Finger Movement Function After Ultrasound-Guided Percutaneous Pulley Release for Trigger Finger: Effects of Postoperative Rehabilitation
Abstract
Objective
To develop and test a postoperative rehabilitation protocol for use by individuals with trigger finger undergoing ultrasound-guided percutaneous pulley release.
Design
Nonrandomized controlled trial.
Setting
Hospital and local community.
Participants
Individuals suffering from trigger finger with joint contracture (N=21) were recruited and grouped into an intervention group (n=9) or a control group (n=12).
Interventions
All the participants underwent the same surgical procedure performed by the same surgeon. A 4-week postoperative rehabilitation program was designed based on the wound healing process. The intervention group received postoperative rehabilitation after the surgery, whereas the control group received no treatment after the surgery.
Main Outcome Measures
The finger movement functions were quantitatively evaluated before and 1 month after the surgery using a 3-dimensional motion capture system. The fingertip workspace and joint range of motion (ROM) were evaluated while the participant was performing a sequential 5-posture movement, including finger extension, intrinsic plus, straight fist, full fist, and hook fist.
Results
The intervention group demonstrated significantly more improvements than the control group in the fingertip workspace (49% vs 17%), ROM of the distal interphalangeal (DIP) joint (16% vs 4%), ROM of the proximal interphalangeal (PIP) joint (21% vs 5%), and total active ROM (17% vs 5%).
Conclusions
This pilot study evaluated a postoperative rehabilitation protocol for trigger finger and demonstrated its effects on various finger functions. Participants who underwent the rehabilitation program had significantly more improvements in the fingertip workspace, ROM of the DIP and PIP joints, and total active ROM.
List of abbreviations:
A1 (first annular), DIP (distal interphalangeal), MP (metacarpophalangeal), PIP (proximal interphalangeal), ROM (range of motion)
Individuals suffering from trigger finger experience discomfort during finger movement, and some of the individuals have limited joint excursion. Triggering is a typical presentation of trigger finger, and it describes the catching and sudden releasing that occurs during finger extension movement. The clinical diagnosis of trigger finger is mainly based on subjective observations and physical examinations. Froimson1 proposed a method for grading the severity of trigger finger that divides the conditions into 4 grades. Grade I trigger fingers present tenderness over the metacarpophalangeal (MP) joint on the palmar side of the hand. Grade II trigger fingers present triggering and are able to extend and flex actively. Grade III trigger fingers present triggering and are unable to extend or flex actively. Grade IV trigger fingers present joint contracture problems. The kinematic characteristics of trigger fingers of different grades can be quantitatively measured using an electromagnetic tracking device.2 Trigger fingers with more severe symptoms present less joint range of motion (ROM), a smaller fingertip workspace, and a higher angular acceleration range ratio. In addition to the kinematic performance, the tendon forces at the moment of triggering have been quantified in vivo via biomechanical modeling,3with greater force than usual needed to complete the extension movement in trigger fingers. The size discrepancy between the flexor tendons and the first annular (A1) pulley is believed to be the cause of the symptoms of trigger finger.4,5, 6 A1 pulley release surgery has therefore been used to treat trigger fingers if more conservative interventions fail to relieve the discomfort. In recent years, percutaneous and ultrasound-guided techniques have been developed to improve surgical outcomes in relation to this condition,7, 8 and the functional improvements after such techniques have also been evaluated.9 Follow-up examinations showed significant improvements in joint ROM and fingertip workspace, and the occurrence of triggering was also alleviated after the surgery.
Although improvements after pulley release surgery have been quantitatively demonstrated, certain individuals suffering from trigger finger still complain about postoperative finger functions remaining unsatisfactory,10 with patients suffering from joint contracture problems having especially poor outcomes, based on clinical observations. Active joint ROM initiating on the same day of the procedure has been suggested as one way to deal with this problem.11, 12 Edema control and tendon gliding exercise are also recommended, whereas splinting can be offered to prevent or improve joint contracture.11 Strengthening exercises can also be initiated 3 weeks after surgery.11, 12 Although various forms of postoperative management for trigger finger have been proposed, no studies, to our knowledge, have reported the effectiveness of these approaches. In addition, there is currently no standard rehabilitation protocol for trigger finger after pulley release surgery, and few individuals suffering from trigger finger actually receive such rehabilitation. The minimally invasive surgery usually makes the patients decline to receive postoperative treatments. The conservative intervention before surgery also generates an assumption that the patients have already experienced some exercise programs; consequently, they are not referred to postoperative treatment. However, clinical observations show that there is a need for postoperative rehabilitation for this condition. We hypothesized significant differences in functional outcome of trigger finger between groups with and without postoperative rehabilitation. Therefore, the purpose of this study was to develop a practical postoperative rehabilitation protocol for trigger finger, to quantitatively evaluate various finger functions before and after surgery, and to determine the effectiveness of the rehabilitation protocol for improving the quantitative measures of finger function.
