Synopsis
Distinguish stenosing flexor tenosynovitis from palmar fascial contracture and other causes of a stiff or catching digit, deliver staged non-operative care, and refer functional contracture or locked disease for the appropriate hand procedure.
- Trigger finger causes painful clicking, catching or locking at the A1 pulley near the metacarpal head; a tender mobile tendon nodule may be felt during flexion and extension.
- Dupuytren disease causes a usually painless palmar nodule and cord with progressive metacarpophalangeal or proximal interphalangeal flexion contracture, commonly affecting ring and little fingers.
- The tabletop test is positive when the patient cannot place the hand and fingers flat; functional impact and measured joint contracture, not the nodule alone, guide referral.
- First-line investigation for typical trigger digit or Dupuytren disease is clinical examination; ultrasound or radiographs are reserved for an atypical mass, trauma or competing joint diagnosis.
- First-line mild trigger management includes activity adjustment, analgesia and sometimes night or relative-extension splinting; one corticosteroid injection into the flexor sheath region is an established next option.
- Persistent, recurrent or locked trigger digit and objective fixed contracture should be referred for percutaneous or open A1-pulley release discussion.
- Mild Dupuytren disease without functional contracture can be observed; refer when the hand no longer lies flat, daily activities are limited or proximal interphalangeal involvement progresses.
- Dupuytren procedures include needle fasciotomy and limited fasciectomy within specialist pathways; none cures the underlying diathesis, so recurrence and nerve, tendon, skin and stiffness risks require explicit discussion.
Key red flags
Fusiform swelling, flexed resting posture, sheath-line tenderness and pain on passive extension requires immediate hand-surgical assessment for pyogenic flexor tenosynovitis.
Open injury with inability to flex or extend a joint, altered cascade or neurovascular deficit requires urgent tendon, nerve and vascular evaluation.
Acutely locked flexion with severe swelling, skin compromise or uncertain diagnosis needs prompt hand review rather than repeated forced manipulation.
A rapidly growing, painful or atypical palmar mass, skin ulceration or neurological symptoms requires imaging or tumour-pathway assessment.
Sudden several-digit stiffness with systemic inflammatory features may reflect inflammatory arthritis or infection, not simultaneous trigger digits alone.
Investigation priorities
Observe tendon catching, locate the A1 pulley and distinguish a movable tendon nodule from a fixed fascial cord.
Management branches
Painful catching is intermittent and the digit is not fixed, infected or traumatically disrupted.
- Explain the pulley-tendon mismatch and temporarily reduce repetitive forceful gripping without immobilising the whole hand.
- Trial a suitable night or task splint and preserve comfortable active tendon glide.
- Offer short compatible analgesia and consider one flexor-sheath corticosteroid injection when symptoms persist.
- Review clicking, active extension, work and glucose response over six to twelve weeks rather than repeating injection automatically.