Trigger Finger dnbid

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Trigger Finger:

Trigger Finger dnbid

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Anatomy The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys.

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Pulleys

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These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium .

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Tenosynovium

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The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

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Grasp Objects

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Causes

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Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule.

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Rheumatoid arthritis, partial tendon lacerations, repeated trauma from pistol-gripped power tools, or long hours grasping a steering wheel can cause triggering. Infection or damage to the synovium causes a rounded swelling (nodule) to form in the tendon. Triggering can also be caused by a congenital defect that forms a nodule in the tendon. The condition is not usually noticeable until infants begin to use their hands.

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Symptoms The symptoms of trigger finger or thumb include pain and a funny clicking sensation when the finger or thumb is bent. Pain usually occurs when the finger or thumb is bent and straightened. Tenderness usually occurs over the area of the nodule, at the bottom of the finger or thumb.

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Nodule Area

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The clicking sensation occurs when the nodule moves through the tunnel formed by the pulley ligaments. With the finger straight, the nodule is at the far edge of the surrounding ligament. When the finger is flexed, the nodule passes under the ligament and causes the clicking sensation.

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If the nodule becomes too large it may pass under the ligament, but it gets stuck at the near edge. The nodule cannot move back through the tunnel, and the finger is locked in the flexed trigger position.

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Flexed Trigger Position

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Diagnosis The diagnosis of trigger finger and thumb is usually quite obvious on physical examination. Usually a palpable click can be felt as the nodule snaps under the first finger pulley. If the condition is allowed to progress, the nodule may swell to the point where it gets caught and the finger is locked in a bent, or flexed, position.

Treatment :

Treatment Non-surgical Rehabilitation Physiotherapy programs are most effective when triggering has been present for less than four months. Physiotherapists may build a splint to hold and rest the inflamed area. do special exercises to encourage normal gliding of the tendon. change your activities to prevent triggering and to give the inflamed area a chance to heal.

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Therapy sessions sometimes include iontophoresis , which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can't tolerate injections.

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May recommend a cortisone injection into the tendon sheath to decrease the inflammation and shrink the nodule. This can help relieve the triggering, but the results may be short lived. When triggering has been present for more than four months, nonsurgical treatment is usually short-lived. Patient may get some relief of symptoms with a cortisone injection. If patient wear a splint, the nodule may shrink temporarily, but patients often end up needing surgery for this problem.

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Post-surgical Rehabilitation Patient probably wears a fairly large padded bandage on hand over the area after surgery until the stitches are removed. This is to provide gentle compression and reduce the bleeding and swelling that occurs immediately after surgery. The bandage can be removed fairly soon after surgery, and is usually only required for the first 24 to 48 hours. Physiotherapy after surgery, begins with gentle range-of-motion exercises.

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Patient will particularly benefit from physiotherapy if finger or thumb was locked for a while prior to surgery. In these cases, the finger or thumb may not straighten out right away after the surgery. Physiotherapist may apply a special brace to get the finger or thumb to straighten it. Heat treatments, soft-tissue massage, and hands-on stretching also may help with the range of motion.

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Some of the exercises are to help strengthen and stabilize the muscles and joints in the hand. Physiotherapist will use other exercises to improve fine motor control and dexterity. Provide tips on ways to do your activities while avoiding extra strain on the healing tendon. Although the time required for recovery varies among patients, as a general rule, may need to participate in physiotherapy two to three sessions each week for up to six weeks.

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PT goal is to help speed recovery so that patient can more quickly return to everyday activities. An ongoing home program.

Surgery :

Surgery The usual solution for treating a trigger digit is surgery to open the pulley that is obstructing the nodule and keeping the tendon from sliding smoothly. This surgery can usually be done as an outpatient procedure.

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The surgery can be done using a general anesthetic or a regional anesthetic . A regional anesthetic blocks the nerves going to only a portion of the body. Injection of medications similar to lidocaine are used to block the nerves for several hours. This type of anesthesia could be an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep). The surgery can also be performed by simply injecting lidocaine around the area of the incision.

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There are several types of incisions that can be made, but most are made along the natural creases and lines in the hand. This will help make the scar less noticeable once the hand is healed.

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The skin and fascia are separated so the tendon pulley can be seen. Special care is taken not to damage the nearby nerves and blood vessels. Next, surgeon carefully divides the tendon pulley. Once the tendon pulley has been separated, the skin is sewn together with fine stitches.

Physical Therapy Management  :

Physical Therapy Management As with all disorders of the upper extremity, proximal segments must be screened.  Also, because posture can contribute to distal problems, it should be addressed to provide the patient with optimal outcomes. [12]

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Patient Education Since trigger finger is observed as an overuse injury, education is very important. Education should be given on: Rest Modifications of activities [13] Specialized tools Splinting Modalities Posture

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Splinting A first step in treatment is to stop doing activities that aggravate the condition. Splinting is one of the best ways to limit motion. Most authors agree that the intent of splinting is to alter the biomechanics of the flexor tendons while encouraging maximal differential tendon glide.

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However, authors disagree on which joints to include in the splint and the degree of joint positioning. [4] There are various ways to splint a patient but, ultimately, it will depend on what provides the patient with the most relief. Splints are usually worn for 6-10 weeks. It should be noted that splinting yields lower success rates in patients with severe triggering or longstanding duration of symptoms. [1]

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Two major types of splinting most recently studied: Splinting at the DIP joint.  This showed to have resolution in 50% of the patient’s symptoms. [1] Splinting at the MCP joint with 15 degrees of flexion.  This showed to have resolution of the patient’s symptoms at both 65% and 92.9%, which is consistent with the current literature. [4]

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Other Options [6][14][13] Modalities such as heat/ice, ultrasound, electric stimulation, massage, stretching, and joint motion (active and passive) can have some positive effects on trigger finger. It is thought that heat can help by providing increased blood flow and extensibility to the tendon. Following heat with stretching can provide more extensibility with plastic deformation. Joint movement and mobilizations increase joint and soft tissue mobility via a slow, passive therapeutic traction and translational gliding. [13]

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Tendon Exercises Perform a series of tendon gliding exercises. Start with your fingers extended outward and your thumb pointing away from and perpendicular to the palm. Flex your fingers toward your thumb, as if you're making the shape of a duck's beak. Your finger and thumb should be approximately 1/2 inch apart. From this position, curl your fingers into your palm, placing your thumb along the outside of the index finger. Curl your fingers more and make a fist; this time, curl your thumb over the outside of your knuckles. Slowly open your hand and lift the fingers, knuckles bent, into a upright position, your thumb again extended away from your palm. Repeat the sequence several times.

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Soft Tissue Mobilization Massage or soft tissue mobilization may help reduce the severity of your trigger finger or thumb constriction. Massage manipulates muscle, tendon and ligament tissues and floods the affected area with blood and nutrients. Massage also helps relax tightened muscles, which may facilitate other trigger finger exercises for greater efficacy and benefits.

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Palm Presses Hand and finger exercises that contract and extend the muscles and tendons of the fingers may provide relief and greater range of motion of the finger and thumb. Pick up small items and place them in your palm, squeezing tightly for several seconds. Release, opening your fingers wide, and then repeat as instructed by your physical therapist. Regular exercise and movement may help lengthen the flexor tendons, relieving symptoms of trigger finger.

Tendon Gliding :

Tendon Gliding

Strengthening :

Strengthening

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