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Conservative treatment for trigger thumb in children
Abstract
Conservative treatment was performed for 60 trigger thumbs (19 right, 17 left, 12 bilateral) in 48 children (19 boys, 29 girls); the age at initial diagnosis ranged from 0 to 48 months old (mean 26 months). In this approach, only passive exercise of the affected thumb was performed by the mother. As a result, two patients (two thumbs) dropped out of treatment. Fifty-six thumbs out of 58 showed a satisfactory result (96%). Sixteen thumbs (in stage 2) and eight thumbs (in stage 3) showed completely recovery. Four thumbs (in stage 3) have not yet improved. In conclusion, we suggest that conservative treatment is effective for trigger thumbs in stage 2, while surgical therapy was thought to be indicated for stage 3 before the age of 3 years to avoid flexion deformity.
... Management of pediatric trigger thumb is based on conservative or surgical procedures with various efficacies. Success rates of conservative treatment were 12-63% for observation [3][4][5][6][7][8], 40-80% for stretching [9][10][11][12][13], and 60-92% for splinting [8,13,14]. Operative treatment seemed to have a higher success rate as 77-100% for open technique [4,12,13,[15][16][17][18][19][20][21][22][23][24][25][26][27][28], and 70-97% for percutaneous release [20,[29][30][31]. ...
... Observation for congenital trigger thumbs has the lowest cure rate (12-60%) [4,8,40] when compared with other treatments. Spontaneous resolution is usually expected in young infants [6,43], unlocked thumb [9], and unilateral involvement [10]. One out of three studies included 53% of bilateral involvement, and considered only locked Values above and below diagonal cells were the RRs (95% CI) of cure for the column intervention compared with the reference intervention in row. ...
... Gentle manipulation of interphalangeal joints accomplished resolution about 63-96% [9,11,43]. It needs parents' cooperation and was not indicated for cases of greater deformity and stiffness. ...
To estimate and rank cure and recurrence rates between conservative and operative treatments for trigger thumb in children. A systematic review was conducted by searching PubMed and Scopus. Eligible criteria were comparative studies included non-syndromic trigger thumbs, aged up to 10 years, reported at least 20 thumbs and followed up at least 12 months. Two assessors independently extracted data and appraised for cure, recurrence rates among observation, stretching, splinting, open surgery, and percutaneous surgery. We assessed the risk of bias in non-randomized studies of interventions. A network meta-analysis, and probability of being the best outcomes were estimated with surface under the cumulative ranking curves (SUCRA). From 6853 searched articles, eight studies (799 children and 981 thumbs) were included. Mean age was 1.87-2.83 years and average followed up time was 1-5.7 years. Open surgery, percutaneous release, splinting, and stretching had higher cure rate than observation; pooled risk ratio (95% confidence interval) of 2.06 (1.53-2.78), 1.79 (1.26-2.53), 1.76 (1.30-2.36), and 1.37 (0.93-2.03), respectively. Percutaneous release increased risk of recurrence 3.29 times (1.42-7.60) when compared with open surgery. The best cure rates were open surgery (SUCRA = 95) followed by splint (SUCRA = 63.4), and percutaneous technique (SUCRA= 62.8). The highest recurrence rates were percutaneous (SUCRA = 97.3), and open surgery (SUCRA = 62.4). Splint is the most appropriate intervention for pediatric trigger thumb. After failed conservative methods, open surgery is considered for operative treatment. Level of evidence: Therapeutic study level II-III.
... The vast majority of reports did not conduct any statistical analysis. However, Lee et al. (2006) and Koh et al. (2012) calculated p values for both outcome measures (observation vs. splinting), Ramirez-Barragan et al. (2007) for comparison of open vs. percutaneous surgery, Han et al. (2010) and Jung et al. (2012) for comparison of unilateral vs. bilateral involvement, and Watanabe et al. (2001) and Jung et al. (2012) for comparison of outcomes between different trigger thumb severities. The only studies with a follow-up of less than 80% were by Nemoto et al. (1996) and Forlin et al. (2012). ...
... Three reports assessed the outcome after daily passive exercising performed by the parents (Forlin et al., 2012;Jung et al., 2012;Watanabe et al., 2001). Although this cohort included the only prospective study of this systematic review (Jung et al., 2012), as well as relatively long follow-up periods (up to 16 years; Forlin et al., 2012), the results of this subset were only moderate (40-80% full IP motion). ...
... Although this cohort included the only prospective study of this systematic review (Jung et al., 2012), as well as relatively long follow-up periods (up to 16 years; Forlin et al., 2012), the results of this subset were only moderate (40-80% full IP motion). Although not clearly mentioned by Watanabe et al. (2001), full motion only appeared after exercising for a mean period of 24 (Jung et al., 2012) and 21 months (Forlin et al., 2012), respectively. Complications included IP flexion deformities (3) and drop-outs from therapy (2), and eight patients needed further surgery. ...
The purpose of this systematic review was to determine the outcome of interphalangeal (IP) joint motion in children undergoing open surgical release, splinting, and passive exercising therapy for the treatment of paediatric trigger thumb. We conducted an online literature search of seven major databases. Only studies with a mean follow-up of at least 12 months were considered for inclusion. Seventeen retrospective studies and one prospective study met all the inclusion criteria. They reported on the results of surgery (634 children, 759 thumbs), splinting (115 children, 138 thumbs), and passive exercising (89 children, 108 thumbs). The mean follow-up periods were 59 (surgery), 23 (splinting), and 76 months (exercising), respectively. Full IP joint motion without residual triggering was achieved in 95% of all children undergoing surgery, in 67% of children treated with continuous splinting, and 55% after passive exercising. Based on the low level of evidence available, it seems that open surgery resulted in more reliable and rapid outcomes compared with nonoperative treatment.
... The spontaneous resolution rate of PTT is reportedly 24-80% [5][6][7][8][9][10][11][12]. Baek et al. presented the natural history of PTT and reported a spontaneous resolution rate of 63% [5]. ...
The present study aimed to evaluate conformational changes in the flexor pollicis longus (FPL) tendon and inner space of the A1 pulley during spontaneous resolution of pediatric trigger thumb (PTT) and to compare them versus the normal contralateral side. We enrolled 36 patients with unilateral PTT who underwent ultrasonography twice between January 2016 and July 2020 and showed >10° improvement in thumb interphalangeal (IP) joint extension lag. Ultrasonography was used to measure the anteroposterior (AP) and radioulnar (RU) diameters of the FPL tendon proximal to the A1 pulley and of the inner space of the A1 pulley. On the side of the PTT, the average extension lag in the thumb IP joint significantly improved, from 35.6° to 14.2°. The AP and RU diameters of the FPL tendon increased by 0.3% and 1.9%, respectively, and those of the inner space of the A1 pulley increased by 15.3% and 5.0%, respectively. In the contralateral normal thumb, the AP and RU diameters of the FPL tendon increased by 12% and 9.3%, respectively, and those in the inner space of the A1 pulley increased by 9.9% and 4.6%. During improvement in IP joint extension lag, the mismatch between the enlarged FPL tendon and the inner space of the A1 pulley was reduced by their asymmetric growth.
