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Thank you all for uh joining our CM E presentation today. I'm Doctor David Bene, uh E VP of Clinical Value Based Care for HCO uh health care outcomes uh performance company. Our topic for today is initial management of trigger digits before we get started on the topic of the day as we do for all uh CM E events, I want to assure the audience that I have no financial or nonfinancial relationships um to disclose as it relates to this topic and subsequent uh presentation as a reminder to those of you who have attended other CM E topics. Um We have uh presented in the series. Our objective is to improve the continuum of care and outcomes for musculoskeletal patients by defining the role of primary care providers in musculoskeletal value based care. Uh We also aim to provide diagnostic and management pearls to PCPs um uh and other providers referring to uh M SK specialists. So the providers who manage the initial uh presentation of many common M SK issues can be um uh can more accurately diagnose and treat these conditions. In addition, we aim to help providers identify red flags and other clinical factors, necessitating urgent imaging or specialist referral. At the uh end of today's session, we hope the audience will be able to identify patients at risk for a trigger digit, um diagnose trigger digits based on symptomatology and a physical examination. Initiate non surgical uh treatment for patients with symptoms of trigger digit including um the use of DME and therapy uh and determine when a patient should be referred for diagnostic testing and to a specialist for injection and or surgical management. In order to achieve these objectives, we'll briefly review the HCO specialty care um network tip sheet. Uh And then we'll do a brief run through multiple important topics in the initial management of trigger digits, starting with a background and moving uh to an evaluation of the hand for trigger finger, um trigger digits and then moving to tips for conservative treatment testing. And finally, we'll touch on when a specialist referral uh may be clinically uh warranted, hop and hop hop o specialty care network also abbreviated as HS CN. Uh believes that this uh information is important to distribute to our referral network including pcps and all our upstream providers as a way of context. The HSN HSC N network comprises more than 230 orthopedic surgeons and musculoskeletal providers across Arizona who have joined forces to follow standardized evidence based clinical pathways. Uh Never before um ha has there been a network of musculoskeletal specialists from across the street uh across the state that have come together to align around best practice delivery and education. Our network is the first of its kind in the country and is already managing and improving outcomes for United Healthcare and Medicare advantage patients across Arizona. We anticipate adding additional populations uh in the near future. HCO uh Specialty care network is a clinically integrated network which is a type of value based care program and by definition, value based care programs incentivize health providers to provide improved quality of care while reducing unnecessary cost of note. Uh HSEN was recently recognized by uh the top national accreditation organization U A for its commitment to clinical integration and high quality care. HSEN is actually the first specialty network in the country to be awarded accreditation as a high quality clinically integrated network. HSEN also collaborates with other providers including yourselves who encounter M SK conditions uh with a goal of improving patient outcomes and experience. And as you are uh well aware, a lot of the initial management of M SK care uh occurs not at the specialist level uh but upstream uh at PCP uh uh office visits in saying this, uh it's clear the population health program clearly relies on PCPs um to help reduce unnecessary M SK costs. Um As they are the common, the most common gatekeeper uh for M SK care. Before we dive into the topic of the day, it's important to mention that the information shared in this talk is evidence based and consensus driven with recommended practices designed to be implemented for patients with M SK conditions. Um but it should be said for all clinical programs, clinical discretion should be used with these guidelines for patients, especially if there's concomitant clinical uh clinic, uh clinical factors or comorbid conditions that may alter uh the clinically appropriate treatment path. Let's uh let's start uh with a review of the HSEN uh tip sheet as we do for other uh talks as well uh within the series and we send out this tip sheet to all of you. Um uh but if you don't have a copy, as I said in uh prior uh talks as well, please feel free to email us and we can send you a copy so you can have it in your clinic. Uh You can email us uh and we'd be happy to send you a copy that's HS en at HCO dot com. This tip sheet is uh more specific uh to the older Medicare Medicare advantage population. But uh uh again, many tips here are relevant to a younger population as well. Today, we're focusing on hand pain due to trigger digit. That's the fifth line on this um uh tip sheet. Um We will go through each column in more detail, but it's a good way to see the overall um suggestions for the specialist for initial management as you can see on this tip sheet, uh trigger digit um pain um uh trigger due to related pain. Initial management comprises