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Trigger finger release

Trigger finger is a mechanical mismatch between a flexor tendon and the thickened first annular pulley at the base of the digit, so that the tendon catches, clicks or locks as the finger bends.

Last clinically reviewed

1. Indications

  • Triggering that persists or recurs after non-operative treatment. A single relieves most digits in the short term, but symptoms recur in 56 per cent within a year1; 45 per cent of digits remain treated at five years or more after one injection2, and second or third injections give long-term relief in 39 per cent3. A 2017 systematic review concluded that surgery "should be the next line if the injection fails, symptoms recur or the patient chooses"4.
  • A locked digit. Grading systems describe the spectrum from pain and uneven movement to a digit that locks and cannot be actively extended56; the randomised trials of surgery enrolled the symptomatic grades7.
  • Diabetes with systemic complications. In a randomised, placebo-controlled trial in diabetic patients, corticosteroid injection did not reduce the need for surgery or improve symptom relief compared with placebo8, and insulin-dependent diabetes strongly predicts recurrence after injection1. Earlier surgery is reasonable in this group.
  • Patient factors that predict eventual surgery — younger age, several affected digits and other upper-limb tendinopathies1 — support an earlier operative discussion.
  • Trigger thumb in a child that has not resolved: A1 release is reliable in this group6. Release is offered from about three to four years of age when the interphalangeal joint remains fixed in flexion.
In practice, a single corticosteroid injection is the usual first step. Release is offered when the injection fails or the triggering returns, and it is a reasonable first choice for a locked digit, for insulin-dependent diabetes or several affected digits, or when the patient prefers a definitive operation.

2. Contraindications

  • Active infection of the hand or of the skin over the incision site.
  • A corticosteroid injection into the hand within the previous three months. Deep infection after release was 2.0 per cent when surgery followed an injection within 90 days, against 0.3 per cent when the interval was longer9; a database of 14,686 patients found about three-fold odds of deep infection when surgery followed within a month10; one series recommends scheduling surgery more than 80 days after the last injection11. This is a relative contraindication: surgery is usually scheduled at least three months after the last injection, and earlier only after the higher deep-infection risk has been discussed with the patient.
  • Rheumatoid arthritis with flexor tenosynovitis. Isolated A1 release is avoided because loss of the pulley has been thought to allow ulnar subluxation of the tendons12; tenosynovectomy is the operation of choice6.
  • Triggering that does not arise at the A1 pulley. Catching at the A2 or A3 pulley or at the palmar aponeurosis, tendon nodules and tumours are uncommon causes that need a different operation136.
  • Anticoagulation is not in itself a reason to withhold a minor procedure under local anaesthetic. Anticoagulant and antiplatelet drugs are continued; for warfarin a recent INR within the therapeutic range is confirmed, and haemostasis relies on the adrenaline in the infiltration and on bipolar diathermy. An unusual bleeding risk is discussed with the prescriber case by case.

3. Relevant anatomy

The finger flexor sheath is a synovial-lined fibro-osseous tunnel reinforced by the palmar aponeurosis pulley, five annular pulleys (A1 to A5) and three cruciform pulleys1415. A2 and A4 are the largest, thickest and most constant; A1, A3, A5 and the cruciform pulleys vary in shape and incidence15. The A1 pulley lies over the metacarpal head at the level of the metacarpophalangeal joint, where the tendon is subjected to the highest forces during grip1316.
The pathology is not inflammation. Histology of 89 diseased pulleys showed a fibrocartilaginous inner gliding layer with markedly increased chondrocytes and matrix, and no synovial cell layer — a fibrocartilage metaplasia17. The traditional name is therefore a misnomer.
The thumb has one oblique and two annular pulleys. Division of A1 alone does not measurably reduce interphalangeal motion provided the oblique pulley is intact; loss of both the proximal annular and the oblique pulley does18. In a cadaveric study the proximal edge of the thumb A1 pulley lay on average 3.5 mm distal to the metacarpophalangeal flexion crease19.
The run on either side of the sheath. In the thumb the radial digital nerve crosses the field obliquely, 2.19 mm beneath the dermis and 1.15 mm anterior to the radial sesamoid at the level of the metacarpophalangeal crease, where it can be trapped between the sesamoid and the blade20; it "courses directly over the A1 pulley"16. The ulnar digital nerve of the thumb lies closer to the pulley than the radial nerve (1.95 versus 3.40 mm) and is at risk in an open release19.
Extent of release and . In 48 cadaver fingers, dividing A1 — from either the radial or the ulnar side — with up to a quarter of A2 produced no bowstringing or subluxation; division of half of A2 produced bowstringing in 3 of 48, and of all of A2 in every finger. The distal quarter of A2 corresponds to the level of the palmar digital crease, which marks the safe distal limit12.