... No utilizamos férulas de inmovilización por la dificultad para su colocación en un niño de esta edad y la falta de evidencia en la eficacia de este método. 21 Luego de esta edad, recomendamos la cirugía ya que las posibilidades de recuperación espontánea son mínimas. 9,11 La mayoría de los estudios en la literatura presentan buenos resultados y una baja tasa de complicaciones con la liberación por vía palmar (Cuadro I). ...
Introduction: Trigger finger is a rare condition in children, affecting mainly the thumb. The aim of this study was to evaluate the functional results and complications of surgical treatment of trigger thumb in children. Methods: We retrospectively evaluated all patients with surgically treated between January 2002 and August 2011. We evaluated interphalangeal range of motion and complications such as infection or sensory deficit. A satisfactory result indicated no triggering and full range of motion. Parents were asked about satisfaction of the procedure.
Results: We performed 45 surgeries in the evaluated period; 31 patients (38 thumbs) could be located and evaluated (17 female and 14 male). Average age at time of surgery was 2.4 years (range:
1.7 to 7.2 years). Average follow-up was 4.7 years (range: 1-9 years). Three cases (8%) had recurrence and required subsequent release. All patients recovered full range of motion. There were no residual flexion contractures or sensory deficit. Two patients (5%) had superficial wound infection. Both responded favorably to oral antibiotic therapy. Parents reported satisfaction with the treatment.
Conclusion: Open release of the A1 pulley is a safe and effective procedure for the treatment of trigger thumb in the pediatric population, with a low rate of recurrence and complications.
Level evidence: IV
... In two different studies where two cases aged four and five years old received physical therapy and anti-inflammatory therapy, positive results were reported from the treatment (Pargali and Habibzadeh, 2011;Kelle, 2012). In another study, the mothers of children with trigger thumb were taught passive stretching exercises and after a mean 28 months of application positive results were obtained in the vast majority of cases (Watanabe, 2001). ...
Trigger finger is a rarely seen condition in childhood. It generally occurs in the thumbs and in the differential diagnosis flexion deformities originating in the joint should be included. This study comprised 23 cases in 19 children who underwent surgery for trigger finger between 2005 and 2013 in our clinic. All the patients passed through the postoperative period without any problems. Several treatment methods are in use, however it is suggested that surgery is required as the first treatment option especially in childhood. Surgical treatment is made in the form of a percutaneous or open incision in the longitudinal plane of the A1 pulley system. In recent years, although percutaneous methods are in common use, open surgical methods have been thought to be more reliable as the surgical area is small and the digital veins and nerves can be easily damaged in pediatric cases. In addition, it can be considered necessary for early movement in the postoperative period.
... Watanabe et al (32) , estudando 58 polegares em gatilho cuja orientação foi exercícios passivos realizados pelas mães dos pacientes, obtiveram resultados satisfatórios em 54 polegares (96%). Em pacientes abaixo de três anos de idade, a indicação de cirurgia foi somente para os casos de maior deformidade. ...
Objective:
The aim of this study was to evaluate the outcome of conservative treatment of trigger thumb in children, in order to discuss the real need for surgical release in these patients.
Methods:
This was a retrospective study on a group of children with trigger thumb who were treated conservatively by the same orthopedic surgeon with gentle manipulation at the time of the consultation and guidance on stretching to be performed at home. The cases were followed up for at least five years.
Results:
Thirteen thumbs in 11 children (seven boys and four girls) were treated. The mean age at the first consultation was 26.3 months (range: 11 to 36 months). The mean follow-up was 10 years (range: 5 to 16 years). Ten thumbs showed satisfactory results (77%): eight of these were diagnosed when the child was younger than two years of age. The mean time taken from diagnosis to clinical improvement was 20.8 months (range: 6 to 36 months). The three thumbs that required surgical treatment were diagnosed after the age of two years and six months.
Conclusions:
Conservative treatment of trigger thumb in children showed a high rate of success, especially in children who were diagnosed up to the age of two years. This is important information to be passed on to parents and may avoid unnecessary surgery in many cases.
... The clinical improvement was compared by a reciprocal comparative evaluation among the each follow-up stage. Patients were asked to answer as one of four stages by the W stage(Table 1)8) and VNRS. ...
Conservative management for the trigger fingers includes splinting, steroid injection and other adjuvant methods. If conservative treatment fails, a surgical release of the A1 pulley is offered. Although the success rate of the surgical intervention is high, the complications, for example, a digital nerve injury, bowstringing, infection and continued triggering, have been reported. Percutaneous release with an 18 guage needle has been reported as a safe and effective procedure for the trigger fingers. This study evaluates the safety and efficacy of the percutaneous release.
... In the pediatric literature, spontaneous resolution of trigger thumb has been shown to occur in over 50% of patients if the families are willing to wait several years. [5][6][7] Surgery is the definitive management option for adult trigger finger, and we reserve this treatment option for those patients who do not undergo spontaneous resolution and whose symptoms have plateaued or for patients who are too impatient or symptomatic to wait. In our practice, we do not have a significant role for steroid injection or splinting, as the literature provides comparable success rates to our patients who receive no treatment at all. ...
Introduction:
There is very little information in the literature evaluating the natural history of adult trigger fingers and their rate of spontaneous resolution over time.
Methods:
A consecutive case series of patients with trigger finger was generated. For each patient, we recorded whether the patient's disease resolved from either no treatment versus active treatment options and over what time period.
Results:
Three hundred forty-three patients with trigger finger were included in the study. Fifty-two percent of patients resolved without any treatment whatsoever after waiting a mean (and median) of 8 months from initial consultation. The thumb was the most frequent digit to resolve without treatment (72%).
Conclusions:
We found that just over half of patients with trigger fingers who are referred to our office resolve spontaneously without any intervention.
... Beleid bij kinderen met een trigger thumb Er zijn twee observationeel onderzoeken gevonden naar respectievelijk de effectiviteit van oefe- ningen [Watanabe 2001] en chirurgische behan- deling [Van den Borne 2000] bij kinderen met een trigger thumb. Een observationeel onderzoek (n = 48; gemiddelde leeftijd 26 maanden (bereik 0 tot 48 maanden )) toont aan dat 96% van de kinderen herstelt door oefeningen uitgevoerd door de moeder (passief strekken van de duim). ...
