Sunday, March 27, 2011

TRIGGER FINGER - your finger is catching

Trigger finger (stenosing tenosynovitis),  is one of the common causes of pain and dysfunction in the hand.
The initial symptom is of a painless "click" in the hand on moving the fingers which might eventually progress into a locked finger. The finger might be locked in flexion, whereby a forceful extension of the finger is required to unlock the finger , causing a feeling of "triggering" at the base of the finger (the metacarpo-phalangeal joint). Patients may or may not notice a lump or knot in the palm of the hand, again typically at the base of finger.

The problem occurs when there is a constriction where the finger flexor tendon enters the tendon sheath at the base of the finger. It is caused either by a thickening (hypertrophy) of the tendon sheath, or a nodular swelling of the tendon itself just proximal to the sheath. Either way, the basic problem lies in the discrepancy between the size of the tendon nodule and the thickened tendon sheath. This means that the tendon can no longer slide easily through it and it becomes harder to bend or straighten the affected finger or thumb as a result. 



Trigger finger occurs two or three times more frequently in women than in men and has a peak incidence of around 40- 60 years of age (the demographics sounds similar to carpal tunnel syndrome... ) The ring finger is the most frequently involved, followed by thumb and ring finger.Frequently one finds that multiple fingers are affected and bilateral hand involvements are not uncommon.

As many as 85% of trigger finger can be successfully treated non-operatively. These include activity modification, splinting, anti-inflammatory drugs (NSAIDs) and steroid injections.

Steroid injection around the flexor sheath can be an effective treatment, and in my experience, for the patients with mild triggering and short duration of symptoms, one can expect a complete resolution of symptoms.

Surgical release of trigger finger is reserved for patients not responding to conservative management, the chronically locked finger, long duration of symptoms, and multiple digit involvement. As with most of my minor hand surgery cases, this can be done as a daycare procedure under local anaesthesia and takes about 15 minutes. However, in instances where multiple fingers need to be operated upon, general anaesthesia may be a more comfortable option.

Similar to carpal tunnel release, a small incision about 1cm is made at the base of the affected finger and the constricting sheath is then cut open longitudinally under direct vision. Care is taken to ensure that the nerves running alongside the tendon is not disturbed, and this can only be done if the surrounding structures are well visualized; this is the reason that I am not in favour of percutaneous release of trigger finger, although the proponents say that it is a reasonably safe option.


A surgical loupe is frequently needed to identify the structures

Incision at the base of the finger


the constricting sheath (A1 pulley) is visualized and divided

sutured up

Trigger finger in infants or children almost always involves the thumb and could be a different entity from the adult type. Most authors recommend observation as children below 6 months can have spontaneous resolution of symptoms ( I know, because my nephew had the same problem - it resolved spontaneously!). Surgery, as with adults, could be considered if symptoms persist.

- the BomohTulang - 

References: 

Trigger digits: diagnosis and treatment.   J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):246-52.

Trigger digits: principles, management, and complications. J Hand Surg Am. 2006 Jan;31(1):135-46.

The Natural History of Pediatric Trigger Thumb. The Journal of Bone and Joint Surgery-American Volume
Issue: Volume 90-A(5), May 2008, pp 980-985

Core Knowledge in Orthopaedics: Hand, Elbow, and Shoulder. Trumble, Budoff, Cornwall. Mosby 2005

Monday, March 14, 2011

BOMOH TULANG - a bit about me

*ehem* I have taken the liberty to "cekup" my profile from the ColumbiaAsia's blog and put it here, just for you loyal readers.

Dr Saiful Akhtar Shamsuddin - Consultant Orthopedic Surgeon

Dr Saiful Akhtar Shamsuddin
Consultant Orthopedic Surgeon
Columbia Asia Hospital, Bukit Rimau, Malaysia
MBBS (UM), MS Ortho (UKM), CMIA (NIOSH)
Fellowship in Lower Limb Arthroplasty & Reconstruction (Aus)
AO Fellowship in Hand Surgery (USA)
saiful.akhtar@columbiaasia.com


Dr Saiful Akhtar Shamsuddin is an orthopedic surgeon, with a keen interest in Hand surgery and also Arthroplasty surgery as a sub-specialty.

He brings to Columbia Hospitals a wealth of experience and knowledge in orthopedics, having had 18 years of orthopedic experience and more than a decade of specialist orthopedic experience, serving in one of the busiest hospitals in Malaysia.
Dr Saiful was born, raised and schooled in Klang, Selangor,  making him a native Klang-ite. After Form Five, he furthered his studies in Pusat Asasi Sains and henceforth continued to study medicine in University Malaya.

Having completed his undergraduate studies, he went on to work mainly in the Orthopedic and Surgical departments throughout his career. His first ever posting as a houseman was in the Orthopedic Department in Hospital Kuala Lumpur, where he made the decision to pursue Orthopedics as a career. He had the priviledge to work in various hospitals throughout his career; namely Hospital Seremban, Hospital Kuala Pilah, Hospital Kuala Lumpur and Hospital UKM, prior to completing his Masters Progamme in Orthopedic surgery. He last served Hospital Tengku Ampuan Rahimah Klang before joining Columbia Asia Hospital, Bukit Rimau as a Consultant Orthopedic Surgeon

During the earlier part of his career as a specialist, he was attached to the Hand and Micro-Surgery Department of Hospital Selayang, under the guidance of Dato’ Dr Pathmanathan, where he developed a keen interest in Hand Surgery as a sub-specialty. He continued his involvement in hand surgery while in Hospital Klang and was instrumental in setting up the hand services there.

Dr Saiful later obtained a fellowship in Lower Limb Arthroplasty and Reconstruction from the Gold Coast Hospital, Australia  to strengthen his knowledge in Joint replacement surgery.
Besides hand surgery and arthroplasty surgery, he also manages various orthopedic problems, ranging from simple backache to congenital deformities to severe limb and spine trauma.

Dr Saiful is married, and is blessed with three wonderful children. In his spare time he can be found scuba diving beneath the tropical waters off Malaysia’s east coast islands. He is also passionate about photography, a hobby he picked up during his student days.

Contacts or appointments?
click here


- the BOMOH TULANG -

Friday, March 11, 2011

At the AO principles course 2011


The AO principles and advanced course Malaysia 2011 was held at the Dorsett Regency, Subang, and attended by more than 70 local and international participants. Held over a period of two days, it encompasses lectures, case discussions and hands-on workshops on fixation techniques.

The Bomoh Tulang has been fortunate to be a part of the teaching faculty for past few years, and this year was not an exception. 

The AO Foundation - Arbeitsgemeinschaft für Osteosynthesefragen (German for: Association for the Study of Internal Fixation) - is a non-profit organization based in Davos Switzerland, dedicated to the advancement of the treatment of musculoskeletal injuries. Founded in 1958, the AO foundation promotes the understanding of fracture management through research, meetings and education. 

As an integral part of education, the AO foundation through AO Education conducts courses on the principles and techniques of fracture fixation,  for Orthopedic surgeons and also operating room personnel. These courses are held on a regular basis throughout the world and is a great place for trainee orthopedic surgeons or even senior surgeons to learn, exchange notes and at the same time update their skills on the latest fixation techniques.



Dr Ivan explaining the finer points of external fixation to the participants



Plating the fibula

Dr Rashdeen and Dr Hazrin trying out some fixation techniques. This was at the 2010 course.

Also at the 2010 course. Dr Azfar was a participant.

Interested in next year's AO course?
Click here for registration. Spaces are limited so better hurry!

- the BOMOH TULANG -