Methods
Participants
This study recruited individuals with unilateral trigger finger diagnosed as grade IV using Froimson's classification.1Exclusion criteria included individuals who had other traumatic or neural injuries in the involved finger and individuals who had orthopedic or neural injuries in the contralateral finger. Individuals who met the inclusion criteria and needed pulley release surgery were enrolled from the Department of Orthopedics at National Cheng Kung University Hospital, and they were informed of the purpose and procedures of this study prior to participation. A total of 21 individuals who agreed to participate signed a consent form approved by the Institutional Review Board at National Cheng Kung University Hospital. Participants were given the choice to participate in the intervention group or control group. Nine of them participated in the intervention group, and 12 of them participated in the control group (fig 1). The symptom duration of the participants ranged from 1 to 24 months, and some of the participants had received steroid injection. Table 1 shows the distributions of age, duration of symptoms, sex, involved finger, and history of steroid injection of the 2 groups.
Fig 1
Flow diagram presenting the study design, including the enrollment of subjects, participant grouping, presurgery finger function evaluation, surgical treatment, different postsurgery management for the 2 groups, and follow-up finger function evaluation.
| Characteristic | Intervention Group (n=9) | Control Group (n=12) | P |
|---|---|---|---|
| Age (y) | 53.44±13.46 | 58.67±9.08 | .219 |
| Duration of symptoms (mo) | 5.56±4.22 | 11.82±9.33 | .175 |
| Sex (female:male) | 7:2 | 8:4 | NA |
| Involved finger | 5 middle fingers 3 ring fingers 1 little finger | 7 middle fingers 5 ring fingers | NA |
| History of steroid injection(s) | Yes: 1 finger No: 7 fingers Unknown: 1 finger | Yes: 5 fingers No: 4 fingers Unknown: 3 fingers | NA |
NOTE. Values are mean ± SD or as otherwise indicated.
Abbreviation: NA, not applicable.
Surgical procedure
All participants were treated using ultrasound-guided percutaneous pulley release surgery performed by the same surgeon. The sonographically assisted percutaneous release of the A1 pulley has been described in the literature.7, 8Because it produces only a small wound, percutaneous release has been shown to lead to a quicker recovery than open release. In addition, the ultrasound-guided technique provides real-time visualization of the flexor tendon pulley system; therefore, the risk of incomplete release and injuries to the adjacent structures can be avoided.
Rehabilitation program
We developed a practical postoperative rehabilitation protocol for trigger fingers (table 2). The participants in the intervention group were referred to the Department of Physical Medicine and Rehabilitation at National Cheng Kung University Hospital after surgery and received postoperative rehabilitation, whereas the control group received no therapy after the pulley release surgery. The postoperative rehabilitation programs were performed by an experienced occupational therapist knowledgeable about the protocol. The intervention group received postoperative therapy for 30 minutes during each treatment, and treatments occurred twice a week for 4 weeks. Specific interventions of the 4-week postoperative rehabilitation protocol were implemented based on the process of wound healing. In the first week after surgery, the management focused on edema control, scar management, and prevention of joint contracture. In the second week, regaining smooth tendon excursion was emphasized as was the prevention of adhesion, joint contracture, and intrinsic muscle tightness. In the third week, the goal was to regain full and smooth ROM. In the fourth week, strengthening exercise and functional activities were performed. In addition to the treatment in hospital, home programs were assigned by occupational therapists, including active and passive ROM exercises.
| Postsurgery Week | Treatment Goals | Treatment Programs |
|---|---|---|
| 1 | Edema control and scar management | Compression with a self-adhering bandage |
| Prevent PIP flexion contracture | Gentle DIP and PIP ROM exercises with day splint; night splint | |
| 2 | Regain smooth tendon excursion | Tendon gliding exercise |
| Prevent adhesion | Compressive massage | |
| Prevent PIP flexion contracture | Night splint; joint stretch | |
| Check intrinsic muscle tightness | Passive DIP and PIP flexion with MP extension | |
| 3 | Regain full, smooth ROM | Remove splint; frictional massage; blocking exercise |
| 4 | Strengthening exercise | Lumbrical muscles; extrinsic flexor and extensor muscles |
| Functional activities | Participation in full activities of daily living |
Quantitative evaluation of finger movement functions
The finger movement functions were evaluated before pulley release surgery on the trigger finger and the contralateral intact finger, and a follow-up examination was also carried out on the same involved finger 1 month after surgery.