4. Patient positioning

Supine, arm on a hand table, forearm supinated. The incision is marked before infiltration.
Anaesthesia. Two techniques used for open carpal tunnel release transfer to this operation: local infiltration of 0.4 per cent lignocaine with 1:250,000 adrenaline under an upper-arm tourniquet, or with 1 per cent lignocaine and 1:100,000 adrenaline buffered 10:1 with 8.4 per cent sodium bicarbonate and no tourniquet. Adrenaline in the digit is safe and, without a tourniquet, allows the patient to move the finger during the operation21. A meta-analysis of eleven studies of trigger finger release found higher patient and surgeon satisfaction, less analgesic use and lower cost with WALANT, with no difference in function or adverse events, although the included studies carried a moderate to high risk of bias22. In a randomised trial of minor hand procedures, discomfort was higher with a tourniquet and the tourniquet-free technique was non-inferior for operative time and complications23; in a single-surgeon series of A1 releases most pain outcomes were similar with either method24. No infections occurred in 129 trigger finger releases performed wide awake25.
The default for this operation is the first of these, as for carpal tunnel release: local infiltration of 0.4 per cent lignocaine with 1:250,000 adrenaline, about 5 mL per digit, along the planned incision and into the flexor sheath, under an upper-arm tourniquet at 250 mmHg. Under the tourniquet the release is confirmed by passive traction on the tendons, and the tourniquet is released before haemostasis. WALANT is the alternative when a tourniquet is to be avoided; the patient then confirms the release by active flexion and extension.
Antibiotic prophylaxis is not given for a clean procedure without an implant, as for open carpal tunnel release.

5. Approach

A 1–1.5 cm incision is made over the A1 pulley: for the fingers in or just distal to the distal palmar crease, for the thumb in the metacarpophalangeal flexion crease2616. Transverse, oblique and longitudinal incisions are all in use, "at the discretion of the surgeon"16. A prospective registry of 875 trigger thumb releases found no difference in hand function, pain, aesthetics or complications between four incision types, with 76 per cent of patients reporting good or excellent satisfaction27; the Cochrane review identified a single small trial of incision types and could not favour any28. The trade-off is exposure against scar: a longitudinal incision exposes the pulley and the bundles well but may contract; a transverse incision contracts less but exposes less; oblique and V-shaped incisions expose well at the cost of wider dissection27.
The incision used here is transverse: 1–1.5 cm in or just distal to the distal palmar crease, directly over the A1 pulley, for the fingers, and in the metacarpophalangeal flexion crease for the thumb.

6. Key steps

  1. 1. Marking and infiltration

    Mark the A1 pulley over the metacarpal head, between the distal palmar crease and the proximal digital crease in the fingers, or at the metacarpophalangeal flexion crease in the thumb, and mark a transverse incision of 1–1.5 cm — in or just distal to the distal palmar crease for a finger, in the flexion crease for the thumb — before infiltrating. Infiltrate about 5 mL of 0.4 per cent lignocaine with 1:250,000 adrenaline subcutaneously along the incision and into the sheath, then wait for vasoconstriction before prepping and draping.

