OT notes · Orthopaedics

Trigger finger release (A1 pulley)

Usual anaesthesia
Local infiltration, with or without IV sedation (wide-awake so the patient can move the finger after release); general anaesthesia in children
Position
Supine, arm abducted on a hand table, palm up
Setting
elective

Operative note template for open or percutaneous release of the A1 pulley for trigger finger or trigger thumb, with a filled example for an open release of a ring finger under local anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • digital nerve injury with numbness of one side of the finger (thumb radial digital nerve is most at risk)
  • persistent triggering needing further release
  • bowstringing if the A2 or oblique pulley is cut
  • tender or thick palm scar
  • wound infection
  • stiffness, especially if the PIP joint was already contracted
  • conversion from percutaneous to open release

Pre-operative details for this operation

  1. Digit and sidee.g. right ring finger; mark the digit
  2. Symptoms and durationcatching, locking, painful nodule over A1 pulley; fixed PIP flexion contracture if any
  3. Previous treatmentnumber and dates of steroid injections into the sheath
  4. Associated diseaseNone (primary)DiabetesRheumatoid arthritisOtherin rheumatoid arthritis the A1 pulley is usually kept and a tenosynovectomy done instead
  5. Other digits triggeringadjacent digits may be released at the same sitting if consented
  6. Blood sugar on the day (if diabetic)

Anaesthesia and position

  1. AnaesthesiaLocal infiltration (wide awake)Local with IV sedationGeneral (child)drug, strength and volume; site infiltrated
  2. TourniquetForearm pneumatic tourniquetArm pneumatic tourniquetHigh forearm Esmarch wrapNone (adrenaline in local)pressure, inflation and deflation times
  3. PositionSupine, arm on hand table, palm up

Operative findings

  1. A1 pulleythickened / normal; length divided
  2. Flexor tendonnodule on FDS or FDP, fraying, tenosynovitis
  3. Digital nervesseen and protected; position of thumb radial digital nerve if thumb
  4. Triggering after releaseAbolished on active flexion and extensionPersisted: further release doneNot tested (GA): tendons pulled and glided freely
  5. Other findingsganglion on sheath, abnormal lumbrical, thick A2/A3 pulley

Procedure (steps)

  1. Skin preparation and drapingantiseptic used
  2. Local anaesthetic infiltrationpalm proximal to the incision site; drug, strength, volume
  3. Tourniquet inflatedpressure and time
  4. Skin incisionTransverseObliqueLongitudinalV-shapedlength (about 1 to 2 cm) and landmark: distal palmar crease for middle, ring and little; proximal palmar crease for index; MP flexion crease for thumb
  5. Exposure of flexor sheathblunt longitudinal spreading; neurovascular bundles retracted on both sides
  6. Proximal edge of A1 pulley identifiedwith a probe
  7. A1 pulley dividedScalpel under direct visionScissorsScalpel over Freer elevatorlength divided (about 1 cm); A2 pulley (fingers) or oblique pulley (thumb) preserved
  8. Proximal structures checkeddistal palmar fascia and proximal tenosynovium freed if binding
  9. Release confirmedpatient actively flexes and extends the digit; under GA, each tendon pulled to confirm free gliding
  10. Additional procedure (if any)partial A2 or A3 release, excision of sheath ganglion or thick synovium, with reason
  11. Percutaneous release (if chosen instead)needle gauge (18 or 19 G), MP hyperextended over towel, bevel along tendon, grating felt and then lost, triggering rechecked
  12. Tourniquet released and haemostasisBipolar cauteryPressuredeflation time

Closure, drains and dressing

  1. SkinInterrupted monofilament nylonNot sutured (percutaneous)number of sutures and size
  2. DressingSmall dry compression dressing, digits freeAdhesive bandage (percutaneous)Bulky dressing or splint (child)
  3. Circulation and sensation of digit at end

Specimens and implants

  1. SpecimenNoneExcised sheath ganglion / synovium sent for HPE

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevationhand above heart level on the day of surgery
  2. Finger movementactive finger and thumb movement from the day of surgery; light use of the hand
  3. Dressingcompression dressing off at 48 hours, then light dressing
  4. Analgesiadrug, dose, frequency
  5. Suture removal10 to 14 days
  6. Hand therapyonly if a PIP flexion contracture was present before surgery: stretching exercises
  7. Warning signsnumbness of the finger, spreading redness, discharge
  8. Follow-update and place

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. S.K., 54 years, type 2 diabetic, with painful catching and intermittent locking of the right ring finger for 8 months, not relieved by two steroid injections into the flexor sheath.

Case details

Date: 14/08/2026. Elective day-care list. Minor OT.

In OT 11:05. Local given 11:12. Tourniquet inflated 11:18. Skin incision 11:20. Tourniquet deflated 11:31. Skin closed 11:35.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. (monitored anaesthesia care, no sedation given). Scrub nurse: Sr E.

Indication and pre-op

Indication: right ring finger trigger finger with locking, tender nodule over the A1 pulley, failed two steroid injections (March and June 2026). No fixed PIP contracture.

