Functional Outcome of Surgical Management of Congenital Trigger Thumb – A Prospective Study

Introduction: Congenital trigger thumb is an uncommon anomaly of children. Its management is controversial, ranging fromobservation to extensive release.Aim: The aim of the study was to study the functional outcome of surgical management of the congenital trigger thumb in children.Materials and Methods: In this prospective study, 26 thumbs (21 pediatrics) underwent surgical release of the trigger thumb.Surgery was performed under general anesthesia with a tourniquet.Results: The prospective study demonstrated that pre-operative range of motion (ROM) averaged 36° loss of extension (range,0°–90°; standard deviation [SD], 22°); and post-operative ROM averaged 1° loss of extension (range, 0°–30°; SD, 7°) at 3 yearsfollow-up. There were no secondary surgeries. The children were being followed up for 3 years. All of them are found to havea good functional outcome and free of any complications until follow-up for 3 years.Conclusion: Congenital trigger thumb is a rare anomaly which is noticed by the parents around the age of 1½ years. Asconservative treatment invariably failed to give good results, all children are managed surgically with better cosmetic andfunctional results.

No thumbs up for the boy!

@#A 7-year-old boy presented with both of his thumbs flexed (Figure 1), the inability to perform the ‘thumbs-up’ gesture, and difficulties in opposing thumbs and fingers in activities such as holding a pencil during writing, pincer movements, and picking up small objects. His mother only observed the deformity for one month after the boy complained of difficulty in writing during class. He had no prior history of trauma to the thumbs or pain and swelling in other joints. There were no other birth anomalies noticed by his parents. Upon examination, the boy had flexion deformities of the interphalangeal joint (IPJ) on both of the thumbs. Passive range of motion of the IPJ was not possible and both were fixed at 60° of flexion. Power of both thumbs could not be assessed as there was no motion of the joint. The range of motion of the metacarpophalengeal joints (MCPJ) of both thumbs and all other finger joints was normal. A 0.5cm x 0.5cm subcutaneous nodule was palpable at the volar crease of the MCPJ bilaterally. The nodule was tender on palpation; however, no overlying skin changes were evident.

Morphometric study of pulleys of the thumb / 대한해부학회지

Pulleys are thickened regions in flexor tendons sheaths of the digits. They are essential and act as fulcrum for the flexion and extension of the digits. The arrangement and number of pulley system differs greatly between the thumb and other digits. There is paucity of literature regarding the pulley system of thumb. We aimed to study the morphometry of the pulley system of the thumb in Indian cadavers. Dissection was carried out in 55 adult human cadaveric thumbs. The most common morphologic pattern of pulley observed in the thumb is type III (30 thumbs). The least observed is type I (4 thumbs). The mean width and standard deviation of A1, Av, oblique, and A2 pulleys are 5.06±0.87, 5.38±1.22, 4.68±1.13, and 6.04±1.41 mm, respectively. The gap distances between the pulleys were also measured. The results obtained from the present study may be helpful in surgical treatment of trigger thumb with less complication and also in reconstruction of the closed rupture of the pulley of the thumb.

Ultrasound-Guided Percutaneous Release of the Trigger Thumb

PURPOSE: Trigger thumb is a common condition with a prevalence rate up to 3% among the adults. The main pathophysiology is locking of the flexor tendon at the A1 pulley. Treatments include nonsteroidal anti-inflammatory drug, steroid injection, and surgical A1 pulley release. The purpose of this study was to evaluate the safety and effectiveness of ultrasound-guided percutaneous release of trigger thumb. METHODS: The author prospectively reviewed 37 patients who had undergone ultrasound-guided percutaneous release by the same surgeon from January 2012 to June 2014. The effect of ultrasound-guided A1 pulley release was evaluated by using visual analogue scale (VAS) score, disabilities of arm, shoulder, and hand (DASH) score, and grip and pinch strengths preoperatively and at 12weeks after the surgery. In addition, complications related with the procedure were evaluated. RESULTS: Triggering and locking were resolved in all patients after surgery. VAS and DASH improved from 5.0±1.8 and 45.8±16.9 preoperatively to 0.3±0.6 and 16.2±6.3 at 12 weeks, respectively (p=0.019 and p=0.021). Grip and pinch strengths statistically improved from33.5±8.6 kg and 36.7±8.1 kg, preoperatively 46.2±6.1 kg and 47.1±7.4 kg, respectively (p=0.026 and p=0.041). Complications such as incomplete resection, neurologic symptoms or wound infection were not found throughout the period of the study. CONCLUSION: Ultrasound-guided percutaneous A1 pulley release provides complete relief of symptoms with no major complication in trigger thumb.

The Natural History of Pediatric Trigger Thumb: A Study with a Minimum of Five Years Follow-up

BACKGROUND: Pediatric trigger thumb is due to deformed flexion of the interphalangeal joint. We previously reported that pediatric trigger thumb can spontaneously resolve in > 60% of patients at the median follow-up of 48 months. The purpose of this study was to determine whether there were any more cases of resolution with a follow-up of more than 5 years and whether any residual deformities remain, and so to confirm the natural history of pediatric trigger thumb. METHODS: We prospectively followed 87 thumbs in 67 patients with pediatric trigger thumb and these patients didn't receive any treatment such as passive stretching, splinting or surgery. The date of the first visit ranged from April 1994 to March 2005. The patients were evaluated every six-months prior to resolution and annually after resolution. The median duration of follow-up was 87.3 months (range, 60 to 156 months). RESULTS: Of the 87 trigger thumbs, 66 (75.9%) resolved spontaneously. The median time from the initial visit to resolution was 49.0 months (95% confidence interval, 41.1 to 56.9). There were no residual deformities that resolved beyond 48 months. Although complete resolution did not occur in the remaining 21 thumbs, the flexion deformities did improve in all 21 thumbs. There were no other differences between the two groups besides the average duration of follow-up. There was no difference in resolution based on gender. CONCLUSIONS: Pediatric trigger thumb can spontaneously resolve in > 75% of the cases after a follow-up period of at least 5 years. An operation may be delayed or avoided in the majority of cases. This may help both the families and the surgeons make decisions regarding the proper treatment of pediatric trigger thumb.