De NHG-Standaard Hand- en polsklachten geeft richtlijnen voor diagnostiek en behandeling van patiënten met klachten van de
hand en pols in de huisartsenpraktijk. De huisarts wordt bij hand- en polsklachten meestal direct op het spoor van een specifieke
aandoening gezet. Daarom behandelt deze standaard de diagnostiek en het beleid bij de meest voorkomende specifieke aandoeningen
van de hand en pols: carpaletunnelsyndroom (CTS), ganglion, artrose van de hand, trigger finger en trigger thumb, mallet finger,
contractuur van Dupuytren en tendovaginitis van De Quervain.1
... Although the investigators reported that 56 of 58 thumbs (96%) achieved a "satisfactory" result, motion remained abnormal in 34 thumbs (59%) at final follow-up. In addition, because there was no control group, it is unclear whether passive stretching produced more improvement than did observation alone [9]. ...
... Característica clínica 16 em um estudo, realizando fisioterapia feita pelas próprias mães dos pacientes com "polegar em gatilho congênito", tiveram como resultado a taxa de cura de 80% para os estágios 2 (gatilho que destrava no movimento ativo) e de 25% para o estágio 3 (gatilho que destrava somente no movimento passivo). ...
Resumo
O dedo em gatilho é uma afecção frequente. Não obstante a tenossinovite e a alteração da polia A1 serem identificados como fatores desencadeantes, não há consenso sobre a verdadeira causa na literatura, sendo que a sua verdadeira etiologia permanece desconhecida. O diagnóstico é puramente clínico na maior parte das vezes. Ele depende unicamente da existência do travamento do dedo no decorrer da movimentação flexão ativa. O tratamento do dedo em gatilho geralmente se inicia com intervenções não cirúrgicas que são instituídas por pelo menos 3 meses. Nos pacientes em quem haja apresentação inicial com deformidade em flexão ou incapacidade de flexão do dedo, pode haver indicação mais precoce do tratamento cirúrgico em razão da intensidade do quadro álgico e da incapacidade funcional do paciente.
No presente artigo de revisão, apresentaremos as modalidades e o nosso algoritmo para o tratamento do dedo em gatilho.
... Parents were advised to apply the splint during sleeping hours for a minimum of 3 months. Children were included regardless of their stage of the disease according to Watanabe et al. (flexible or fixed IP joint flexion contractures; Watanabe types one to three [9]). Primary endpoint was conversion to surgery determined after chart review after a mean follow-up of 2.4 years (range 1.2-2.8 ...
Controversy still exists whether conservative treatment may be a useful option for the treatment of pediatric trigger thumbs. We reviewed a random sample patient cohort with regard to success rates depending on whether flexible or fixed trigger thumbs were present. We performed a pilot study of 13 children (15 thumbs), who received a standardized treatment protocol including a custom-made thermoplastic splint for use during sleeping hours for a minimum of 3 months. Splinting was of only minor value for moderate and severe cases was but was beneficial for the majority of patients showing triggering symptoms only. It may thus be a reasonable option to delay surgery in infants with mild/flexible cases.
OBJECTIVE. To evaluate results from surgical release of trigger thumbs in children in a regional hospital cluster in Hong Kong. DESIGN. Descriptive case series. SETTING. A regional hospital cluster, Hong Kong. PATIENTS. Data from 1993 to 2009 on 180 children with 209 trigger thumbs were collected. Analyses into gender, predominance of thumb, age of onset, associated abnormalities and family history, symptoms and signs, surgical outcomes, and postoperative complications were carried out retrospectively. RESULTS. There were 92 girls and 88 boys having trigger thumbs (1.05:1). In all, 29 (16%) of the children presented with bilateral trigger thumbs, while the right thumb was singly involved in 81 (45%) and the left thumb in 70 (39%) of the children. The mean age of onset was 19 months; only 20% were diagnosed before the age of 1 year. Only nine (5%) of the children were associated with congenital diseases and none had a positive family history of trigger thumb. Flexion deformity was the major presenting feature, other than triggering or pain. A nodule and flexion deformity were very commonly observed during physical examination. More than 95% of the operated thumbs with transverse incision acquired a good range of movement with a scarcely apparent scar. A residual flexion deformity was evident in only 4%, mostly in children who underwent surgical release under the age of 1 year. CONCLUSION. Surgical release is recommended for children with trigger thumbs aged more than 1 year, which attains satisfactory results with minimal complications.
Een trigger finger, ofwel ‘hokkende vinger’, ontstaat wanneer door verdikking van de flexorpezen van de vinger of vernauwing
van de peesschede (pulley) ter hoogte van het metacarpofalangeale gewricht de pezen niet soepel meer door de peesschede glijden.
Kenmerkend voor de aandoening is dat de pezen bij het strekken van de vinger blijven steken en vervolgens met een klik door
de peesschede schieten. Dit wordt ook wel ‘hokken’ of ‘knappen’ genoemd. Daarnaast is er sprake van pijn en een verminderde
mobiliteit van de aangedane vinger.
Trigger thumb is a relatively uncommon condition in children. If it occurs or persists after 1 year of age, surgical release is the most traditional treatment method. The aim of this prospective study is to describe a technique for the percutaneous release of trigger thumb and to assess the clinical outcome of the presented technique in the pediatric age group.
This study includes 31 thumbs of 26 consecutive children with a mean age of 2.6 years. An 18-gauge needle that was connected to 10-cc saline filled syringe was used as the surgical instrument for release. Contrary to the earlier reports, the A1pulley was cut from distal pole of the Notta nodule towards the proximal direction.
Mean follow-up period was 2.5 years. A successful release without any complication was obtained in all (97% of thumbs) but 1 thumb. Recurrence was seen in only 1 thumb at postoperative 3 weeks.
The presented minimal invasive surgical procedure has a high rate of satisfactory outcome, a minimal rate of complications, and a high rate of parent satisfaction. As percutaneous release has satisfactory and encouraging results, it can be a preferred method by the parents for trigger thumb release. STUDY LEVEL: III.
There have been debates about the results of surgical treatment in older children, even though many studies showed excellent results in pediatric trigger thumb. The objective of this study was to identify the possible problems or complications related to the delayed surgery for trigger thumb in children. Authors clinically reexamined the patients who had undergone A1 pulley release above the age of 5 years and analyzed the results of surgical treatment.
A retrospective study of 31 trigger thumbs was performed on 23 consecutive children treated using a standardized surgical technique. The mean age at the operation was 7.46 years and average period of clinical follow-up was 2 years and 3 months. We investigated the presence or absence of interphalangeal joint flexion contracture, triggering, recovery of active range of motion, postoperative period that the patients get more than 0 degree interphalangeal joint extension, and complications.
