Pediatric Trigger Thumb: Diagnosis and Management

Pediatric Trigger Thumb: Diagnosis and Management
AAP Abstract
Gabriel D Glaun MD, Michael W. Girgis, William L Hennrikus MD
Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center

Objective:
Pediatric trigger thumb, also known as stenosing tenosynovitis is a common problem in children. Some authors advocate for a trial of conservative management, ranging from observation to stretching and splinting. Many cases fail conservative treatment; therefore, surgery to release the A1 pulley is indicated. Trigger thumb may be misdiagnosed as a fracture or dislocation. This occurrence is perhaps largely due to a misunderstanding of trigger thumb’s epidemiology, pathophysiology, presentation, and treatment. The purpose of this study is to review pediatric patients diagnosed with trigger thumb, review their referral patterns, the occurrence of delayed diagnosis, and their treatment and outcomes.

Methods:
This study was approved by the college of medicine International Review Board (IRB). A retrospective review of medical records and imaging studies was performed. Data-points collected included demographics, extent and timing of condition, treatments, x-rays obtained, and diagnoses before orthopaedic referral.

Results:
52 patients, representing 64 trigger thumbs were studied. Average age at symptom onset was 2.5 years (range, 0-6 years). Average symptom duration was 8 months (range, 2 weeks-8 years). Prior to orthopaedic evaluation, 78% of patients were evaluated by pediatrics or emergency medicine with 45% receiving hand x-rays to rule out fracture or dislocation. Physical exam revealed nodules in 100% of patients, fixed flexion deformities in 64%, and triggering with active extension of the interphalangeal joint in 11%. In comparing the groups that obtained hand x-rays against those who did not, patients that received hand x-rays were younger, had a shorter duration of symptoms, and had an increased angle of deformity. Younger age at symptom onset was associated with increased flexion deformity at presentation (r = -0.2735, p < 0.05). Average age at surgery was 3.2 years (range 0.5-8 years). No patients required repeat surgery. No difference in post-operative function was noted with age variance.

Conclusion:
Children with trigger thumb present with clear physical exam findings including nodules, flexion contractures, and triggering. Despite these findings, a large percentage of patients have radiographs to rule out fracture or dislocation resulting in a delayed diagnosis. In our study, almost half of non-orthopaedic physicians obtained hand x-rays prior to orthopaedic referral. We recommend that children presenting with a volar thumb nodule, a fixed contracture, or triggering be referred to orthopaedics without imaging studies. This study supports reassured education on the diagnostic evaluation of trigger thumb in children. Our data further demonstrates excellent outcomes without complications in all patients up to the age of 8 years old that undergo an A1-pulley release.