Overview
Adult trigger finger and thumb result from a mismatch between the flexor tendon and a constricting pulley region, causing catching or locking during motion. Open release permits direct protection of the digital nerves and assessment of tendon excursion. Adult stenosing tenosynovitis is distinct from pediatric trigger thumb and should not be treated as the same condition (Campbell, Chapter 81).
Assessment and Indications
Confirm palpable or reproducible triggering and localize the constriction rather than accepting the patient's perceived distal joint location as the operative target.
Examine motion, fixed contracture and neighboring digits. Joint disease, extensor tendon subluxation and a previously injured flexor tendon can produce similar symptoms.
Review diabetes, inflammatory disease, prior injections and previous surgery.
Initial treatment may include stretching, night splinting or corticosteroid injection. Persistent symptoms after appropriate conservative treatment are a common indication for release.
Discuss that injection can temporarily elevate glucose and that surgical planning must account for the patient's medical condition and treatment history.
(Campbell, Chapter 81.)
Procedure Planning
Region | Important distinction |
|---|---|
Adult trigger finger | The source describes release of the A1 and proximal palmar pulley region when required to eliminate constriction. |
Adult trigger thumb | Release the A1 pulley while protecting the oblique pulley distally. |
Digital nerves | The thumb nerves are more superficial and closer to the sheath than expected; the radial digital nerve is particularly vulnerable. |
Active motion | A local anesthetic approach permits immediate confirmation that triggering has stopped. |
(Campbell, Chapter 81, Technique 81.2.)
Anesthesia and Setup
Use the source's local infiltration approach proximal to the incision so that active motion can be assessed during the procedure.
Select an appropriate hemostasis method. Campbell describes a tourniquet or a local anesthetic technique with epinephrine as alternatives.
Position the hand to permit direct visualization and free movement of the affected digit.
Mark the planned incision and have fine instruments and retractors available for nerve protection.
(Campbell, Chapter 81.)
Surgical Technique
Incision and Nerve Protection
Place an incision over the involved pulley region. Technique 81.2 describes a short transverse incision distal to the relevant palmar crease for the fingers, with oblique or longitudinal alternatives.
For the thumb, choose an approach appropriate to the MCP flexion crease and the underlying nerve anatomy.
Spread the subcutaneous tissues carefully and identify or protect the digital neurovascular structures before exposing the pulley.
Take particular care around the thumb radial digital nerve; avoid assuming it lies safely deep to the intended cut.
(Campbell, Chapter 81, Technique 81.2.)
Pulley Release
Identify the annular pulley and its relationship to the flexor tendon.
Make a controlled initial opening and continue the release with tenotomy scissors under direct vision.
For a trigger finger, assess the proximal palmar constriction as well as A1 so that a residual proximal band is not overlooked.
Identify the distal extent of A1 and preserve A2. The boundary may be clearer from the deep surface after the initial release.
For trigger thumb, avoid continuing distally into the oblique pulley.
(Campbell, Chapter 81.)
Active Testing and Persistent Triggering
Ask the patient to actively flex and extend the digit once the intended release is complete.
If triggering persists, inspect for an incompletely divided A1 or proximal palmar pulley.
Consider an alternative site of catching or tendon abnormality rather than extending the release indiscriminately into a functionally important pulley.
Reassess adjacent digits when symptoms or examination suggest another trigger, and document the procedures actually performed.
Confirm smooth excursion before closing the skin and applying a small dry compressive dressing.
(Campbell, Chapter 81, Technique 81.2.)
Final Checks
The constricting pulley region has been released completely and triggering is absent on active testing.
The digital nerves and flexor tendons have been protected.
A2 in the finger and the oblique pulley in the thumb remain intact.
Residual locking is not being mistaken for an instruction to perform a longer blind release.
The wound and dressing allow the planned early motion.
(Campbell, Chapter 81.)
Postoperative Care
Technique 81.2 removes the compression dressing at approximately 48 hours and the sutures at 10–14 days. Encourage normal motion and progressive use of the finger or thumb as comfort and wound recovery allow. Persistent stiffness or catching warrants reassessment of tendon motion and the original diagnosis rather than prolonged immobilization without explanation (Campbell, Chapter 81).
Complications and Pitfalls
Persistent triggering: incomplete release is more common than true recurrence in the source's discussion.
Digital nerve injury: especially important in the thumb and index digit and with limited-visualization techniques.
Tendon injury: avoid cutting against the flexor tendon during pulley division.
Excessive pulley release: preserve A2 and the thumb oblique pulley.
Scar pain, wound problems or stiffness: evaluate in the context of local healing and preexisting contracture.
Incorrect diagnosis: joint pathology or extensor tendon subluxation may mimic triggering.
(Campbell, Chapter 81.)
Outcomes and Alternative Techniques
Campbell reports reliable relief after surgical release, with approximately 97% complete resolution in the cited operative literature. Percutaneous techniques can also be effective, but incomplete division and injury to tendons or digital nerves remain concerns, particularly in the thumb and index finger. The open method provides direct visual assessment and active confirmation of the endpoint (Chapter 81).
References
Murphy AB. Stenosing tenosynovitis of the wrist and hand. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 81, trigger finger and thumb, pp. 3538–3540; open surgical release, Technique 81.2.