way. It doesn’t really matter which way you go. The important thing is to get the steroid in the right place.
So thanks very much for watching the video. I hope you found it interesting. Good luck with your steroid injections for trigger finger. It could be a really rewarding treatment actually because it’s a very painful condition, trigger finger, locking in the morning, very debilitating. Simple injection, 90% of the time it’s going to cure it. It can be great for you, great for the patient. But again, if it keeps coming back after three goes, probably the best thing to do is refer it to a suitable hand surgeon.
Thanks very much for watching the video.