of conservative care which may include activity modification but does not uh uh include DM E doesn't necessarily include um uh therapy uh and does not include advanced imaging as you can see uh here, um notated by a red uh icon. Uh trigger occurs um when a digital uh flexor tendon becomes enlarged and it's trapped under the A one pulley uh ligament leading to catching or locking of the tendon. Uh It's pretty common in the population. About 2% of the general population uh has trigger digit. Uh uh most, it's most common in women um by the fifth or sixth decade of their life. Um but it happens in men in significant numbers. Uh as well. There are risk factors that increase the risk for trigger finger uh developing uh as noted already. Uh age is a risk factor. Um But so is um diabetes, uh patients with amyloidosis and those who have uh carpal tunnel syndrome as well. In addition, trigger finger is more common in patients with cer certain comorbid uh conditions uh such as gout thyroid disease and rheumatoid arthritis and forceful hand activities, especially uh forceful use of the fingers and the thumb. Uh also increase the risk of uh trigger, trigger digit when getting a history on a patient with a trigger digit. Often there's a a you, you um have AAA story of a progressive amount of discomfort in the palmar side of the affected digit. Um, it when it's flexed, um, patient may notice a swelling or a nodule or a painful click or a locking of the digit. Typically, the symptoms are progressive. Although for some symptoms, um, uh for some patients, uh, the symptoms can come on, uh quite quickly. On uh physical examination. You may feel a tender nodule, the distal uh palmar crease, uh, right where the finger begins. Um, the affected, uh, digit may be flexed and locked. Um, and attempts may be made by the patient to move. Uh, the digit. Uh, the digit may cause uh, pain or snapping after uh obtaining history and uh physical consistent with trigger digit. Uh, let, now let's walk through, uh, the initial management of this uh, condition. Uh, the first line treatment, um, is, uh a conservative uh intervention for at least six weeks. Uh, this includes activity modification and topical nonsteroidal antiinflammatory drugs. And, uh, splinting at times can also be trialed, but it's not always, uh, necessarily a first line treatment. Uh, but it can be tried after nsaids and um, a and alleviation of other activities that may be aggravating the symptoms if you're able to in the office. Um, a local, um, uh Glucocorticoid injection may be offered to patients whose symptoms have not resolved with conservative management. Uh, but this is, uh, this should not be the sole reason for a referral, uh to a specialist, uh, for those patients where splinting is, uh, trialed, um, MCP, joint splints are usually worn, um, at night but also can be worn continuously. Uh, importantly, a trial of 1 to 2 months is necessary. Um, a and reasonable to assess the response of splinting. Uh, sometimes it takes a little longer than you may think to see if they have a response, uh, to splinting mcb joints, um, are actually, uh, pretty easy to find, uh, in most drug stores and it's actually usually pretty, uh, a little cheaper to, to get, get them in a drugstore versus prescribing them. Um, you should avoid prescribing custom splints. Um, unless an over the counter splint has failed. Uh, and as I've said, in other talks, it's supposed best to keep the ordering of any custom, uh DM E, um, to a specialist. Um, and, uh, just as a note, um, uh, physical and occupational therapy are not indicated for trigger digit. Uh, and it may not be co uh come as much of a surprise but imaging including x rays, CT scans, uh MRI S are not necessary in the treatment of trigger digit. Uh, if any imaging is required, it would be more likely in the situation in which the patient is referred to a specialist. Uh, in that case, it's best to have the specialist order any testing so it could help them better direct future care needs. There are some clinical, uh, circumstances in which a surgical, uh, referral to a hand specialist is clinically warranted. Um, surgical release is usually reserved for patients who have failed conservative therapy and have not improved, um, with two injections or have a locked uh digit. Um, and a referral should be made to a hand specialist. A after symptoms do not approve for at least six weeks uh, of conservative treatment. And as I've mentioned in other M SK talks, uh within a series of a patient doesn't want to consider a procedure or surgical intervention, referring to a hand specialist may not be uh necessary or the right uh choice for that patient. I'd like to end all the talks in the series with some uh take home points um for trigger digits. Patients who require DM E should research the cost of attaining noncustom DM E at a drug store instead of through insurance uh imaging including x rays um is not necessary for patients um with trigger digit um which is, is diagnosed clinically. Um Likewise, uh MRI S are not indicated for trigger uh digits and therapy is also not indicated uh for patients with trigger digits as well. Uh And specialist referrals uh should only occur after a significant trial of conservative care except in some extreme uh clinical uh scenarios. Uh I wanna thank you all for uh joining uh joining me today for this presentation. Uh We hope you enjoyed the talk and uh I hope you join us uh again as we explore other topics in, uh, M SK care, take care and have a good day.