  2. 2. Skin incision and blunt dissection

    Incise the skin only. Spread longitudinally through the subcutaneous fat with tenotomy scissors down to the sheath, identifying and retracting the neurovascular bundles on both sides before any sharp dissection16.

  3. 3. Exposure of the A1 pulley

    Place a small self-retaining retractor. Define the proximal edge of A1 (in the thumb about 3.5 mm distal to the flexion crease19) and the junction with A2, which may be indistinct12.

  4. 4. Division of the pulley

    Divide the A1 pulley longitudinally along its full length under direct vision, on the radial or ulnar side of the midline; the side of the incision does not affect subluxation or bowstringing12. Extend the release to the proximal edge of A2, and at most through its proximal quarter1216.

  5. 5. Confirmation of release

    Under the tourniquet, apply gentle proximal traction to flexor digitorum superficialis and profundus in turn: free excursion of each tendon without triggering confirms the release, and the tendons are inspected for nodules or synovitis. Under WALANT, ask the patient instead to flex and extend the digit fully; free, silent excursion of both tendons confirms the release1621. Excision of a slip of flexor digitorum superficialis is reserved for triggering that persists despite pulley release, or for a persistent flexion contracture29.

  6. 6. Haemostasis

    Release the tourniquet (there is none under WALANT), secure haemostasis with bipolar diathermy and irrigate with saline.

7. Closure

Skin only, with 3-0 Pronova interrupted mattress sutures, as for open carpal tunnel release; no deep sutures. A non-adherent layer and a soft, bulky, non-circumferential wool-and-crepe dressing; no splint.

8. Aftercare

  • Elevation when comfortable; immediate active flexion and extension of all digits; light use of the hand from the first day. No splint.
  • Analgesia: paracetamol with a non-steroidal anti-inflammatory drug for 48–72 hours. Early pain is greater after surgery than after injection — 68 versus 18 per cent of patients had palm pain at one week in the pooled trials28; patients in one trial took analgesics for a mean of 2.9 days after open release30.
  • Dressing: the bulky dressing is reduced to a light dry dressing at 48–72 hours by the GP or dressings clinic and kept dry until wound review; sutures out at 10–14 days.
  • Hand therapy: every patient is referred for a single early consultation covering range of motion, oedema, scar management and return-to-work guidance, as after carpal tunnel release. Further sessions are seldom needed: in 1,598 releases, 3 per cent of patients needed therapy or a repeat injection for slow recovery of motion31; some units offer three standard sessions of tendon-gliding exercises and scar management27.
  • Return to activity: about 18 days to normal activities after open release in one trial30; percutaneous release returned patients to work a mean of 13 days sooner in a meta-analysis of 14 trials, with no long-term difference32; grip strength exceeded 90 per cent of normal by six weeks in men and three months in women after percutaneous release33. The advice given here: driving once the patient can grip the wheel comfortably and is off strong analgesics, typically within one to two weeks; desk work within the first week once the dressing is reduced; heavy gripping and manual work at two to three weeks.
  • Expectation setting: at a mean of 5.5 years after open release, 8 per cent of patients reported mild residual pain and 16 per cent stiffness, and 98 per cent were satisfied34.
  • Follow-up: sutures out at 10–14 days via the GP or dressings clinic, with a further hand-therapy referral if the finger is still stiff at that visit; clinic review at six weeks, as after carpal tunnel release.

