Perioperative management - Division of the A1 pulley

• Irreversible movement disorder in the sense of a trapped finger
• Relevant and patient-impairing painful snapping phenomenon (not improved by conservative measures)

• Local or general diseases that contraindicate elective surgery either surgically or anesthesiologically, or are improvable preoperatively
• Cortisone injection in the area of the surgical field within the last three months (increased complication rate such as wound healing disorder, synovial fistula)

• History of the typical clinic:
  – Tenderness in the area of the palmar crease
  – Limited finger movement, typically beginning in the morning after waking up
  – Classic snapping phenomenon with the finger getting stuck in maximum flexion, extension of the finger is only possible passively with the help of the other hand
• Clinical examination:
  – Inspection/palpation of a painful thickening in the area of the A-1 pulley, the nodule moves with the flexor tendon and sometimes gets caught on the pulley itself
  – Demonstration of the snapping phenomenon by the patient
  – In advanced cases (so-called trigger finger): The finger is maximally flexed at the PIP joint and can no longer be extended even passively, or it is stiffened in extension and can no longer be flexed.

Tip: In both cases, the patient reports a long-standing snapping symptomatology in the past, which after some time could no longer be corrected.

• no special preparation of the patient necessary
• generally an outpatient procedure
• clarification of contraindication for bloodlessness (e.g., existing shunt in dialysis)

• Information about the surgical method
• Information about additional procedures such as accompanying tenosynovectomy, tenolysis, or arthrolysis, especially in advanced cases (ingrown digit)
• Information about general surgical risks (wound healing disorder, hematoma)

Information about specific surgical risks, which, depending on pre-existing conditions (diabetes mellitus, immune deficiency) and literature, can be up to 43%:

• Injury to digital nerves with neuropathic pain
• Protracted scar pain (usually subsides after 6 months)
• Persistent complaints, revision surgery
• Risk of recurrence (increased in patients with rheumatic synovitis and diabetes mellitus)
• Pyogenic synovitis
• Tendon/vascular injury
• Synovial fistula (extremely rare)
• Functional deficit of the wrist/hand
• CRPS (extremely rare)
• Incomplete success with permanent movement restriction in pre-existing tenodesis and joint stiffening

• Local infiltration anesthesia with a fine needle
• Intravenous regional anesthesia
• Plexus anesthesia
• General anesthesia

• Supine positioning
• Positioning of the hand on a hand table
• Recommended: Application of upper arm tourniquet

• The surgeon should sit on the side where the dominant hand points distally with the scissor tip
• An assistant may sit opposite
• The instrument nurse positions themselves at the head of the hand table

• The use of a hand holder such as a lead hand or similar is advisable
• The application of an upper arm tourniquet is recommended
• The use of magnifying optics such as loupes is recommended
• A hand instrument set is used
• Special instruments are not necessary for the open method

Postoperative Analgesia

Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Aftercare

• Regular wound inspection
• Elastic compression bandage (Caution: Constriction!) for a few days
• Suture removal after 14 days
• If necessary, fatty ointment for scar care (special scar ointment not necessary)
• Release of load after 14 days

Thrombosis Prophylaxis

• not applicable

Mobilization

• immediate

Physical Therapy

• Active exercise treatment with possible physiotherapeutic support with full extension and fist closure of the fingers from the 1st postoperative day (prevents hand edema and finger stiffness)
• Specific hand therapeutic measures for advanced findings with movement restriction of the PIP joint or tendon adhesions

Diet Progression

• not applicable

Bowel Regulation

• not applicable

Incapacity for Work

• Generally 14-21 days, depending on manual activity (maximum 6 weeks)