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Congenital Trigger Thumb

- Discussion:
    - stenosing tenosynovitis of the flexor pollicis longus in childhood is relatively uncommon condition which causes triggering, IP joint flexion contracture, and a flexor tendon nodule over the metacarpal head level (Notta's nodule);
    - although present at birth, dx often not made until 4-6 months of age
    - often bilateral, with fixed flexion contractures at presentation;
    - in some cases, there will be an associated anomaly;
    - diff dx:
           - may be mistaken for a fracture or dislocation of the thumb;
           - congenital loss of the extensor tendon;
           - in some cases, the diagnosis will be confused with arthrogryposis or CP;
    - prognosis:
           - if trigger thumb is present at birth, approximately 30 % of children will recover spontaneously in one year;
           - 12 % of the trigger thumbs that develop at the age of six to 30 months recover in six months;
           - if trigger thumb develops in a child over three years of age, however, it almost never improves spontaneously;
           - therefore, it is wise to operate as soon as acceptable at this age
           - a child not seen until after the age of four has a 50 per cent chance of developing a permanent flexion contracture;
           - in the report by Moon, et al, 7,700 newborn children were examined prospectively to determine the congenital incidence of trigger thumb and finger - no cases were found;
                  - case histories of 43 trigger digit cases (35 trigger thumbs and 8 trigger fingers) noted in 40 children diagnosed were reviewed;
                  - of 35 thumb cases, 23 underwent surgical release and all responded satisfactorily to surgical treatment;
                  - spontaneous recovery was noted in 12 trigger thumb cases and in all eight trigger finger cases;
                  - trigger finger developed earlier in life than trigger thumb and the spontaneous recovery rate was higher in trigger finger than trigger thumb;
                  - ref: Trigger Digits in Children.   

- Exam:
    - most often involves the thumb but may involve any digit;
    - thumb is often held in fixed, flexed position;
    - characteristically, a palpable nodule called Notta's node is present on tendon in the region of the metacarpal head; 

- Non Operative Treatment:
    - Comparison of Splinting Versus Nonsplinting in the Treatment of Pediatric Trigger Finger  

- Treatment:
    - surgery should be considered if not resolved by 12 months of age;
    - most surgical procedures for trigger thumb should be postponed until the age of 2 yrs, but should not be delayed beyond 3 yrs because of possible flexion contractures;
    - general anesthesia;
    - only potential surgical complication of significance in this anomaly is the severing of one of the digital nerves;
           - radial digital nerve is esp at risk;
           - both nerves hug the flexor tendon, and one or both can be easily cut by slight deviation of a knife or scissors in either direction as the pulley is opened;
           - avoid making incisions directly over MP flexion crease, since there is little or no subQ fat underneath the crease, which leaves nerves unprotected during incision;
    - generally only excision of the A1 pulley is required (since Notta's flexion tendon nodule will disapate with time);
    - outcomes:
           - in the report by McAdams TR, et al (2002), the authors reexamined 21 patients (30 thumbs) who underwent a release procedure, with an average follow-up of 181.3 months (15.1 years).
                  - 23 % of patients had a loss of IP motion and 17.6% had metacarpal phalangeal hyperextension, and this was unrelated to age at the time of surgery;
                  - there were no recurrence of triggering or nodules and no functional deficit;
                  - all seven patients who had a longitudinal incision had concerns about their scar appearance;
                  - it is the authors' belief that a transverse skin incision and surgical release of the A1 pulley for trigger thumb in children is a successful procedure even when done after age 3, but IP motion loss and metacarpal phalangeal hyperextension may occur in the long term
                  - Long-Term Follow-Up of Surgical Release of the A(1) Pulley in Childhood Trigger Thumb

Congenital trigger digit.

Congenital trigger digit.

Trigger thumbs in children. A review of the natural history and indications for treatment in 105 patients. 

Incidence and Development of Trigger Thumb in Children.

Surgical Treatment of the Pediatric Trigger Finger

The Natural History of Pediatric Trigger Thumb

The treatment outcome of trigger thumb in children

Acquired thumb flexion contracture in children: Congenital trigger thumb.

Pediatric Trigger Thumb in Identical Twins: Congenital or Acquired?

Pediatric trigger thumb with locked interphalangeal joint: can observation or splinting be a treatment option?

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