9. Complications

10. Evidence

Injection versus surgery. In a three-arm randomised trial of 150 fingers, one injection cured 57 per cent and two injections 86 per cent, whereas percutaneous and open release cured every finger7. The Cochrane review pooled two trials: recurrence at six to twelve months was 8 of 140 after open surgery and 50 of 130 after injection (risk ratio 0.17), at the cost of more pain in the first week; the evidence was graded low quality28. A systematic review with guideline recommendations found strong evidence that surgical release is safe and that injection carries more recurrence at six months4.
Open versus percutaneous release. The first randomised trial reported success in 98 per cent of open and 100 per cent of percutaneous releases, with shorter operating time and faster recovery of motion after the percutaneous technique and no serious complication in either group39. Three meta-analyses of randomised trials found no difference in failure, revision or complication rates404132; the most recent, of 14 trials and 996 patients, found faster functional recovery and a 13-day earlier return to work after percutaneous release and no long-term difference32. In cadavers, blind percutaneous release was complete in 72 per cent of fingers, nicked the proximal A2 in 22 per cent and scored the tendon in 11 of 5442; the radial digital nerve of the thumb is the structure at risk2034. Open release gives direct vision of the nerves and of the extent of release, which is why it is described here.
Anaesthesia. WALANT and local anaesthesia with a tourniquet give equivalent functional results and adverse-event rates; satisfaction and analgesic use favour WALANT in a meta-analysis at risk of bias22, tourniquet discomfort is measurable in a randomised trial23, and for A1 release specifically most pain outcomes are similar24. Adrenaline in the digit is safe21.
Timing after injection. Three cohorts agree that surgery within one to three months of a corticosteroid injection increases deep infection91110; a fourth cohort found recent injection not associated with complications35.
Durability. Complete resolution in 97 per cent with 3 per cent recurrence at four years37; 234 patients free of complaints at a mean of 14 years26; 98 per cent satisfaction at 5.5 years34.
For patients — plain-language summary
Trigger finger happens when a tendon that bends your finger no longer slides freely through a small band at the base of the finger, so the finger catches or locks. If a steroid injection has not worked, or the finger keeps locking, a small operation can cut the band and free the tendon. It is done under local anaesthetic, you go home the same day, and it takes a few minutes to half an hour. You can move the fingers straight away and use the hand for light tasks; most people are back to normal in two to three weeks. Almost everyone is cured: the catching comes back in about 6 in 100, compared with about 40 in 100 after an injection. Problems are mostly minor — a tender scar, stiffness or a wound infection in about 2 in 100 — and fewer than 3 in 100 need a second operation. If you have had a steroid injection in the hand in the last three months, the operation is usually delayed to lower the small risk of a deep infection.

