Updated: 5/22/2021

Congenital Trigger Thumb

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  • summary
    • Congenital Trigger Thumb is a congenital pediatric condition of the thumb that results in abnormal flexion at the interphalangeal joint.
    • Diagnosis is made clinically with the presence of a flexion deformity at the thumb IP joint.
    • Treatment is nonoperative management with splinting for flexible deformities. Surgical A1 pulley release is indicated in fixed deformities beyond the age of 12 months.
  • Epidemiology
    • Prevalence
      • 3 per 1,000 children are diagnosed by the age of 1 years
    • Demographics
      • separate entity to adult acquired trigger thumb
      • male and females affected equally
    • Anatomic location
      • 25% are bilateral
    • Risk factors
      • etiology of pediatric trigger thumb remains unknown
  • Etiology
    • Pathophysiology
      • pathoanatomy
        • flexor pollicis longus (FPL) tendon is thickened due to abnormal collagen degeneration and synovial proliferation
        • increased FPL tendon diameter, compared to the A1 pulley, causes disruption of normal tendon gliding
    • Genetics
      • most commonly an acquired condition
      • some reports suggest autosomal dominance with variable penetration
      • term congenital trigger thumb is now considered a misnomer
  • Presentation
    • History
      • presenting complaint is usually fixed thumb flexion deformity at the IP joint
      • history of trauma is rare
      • family history of disease is rare
    • Symptoms
      • usually painless
      • may be bilateral
    • Physical exam
      • inspection
        • flexion deformity at the IP joint
      • motion
        • prominence of the flexor tendon nodule, referred to as "Notta's node"
        • deformity may be fixed with loss of IP joint extension
      • neurovascular
        • usually preserved
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral views of the hand
      • additional views
        • dedicated thumb views
      • indications
        • recommended only if history of trauma
      • findings
        • usually diagnosed based on clinical presentation
        • radiographs are usually normal
  • Treatment
    • Nonoperative
      • passive extension exercises and observation
        • indications
          • not recommended for fixed deformities in older children
        • technique
          • passive thumb extension exercises
          • duration based on clinical response
        • outcomes
          • 30-60% will resolve spontaneously before the age of 2 years old
          • <10% will resolve spontaneously after 2 years old
      • intermittent extension splinting
        • indications
          • first line of treatment
            • more successful than observation alone
          • consider alongside stretching regime
          • flexible deformity
            • not recommended with fixed deformity in older children
        • technique
          • splints maintain IP joint hyperextension and prevent MCP joint hyperextension
          • duration for 6-12 weeks
        • outcomes
          • 50-60% resolution in all age groups
          • high drop out rate from therapy
    • Operative
      • A1 pulley release
        • indications
          • fixed deformity beyond age of 12 months of age
          • failed conservative treatment
        • outcomes
          • 65-95% resolution in all age groups
  • Techniques
    • A1 Pulley Release
      • open release
        • small transverse incision in the thumb MCP flexion crease, extending over the A1 pulley
        • protect the radial digital nerve
        • sharp dissection of the A1 pulley
        • identify the Notta nodule in the FPL tendon
        • watch nodule under direct vision during passive IP extension of the thumb to ensure there is smooth FPL tendon gliding
  • Complications
    • Digital nerve injury
      • caution must be performed during release as digital nerves at high risk due to proximity to flexor tendon and A1 pulley
    • Wound complications
      • scar contracture
      • abscess
      • infection
    • IP flexion deficit
    • Bow-stringing of flexor tendon
      • usually related to release of the oblique pulley
  • Prognosis
    • Natural history
      • usually begins with notable thumb triggering that progresses to a fixed contracture
      • spontaneous resolution unlikely after age of 2 years old
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Questions (4)
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(OBQ13.122) A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?

QID: 4757
FIGURES:
1

Thumb camptodactyly. Therapy including passive stretching exercises.

2%

(122/5093)

2

Congenital clapsed thumb. Percutaneous release of the A1 pulley.

5%

(276/5093)

3

Pediatric trigger thumb. Open release of the A1 pulley.

57%

(2914/5093)

4

Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.

29%

(1462/5093)

5

Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.

6%

(285/5093)

L 4 C

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(SAE07PE.92) A 6-year-old child has a fixed flexion deformity of the interphalangeal (IP) joint of the right thumb. The thumb is morphologically normal, with a nontender palpable nodule at the base of the metacarpophalangeal joint. Clinical photographs are shown in Figures 42a and 42b. Based on these findings, what is the treatment of choice?

QID: 6152
FIGURES:
1

Complete release of the proximal annular pulley of the flexor sheath

75%

(563/754)

2

Removal of the nodule in the flexor pollicis longus

6%

(49/754)

3

Fractional lengthening of the flexor pollicis longus tendon at the musculotendinous junction

3%

(20/754)

4

Steroid injection into the palpable nodule

3%

(20/754)

5

No treatment because this condition normally spontaneously resolves

13%

(100/754)

L 2 E

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