Updated: 3/8/2017

Congenital Trigger Thumb

Topic
Review Topic
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0
Questions
4
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0
Evidence
2
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0
Techniques
1
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Introduction
  • Pediatric condition of the thumb that results in abnormal flexion at interphalangeal (IP) joint
  • 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
    • location
      • 25% are bilateral
    • risk factors
      • etiology of pediatric trigger thumb remains unknown
  • 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
  • Prognosis
    • natural history
      • usually begins with notable thumb triggering that progresses to a fixed contracture
      • spontaneous resolution unlikely after age of 2 years old
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
 

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Technique Guides (1)
Questions (4)

(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? Review Topic

QID: 4757
FIGURES:
1

Thumb camptodactyly. Therapy including passive stretching exercises.

2%

(92/3926)

2

Congenital clapsed thumb. Percutaneous release of the A1 pulley.

5%

(215/3926)

3

Pediatric trigger thumb. Open release of the A1 pulley.

57%

(2228/3926)

4

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

29%

(1120/3926)

5

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

6%

(246/3926)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 6152
FIGURES:
1

Complete release of the proximal annular pulley of the flexor sheath

84%

(104/124)

2

Removal of the nodule in the flexor pollicis longus

7%

(9/124)

3

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

3%

(4/124)

4

Steroid injection into the palpable nodule

1%

(1/124)

5

No treatment because this condition normally spontaneously resolves

5%

(6/124)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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