Flexion contracture and painful triggering were successfully relieved after surgery in all cases. Patients showed variable periods in improving temporary extension weakness of interphalangeal joint, but there was no statistical difference in the final result between early and delayed improvement or between symptom duration and healing time. None of these patients had any postoperative complications.
Surgical treatment with A1 pulley release for over 5 years of age resulted in successful resolution of trigger thumb and satisfactory clinical outcome in all our cases regardless the age at the time of surgery. From the author's findings, we can expect satisfactory results of surgical treatment in pediatric trigger thumb even in the case of delayed diagnosis or late treatment.
Objective: Assess the differences between open and percutaneous release of trigger thumb in children. Material and methods: We performed a retrospective study of all the patients operated on at our institution between January 2000 and February 2009. Our exclusion criteria were: patients with trigger fingers other than the thumb, that were being operated on simultaneously of another condition, admitted for other reasons or refused treatment. The surgical technique was left to the preference of the attending physician. Results: We found 176 trigger thumbs (159 children), with a mean age of 2.58 years, the majority being unilateral (n=142). Statistically significant differences between the two treatments were only found regarding surgical time (p<0.01); percutaneous release (14,56. min) was less time-consuming than the open technique (33,49. min). Conclusion: Percutaneous release in children is a good, simple, cheap and fast alternative but it requires compliance of the parents in order to avoid recurrence and to obtain complete success.
Objective
Assess the differences between open and percutaneous release of trigger thumb in children.
Trigger finger is an entity seen commonly by hand surgeons. It is produced by a size mismatch between the flexor tendon and the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. The diagnosis is usually easy but other pathological processes (extensor apparatus instability, locked metacarpo-phalangeal joint) must be excluded. Treatment modalities in trigger finger include splinting, corticosteroid injection and/or surgery. Indication depends on the clinical form of trigger finger.
Trigger finger is an entity seen commonly by hand surgeons. It is produced by a size mismatch between the flexor tendon and the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. The diagnosis is usually easy but other pathological processes (extensor apparatus instability, locked metacarpo-phalangeal joint) must be excluded. Treatment modalities in trigger finger include splinting, corticosteroid injection and/or surgery. Indication depends on the clinical form of trigger finger.
We analyzed the outcomes of our conservative treatment for pediatric trigger thumb. Since March 2004, we have used conservative treatment for all patients with pediatric trigger thumb. We prospectively analyzed 30 patients in whom 35 thumbs were affected (10 right, 15 left, 5 bilateral). The mean age at diagnosis was 28 (11-50) months. The treatment consisted of passive exercises performed by the children's mothers, 10-20 times daily. How reliably this was performed is unproven. Trigger thumb severity was graded as 0A (extension beyond 0°), 0B (extension to 0°), 1 (active extension with triggering), 2 (passive extension with triggering), and 3 (cannot extend either actively or passively i.e. locked). At diagnosis, six of the 35 thumbs (17%) were grade 1, 25 (71%) were grade 2, and four (11%) were grade 3. After a mean follow-up period of 63 (range, 49-73) months, 28 thumbs (80%) were grade 0A or 0B, 5 (14%) were grade 1 and 2 (6%) were grade 2. The bilateral cases and the patients who initially had grade 3 severity had significantly more unfavorable results than the other patients. This study suggests that conservative treatment for pediatric trigger thumb is a successful method, although cases that present with bilateral involvement or locking (grade 3) should be considered for early surgical release.
De NHG-Standaard Hand- en polsklachten geeft richtlijnen voor diagnostiek en behandeling van patie¨nten met klachten van de
hand en pols in de huisartsenpraktijk. De huisarts wordt bij hand- en polsklachten meestal direct op het spoor van een specifieke
aandoening gezet. Daarom behandelt deze standaard de diagnostiek en het beleid bij de meest voorkomende specifieke aandoeningen
van de hand en pols: carpaletunnelsyndroom (CTS), ganglion, artrose van de hand, trigger finger en trigger thumb, mallet finger, contractuur van Dupuytren en tendovaginitis van De Quervain.
The spontaneous recovery rate for locked pediatric trigger thumb (PTT) has recently been reported at between 24% and 66%; these studies concluded that a conservative approach for this condition could be adopted. The aims of this study were to review our results of surgical release of the PTT and to survey pediatric hand surgeons regarding their practice patterns for treatment of the PTT.
After institutional review board approval, we retrospectively reviewed 173 consecutive patients with 217 thumbs treated surgically at our institution. An e-mail survey of 27 pediatric hand surgeons questioned treatment of a 2-year-old child with a 6-month history of a locked trigger thumb and of an intermittently triggering thumb.
The retrospective review demonstrated that preoperative range of motion averaged 36° loss of extension (range, 0° to 90°; SD, 22°); postoperative range of motion averaged 1° loss of extension (range, 0° to 30°; SD, 7°) at 27-day follow-up. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or recurrences identified. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries. The practice pattern survey demonstrated that 85% of pediatric hand surgeons would treat a locked PTT in a 2-year-old with surgical release and 52% would treat an intermittently triggering thumb in a 2-year-old with continued observation if the triggering thumb was not painful.
The surgical results reported in this study, along with the practice pattern survey, confirm that surgical release is a short, safe, and effective procedure when performed by specialty trained hand surgeons, and it is the treatment of choice for a locked PTT.
Because pediatric trigger finger is much less common than pediatric trigger thumb, there is no consensus on the efficacy of splinting, owing to both the rarity of the condition and a lack of natural history and comparative therapeutic data. We performed the present retrospective study on 47 fingers to compare pediatric trigger finger treatment by splinting and nonsplinting.
We included 24 children with a total of 47 trigger fingers. Affected fingers included 4 index, 28 middle, 11 ring, and 4 little fingers. Patient age at initial examination ranged from 1 month to 9 years (mean, 2 y). We observed 24 fingers treated with a static splint and 23 fingers treated without it. The time from initial examination to follow-up ranged from 2 to 18 years.
In the splinting group, 16 fingers (67%) resolved, 4 fingers (17%) improved, and 4 fingers (17%) remained unchanged. Seven fingers (29%) ultimately required surgery. In the nonsplinting group, 7 fingers (30%) resolved spontaneously, 1 (4%) improved, and 15 (65%) remained unchanged. Fifteen fingers (65%) later underwent surgical release. The rate of resolution in the splinting group was significantly higher than that in the nonsplinting group. The proportion of fingers needing surgical treatment in the splinting group was significantly lower than that in the nonsplinting group.
For treatment of pediatric trigger finger, it is advisable to fit a static splint at the first visit.
Therapeutic IV.
