QD95 - The Trigger Finger Save
QD Clinic - Lessons from the clinic
How I treat trigger finger with an ice cube
Features Dr. Jack Cush
Transcription
This is QD Clinic. Hi. I'm doctor Jack Cush with RheumNow. QD Clinic is brought to you by RheumNow's coverage of virtual ACR twenty twenty coming up in November. We've got the speakers, teachers, faculty.
We need the interactors. That's you. Today's case is the trigger finger. The patient's about 65 years old, well managed with knee OA, hand OA, history of diabetes, male, doing very well, and all of a sudden comes in with a new urgent appointment, and turns out my finger keeps getting stuck, doc. And they show you their finger that looks like this, although it's not stuck at this time.
And, of course, it's trigger finger. They thought it was a Dupuytren's contracture, and in fact, it's just the trigger finger. Intermittent pain, clicking, catching, when it gets stuck, it hurts. When it they try to open, it hurts. You know, trigger finger is not uncommon.
Who gets it? As you get older, although it starts usually around age 50, peaks around age 60, and is not uncommon in the elderly. Diabetics, women, people with osteoarthritis, even inflammatory arthritis, sometimes trauma, you can get a nodule on that, that tendon, and that gets stuck in the pulley as the tendon goes through the pulley, and that is basically the pathophysiology of the trigger finger. The objective would be to reduce the size of the nodular change that occurs. What fingers are most affected by this?
As you might imagine, it's the ring finger first, then the middle finger next, and then the index finger. It's seldom or less frequent on the thumb. It's pretty infrequent on the pinky. So the question is, how do you manage this? I thought this was really humorous.
I actually looked it up. I have my management of it, and I'm wondering if it sort of jives with your management of it. But if you look up the treatment of trigger finger, the literature is really bad, and it the literature is all very self serving, meaning that if you're a surgeon, the literature's all about the success of surgery. You know, surgery on the A1 pulley, and then, you know, it's fifty to eighty percent effective. If you're not a surgeon, you're talking about, actually, an interesting article from the Mayo Clinic this year, called, just shoot it.
Trigger finger, just shoot. Meaning, obviously, they're a big advocate for local injections. There's three approaches. There's conservative, there's local injections, and then there's surgery. By the way, in my opinion, half the patients work with conservative management.
That's meaning you don't do surgery, you don't inject, you tell the patient, rest. I like the idea of using a, ice cube. An ice cube is about the size of this RheumNow chip. I tell the patient, take the ice cube, put it in a paper towel, put it right there on the on that trigger finger three times a day for ten days. You're trying to shrink the size of the nodule.
It's kind of the same as basically putting a splint on the hand, not using the hand, using some reminder to reduce the activity. That's conservative management, with or without, an analgesic drug or non steroidal if that's tolerated. But basically, immobilization, ice, usual principles, and for the most part, time is taking care of the problem. That works in half the patients. These are my numbers.
The other half get steroid injections, and I often ask patients, What do you want? I can give you a steroid injection right there, and I can we do the ice, you know, three times a day for and you'll leave it on for, what, again, ten to fifteen minutes until it melts. Or we can do the steroid injection, and in my experience, they both work about half the time. The point being, conservative management works in fifty percent. Of those that whom it doesn't work, you do a steroid injection, and that works in fifty percent.
The literature on steroid injections, by the way, is somewhere between fifty and seventy percent effective when you use local infiltrated steroids, not into the tendon but peritendinous around the nodule, usually going in right at the crease here and going proximal to the nodule, or just distal to the nodule, proximal to the crease. And then surgery. And I don't know what the success of those guys are, but the hand surgeons say, Oh yeah, we fix these all the time. So, very few of my patients have progressed to surgery with trigger finger. Most time can take care of it, and getting to that time point that they're gonna get better, you can either use an injection or you can use, again, conservative management.
Systemic therapies don't work here. I mean, I would not use systemic steroids, I would not use disease modifying drugs, Nonsteroidals, I don't think really make much of a difference other than taking care of local pain. That's trigger finger. It happens a lot. I thought you'd want to know my perspective.
