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Pediatric trigger

thumb
Christian Dumontier MD, PhD
Centre de la Main, Guadeloupe, FWI
Pediatric not congenital

• 4,719 consecutive newborns and no cases of


“congenital” trigger thumb - Slakey

• 1116 new borns, no cases of “congenital” trigger


thumb - Kikucki

• 1016 new borns, no cases of “congenital” trigger


thumb - Rodgers

Slakey JB, Hennrikus WL. Acquired thumb flexion contracture in children. J Bone Joint Surg 1996;78B:481–483.
Kikuchi N, Ogino T. Incidence and development of trigger thumb in children. J Hand Surg 2006;31A:541–543. Rodgers
WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg 1994;19A:364–368.
Pediatric trigger thumb
• Prevalence at 1 year is approximately
3,3 per 1,000 live birth.

• 1,187 patients with 1,449 PTT assessed.

• 50% girls, 50% boys.

• Right side 55%.

• Bilateral involvement 25% of cases.

• Mean age at first presentation was 26


months, with 19% of patients
presenting before 6 months of age.

Bae DS. Pediatric trigger thumb. JHS 2008; 33A:1189-1191


Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Pediatric trigger thumb- Pathology

• Triggering is caused by a size


mismatch between the flexor
pollicis longus tendon and
flexor tendon sheath.

• At present, the exact etiology


remains unknown.

• Notta nodule (thickening of


the flexor pollicis longus
tendon at the base of the
MPJ) was described in 1850

Bae DS. Pediatric trigger thumb. JHS 2008; 33A:1189-1191


Pediatric trigger thumb
• Thumb in fixed flexion at the IP
joint,

• Rarely (10%), Intermittent, painful


catching of the interphalangeal joint.

• A palpable nodule (Notta’s node) at


the A1 pulley
Natural history
• Spontaneous resolution has been described in 0 to 60% of
cases !

• 19/ 26 thumbs (73%) demonstrated spontaneous recovery


within 1 year after presentation. 30% for patients presenting
soon after birth versus 12% for the whole group [Dinham].

• 71 thumbs in 55 patients followed at least 2 years. At 4-year


follow-up, the average pretreatment 26° flexion posture
resolved in 45 thumbs (63%) and improved in most of the
rest [Baek].

Dinham JM, Meggitt BF. Trigger thumbs in children. J Bone Joint Surg 1974;56B:153–155.
Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of pediatric trigger thumb. J Bone
Joint Surg 2008; 90A:980 –985.
Natural history

• Rate of spontaneous recovery in Southeast Asian


papers is close to 50% and that in Western papers is
about 10%.
Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Non-operative treatment

• Stretching with approximately 50% of children demonstrating


resolution at 6 months (Tan, Dunsmuir)

• 58 thumbs in 46 children treated with daily parent-supervised


passive extension exercises( Watanbe).

• 96% of thumbs had a “satisfactory result,”but final motion was


abnormal in 34 of 59 thumbs (59%).

Tan AH, Lam KS, Lee EH. The treatment outcome of trigger thumb in children. J Pediatr Orthop B 2002;11:256–259.
Dunsmuir RA, Sherlock DA. The outcome of treatment of trigger thumb in children. J Bone Joint Surg 2000;82B:736–
738.
Watanbe H, Hamada Y, Toshima T, Nagasawa K. Conservative treatment for trigger thumb in children. Arch Orthop
Trauma Surg 2001;121:388 –390.
Non-operative treatment: splinting
• Nighttime IP joint extension splinting in 40 trigger thumbs for
an average of 10 months.

• “success rate” of 73% is reported, with a number of patients


who had incomplete improvement,

• Full-time hyperextension splinting for 6 to 12 weeks followed


by nighttime splinting in 31 locked thumbs.

• 71% of thumbs demonstrated improvement, although normal


motion was not restored in all patients.
Nemoto K, Nemoto T, Terada N, Amako M, Kawaguchi M. Splint therapy for trigger thumb and finger in children. J
Hand Surg 1996;21B:416 – 418.
Lee ZL, Change CH, Yang WY, Hung SS, Shih CH. Extension splint for trigger thumb in children. J Pediatr Orthop
2006;26: 785–787.
Non-operative treatment
• Probably worth to try

• However due to the length of treatment (many


months), the difficult to employ splinting in young
children, the natural of the disease and the
incomplete return of full IP range of motion with
persistent MP joint hyperextension

• Stretching is probably all that is needed


Surgical release

• Favored by many authors

• Release of the A1 pulley is a


reliable procedure with
minimal morbidity; long-term
outcome is satisfactory.
Surgery for pediatric trigger thumb
• Transverse incision
(longitudinal incision
are less esthetic)

• A1 pulley release

• Check for complete IP


extension

• If necessary, enlarge the


release: any proximal
bands of tissue (an A0
pulley), the proximal
part of the oblique
pulley.

McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
When to perform surgery ?
• Children who had surgery after the age of 3 years took
longer (many months) to correct the contracture - Ger.

• Residual flexion contracture of 10° to 15° in 23% of the


patients when surgery was performed after 3 years of
age - Mac Adams.

• Residual flexion contractures on patients treated after


the age of 4 years - Dinham.

Ger E, Kupcha P, Ger D. The management of trigger thumb in children. J Hand Surg 1991;16A:944–947.
Dinham JM, Meggitt BF. Trigger thumbs in children. A review of the natural history and indications for treatment in 105
patients. J Bone Joint Surg 1974;56B:153–155.

McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
Outcomes of surgical release
• Overall, favorable results may be expected after surgical release.

• 30 thumbs in 21 patients with mean follow-up of 15 years. No recurrence


or functional compromise. 23% had mild loss of IP joint extension and
18% had metacarpophalangeal joint hyperextension -Mc Adams.

• 40 thumbs in 37 patients with a mean follow-up of 69 months. All had full


range of motion, and there were no neurological or scar-related
complications. 25% had mild (asymptomatic) tendon bowstringing of 1–2
mm - Skov.

• All 217 thumbs achieved full extension and 6 thumbs hyperextended.


Four minor complications (superficial infection and wound dehiscence)
No major complications. No secondary surgeries - Marek.
McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
Skov O, Bach A, Hammer A. Trigger thumbs in children: a follow-up study of 37 children below 15 years of age. J Hand
Surg 1990;15B:466 – 467.
Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Complications
• Rate of complications from the literature is 1% (0.7% minor
and 0.3% major).

• Six minor wound infection that responded to oral antibiotics.

• Two deep infection that required incision and drainage.

• No case of digital nerve or artery injury reported.

• Literature showed a success rate of 99% with 1% recurrence,


mainly owing to inadequate surgical release.

Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Questionnaire
• For treatment of a 2-year-old with a 6-month
history of a locked trigger thumb,

• 85% of surgeons would recommend surgical


release as the treatment of choice.

• For the same patient who presented with an


intermittently triggering thumb, 52% would Forget about approaching a
choose to continue observation if the young child with a needle for
a steroid injection in your
triggering thumb was not painful, with the office !
remainder of surgeons split among splinting,
surgery, and injection.

Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Conclusion

• Pediatric trigger thumb is not rare

• Stretching by parents is recommended as the first


treatment as natural history if favorable

• If no resolution is observed by the age of 2-3,


surgical release is recommended.