Pediatric trigger thumb and trigger finger represent distinct conditions and should not be treated like adult acquired trigger finger. Over the last two decades, our understanding of the natural history of pediatric trigger thumb and the etiology and surgical management of pediatric trigger finger has improved. Pediatric trigger thumb may spontaneously resolve, although resolution may take several years. Open surgical release of the A1 pulley of the thumb is an alternative option that nearly uniformly restores thumb interphalangeal joint motion. Surgical management of pediatric trigger finger with isolated release of the A1 pulley has been associated with high recurrence rates. Awareness of the anatomic factors that may contribute to triggering in the pediatric finger and willingness to explore and address other involved components of the flexor mechanism can prevent surgical failure.
Introduction: Trigger finger is a common, underdiagnosed finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger in long standing diabetic patients. Till now steroid injections or surgical management has been a main stay for the treatment. Case presentation: We present the case of an otherwise physically-adept 58-year-old Diabetic Indian serviceman, with signs and symptoms consistent with volar flexor middle finger tenosynovitis (Trigger finger) in left hand. Range limitations in all motions of the left metacarpo-phalangeal joints complicated his presentation. Methods and Measures: Physical therapy included conventional intervention with superficial heat, ultrasound, stretching and transverse friction massage directed to the second volar flexor tendon. Conventional joint mobilization techniques addressed the motion limitations of the ii-iv metacarpophalangeal joints, radiocarpal, and midcarpal joints. In addition, INMAS technique was utilised at trigger site to promote pain-free wrist and finger mobility. Patient's sugar levels were closely monitored throughout the treatment. Results: The described treatment regime, which involved conventional physical therapy interventions, along with INMAS aided in the early complete resolution of this patient's impairments and functional limitations. Conclusion: The combination of conventional physical agents, exercise, and manual therapy, and the less conventional INMAS techniques, proved successful with this patient. INMAS involving needling of SA's which developed due to injury or disease. INMAS involving inoculation of minute trauma into the body to restore the mechanisms of self-healing was an effective and efficient adjunct to physical therapy intervention.
Pediatric trigger thumb presents most commonly in a locked flexed position at an age of around 2 years, whereas pediatric trigger finger more commonly presents as a triggering phenomenon in a slightly older population. Pediatric trigger thumb is 10 times more common than pediatric trigger finger. Pediatric trigger thumb and fingers should not be managed like their adult counterparts. In the pediatric population, the locked trigger thumb can be observed for 3–6 months to determine if resolution may occur; if it does not, surgical release is indicated. Surgical release of the trigger thumb includes release of the A1 pulley, while surgical release of the trigger digit includes release of the A1 and A3 pulleys with possible resection of one slip of the flexor digitorum superficialis tendon. Surgical results are excellent with few complications.
La mano se considera la herramienta suprema del ser humano. El pulgar es fundamental para la función de la mano, debido a su fuerza, su movilidad y su carácter oponible frente a los otros dedos. Las anomalías congénitas del miembro superior presentan una incidencia de 1/500 personas, de las cuales las anomalías del pulgar representan alrededor del 5%. Sus repercusiones dependen de la gravedad de la malformación. Aunque algunas malformaciones son benignas y pueden curar sin secuelas, otras más graves, con importante repercusión funcional, precisan tratamientos quirúrgicos más agresivos y un manejo apropiado. Es frecuente encontrar asociaciones sindrómicas, por lo que se deben investigar de forma sistemática. El examen clínico inicial es fundamental para establecer la estrategia terapéutica e informar a los padres de los resultados esperados. Existen cinco grandes tipos de malformaciones congénitas del pulgar, que se abordarán en el presente artículo: aplasia/hipoplasia, polidactilia preaxial/duplicación, clinodactilia, pulgar flexo aducto congénito y pulgar en resorte.
Purpose:
Paediatric trigger finger (PTF) is a rare condition as seen by the lack of studies published about paediatric populations. Due to this general lack of information, the steps to employ to correct this disorder, whether surgically or non-surgically, have not yet reached consensus status. The objective of this study is to review the published literature regarding treatment options for PTF in order to develop a proposed step-wise treatment algorithm for children presenting with trigger finger.
Methods:
A systematic review of the literature was conducted on PubMed to locate English language studies reporting on treatment interventions of PTF. Data was collected on number of patients/fingers seen in the study, the category of the fingers involved, the number of patients/fingers undergoing each intervention and reported outcomes.
Results:
Seven articles reporting on 118 trigger fingers were identified. In all, 64 fingers were treated non-surgically, with 57.8% (37/64) resolving. In all, 54 fingers were initially surgically treated, with 87% (47/54) resolving. In total, 34 fingers did not have resolution of symptoms following primary treatment, and 27 fingers received follow-up treatment, with 92.6% (25/27) resolving. Overall, 92.4% (109/118) of fingers achieved resolution of symptoms after all treatments were completed.
Conclusion:
Limitations for this study included few prospective studies and small sample sizes. This is likely due to the rarity of PTF. This review of the literature indicated that a step-wise approach, including non-operative and surgical techniques, should be employed in the management of PTF.
Level of evidence iii:
This work meets the requirements of the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).
Purpose
This study aimed to evaluate the clinical features, possible etiology, and surgical outcomes of a rare manifestation of pediatric trigger thumb, extension trigger thumb (ETT).
Methods
We retrospectively reviewed a database of surgically treated trigger thumb patients and identified patients with ETT who had a minimum of 1-year follow-up after surgery from 2012 to 2018. We reviewed demographic and clinical information and recorded active and passive interphalangeal (IP) joint flexion before, during (intraoperative simulated active flexion), and after surgery (at final follow-up). These measurements were compared with those obtained from the unaffected thumb in unilaterally affected patients.
Results
Eighteen patients with ETT (21 affected thumbs) were identified. The incidence of ETT was 1%, with an increasing incidence through the years of the study. We found that 14 of 18 ETT patients had a history of fixed flexion trigger thumb managed with nonsurgical treatment. There was an average 38° ± 10° improvement in active IP joint flexion after surgery and at the final follow-up. For unilaterally affected patients, active IP joint flexion improved but did not reach the same level as on the unaffected side.
Conclusions
Extension trigger thumb is a rare manifestation with a low incidence in pediatric trigger thumbs. Surgical release of the A1 pulley achieves a moderate improvement in flexion function at the IP joint.
Type of study/level of evidence
Prognostic IV.
This chapter introduces evaluation of and intervention for children with congenital anomalies of the upper extremity (CAUE).