Check out RheumNow's coverage of the meeting. Again, we need interactors, people to learn and to basically teach us what they think about what we're saying about the meeting. Hopefully, it's gonna be you. We'll see you then.
We need the interactors. That's you. Today's case is the trigger finger. The patient's about 65 years old, well managed with knee OA, hand OA, history of diabetes, male, doing very well, and all of a sudden comes in with a new urgent appointment, and turns out my finger keeps getting stuck, doc. And they show you their finger that looks like this, although it's not stuck at this time.
And, of course, it's trigger finger. They thought it was a Dupuytren's contracture, and in fact, it's just the trigger finger. Intermittent pain, clicking, catching, when it gets stuck, it hurts. When it they try to open, it hurts. You know, trigger finger is not uncommon.
Who gets it? As you get older, although it starts usually around age 50, peaks around age 60, and is not uncommon in the elderly. Diabetics, women, people with osteoarthritis, even inflammatory arthritis, sometimes trauma, you can get a nodule on that, that tendon, and that gets stuck in the pulley as the tendon goes through the pulley, and that is basically the pathophysiology of the trigger finger. The objective would be to reduce the size of the nodular change that occurs. What fingers are most affected by this?
As you might imagine, it's the ring finger first, then the middle finger next, and then the index finger. It's seldom or less frequent on the thumb. It's pretty infrequent on the pinky. So the question is, how do you manage this? I thought this was really humorous.
I actually looked it up. I have my management of it, and I'm wondering if it sort of jives with your management of it. But if you look up the treatment of trigger finger, the literature is really bad, and it the literature is all very self serving, meaning that if you're a surgeon, the literature's all about the success of surgery. You know, surgery on the A1 pulley, and then, you know, it's fifty to eighty percent effective. If you're not a surgeon, you're talking about, actually, an interesting article from the Mayo Clinic this year, called, just shoot it.
Trigger finger, just shoot. Meaning, obviously, they're a big advocate for local injections. There's three approaches. There's conservative, there's local injections, and then there's surgery. By the way, in my opinion, half the patients work with conservative management.
That's meaning you don't do surgery, you don't inject, you tell the patient, rest. I like the idea of using a, ice cube. An ice cube is about the size of this RheumNow chip. I tell the patient, take the ice cube, put it in a paper towel, put it right there on the on that trigger finger three times a day for ten days. You're trying to shrink the size of the nodule.
It's kind of the same as basically putting a splint on the hand, not using the hand, using some reminder to reduce the activity. That's conservative management, with or without, an analgesic drug or non steroidal if that's tolerated. But basically, immobilization, ice, usual principles, and for the most part, time is taking care of the problem. That works in half the patients. These are my numbers.
The other half get steroid injections, and I often ask patients, What do you want? I can give you a steroid injection right there, and I can we do the ice, you know, three times a day for and you'll leave it on for, what, again, ten to fifteen minutes until it melts. Or we can do the steroid injection, and in my experience, they both work about half the time. The point being, conservative management works in fifty percent. Of those that whom it doesn't work, you do a steroid injection, and that works in fifty percent.
The literature on steroid injections, by the way, is somewhere between fifty and seventy percent effective when you use local infiltrated steroids, not into the tendon but peritendinous around the nodule, usually going in right at the crease here and going proximal to the nodule, or just distal to the nodule, proximal to the crease. And then surgery. And I don't know what the success of those guys are, but the hand surgeons say, Oh yeah, we fix these all the time. So, very few of my patients have progressed to surgery with trigger finger. Most time can take care of it, and getting to that time point that they're gonna get better, you can either use an injection or you can use, again, conservative management.
Systemic therapies don't work here. I mean, I would not use systemic steroids, I would not use disease modifying drugs, Nonsteroidals, I don't think really make much of a difference other than taking care of local pain. That's trigger finger. It happens a lot. I thought you'd want to know my perspective.
Check out RheumNow's coverage of the meeting. Again, we need interactors, people to learn and to basically teach us what they think about what we're saying about the meeting. Hopefully, it's gonna be you. We'll see you then.
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