A 3-dimensional video-based motion capture systema with 8 cameras was used to quantitatively evaluate the finger movement functions. Each participant was seated beside a table. Then 8 reflective markers (2mm in diameter) were placed on the dorsal surface of the affected hand. These markers were placed on the fingertip, distal interphalangeal (DIP) joint, distal and proximal edges of the proximal interphalangeal (PIP) joint, distal and proximal edges of the MP joint, base of the metacarpal bone, and base of the adjacent metacarpal bone (fig 2). More details about this marker set are given in the literature.13, 14 The same marker setup was provided for the contralateral intact finger.
Fig 2
Eight markers were placed on the dorsal aspect of the hand.
A customized jig was used to immobilize each participant's wrist and forearm to prevent unnecessary motion, and the participant was then requested to perform a sequential movement of 5 postures (fig 3), including finger extension, intrinsic plus, straight fist, full fist, and hook fist. These 5 postures were used because they represent various combinations of the contraction and relaxation of the finger muscles.15 This sequence of 5 postures combines the maximum flexion and extension of the 3 finger joints, and the fingertip encloses a maximum region as the fingertip workspace when performing these movements (fig 4). The fingertip workspace can be used to describe the functional abnormalities or deformities of finger function in a dynamic manner and can also easily be compared in serial examinations.15, 16, 17 The fingertip workspace has also been used as a functional parameter for quantitative evaluations of trigger finger kinematics in previous studies.2, 9
Fig 3
Sequential movement of 5 postures was performed to evaluate finger function.
Fig 4
Fingertip workspace measured before and after the pulley release surgery of a participant in the intervention group (52-y-old woman; ring finger).
The fingertip workspace and joint excursion of the DIP, PIP, and MP joints were measured continuously during the sequential movement of the 5 postures. The measurement was performed 3 times for each finger in this study. The average of the 3 trials was used to represent the kinematic performance of each finger.
Data analysis
Custom-made MATLABb programs were used to analyze the collected data. The joint excursion of the 3 finger joints and the fingertip workspace were computed from the displacement of the surface markers. The improvement in the fingertip workspace is defined as the difference between post- and preoperative fingertip workspace, normalized by the fingertip workspace of the contralateral intact finger.
The improvement in the ROM of the involved finger joint is defined as the difference between post- and preoperative ROM, normalized by the reference value of the normative ROM. The reference value of the normative ROM is 80° for the DIP joint, 100° for the PIP joint, and 90° for the MP joint.
The total active ROM is the summation of the ROM of the 3 finger joints. The reference value of the normative ROM is therefore 270° for the total active ROM.
Statistical analysis
Statistical analyses were performed using SPSS version 17.0.c The Mann-Whitney U test was used to compare age, symptom duration, and all the measured variables between the intervention group control groups. The statistical significance level was set at .05. The statistical power was also calculated to ensure this analysis had sufficient power to detect the significant difference between the intervention and control groups.
Results
No significant differences in age and symptom duration were found between the intervention and control groups (seetable 1). Table 3 shows the fingertip workspace, ROM, and joint excursion angles of the involved finger before and after surgery. It also shows the measured variables of the contralateral intact finger. All measured variables demonstrated improvement after the pulley release surgery in both groups. Figure 5 shows the improvement percentage of the fingertip workspace, the ROM of the 3 finger joints, and the total active ROM. The improvement in the fingertip workspace averaged 49.4%±15.37% in the intervention group and 17.13%±25.2% in the control group. The improvement in the ROM of the DIP joint averaged 15.64%±9.56% in the intervention group and 3.86%±8.02% in the control group. The improvement in the ROM of the PIP joint averaged 21.39%±11.26% in the intervention group and 5.16%±14.5% in the control group. The improvement in the ROM of the MP joint averaged 12.64%±5.4% in the intervention group and 6.47%±10.82% in the control group. The improvement in total active ROM averaged 16.77%±6.61% in the intervention group and 5.21%±8.94% in the control group.