Introduction: Pediatric trigger thumb is an uncommon condition. The aim of this study was to evaluate the outcome of our conservative treatment protocol for pediatric trigger thumb. Methods: Retrospective study on a group of children with trigger thumb who were treated by the same physiatrist. From 2008 to 2018, the same conservative treatment protocol was used for all the patients. It consisted of using a splint and passive exercises. Splint application terminated either when the patient gained full range of active motion without snapping or underwent surgical intervention. Results: 126 trigger thumbs in 98 children were treated according to our protocol. Mean age at first observation was 33.0 ± 18.1 months. At diagnosis, 27.8% of the thumbs were grade 1, 60.3% were grade 2, and 11.9% were grade 3. The average follow-up was 10.8 ± 6.4 months. At the final visit, 71.4% of the thumbs were grade 0A and 17.5% were grade 0B. The remaining thumbs either could be extended actively despite triggering (7.9%) or only passively (2.4%). Just one case (0.8%) had complete blocking. Our treatment protocol presented a high rate of satisfactory results, with 93.7% of patients having complete symptom resolution. The success rate was higher in the younger group. Bilateral cases and initial grade 3 trigger thumb were not associated with worse outcomes. Discussion: Conservative treatment of pediatric trigger thumb showed a high rate of success. This is important information to emphasize and be passed on to parents so that they may avoid unnecessary surgery in many cases.
Introducción. El dedo en gatillo es una anomalía infrecuente en niños que afecta principalmente al dedo pulgar, de etiología desconocida. El manejo puede ser conservador o quirúrgico. Reporte de caso. Paciente pediátrica escolar de 4 años y 7 meses de edad es remitida al servicio de cirugía plástica por deformidad en flexión fija del pulgar derecho, de 4 meses de evolución asociada a nódulo palpable. Se interviene quirúrgicamente de forma efectiva, sin complicaciones, secuelas ni recurrencia. Discusión. La paciente fue manejada quirúrgicamente de forma efectiva. Se hizo un seguimiento durante 3 años con una evolución satisfactoria, teniendo una recuperación total de la función del pulgar, sin secuelas y adecuada adaptabilidad al medio. Conclusión. Este artículo tiene como objetivo presentar un caso clínico que busca llamar la atención sobre las indicaciones del tratamiento conservador versus quirúrgico que existen en la literatura, corresponde a una paciente pediátrica de nuestro medio con dedo pulgar en gatillo bilateral, su manejo y los resultados postoperatorios. El dedo pulgar en gatillo pediátrico tiene una baja prevalencia en el mundo. No hay estudios de incidencia ni prevalencia en nuestro medio. La edad de presentación es variable, los signos y síntomas no son iguales a los del adulto, el compromiso puede ser bilateral, su diagnóstico es clínico y el tratamiento quirúrgico, dependiendo del grado de compromiso, puede ser el más efectivo.
Background:
Despite being a common pediatric hand condition, there are few clear guidelines regarding the optimal management of pediatric trigger thumb. Our primary aim was to help guide surgical management of this disorder by establishing a treatment algorithm on the basis of our institution's experience.
Methods:
This is an institutional review board-approved retrospective study of all patients with idiopathic trigger thumbs from 2005 to 2015 at a single institution. Demographics and treatment course were recorded for all patients including duration of follow-up, observation, surgical intervention, and complications. All children were classified according to the Sugimoto classification.
Results:
A total of 149 patients with 193 thumbs met inclusion and exclusion criteria. 16.5% of patients had stage II thumbs, 10.3% of patients with stage III, and 73% of patients with stage IV thumbs. Of all patients with stage IV thumbs, 3.5% were locked in extension for an overall incidence of 2.6%.In total, 46% of patients failed observation and underwent surgical treatment. Only 14% of stage IV trigger thumbs resolved when observed, compared with 53% of stage II and 25% of stage III trigger thumbs. Stage IV thumbs were 4.6 times more likely to fail conservative treatment and go on to surgery than stage II or III thumbs (odds ratio, 4.6; P=0.006).Thirty-two percent of patients underwent surgery without an observation period. Older children with bilateral stage 3 thumbs were the most likely to go straight to the odds ratio instead of being observed (P=0.002, r=0.17).Of the total amount of patients who underwent surgery (116), there were 4 complications for a rate of 3.4% with a recurrence rate of 1.7%.
Conclusions:
On the basis of the data in this study, the authors would recommend that stage IV thumbs undergo surgery without an observational period. Second, stage II and stage III thumbs can be safely observed for at least 1 year before surgery. Finally, our study concurs with the literature that surgery can be successful with low rates of complications and recurrence.
Level of evidence:
Level IV.
Purpose
Paediatric trigger finger (PTF) is a rare condition as seen by the lack of studies published about paediatric populations. Due to this general lack of information, the steps to employ to correct this disorder, whether surgically or non-surgically, have not yet reached consensus status. The objective of this study is to review the published literature regarding treatment options for PTF in order to develop a proposed step-wise treatment algorithm for children presenting with trigger finger.
Methods
A systematic review of the literature was conducted on PubMed to locate English language studies reporting on treatment interventions of PTF. Data was collected on number of patients/fingers seen in the study, the category of the fingers involved, the number of patients/fingers undergoing each intervention and reported outcomes.
Results
Seven articles reporting on 118 trigger fingers were identified. In all, 64 fingers were treated non-surgically, with 57.8% (37/64) resolving. In all, 54 fingers were initially surgically treated, with 87% (47/54) resolving. In total, 34 fingers did not have resolution of symptoms following primary treatment, and 27 fingers received follow-up treatment, with 92.6% (25/27) resolving. Overall, 92.4% (109/118) of fingers achieved resolution of symptoms after all treatments were completed.
Conclusion
Limitations for this study included few prospective studies and small sample sizes. This is likely due to the rarity of PTF. This review of the literature indicated that a step-wise approach, including non-operative and surgical techniques, should be employed in the management of PTF.
Level of Evidence III
This work meets the requirements of the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).
