Patients are able to see that the triggering action is gone as they watch themselves moving their fingers through a full range of motion before skin closure. They can see and anticipate that their hand will work well once they get past the postoperative discomfort and stiffness.

You only need to divide the part of the pulley that is required to solve the problem as seen by active flexion, not the entire A1 pulley.

After you release the pulley, you will occasionally see a band of fibrous tissue proximal to the pulley still causing triggering with active movement. You can release it and verify that you have solved the problem with full active flexion.

A major advantage of eliminating sedation for trigger finger surgery is that you do not need to perform the procedure in the main operating room. We perform all trigger finger procedures in minor treatment rooms in the clinic outside the main operating room with field sterility (see Chapter 10).

Many of these patients have diabetes, and because no sedation is given, you do not have to deal with their medical comorbidities, which are only a problem with sedation.

You can easily perform 15 or more carpal tunnel releases mixed with trigger finger procedures in 1 day with only one nurse with field sterility in the office or clinic. You can also see consultation and recheck patients between operations (see Chapter 14).

Although patients can “tolerate” 7 minutes of tourniquet use, they don′t have to have any tourniquet pain at all if you simply use epinephrine with the lidocaine solution. There is ample high-level evidence that the tourniquet hurts twice as much as the local anesthetic injection in carpal tunnel surgery.1,2 Patients appreciate the tourniquet-free experience.

You avoid tourniquet let-down bleeding.

You do not need cautery, particularly if you inject the lidocaine-epinephrine solution half an hour before you make an incision. We have not opened a cautery for 25 years for trigger fingers, and hematoma has not been a problem, even in patients receiving anticoagulants.

Your patients remain pain free for at least 3 to 5 hours using the technique described below.

There is no nausea and vomiting.

All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.

See Chapter 1, Atlas, for more illustrations of the anatomy of diffusion of tumescent local anesthetic in the forearm, wrist, and hand.