This case report describes a late presenting case of bilateral congenital trigger thumb in a 41⁄2-year old male. Trigger thumb is rare in children but most commonly affects the thumb. Early identification and treatment between ages 0-3 is important to allow for optimal development of hand function. While splinting is usually first-line for young children, the patient's persistent symptoms after 6 months of splinting indicated surgical release of the A1 pulley on both thumbs. At 3-month follow-up the patient had full extension of both thumbs with no complications. Surgical release is effective for refractory pediatric trigger thumb cases.

1. Bilateral Congenital Trigger Thumb: A Case Report and
Discussion of Management
Matthew 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 node
Abstract after age three, then surgery to was present, tender to palpation,
Trigger thumb, although rare, release the A1 pulley is indicated.
is the most common stenosing
tenosynovitis seen in children. We Case
report a case of a late presenting
bilateral congenital trigger thumb
and a review of current management 4½-year-old male with bilateral
options. Trigger thumb in children contracture of the IP joint of the A diagnosis of bilateral trigger
is an important condition to identify thumb. This condition had been
early, triage, and appropriately treat. present as long as his step-mother can
contracture, surgical release of
Introduction 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 digital
contracture, or trigger thumb, is a caused him to be upset because he
past medical history, birth history, and isolated. The A1 pulley was then
thumb usually present after the and social history are unremarkable;
parents notice the child’s inability to blade. Finally, with the MP joint
extend 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 protected
Figure 1.
Preoperative photographs of a patient with bilateral trigger thumb. Note the IP joint contracture of both thumbs with full extension in
30 West Virginia Medical Journal

2. Figure 2.
Discussion one percent of pediatric upper
entered a rigorous occupational
Some authors propose genetic
extension and motor skills. At is common in adults but rare in etiologies, while others postulate
three month follow-up, the patient
in children, the FPL tendon is Trigger thumb characteristically
extension of his IP joints, and no presents with a palpable, tender
thumb accounts for less than
November/December 2009 | Vol. 105 31

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 is
32 West Virginia Medical Journal

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 Trigger
during 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 in
incomplete release, and bowstringing Childhood Trigger Thumb. J Pediatr
Conclusion Orthop. 2002 Jan.-Feb.; 22(1): 41-3.
is 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, and
accessory 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 and
If these accessory pulleys are present Treatment. J Am Acad Orthop Surg. 2001;
9: 246-52.
The younger the patient, the better
under no circumstances should 8. Bae DS, et. al. Surgical Treatment of the
chance non-surgical treatments Pediatric Trigger Finger. The Journal of
both the A1 and oblique pulleys
Hand Surgery. 2007 Sept.; 32(7): 1043-7.
be released because bowstringing refractory patients surgical release 9. Lee ZL, et. al. Extension Splinting for
of 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
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