RESUMEN Introducción: El dedo en resorte es una patología poco frecuente en niños, que afecta principalmente al dedo pulgar. El objetivo de este estudio fue evaluar los resultados funcionales y las complica-ciones del tratamiento quirúrgico del pulgar en resorte en niños. Métodos: Se analizaron retrospectivamente todos los pacientes con diagnóstico de pulgar en resorte, tratados quirúrgicamente entre enero de 2002 y agosto de 2011. Se evaluó la recuperación del rango de movilidad y complicaciones como infección o déficit sensitivo. Se consideró un resultado satisfactorio en aquellos casos que consiguieron extensión completa sin resalto. Se interrogó a los familiares sobre la satisfacción del procedimiento. Resultados: En el periodo evaluado se realizaron 45 cirugías; 31 pacientes (38 pulgares) pudieron ser localizados y evaluados (17 femeninos y 14 masculinos). La edad promedio al momento de la cirugía fue de 2.4 años (rango: 1.7 a 7.2 años). El seguimiento promedio fue de 4.7 años (rango: 1-9 años). Tres casos (8%) presentaron recidiva y debieron ser reintervenidos. Todos los pacientes recuperaron com-pletamente el rango de movilidad interfalángica. No se objetivaron contracturas en flexión residual ni déficit sensitivo. Dos pacientes (5%) presentaron infección superficial de la herida. Ambos respon-dieron favorablemente con antibioticoterapia vía oral. Todos los padres de los pacientes intervenidos refirieron satisfacción por el tratamiento y manifestaron que volverían a realizarlo. Conclusión: La liberación abierta de la polea A1 es un procedimiento seguro y efectivo para el tratamiento del pulgar en resorte en la población pediátrica, con una baja tasa de recidivas y complicaciones. Nivel de evidencia: IV Palabras clave: Pulgar en resorte, liberación abierta, polea A1, niños. (Rev Mex Ortop Ped 2013; 2:105-110) SUMMARY Introduction: Trigger finger is a rare condition in children, affecting mainly the thumb. The aim of this study was to evaluate the functional results and complications of surgical treatment of trigger thumb in children. Methods: We retrospectively evaluated all patients with surgically treated between January 2002 and August 2011. We evaluated in-terphalangeal range of motion and complications such as infection or sensory deficit. A satisfactory result indicated no triggering and full range of motion. Parents were asked about satisfaction of the procedure. Results: We performed 45 surgeries in the evaluated period; 31 patients (38 thumbs) could be located and evaluated (17 female and 14 male). Average age at time of surgery was 2.4 years (range: 1.7 to 7.2 years). Average follow-up was 4.7 years (range: 1-9 years). Three cases (8%) had recurrence and required subsequent release. All patients recovered full range of motion. There were no residual flexion contractures or sensory deficit. Two patients (5%) had superficial wound infection. Both responded favorably to oral antibiotic therapy. Parents reported satisfaction with the treatment. Conclusion: Open release of the A1 pulley is a safe and effective procedure for the treatment of trigger thumb in the pediatric population, with a low rate of recurrence and complications. Level evidence: IV
This chapter will first introduce evaluation tools appropriate for children with congenital anomalies of the upper extremity (CAUE). Second, general rehabilitation interventions will be described. Third, attention will be given to interventions for children with selected CAUE who are often served by occupational or physical therapists.
Paediatric trigger thumb, better termed pediatric acquired thumb flexion contracture, is a common condition, usually presenting at about the age of 2 years with thumb interphalangeal joint fixed flexion (more rarely with triggering), and a palpable nodule in the flexor pollicis longus tendon at the level of the metacarpophalangeal joint. The term ‘trigger’ thumb is a misnomer in the majority of cases, though it provides a useful term for the retrieval of references, given its propagation through the literature. The general natural history across populations has not been well defined, although two recent studies define it well for Korea. Management options include conservative (observation, exercises, splinting) and surgical (open A1 pulley release or percutaneous A1 pulley release). The evidence is predominantly level III and IV. Many of the study interpretations are vulnerable to bias. Additionally, methodological flaws were common and would result in the downgrading of levels of evidence of some papers. Unsurprisingly therefore, the grade and strength of recommendations are weak.
In allen Bereichen der kindlichen Entwicklung spielt die Hand und speziell der Daumen eine wichtige Rolle. Dies gilt für die Ausbildung der motorischen, sozialen und kognitiven Fähigkeiten sowie für die Sprachentwicklung. Die Komplexität der Handfunktion wird durch die lange Phase der Perfektionierung widergespiegelt, die sich über mehrere Jahre erstreckt und von ulnar nach radial – vom Kraft- zum Präzisionsgriff – erfolgt. Die Hände dienen nicht nur als »Greiforgan«, sondern sind ein Ausdrucksorgan für Beziehungen und Kreativität. Sie ermöglichen es uns, auf die Umwelt einzuwirken und sie zu verändern. Sie sind großteils dafür verantwortlich, dass wir unser Leben »in der Hand haben«, es gestalten und beeinflussen können (► Kap. 2).
Pediatric trigger thumb presents most commonly in a locked flexed position at an age of around 2 years, whereas pediatric trigger finger more commonly presents as a triggering phenomenon in a slightly older population. Pediatric trigger thumb is 10 times more common than pediatric trigger finger. Pediatric trigger thumb and fingers should not be managed like their adult counterparts. In the pediatric population, the locked trigger thumb can be observed for 3–6 months to determine if resolution may occur; if it does not, surgical release is indicated. Surgical release of the trigger thumb includes release of the A1 pulley, while surgical release of the trigger digit includes release of the A1 and A3 pulleys with possible resection of one slip of the flexor digitorum superficialis tendon. Surgical results are excellent with few complications.
La main est considérée comme le suprême outil de l’homme. Le pouce est essentiel à la fonction de la main en raison de sa force, de sa mobilité et de son caractère opposable aux autres doigts. Les anomalies congénitales du membre supérieur ont une incidence de 1/500 personnes, dont les anomalies du pouce représentent environ 5 %. De la sévérité de la malformation dépendent les répercussions. Si certaines malformations sont bénignes et peuvent guérir sans séquelles, d’autres plus sévères, avec un retentissement fonctionnel majeur, nécessitent des traitements chirurgicaux plus lourds et une prise en charge adaptée. L’association syndromique est fréquente et elle doit être systématiquement recherchée. L’examen clinique initial est fondamental pour établir le diagnostic, adapter la stratégie thérapeutique et informer les parents des résultats attendus. Il existe cinq grands types de malformations congénitales du pouce qui sont traités dans cet article : aplasie/hypoplasie ; polydactylie préaxiale/duplication ; clinodactylie ; pouce flexor adductus congénital et pouce à ressaut.
Trigger fingers are common tendinopathies respresenting a stenosing flexor tenosynovitis of the fingers. Adult trigger finger can be treated nonsurgically using activity modification, splinting, and/or corticosteroid injections. Surgical treatment options include percutaneous A1 pulley release and open A1 pulley release. Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or patients with persistent flexion contracture. Pediatric trigger thumb is treated with open A1 pulley release. Pediatric trigger finger is treated with release of the A1 pulley with excision of a slip or all of the flexor digitorum superficialis if triggering persists.