No other digit triggering. Not rheumatoid. Capillary blood sugar 148 mg/dl at 10:30.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi from the patient. Nerve injury, persistent triggering and tender scar explained.

Right ring finger marked. WHO checklist sign in and time out done.

No antibiotic prophylaxis: clean hand procedure with no implant.

Anaesthesia and position

Supine, right arm abducted on hand table, palm up. Parts painted with povidone-iodine and draped.

Local infiltration with 4 ml of 1 percent lignocaine (lidocaine) buffered with sodium bicarbonate (10:1) into the skin over the A1 pulley.

Padded pneumatic forearm tourniquet, inflated to 250 mmHg at 11:18 without exsanguination.

Procedure

1.5 cm transverse incision a few millimetres distal to the distal palmar crease over the ring finger ray.

Subcutaneous tissue and palmar fascia spread bluntly in a longitudinal direction. Radial and ulnar neurovascular bundles retracted with small right-angled retractors and protected.

Findings: A1 pulley thickened and glistening. Nodule on the flexor tendon just proximal to the pulley. No tenosynovitis. No ganglion.

Proximal edge of the A1 pulley identified with a probe. A1 pulley divided under direct vision with a No. 11 blade over about 1 cm, from proximal to distal. Divided pulley edges lay parallel. A2 pulley seen and preserved.

Patient asked to flex and extend the finger fully five times: no catching, full range.

Tourniquet released at 11:31 (tourniquet time 13 minutes). Haemostasis with bipolar cautery.

Closure

Skin closed with two interrupted monofilament polyamide (Ethilon) sutures.

Small dry compression dressing applied, all fingers left free. Finger pink, capillary refill brisk, sensation intact on both sides of the ring finger.

End of procedure

Estimated blood loss: less than 5 ml.

Needle, blade and swab count correct, confirmed by scrub nurse.

No intra-operative complications. Specimens: none. Implants: none.

Patient walked to day-care ward in stable condition. Pulse 80/min, BP 130/80 mmHg.

Post-op orders

Keep hand elevated today. Move all fingers fully from today. Light use of the hand allowed.

Oral paracetamol for pain as per unit protocol.

Continue usual diabetic medicines.

Remove compression dressing after 48 hours and apply a light dressing.

Stitch removal on day 12 in the orthopaedic OPD.

Return early if the finger becomes numb, or there is redness or discharge.

Discharge today. Instructions explained in Marathi.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 14/08/2026, 11:50.

Must document for this operation

  • Digit and side released, and every other digit released at the same sitting. Several digits are often involved, and a wrong-digit release is a wrong-site surgery.
  • That the digital nerves were seen and protected (for the thumb, the radial digital nerve). Digital nerve injury is the main complaint after this operation, and the note is the evidence that the nerve was looked for.
  • The extent of the pulley release and that the A2 pulley (or the thumb oblique pulley) was kept. If the patient later has bowstringing or persistent triggering, the next surgeon needs to know exactly what was cut.
  • How the release was confirmed: active movement by the awake patient, or tendon pull under general anaesthesia. Persistent triggering is more common than recurrence, and the note shows whether release was tested on the table.
  • Tourniquet type, pressure and time, or that none was used. Tourniquet time is one of the items most often missing in Indian orthopaedic op-note audits.
  • Whether the patient has rheumatoid arthritis and what was done for it. In rheumatoid arthritis the A1 pulley is usually kept and a tenosynovectomy done, so a plain pulley release needs a written reason.

Common mistakes in these notes

  • Writing 'trigger finger released' without naming the digit and side.
  • Not recording that the digital nerves were identified and protected.
  • Not writing whether triggering was checked by active movement after the release.
  • Leaving out the local anaesthetic drug, strength and volume.
  • Leaving out tourniquet pressure and time.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands, and be taken by the person doing the procedure. (NABH Hospital Standards 5th ed., PRE.4(c) and (e))
  • In a Mumbai audit of 153 orthopaedic operation notes, tourniquet time was recorded in only 41.8 percent and closure details in 17 percent. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227)
  • NABH expects the operative note to be written before the patient leaves recovery, which for a day-care hand case means before the patient walks out of the minor OT area. (NABH 5th ed., COP.14(e))
  • Any excised sheath ganglion or synovium not sent for HPE goes in the yellow bag as human anatomical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 43, Trigger finger release: open and percutaneous (Weller WJ), pp. 203-206.
  • Chung KC. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Elsevier; 2018, Procedure 70, Release of trigger finger (Sears ED, Fujihara N, Chung KC), pp. 642-647.
  • Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. 7th ed. Elsevier; 2017, Ch 56 Tendinopathy: operative technique of open trigger digit release, pp. 1911-1913.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Clean orthopaedic procedures of the hand, knee or foot without implants: no prophylaxis recommended (strength C). academic.oup.com/ajhp/article/70/3/195/5112717
  • Green's Operative Hand Surgery 7e, Ch 56, printed p. 1912: 3 to 5 ml of 1% lidocaine neutralised with sodium bicarbonate (10:1) infiltrated over the A1 pulley, forearm tourniquet on the awake patient.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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