Introduction

The following information is a guide to your upcoming surgery. It describes what is likely to happen at your upcoming surgery. This is a guide only and there maybe some individual variation depending on your circumstances. Dr Lawrie will discuss these with you.

Please become familiar with this guide and discuss any aspects you wish to with your surgeon, anaesthetist and/or nursing staff. Trigger Finger Release is typically performed as a day procedure. You will be admitted and discharged on the day of surgery unless this is impractical or there are medical circumstances which preclude this. You must have a responsible adult to accompany you home and be with you overnight.

What is Trigger Finger Syndrome?

Trigger Finger Syndrome is an inflammatory condition resulting in a thickening of the flexor tendon and/or the tunnel it runs in to the finger or thumb. The entrance to the tunnel is about at the level of the transverse creases of the palm near the base of the fingers. This results in a painful nodule within the tendon. A painful crunching is felt as the nodule runs through the entry of the tunnel to the digit. This is felt as the tendon goes from a flexed or curled up position to a straight or extended position.

As the disease progresses the nodule can become caught at the entrance and only progresses through the tunnel as the finger is forced out straight. This causes a painful triggering of the digit. As the disease progresses further the finger can become locked in a flexed position as the nodule becomes caught in the tunnel and it can be extremely painful to unlock the finger. Trigger Finger can occur in each of the fingers and thumbs and it is not uncommon to need a number of fingers operated on over time. Trigger Finger is associated with conditions that result in inflammation to the tendons such as Rheumatoid arthritis, Diabetes and Pregnancy.

It also commonly occurs as one ages and the lining of the tendons naturally thickens as time goes on. Trigger Finger is often associated with other conditions such as Carpal Tunnel Syndrome and DeQuervain’s Disease which are due to the same inflammatory process (tenosynovitis) and it is not uncommon to need surgery for these in the future. There is also a similar condition in infants were triggering of the thumb occurs.

Trigger Finger may settle with non-operative treatment especially if the cause is temporary such as pregnancy or a sudden increase in the stress on the tendons such as some work situations. Anti-inflammatory medications, rest and occasionally injections of cortisone can alleviate symptoms on some occasions.

If symptoms are not settling or the disease is quite advanced then surgical release is necessary. Surgery is usually performed under a light general anaesthetic. Following infiltration of the anaesthetic a small one to two centimetre incision is made over the nodule which will be marked beforehand. The nerves and blood vessels to the digit will be identified and protected and the entrance to the flexor tunnel to the digit will be identified. This is called the A1 pulley. The A1 pulley is then incised in such a way as to release the triggering and hopefullyprevent recurrence as the pulley heals. The tendon nodule typically does not need to be excised. The finger is checked to make sure the triggering is relieved and the nerves and blood vessels have not been injured. The wound is sutured and a bulky firm dressing is applied. The tourniquet is released and you will be moved to the recovery area.

Before Surgery

You should stop anti-inflammatory drugs at least five days prior to surgery as they can increase the chance of bleeding (e.g. Voltaren, Naprosyn, Nurofen, Brufen, Feldene, Naprosyn and Indocid. Celebrex and Mobic are not a problem). You may continue to take low dose aspirin (to prevent heart attack or stroke) It is extremely important you have no cuts, scratches or sores on the involved limb at the time of surgery. If present these increase the chances of infection. If present your surgery should be postponed till all are well and truly healed.

Please contact Dr Lawrie’s rooms well before the day of surgery if you have any problems. On the day of surgery a nurse will inspect your limb for lesions and dress the limb in an antiseptic solution. Dr Lawrie will also inspect the limb and mark the appropriate limb and finger or thumb to be operated on with an indelible marking pen. You should stop smoking prior to surgery. Smoking increases the risks associated with an anaesthetic and the risk of blood clots (DVT) following surgery.

Admission

You should not eat or drink 6 hours prior to surgery. You should bring with you;

Prior to going to the operating room, you will be taken to the Day Surgery Unit and you will;

If you wish Dr Lawrie to speak to a family member after the operation please notify the nursing staff with contact details.

The procedure

You will be taken into the operating room on a trolley by the nursing staff. The operation will take about fifteen minutes but you may spend up to one hour in the theatre complex by the time you wait in the pre-operative area, are prepared from your anaesthetic and then woken up in the recovery area.

The Anaesthetic

The operation is usually performed under a light general anaesthetic. Local anaesthetic injection can make it difficult to see the nerve and blood vessels to the finger and so makes damage to these structures more likely. The anaesthetist will give you a general anaesthetic and will discuss this with you prior to the operation.

A drip will be placed in the back of your hand where anaesthetic medicines and antibiotics can be injected. You will be asked to breathe into an oxygen mask and the drugs to make you fall asleep will be injected through that drip. You will be asleep and not aware of anything further until the operation is over and you wake up in the recovery area. It is not uncommon to have some amnesia prior to or immediately after the surgery due to the anaesthetic drugs.

The Surgery

You will be placed on the operating table lying on your back. A well padded tourniquet will be applied to your upper arm and inflated to a safe level just prior to the commencement of surgery. You arm will be laid out to your side on the operating table. Your arm will be prepared with an antiseptic solution and sterile drapes will be placed around the arm and over your body. Following infiltration of the anaesthetic a small one to two centimetre incision is made over the nodule which will be marked beforehand.