References

  1. Rozental TD, Zurakowski D, Blazar PE. Trigger finger: prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg Am. 2008;90(8):1665-72. PubMed DOI
  2. Wojahn RD, Foeger NC, Gelberman RH, Calfee RP. Long-term outcomes following a single corticosteroid injection for trigger finger. J Bone Joint Surg Am. 2014;96(22):1849-54. PubMed DOI PMC
  3. Dardas AZ, VandenBerg J, Shen T, Gelberman RH, Calfee RP. Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger. J Hand Surg Am. 2017;42(4):227-235. PubMed DOI PMC
  4. Amirfeyz R, McNinch R, Watts A, Rodrigues J, Davis TRC, Glassey N, et al. Evidence-based management of adult trigger digits. J Hand Surg Eur Vol. 2017;42(5):473-480. PubMed DOI
  5. Quinnell RC. Conservative management of trigger finger. Practitioner. 1980;224(1340):187-90. PubMed
  6. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am. 2006;31(1):135-46. PubMed DOI
  7. Sato ES, Gomes Dos Santos JB, Belloti JC, Albertoni WM, Faloppa F. Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford). 2012;51(1):93-9. PubMed DOI
  8. Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint Surg Am. 2007;89(12):2604-11. PubMed DOI
  9. Matzon JL, Lebowitz C, Graham JG, Lucenti L, Lutsky KF, Beredjiklian PK. Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection. J Hand Surg Am. 2020;45(4):310-316. PubMed DOI
  10. Straszewski AJ, Lee CS, Dickherber JL, Wolf JM. Temporal Relationship of Corticosteroid Injection and Open Release for Trigger Finger and Correlation With Postoperative Deep Infections. J Hand Surg Am. 2022;47(11):1116.e1-1116.e11. PubMed DOI
  11. Ng WKY, Olmscheid N, Worhacz K, Sietsema D, Edwards S. Steroid Injection and Open Trigger Finger Release Outcomes: A Retrospective Review of 999 Digits. Hand (N Y). 2020;15(3):399-406. PubMed DOI PMC
  12. Bhandari L, Hamidian Jahromi A, Miller AG, Tien H. Location and Extent of A1, A2 Release and Its Impact on Tendon Subluxation and Bowstringing-A Cadaveric Study. Indian J Plast Surg. 2019;52(3):349-354. PubMed DOI PMC
  13. Makkouk AH, Oetgen ME, Swigart CR, Dodds SD. Trigger finger: etiology, evaluation, and treatment. Curr Rev Musculoskelet Med. 2008;1(2):92-6. PubMed DOI PMC
  14. Doyle JR. Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg Am. 1988;13(4):473-84. PubMed DOI
  15. Doyle JR. Anatomy of the flexor tendon sheath and pulley system: a current review. J Hand Surg Am. 1989;14(2 Pt 2):349-51. PubMed DOI
  16. Elahi MA, Pollock JR, Moore ML, Haglin JM, Lai C, Hinckley NB, et al. Tendon Sheath Incision for Surgical Treatment of Trigger Finger. JBJS Essent Surg Tech. 2023;13(1). PubMed DOI PMC
  17. Sampson SP, Badalamente MA, Hurst LC, Seidman J. Pathobiology of the human A1 pulley in trigger finger. J Hand Surg Am. 1991;16(4):714-21. PubMed DOI
  18. Doyle JR, Blythe WF. Anatomy of the flexor tendon sheath and pulleys of the thumb. J Hand Surg Am. 1977;2(2):149-51. PubMed DOI
  19. Buldu H, Cepel S, Ki N, Ağritmiş H. [References to avoid complications in releases of the trigger thumb: a cadaveric study]. Acta Orthop Traumatol Turc. 2006;40(4):311-4. PubMed
  20. Carrozzella J, Stern PJ, Von Kuster LC. Transection of radial digital nerve of the thumb during trigger release. J Hand Surg Am. 1989;14(2 Pt 1):198-200. PubMed DOI
  21. Lalonde D, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013;21(8):443-7. PubMed DOI
  22. Levit T, Lavoie DCT, Dunn E, Gallo L, Thoma A. Trigger Finger Release Using Wide-Awake Local Anesthesia No Tourniquet Versus Local Anesthesia With a Tourniquet: A Systematic Review and Meta-analysis. Hand (N Y). 2025;20(4):533-541. PubMed DOI PMC
  23. Saleh E, Saleh J, Govshievich A, Ferland-Caron G, Lin JC, Tremblay DM. Comparing Minor Hand Procedures Performed with or without the Use of a Tourniquet: A Randomized Controlled Trial. Plast Reconstr Surg Glob Open. 2021;9(4):e3513. PubMed DOI PMC