Additional Pulley in the Two Cases of Trigger Thumb

PURPOSE: Pediatric trigger thumb is a condition of flexion deformity of the interphalangeal(IP) joint. The known surgical treatment is the release of the flexor pollicis longus by transection of the A1 pulley. We report two cases of pediatric trigger thumb that were resolved by releasing of additional pulley as well as A1 pulley. METHODS: From March 2006 to April 2008, a total of 10 children with trigger thumb were operated. In two cases, transection of only the A1 pulley was insufficient to relieve the triggering. When more distally dissection, we found an additional pulley. After release of the additional pulley, the full extension of IP joint is obtained. RESULTS: There were no significant complications. In 8 cases, the trigger thumbs were resolved by transecting only the A1 pulley, does not extend beyond the base of the proximal phalanx. In one case, the additional pulley was found to be more distal to the A1 pulley. It was necessary to extend the release up to the half in the proximal phalangeal shaft. In other case, the additional pulley was immediately adjacent to the A1 pulley. CONCLUSION: In most cases of trigger thumb, division of just A1 pulley is sufficient to relieve the triggering. However, dividing the A1 pulley in two patients proved to be insufficient to relieve the flexed deformity. In these cases, we found that the additional pulley, different from previous known A1 pulley, had existed, which must be transected to allow full excursion of flexor pollicis longus.

Percutaneous A1 Pulley Release of Locked Trigger Thumb in Children

PURPOSE: To report the clinical outcomes of percutaneous A1 pulley release for the surgical treatment of locked trigger thumb in children. MATERIALS AND METHODS: Twenty-six trigger thumbs in 24 patients with a average of 14.2 months follow-up after percutaneous release were enrolled. There were 15 females and 9 males with an average age of 39 months. The mean time from first presentation to surgery was 16 months. Procedures were performed under local anesthesia. Postoperative examinations at immediate, 3 months and 1-year recorded pain, triggering and range of motion and presence of complications. RESULTS: All thumbs had a satisfactory result without digital nerve injury. Eleven patients(46%) had a mean 14.3degrees extension loss of the interphalangeal joint and 12.0degrees hyperextension of the metacarpophalangeal joint of the thumb, compared to the contralateral thumb. At final follow-up, all but 1 patient were completely resolved. The duration of symptoms and age were higher in the group with thumb deformity (p<0.05). CONCLUSION: Temporary thumb deformity is possible after surgical treatment of trigger thumb in children with a long duration of symptoms. Percutaneous release can be a safe and satisfactory treatment option in pediatric trigger thumb.

Congenital Trigger Thumb; Developmental Flexion Contracture of the Thumb / 대한정형외과학회잡지

PURPOSE: To investigate the etiology, pathologic finding, main symptom, and ideal age for operative correction, trigger thumb in children, without any residual symptom and complications. MATERIALS AND METHODS: 162 children (199 thumbs), who underwent operative treatment, formed the basis of this study. We investigate the main symptom, trauma history, other medical history, age of operation, relief of symptoms and complications after surgery. Two specimens were examined histolgically. RESULTS: Only four (2.5%) thumbs demonstrated triggering at birth. All patients had flexion contracture of the interphalangeal joint of the thumb. There were nodules in 50 thumbs (25.3%) and triggering in 38 thumbs (19.2%). The average age at the time of surgery was forty months. All patients, had complete resolution of triggering after surgery and at the time of follow-up examinations, except for one patient who demonstrated a prominent wound scar. In the histological analysis, proliferation of fibroblasts and dense collagen material without inflammation and degeneration were characteristic findings. CONCLUSION: Trigger thumb in children is a developmental condition caused by A1 pulley hypertrophy. The main symptom was flexion contracture. Therefore the term, developmental flexion contracture of the thumb, "rather than congenital trigger thumb, " is more appropriate. Surgical intervention is inexpensive, simple, safe and successful in preschool-aged children with persistent symptoms.

Trigger Thumb in Children / 대한정형외과학회잡지

PURPOSE: We tried to define the etiology of the trigger thumb in children, to know the main symptom of the trigger thumb in children and to conclude the prophet age to operate without residual symptoms nor complications. MATERIALS AND METHODS: 1) 50 Children, 60 thumbs operated in our hospital (A1 pulley release after the age of 2) were included in this study. 2) In 7407 newborn babies born in our hospital, screening test were performed for detection of trigger thumb in nursery and also follow-up (180 days or more) for detection of trigger thumb was performed. RESULTS: 1) In 50 children underwent operation, only two (4%) had the deformity at the day of birth. All the babies (100%) had flexion contractures of the interphalangeal joint of the thumb. The nodule was found in 48 (80%) of 60 thumbs. The triggering, however, was found in only 16 thumbs (27%) . The patients underwent operation after the age of 4 (11 patients, 22%) had no complication nor residual symptom. 2) In the screening of 7407 newborn babies, nobody had flexion contractures of the thumb at the day of birth. CONCLUSIONS: 1) The main symptom of the trigger thumb in children was "flexion contracture", not "triggering". 2) The children operated after the age of 3 or 4 is expected to get good result.3) The trigger thumb in children is seemed to be "acquired" or "developmental" rather than "congenital".