The nerves and blood vessels to the digit will be identified and protected and the entrance to the flexor tunnel to the digit will be identified. This is called the A1 pulley. The A1 pulley is then incised in such a way as to release the triggering and hopefully prevent recurrence as the pulley heals. The nodule in tendon typically does not need to be excised. The finger is checked to make sure the triggering is relieved and the nerves and blood vessels have not been injured. The wound is sutured and a bulky firm dressing is applied. The tourniquet is released and you will be moved to the recovery area.

The Recovery

If you have had a general anaesthetic the anaesthetist will reverse the anaesthetic. You will wake up in the recovery room. The nurse will check your observations and movement in your fingers. Once you are sufficiently awake you will return to the Day Surgery Unit.

After Surgery

Dr Lawrie will see you before you go home and explain the operative findings to you. A copy of the operative report will be given to you and sent to your local doctor. For pain control you will have tablets available to take home with you (Panadiene forte/ Tramal/ Digesic). You may also be given an anti-inflammatory type medication.

You may resume any previous medications that you were receiving before surgery. If you have any allergies, these should be discussed prior to your discharge. Do not drive or use machinery after taking these medications. You can travel home in a car, but can not drive. If you are travelling more than 100km you should consider staying locally that night or overnight in hospital.

The night of surgery your hand should be reasonably comfortable due to the local anaesthetic. This typically wears off after 12-18 hours. It is normal to experience some discomfort the following day as this wears off.

 

When You Get Home

The amount of post-operative discomfort can be quite variable. The hand can be quite tender and painful for four to six weeks. Typically you will need help with everyday activities such as dressing, preparing meals and driving. Return to work may take two to four weeks. The bulky bandage should remain on your hand for three days to help with postoperative swelling. This compression dressing should be comfortable and absorb any leakage of fluid and/or blood. Although the dressing may become moist or blood stained, this is not a cause for alarm. After three days the bandage can be removed and small primapore type dressings can be applied.

It is very important that the surgical wound is kept clean and dry whilst it is healing. The wound is generally healed after 12 days. Sutures should be removed at day 10- 12 post-operatively. Sometimes steri-strips need to be applied to the wound once the sutures are removed. You may drive a vehicle when you can make a full fist with no discomfort and are not taking pain killers that may cause drowsiness.. You will be seen for follow-up in Dr Lawrie’s rooms after the surgery. The timing of which will be decided on at the time of surgery.

We will again discuss the findings at the time of surgery, what surgery was performed and what the future holds for your hand. Diet – You may resume your diet as tolerated but should avoid greasy foods for the first 24 hours.

Bruising – Bruising may be substantial in the palm and can extend up the forearm or into the fingers. Experience has shown that the bruising and swelling resolve without difficulty within a few weeks.

Incisions – The surgical incision usually heals after about twelve days. The incision should be kept clean and dry until well and truly healed. Incisions over palm can be quite sensitive. This is due to the large number of small sensory nerve fibres present in the area. Once the sutures are removed massaging the wound twice a day with a water based cream such as sorbelene or vitamin E cream can prevent a sensitive scar forming.

Physiotherapy – With all hand surgery the final result that you achieve is greatly dependent upon the amount of rehabilitative effort you make .The keys to your rehabilitation are elevation and early movement. The wrist should be elevated on two to three pillows at night and kept above the heart for the first five to seven days were possible. Avoid holding the wrist in a dependant position. The fingers should be mobilised from day one. Open and close the fingers one hundred times four times per day. Once the dressing is removed wrist exercises can be commenced. No heavy lifting should be performed for six weeks.

Results

Trigger Finger Release typically has very good results. Recurrence occurs in about 10% of cases. The other fingers can be affected by the same disease process and release of one finger does not prevent disease in another. The surgical site can be quite tender for days to weeks. If the finger was stiff pre-operatively then it can be difficult to correct following surgery and a referral to a hand therapist may be necessary.

Precautions

If you develop a fever above 39 degrees centigrade, unexpected pain, redness or swelling in your wrist please contact our office or the hospital. Return appointment Please call our office on 5444 3511 to make your first follow up appointment for approximately 2 to 4 days following your surgery. If you have a problem such as vomiting the same night of your surgery, you should contact the nursing supervisor/ senior nurse on the surgical ward at the hospital you had your surgery at.

Commonly asked questions

Will my surgery be successful?

Trigger finger release surgery has a high success rate with a very low complication rate. However patients may have a painful incision for about six weeks.

Will I need further surgery?

It is uncommon to need further surgery but Trigger fingers can recur. It is more common to suffer similar problems in adjacent fingers or the opposite hand.

When can I start swimming?

Swimming is and excellent exercise and I would strongly encourage swimming following surgery. Once the wounds are well healed, after about 2-3 weeks, then a swimming programme to complement your physiotherapy is a good idea.

When can I return to work?

This varies from individual to individual. Often at one to two weeks one can resume light duties but this can be longer at times.

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