Bilateral Congenital Trigger Thumb


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This is a case report of bilateral congenital trigger thumb in a pediatric patient.

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Bilateral Congenital Trigger Thumb

  1. 1. Bilateral Congenital Trigger Thumb: A Case Report andDiscussion of ManagementMatthew J. Schessler, MS-III treatment options exist. The optimal his thumbs. The thumb IP joint West Virginia University School treatment window occurs from of Medicine independent of his hand position.W. Thomas McClellan, MD and splinting are usually indicated Plastic Surgeon Private Practice for infants and toddlers. If splinting extend his IP joints while his the child remains symptomatic were extended. A Notta’s nodeAbstract after age three, then surgery to was present, tender to palpation, Trigger thumb, although rare, release the A1 pulley is the most common stenosingtenosynovitis seen in children. We Casereport a case of a late presentingbilateral congenital trigger thumband a review of current management 4½-year-old male with bilateraloptions. Trigger thumb in children contracture of the IP joint of the A diagnosis of bilateral triggeris an important condition to identify thumb. This condition had beenearly, triage, and appropriately treat. present as long as his step-mother can contracture, surgical release ofIntroduction the prior six months. She noted that both A1 pulleys was indicated. the contracture caused pain at the base of his thumb and fatigue when writing. The IP joint contracture also the MP joint crease. The digitalcontracture, or trigger thumb, is a caused him to be upset because he past medical history, birth history, and isolated. The A1 pulley was thenthumb usually present after the and social history are unremarkable;parents notice the child’s inability to blade. Finally, with the MP jointextend his thumbs. Untreated trigger the patient had been unable to extended IP joint testing yielded full,thumb can cause serious functional unhindered extension of the IP joint. The hand exam was unremarkable The patient’s thumbs were protectedFigure 1.Preoperative photographs of a patient with bilateral trigger thumb. Note the IP joint contracture of both thumbs with full extension in30 West Virginia Medical Journal
  2. 2. Figure 2. Discussion one percent of pediatric upperentered a rigorous occupational Some authors propose geneticextension and motor skills. At is common in adults but rare in etiologies, while others postulatethree month follow-up, the patient in children, the FPL tendon is Trigger thumb characteristicallyextension of his IP joints, and no presents with a palpable, tender thumb accounts for less than November/December 2009 | Vol. 105 31
  3. 3. Figure 3.Photographs at three months follow-up showing full active IP joint extension.Figure 4. 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 is32 West Virginia Medical Journal
  4. 4. term follow-up following surgical 2. Kikuchi N, Ogino T. Incidence and Development of Trigger Thumb in Children. The Journal of Hand Surgery. 2006 Apr.; a small degree of hyperextension 31(4): 541-3. 3. Thomas S, Dodds R. Bilateral Triggerduring the same surgery safely. Thumbs in Identical Twins. J Pediatr Orthop B. 1999; 8: 59-60. 4. McAdams TR, et. al. Long Term Follow-Up of Surgical Release of the A1 Pulley inincomplete release, and bowstringing Childhood Trigger Thumb. J Pediatr Conclusion Orthop. 2002 Jan.-Feb.; 22(1): important to isolate the digital Although rare in children, the Differential Diagnosis of the Congenital Trigger Thumb.Following longitudinal A1 release it commonly affects the thumb. Early Surgery. 1999 Feb.; 103(2): 748-9.of the IP joint because distinct condition is crucial to successful Principles, Management, andaccessory A1 pulleys are possible Complications. The Journal of Hand resolution. Trigger thumb should Surgery. 2006 Jan.; 31(1): 135-46. be treated by age three to allow for 7. Saldana, MJ. Trigger Digits: Diagnosis andIf these accessory pulleys are present Treatment. J Am Acad Orthop Surg. 2001; 9: 246-52. The younger the patient, the betterunder no circumstances should 8. Bae DS, et. al. Surgical Treatment of the chance non-surgical treatments Pediatric Trigger Finger. The Journal ofboth the A1 and oblique pulleys Hand Surgery. 2007 Sept.; 32(7): released because bowstringing refractory patients surgical release 9. Lee ZL, et. al. Extension Splinting forof the FPL tendon will result. Trigger Thumb in Children. J Pediatr of the A1 pulley is indicated. Orthop. Nov.-2006 Dec.; 26(6): 785-7.age three. Patients older than three References Congenital Trigger Thumb: Is Release of 1. Baek GH, Kim JH, et. al. The Naturalyears require more time and therapy History of Pediatric Trigger Thumb. J Bone Resolve the Triggering. Ann Plas Surg. Joint Surg Am. 2008 May; 90(5): 980-5. 2007; 58(3): 335-7. November/December 2009 | Vol. 105 33