| Measured Variables | Intervention Group | Control Group | ||||
|---|---|---|---|---|---|---|
| Contralateral Intact Finger | Involved Finger | Contralateral Intact Finger | Involved Finger | |||
| Presurgery | Postsurgery | Presurgery | Postsurgery | |||
| Fingertip workspace (cm2) | 34.58±8.94 | 15.37±13.06 | 33.35±14.27 | 44.45±17.97 | 23.08±12.69 | 29.74±13.64 |
| DIP ROM (deg) | 62.82±13.59 | 38.58±17.42 | 51.09±21.88 | 58.95±12.79 | 43.80±11.24 | 46.89±10.40 |
| PIP ROM (deg) | 122.65±14.25 | 83.67±21.80 | 105.06±21.17 | 121.86±16.04 | 102.16±16.72 | 107.32±16.95 |
| MP ROM (deg) | 92.83±9.73 | 80.08±10.56 | 91.46±9.46 | 93.15±15.88 | 71.87±6.28 | 77.69±12.34 |
| Minimum DIP joint angle (deg) | −7.83±7.90 | 1.50±8.28 | −2.10±7.35 | 0.02±10.66 | 7.63±3.68 | 6.06±7.93 |
| Maximum DIP joint angle (deg) | 54.99±11.45 | 40.08±14.58 | 49.00±16.24 | 58.98±7.37 | 51.43±11.70 | 52.95±10.94 |
| Minimum PIP joint angle (deg) | −8.37±10.93 | 5.89±15.48 | 0.61±15.85 | −6.97±14.59 | −0.92±13.33 | −2.72±14.59 |
| Maximum PIP joint angle (deg) | 114.28±9.12 | 89.55±16.90 | 105.67±9.97 | 114.90±5.24 | 101.24±12.36 | 104.60±8.75 |
| Minimum MP joint angle (deg) | −6.00±11.36 | −3.14±6.93 | −6.43±7.24 | −10.81±12.96 | −5.20±6.27 | −4.31±8.07 |
| Maximum MP joint angle (deg) | 86.82±8.52 | 76.95±11.45 | 85.02±7.14 | 82.34±7.06 | 66.68±6.95 | 73.39±10.76 |
NOTE. Positive values are flexion of the contralateral intact finger and involved finger; negative values are hyperextension of the contralateral intact finger and involved finger. The variables are presented as mean ± SD.
Fig 5
Improvement percentage of the fingertip workspace; ROM of the DIP, PIP, and MP joints; and TAROM. Abbreviation: TAROM, total active ROM.
The intervention group showed 32.27% better improvement in fingertip workspace, 11.78% better improvement in ROM of the DIP joint, 16.23% better improvement in ROM of the PIP joint, 6.17% better improvement in ROM of the MP joint, and 11.56% better improvement in total active ROM when compared with the control group. The intervention group demonstrated significant greater improvements in fingertip workspace (P=.002), ROM of the DIP joint (P=.007), ROM of the PIP joint (P=.028), and total active ROM (P=.004) when compared with the control group. In addition, the statistical power was >0.8 for comparisons in the fingertip workspace (.95), ROM of the DIP joint (.85), ROM of the PIP joints (.82), and total active ROM (.93).
Discussion
Although postoperative management for trigger finger has been proposed in a few previous studies,11, 12 there is no evidence in the literature that demonstrates the effectiveness of such treatment, and there is no standard postoperative rehabilitation protocol. In addition, postoperative rehabilitation is not a regular procedure for trigger finger after pulley release surgery despite the unsatisfactory results that have been reported for this surgery.10 Therefore, postoperative rehabilitation for trigger finger is needed, especially for patients with joint contracture problems. Therefore, this study developed a practical postoperative rehabilitation protocol for trigger finger based on the wound healing process. The 4-week protocol presented in this work has clear treatment goals and programs, which offer guidelines for the clinicians to perform the postoperative rehabilitation for individuals undergoing pulley release surgery. Furthermore, this study quantitatively evaluated the effectiveness of the proposed postoperative rehabilitation protocol. The results show that the individuals who received the rehabilitation protocol demonstrated greater improvements than those who received no such treatment after the pulley release surgery.
