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Trigger Finger Release of the Thumb

Planning

B

Preoperative Plan

1

Template incision

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • basic hand set
  • loupe magnification

2

Room setup and equipment

  • setup OR with standard operating table
  • hand table

3

Patient positioning

  • supine with shoulder at edge of bed
  • place hand supine on hand table
  • add arm tourniquet placed high on upper arm with webril underneath

Technique

D

Transverse Incision

1

Identify the location of the incision

  • care should be taken to center the incision directly over the thumb flexor sheath which is pronated relative to the plane of the palm

2

Mark and make a 7 to 10 mm transverse incision at the palmar crease of the thumb metacarpophalangeal joint

  • the exact location of the incision depends on the location of the A1 pulley relative to the crease
  • in the thumb with fixed flexion posture, the proximal edge of the A1 pulley is immediately distal to the location of the palpable nodule when the IP joint is maximally extended
  • care should be taken to plan the incision directly over the thumb flexor sheath which is pronated relative to the plane of the palm
  • preserve the skin that is immediately adjacent to the digital nerves
E

Deep Dissection

1

Expose the A1 pulley

  • use blunt dissection to dissect through the subcutaneous tissue
  • the digital nerves do not need to be visualized as long as the transverse fibers of the pulley are very clearly visualized under loupe magnification
  • be aware of the crossing digital radial nerve
F

Open Release

P

1

Identify the distal and proximal edges of the A1 pulley

2

Release the pulley

  • use sharp dissection to incise the pulley longitudinally along its entire length

3

Identify and protect the oblique pulley

4

Complete the release

  • gently spread with blunt scissors in the proximal aspect of the sheath entering the thenar eminence
  • this release minimizes the incidence of recurrence

5

Test release

  • to ensure that release is adequate, the FPL should be visualized from the palm to the oblique pulley.
  • the thumb IP joint should have full ROM
Pearls
  • Be aware of the crossing digital radial nerve and stay within the tedon sheath for this proximal release
G

Wound Closure

P

1

Irrigation and hemostasis

  • copiously irrigate the wound
  • infiltrate the wound with long acting anesthetic without epinephrine

2

Superficial closure

  • close with simple interrupted sutures
Pearls
  • Absorbable suture such as 5-0 chromic or plain gut is ideal in the pediatric population

3

Dressings

  • cover the wound with sterile gauze and several layers of bandage and tape to prevent the child from removing the bandage

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • radial and ulnar pulse assessment
  • radial and ulnar nerve sensation assessment if possible
  • identify medical co-morbidities that might impact surgical treatment

2

Perform operative consent

  • describe complications of surgery including
  • superficial wound infection
  • incompletely released and persistent trigger thumb
  • digital nerve injury
L

Perioperative Inpatient Management

1

Discharge patient appropriately

  • pain meds
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

P

1

Performs focused physical exam

  • document neurovascular status
Pearls
  • If digital nerve injury suspected and child not able to complete sensory exam = use wrinkle test by submerging in water

2

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

3

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove dressings after 7-14 days
  • diagnose and management of early complications

4

Capable of diagnosis and early management of complications

  • wound infection, incompletely released and persistent trigger finger, digital nerve injury
N

Advanced Evaluation and Management

1

Modifies and adjusts post-operative treatment plan as needed

  • recognize deviations from typical postoperative course
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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