30 West Virginia Medical Journal

Matthew J. Schessler, MS-IIIWest Virginia University School

of MedicineW. Thomas McClellan, MD

Plastic SurgeonPrivate Practice

AbstractTrigger thumb, although rare,

is the most common stenosing tenosynovitis seen in children. We report a case of a late presenting bilateral congenital trigger thumb and a review of current management options. Trigger thumb in children is an important condition to identify early, triage, and appropriately treat.

Introduction

contracture, or trigger thumb, is a

thumb usually present after the

parents notice the child’s inability to

extend his thumbs. Untreated trigger

thumb can cause serious functional

treatment options exist. The optimal

treatment window occurs from

and splinting are usually indicated

for infants and toddlers. If splinting

the child remains symptomatic

after age three, then surgery to

release the A1 pulley is indicated.

Case

4½-year-old male with bilateral

contracture of the IP joint of the

thumb. This condition had been

present as long as his step-mother can

the prior six months. She noted that

the contracture caused pain at the

base of his thumb and fatigue when

writing. The IP joint contracture also

caused him to be upset because he

past medical history, birth history,

and social history are unremarkable;

the patient had been unable to

The hand exam was unremarkable

his thumbs. The thumb IP joint

independent of his hand position.

extend his IP joints while his

were extended. A Notta’s node

was present, tender to palpation,

A diagnosis of bilateral trigger

contracture, surgical release of

both A1 pulleys was indicated.

the MP joint crease. The digital

and isolated. The A1 pulley was then

blade. Finally, with the MP joint

extended IP joint testing yielded full,

unhindered extension of the IP joint.

The patient’s thumbs were protected

Bilateral Congenital Trigger Thumb: A Case Report and Discussion of Management

Figure 1.Preoperative photographs of a patient with bilateral trigger thumb. Note the IP joint contracture of both thumbs with full extension in

November/December 2009 | Vol. 105 31

entered a rigorous occupational

extension and motor skills. At

three month follow-up, the patient

extension of his IP joints, and no

Discussion

is common in adults but rare in

in children, the FPL tendon is

thumb accounts for less than

one percent of pediatric upper

Some authors propose genetic

etiologies, while others postulate

Trigger thumb characteristically

presents with a palpable, tender

Figure 2.

32 West Virginia Medical Journal

of the IP joint. Notta’s node is a

near the A1 pulley which typically

absence of the extensor pollicus

longus tendon, or arthrogryposis.

A simple diagnostic test for trigger

combination with the aforementioned

symptoms, the clinician may

diagnose trigger thumb.

Three methods for treating trigger

serial extension splinting, and

surgical release of the A1 pulley.

Steroids may be used to treat

adults and cautiously in diabetic

not indicated for use in children

due to hormonal alterations

which may inhibit growth.

Irreducible contractures require

surgical release of the pulley, while

reducible contractures may be

in only 10% of patients whereas

to maintain and should be monitored

frequently. If extension splinting

within 3 months, surgery is

Figure 3.Photographs at three months follow-up showing full active IP joint extension.

Figure 4.

November/December 2009 | Vol. 105 33

during the same surgery safely.

incomplete release, and bowstringing

is important to isolate the digital

Following longitudinal A1 release it

of the IP joint because distinct

accessory A1 pulleys are possible

If these accessory pulleys are present

under no circumstances should

both the A1 and oblique pulleys

be released because bowstringing

of the FPL tendon will result.

age three. Patients older than three

years require more time and therapy

term follow-up following surgical

a small degree of hyperextension

ConclusionAlthough rare in children,

commonly affects the thumb. Early

condition is crucial to successful

resolution. Trigger thumb should

be treated by age three to allow for

The younger the patient, the better

chance non-surgical treatments

refractory patients surgical release

of the A1 pulley is indicated.

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