The issue of secondary PIP joint contracture has been reported in cases of trigger finger.6, 17, 18 In addition to PIP contracture, the current study found deficient joint excursion of the DIP and MP joints of the involved finger in the participants before surgery. In general, the PIP extension lag and the MP flexion limitation improved in the participants at the 1-month follow-up examination. The intervention group showed significantly greater improvements in ROM of the DIP joint when compared with the control group. The deficiency in the DIP joint rotation, which is often ignored in clinical treatment, may result from the contracture of the oblique retinacular ligament because of inappropriate immobilization or edema.19 Postoperative massage and ROM exercise may help in improving the problem of contracture. The results also demonstrated that the intervention group had significantly greater improvements in ROM of the PIP joint when compared with the control group. However, ROM of the PIP joint in the control group averaged around 100° before surgery, which might be the reason why the intervention group showed bigger improvements in ROM of the PIP joint. Average fingertip workspace of the intervention group improved from 15.4 to 33.4 cm2, which was close to the average value of the contralateral intact finger (34.6 cm2). On the other hand, the average fingertip workspace of the control group improved from 23.1 to 29.7 cm2, which was significantly smaller than the average value of the contralateral intact finger (44.5 cm2). The fingertip workspace demonstrates the coordination of the 3 finger joints and might be a more practical index of finger functions than single joint rotation.
This study demonstrated the benefits of the postoperative rehabilitation protocol for trigger finger. Participants who received postoperative rehabilitation had significantly greater improvements in the fingertip workspace, ROM of the DIP and PIP joints, and total active ROM compared with the participants who received no therapy after surgery. In addition to the benefits of postoperative rehabilitation, there was one surprising finding during the quantitative finger function evaluation. Certain participants gave positive feedback after performing the sequential movement of 5 postures (see fig 3), with less tenderness and more smooth movement being reported. The sequential movement of the 5 postures was modified from the tendon gliding exercise. The tendon gliding exercise was developed to provide maximum tendon excursion and promote differential tendon gliding.20 The mismatch between the flexor tendons and the A1 pulley has been reported as a possible cause of the symptoms of trigger finger. Thickening of the pulley, an enlarged segment on the flexor tendon, or a combination of these 2 events could lead to an entrapment condition. A specific joint motion pattern may provide different excursions of the 2 flexor tendons and then allow the tendons to pass through the pulley. Further investigations of the coordination of the 3 finger joints could be conducted to develop a specific pattern of joint motion to alleviate the entrapment condition and also to reduce the irritation of the inflamed pulley or tendon.
In addition, the relation between the patient's occupation and postoperative finger function is an interesting issue. Although it was reported that the causation of trigger finger was not always work related,21 the relation between the patient's occupation and the recurrence rate after surgical intervention may suggest something different. The occupation of the participants in this study varied to a broad extent; however, a potential tendency may be found in a larger population.
Study limitations
The study limitations are subsequently listed. Our findings should be considered in light of these limitations. First, in this application of the proposed rehabilitation protocol for trigger finger, the sample size is rather small. However, the statistical power was >0.8 for comparisons in the fingertip workspace, ROM of the DIP and PIP joints, and total active ROM; therefore, the results are believed to have sufficient power to detect significant differences between the intervention and control groups. Second, for ethical reasons, this was not a randomized controlled trial. All the participants were informed of the potential benefits of the postoperative intervention and were given the choice to receive it or not. Furthermore, this study presented the results of follow-up only at 1 month after the surgical treatment, and different results may be found in longer-term follow-up periods (eg, 2 and 3mo postsurgery). In addition, this study did not recruit subjects with trigger thumbs because of the simplification of the experimental setup for the motion capture study. However, we suggest that the quantitative evaluation method used in this study could be modified to evaluate the function of trigger thumbs. The postoperative rehabilitation protocol developed in this work might also be of use with trigger thumb patients.
Conclusions
We have developed and implemented a practical postoperative rehabilitation protocol for trigger finger and provided a quantitative evaluation of the resulting finger movement functions. Although both the intervention and control groups showed improvements in the joint ROM and fingertip workspace at the 1-month follow-up examination after pulley release surgery, the intervention group had significantly greater improvements in the fingertip workspace, ROM of the DIP joint, ROM of the PIP joint, and total active ROM when compared with the control group. These results provide suggestions for the clinical treatment of trigger fingers, especially for cases involving joint contracture. The shape of the fingertip workspace and joint rotation patterns could be further analyzed in future works to better understand the coordination of the 3 finger joints. The development of a specific motion pattern would also help in alleviating the entrapment symptoms and therefore improve the related treatment programs for trigger finger. In addition, the quantitative evaluation of finger functions used in this study could be applied to compare the outcomes of different surgical methods for trigger finger (eg, open release surgery, percutaneous release surgery). Finally, the rehabilitation protocol developed in this study could be further modified for application to individuals with trigger finger undergoing open release surgery because a longer healing process may be needed after this.
Suppliers
- a.Motion Analysis Corp, 3617 Westwind Blvd, Santa Rosa, CA 95403.
- b.MathWorks Inc, 3 Apple Hill Dr, Natick, MA 01760.
- c.SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
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