  24. Kwak SH, Jang HS, Kim DH, Jung SY, Bae JY, Lee SH. Postoperative pain after carpal tunnel or trigger digit release using local anaesthesia with tourniquet or WALANT. J Hand Surg Eur Vol. 2026;51(8):1053-1059. PubMed DOI
  25. Rellán I, Bronenberg Victorica P, Kohan Fortuna Figueira SV, Donndorff AG, De Carli P, Boretto JG. What Is the Infection Rate of Carpal Tunnel Syndrome and Trigger Finger Release Performed Under Wide-Awake Anesthesia? Hand (N Y). 2023;18(2):198-202. PubMed DOI PMC
  26. Lange-Riess D, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of trigger finger and trigger thumb in adults. Arch Orthop Trauma Surg. 2009;129(12):1617-9. PubMed DOI
  27. Koopman JE, Smit JM, Wouters RM, Selles RW, Michiel Zuidam J, Hundepool CA. Incision techniques for trigger thumb release: a comparison of outcomes of four types of skin incision. J Hand Surg Eur Vol. 2024;49(10):1226-1234. PubMed DOI PMC
  28. Fiorini HJ, Tamaoki MJ, Lenza M, Gomes Dos Santos JB, Faloppa F, Belloti JC. Surgery for trigger finger. Cochrane Database Syst Rev. 2018;2(2):CD009860. PubMed DOI PMC
  29. Giugale JM, Fowler JR. Trigger Finger: Adult and Pediatric Treatment Strategies. Orthop Clin North Am. 2015;46(4):561-9. PubMed DOI
  30. Nikolaou VS, Malahias MA, Kaseta MK, Sourlas I, Babis GC. Comparative clinical study of ultrasound-guided A1 pulley release vs open surgical intervention in the treatment of trigger finger. World J Orthop. 2017;8(2):163-169. PubMed DOI PMC
  31. Bruijnzeel H, Neuhaus V, Fostvedt S, Jupiter JB, Mudgal CS, Ring DC. Adverse events of open A1 pulley release for idiopathic trigger finger. J Hand Surg Am. 2012;37(8):1650-6. PubMed DOI
  32. Huang KC, Chu YY, Lin YT, Wang MJ, Lee CH. Comparative effectiveness of open versus percutaneous release for trigger fingers: A systematic review and meta-analysis of randomized controlled trials. J Orthop Sci. 2026;31(4):789-798. PubMed DOI
  33. Rojo-Manaute JM, Rodríguez-Maruri G, Capa-Grasa A, Chana-Rodríguez F, Soto Mdel V, Martín JV. Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 1: clinical efficacy and safety. J Ultrasound Med. 2012;31(3):417-24. PubMed DOI
  34. Gilberts EC, Wereldsma JC. Long-term results of percutaneous and open surgery for trigger fingers and thumbs. Int Surg. 2002;87(1):48-52. PubMed
  35. Everding NG, Bishop GB, Belyea CM, Soong MC. Risk factors for complications of open trigger finger release. Hand (N Y). 2015;10(2):297-300. PubMed DOI PMC
  36. Will R, Lubahn J. Complications of open trigger finger release. J Hand Surg Am. 2010;35(4):594-6. PubMed DOI
  37. Turowski GA, Zdankiewicz PD, Thomson JG. The results of surgical treatment of trigger finger. J Hand Surg Am. 1997;22(1):145-9. PubMed DOI
  38. Stephens AR, Presson AP, Jo YJ, Tyser AR, Wang AA, Hutchinson DT, et al. Evaluating the Safety of the Hand Surgery Procedure Room: A Single-Center Cohort of 1,404 Surgical Encounters. J Hand Surg Am. 2021;46(7):623.e1-623.e9. PubMed DOI PMC
  39. Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JC. Prospective randomized trial of open versus percutaneous surgery for trigger digits. J Hand Surg Am. 2001;26(3):497-500. PubMed DOI
  40. Wang J, Zhao JG, Liang CC. Percutaneous release, open surgery, or corticosteroid injection, which is the best treatment method for trigger digits? Clin Orthop Relat Res. 2013;471(6):1879-86. PubMed DOI PMC
  41. Casey JC, Daher M, Dworkin M, Cusano J, Garavito J, Gil JA. Open Versus Percutaneous Fixation of Trigger Finger: Meta-Analysis of Clinical Outcomes. J Hand Surg Am. 2024;49(6):570-575. PubMed DOI
  42. Habbu R, Putnam MD, Adams JE. Percutaneous release of the A1 pulley: a cadaver study. J Hand Surg Am. 2012;37(11):2273-7. PubMed DOI