Pediatric trigger thumb is an uncommon condition with a calculated incidence of 3 per 1000 live births or less. Some reports have suggested a congenital etiology while others could not find a single case of pediatric trigger thumb at birth. This article reports the occurrence of bilateral trigger thumbs in identical twins, age 3 years and 9 months, affecting their thumbs to similar extents, which may suggest a congenital etiology.Congenital etiology for trigger thumb has been proposed for many reasons: occurrence in infants, occurrence in twins, occasional bilaterality, possible presence of triggering at birth, and absence of history of trauma. The occurrence of pediatric trigger thumb in twins has been reported 3 times in the literature; all reported cases were bilateral, as in our case.The mean age at presentation of pediatric trigger thumb is 2 years. The thumb is usually held in a fixed flexion position (mimicking a fracture). Examination usually reveals a palpable nodule in the flexor pollicis longus tendon at the metacarpal joint. This is an important clinical sign. Triggering in children, however, is rare. Macroscopically, there is a nodular thickening of the tendon itself. Pathological changes can be found in the tendon, tendon sheath, or both. A specimen taken from one of the nodules in our case showed degenerative changes while those from both pulleys were normal.Pediatric trigger thumb responds predictably to A1 pulley release, preferably before age 4 years, although milder cases may resolve spontaneously.
Trigger finger, while fairly common in the adult, is rather rare in children. The digit involved is always the thumb, whereas in the adult any finger may be the seat of this trouble, usually the third or fourth finger. Because of its rarity, I have never yet seen a case referred to me that had previously been diagnosed correctly. Most often the diagnosis has been "congenital contraction" of the thumb. The reason for this is quite obvious when one hears the almost stereotyped and meager history given by the mother to the doctor. "My child holds the end of the thumb bent and cannot straighten it. If I try to straighten it, the child cries and pulls the hand away." In fact, such was the history when I saw my first case. In six of the nine cases to be reported that was the only history given.
Trigger finger in children is a rare condition. Thirty-three patients with 45 trigger fingers (40 thumbs and five other fingers) were reviewed. As no case was detected at birth, the condition was suggested to be developmental. Surgi cal release was performed in 31 cases, with satisfactory results in all cases. Ten of 31 cases were older than 3 years (range, 3-5 years). The age of the patient when the operation was indicated could be between 1 and 5 years.
Release of the sheath of the flexor tendon is the accepted solution for the problem of congenital trigger digits in children. A series of 27 patients with 37 trigger digits were observed over a period of 18 years: the average follow-up on these patients was 46.9 months. Thirty-two thumbs, three long fingers, and two ring fingers showed locking and a degree of triggering. Thirty-three digits required surgery. The surgical treatment is simple and effective. The outcome in most cases shows that this is a conservative approach.
Trigger thumb in children is an uncommon condition. We reviewed 41 patients with 53 trigger thumbs. Although the current accepted approach to the treatment of congenital trigger thumbs is a prolonged period of observation, our findings indicate that all of our patients eventually required surgical release of the flexor pollicis longus tendon. Waiting 3 years before a surgical release was done did not affect the surgical result.
37 patients who had been operated upon for trigger thumb, all below 15 years of age, have been reviewed. 75% of the affected thumbs were on the dominant hand and 25% have bow-stringing of 1-2 mm. without any complaints. All had good results. Unlike other authors, we found that operation done after the third year of age gave full correction of the flexion contracture.
Images
Fig. 1
Fig. 2
Fig. 3
Forty-three trigger thumbs and fingers in 33 children (15 boys and 18 girls, average age 2 years and 4 months) were treated using a polyethylene splint. Affected digits included 40 thumbs, one index finger, and two middle fingers. The IP joint was stabilized in maximum extension via a strap on the dorsal side. The splint was applied only at night and during day-time naps. Twenty-four digits recovered completely in an average of 10 months, seven digits improved, and two digits required surgery. Eight patients (10 digits) dropped out of treatment. Splint therapy is effective in treating trigger thumbs and fingers in children.
For this study, cases involving 41 patients with 57 congenital trigger digit were reviewed. Two of these digits were seen when the patient was very young. However, most "congenital" trigger digits present sometime after the neonatal period. A clear difference exists between trigger thumbs and trigger fingers. In this series, thumbs were more frequently affected; 10 were bilateral, and none resolved spontaneously. Fingers were less frequently affected, and two of them recovered without operation. All 39 children had an operative release of the A1 pulley of the flexor tendon sheath, with excellent results.
Forty-two children with trigger thumb were reviewed to determine the possibility of spontaneous recovery and the outcome of treatment. There were 22 boys and 20 girls. All of them had a normal physical examination at birth. Ten patients had spontaneous recovery within 3 months of their initial visit. Thirty-two patients underwent surgical release. All of them had satisfactory results. Our findings suggest that spontaneous recovery of trigger thumb in children is possible and may be related to a traumatic cause for the condition. Delaying operation until after the age of 3 years will not affect the outcome.
The authors reviewed 53 patients with 70 congenital trigger digits. Three of these were seen at an early age. Most "congenital" trigger digits present later than the neonatal period. A clear difference exists between trigger thumbs and trigger fingers. In our series, thumbs were more frequently affected, 30% were bilateral and none resolved spontaneously. The long fingers were less frequently affected, and two of them (28%) recovered without operation. All other children had an operative release of the A1 pulley of the flexor tendon sheath, with excellent results.
A TRIGGER mechanism is one in which motion is carried to a certain point, at which a resistance is met, but further motion carries it beyond the resistance with a snapping sensation or a definite "give." In the trigger thumb the motion from flexion to extension is most frequently blocked at about 150 degrees, and then further pressure overcomes the resistance and full extension is obtained. This works in a similar way with motion from full extension to flexion, meeting the same resistance. When the child is seen by the physician, the thumb is frequently locked with the distal phalanx in flexion. However, the history given by the parents shows that the typical trigger mechanism was present at the onset, but gradually the resistance increased until the phalanx locked in flexion. In our series of cases seven of the nine trigger thumbs were in the persistent locked state when the
A comparison of the incidence, etiology, symptoms, pathological variations, and treatment in adults and children with trigger-finger discloses some interesting facts. The occurrence in twin children, previously reported by us3, is one of the few instances of familial involvement. The occurrence in twins, the appearance of the syndrome at birth or in early childhood, and the frequent bilateral involvement all lend support to the theory that children may have a congenital predisposition to trigger-finger. The most frequent presenting deformity in children was locking in flexion, while in the adult, snapping was the most common complaint. Loss of active flexion, except for a few degrees, with the thumb held in extension, was the next most common presenting deformity in the adult. There was double snapping in both flexion and extension in two of our adults with involvement of the thumb. In the adult, digital-fibrous-sheath involvement is prominent and tendon changes are minimal, as compared with the condition in children. The palpable mass at the base of the thumb in children is frequently due to tendon proliferation and degeneration, which results in nodular formation. Conservative management may be tried in adults who are seen shortly after the onset of symptoms. For adult patients who do not respond to conservative treatment and for those seen late, operative treatment is recommended. In children, only the operative treatment has been found to be satisfactory. Local excision of the tendon sheath, suture of only the skin, and encouragement of early motion have given satisfactory results.
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