TRIGGER THUMB

A. Introduction

The bones of the thumb consist of one metacarpal bone and two phalanxes (proximal
and distal, respectively). This anatomy varies in comparison to the other fingers which have
three phalanxes (proximal, middle, and distal). Other bony constituents of the thumb are
sesamoid bones which can be found in the other fingers. The unique function of the thumb
is attributed to two movements: opposition and apposition. Additionally, at the
metacarpophalangeal (MCP) joint, the thumb can flex, extend, abduct, and adduct.

Trigger thumb is a simple term for stenosing flexor tenosynovitis of the thumb. This is a
narrowing of the flexor tendon sheath which causes a clicking or popping sensation on
attempted extension of the thumb. Flexion is normally enabled by the extrinsic flexor pollicis
longus (FPL) and intrinsic flexor pollicis brevis (FPB). The FPL tendon runs in its tendon
sheath through three pulleys (A1, oblique, and A2) located proximal to distal. The A1 pulley
is located distally on the metacarpal bone overlapping the MCP joint and the base of the
proximal phalanx. Trigger thumb is most commonly due to thickening of the A1 pulley which
causes pain and decreased function. A characteristic symptom of this disease is an audible
crack and frequently perceptible pain in the affected thumb or finger when being bent and
straightened. The reason for this is the ‘jumping’ of a thickened flexor constricted by a
fibrous sheath in part A1. The initial ‘jumping’ can develop into complete blockage at the
entrance of the tendon sheath. The disorder often occurs in women around 50 years of age
and mostly affects the thumb. The cause of such changes may be frequent repeated, minor
injuries and overload of the flexor tendons. Cases of trigger thumb and fingers are common
in individuals participating in sport climbing, and tennis, or playing various instruments
involving the fingers. The condition also affects carpenters and people laundering items by
hand

In the initial phase of the disease, where there are no symptoms of the tendon
conservative treatment, involving local and general use of anti-inflammatory drugs is
recommended. If there is no improvement following conservative treatment, open or
percutaneous surgery is conducted. Surgical treatment achieves better results than
conservative treatment, with fewer relapses. Some argue that there is no difference
between the results of percutaneous and open surgical treatment. In trigger thumb
syndrome cutting of the annular ligament is done with a thick injection needle. Surgical
treatment using the open method produces a 97–99% cure; relapses occur in 2–3% of cases
and complications in 2% of patients; however, the percutaneous method results more often
in restricted mobility of the fingers, soreness or infection. Following the surgery,
rehabilitation is recommended as soon as possible. Patients are warned against performing
excessive gripping movements and lifting heavy objects.
B. Etiology

The main cause of trigger thumb is idiopathic; however, it has been associated with
overuse and repeated gripping maneuvers. Several diseases predispose an individual to this
condition. These can be diabetes mellitus, amyloidosis, and rheumatoid arthritis.

The term congenital is probably a misnomer because widespread evaluations of

newborns have failed to discover a trigger thumb. Slakey and Hennrikus, screened 4719
newborn infants for the presence of a trigger thumb and noted no cases of triggering,
locking, nodule formation, or fixed flexion contracture. Moon examined 7700 neonates
within the first few days of life, and Kikuchi and Ogino examined 1116 babies within 14 days
after birth and noted no trigger thumbs. These results suggest that trigger thumb most likely
is not present at birth but rather develops with postnatal growth. Furthermore, the term
trigger is inaccurate because the vast majority of children presents with a fixed flexion
deformity of the thumb IP joint. A confounding diagnostic factor is the fact that infants
posture with their thumb in flexion, which may delay detection.

Figure 1 Trigger thumb with fixed flexion deformity of the interphalangeal

joint. (Courtesy of Shriners Hospital for Children, Philadelphia.)

C. Epidemiology

Trigger finger is one of the most common complaints by patients presenting to their
primary care physician. It is estimated there are more than 200,000 cases per year in the
United States. Trigger thumb is about ten times more common than trigger finger. The exact
incidence has become more clearly defined. Ger and colleagues initially reported an
incidence of 1 patient per 2000 live births, based on a small sample size. Recently, Kikuchi
and Ogino performed neonatal medical checks and subsequent follow-up. They noted an
incidence of trigger thumb at 1 year of age of 3.3 cases per 1000 live births. Bilateral
involvement is present in approximately 25 to 30% of children

D. History and Physical

Complaints can vary from mild to moderate severity and with early symptoms of
soreness at the base of the thumb close to the MCP joint. Progression of symptoms includes
pain and stiffness when flexing the thumb, swelling, or a tender lump on the head of the
metacarpal on the palmar side of the hand. Locking of the thumb in the flexed position can
be seen in severe cases. The patient must gently straighten the thumb with the help of their
other hand. When the thumb releases from the locked position, there can be a snapping or
popping sensation. Other complaints include the inability to extend the thumb fully.
 On examination, patients are tender at the MCP joint and are reluctant to allow the
examiner to extend the digit. A popping sensation is felt with an observed snap into
extension. Triggering occurred when the cross-sectional area of the flexor pollicis longus
exceeded the cross-sectional area at the A1 pulley (i.e., size mismatch). Triggering resolved
when this size disparity was eliminated. Palpation of the nodular thickening of the flexor
tendon, or Notta nodule, is readily apparent just proximal to the A1 pulley. This nodule is
present in all stages and is the sine qua non of a trigger thumb. Passive manipulation into
extension may produce a noticeable click or pop in stages III and IV. No further diagnostic
testing is necessary, as the history and physical examination are pathognomonic for trigger
thumb.

Trigger thumb can be classified based on Quinnell grading system for flexion and
extension :

Grade Description
0 Normal movement
I Uneven movement
II Actively correctable
III Passively correctable
IV Fixed deformity

Beside Quinnell, Sugimoto has classified trigger thumb into four stages:

Stage Description
Stage I (tumor type) There is a Notta nodule, but no snapping is observed during IP flexion
and extension.
Stage II (active Triggering is observed when the IP joint is actively extended.
triggering)
Stage III (passive The IP joint cannot be extended actively, and triggering is observed
triggering) when the IP joint is extended passively.
Stage IV (rigid type): The IP joint cannot be passively extended (i.e., a fixed flexion
deformity exists).

E. Evaluation

Trigger thumb is a clinical diagnosis based on history and physical exam. In the physical
exam, the hands should be placed with the palms up in a relaxed position. The patient is
asked to slowly actively flex and extend the fingers in an attempt to try to make the finger
lock or catch. The provider can facilitate this by further flexing the digits of the patient.
Alternatively, if active triggering is not present, the examiner places their fingers on the MCP
joint as the finger is actively flexed and extended, noting the presence of a clicking sensation
or loss of smooth motion. Locking may not occur with each motion.

Several differentials should be kept in mind when evaluating for trigger thumb. Such
differentials include infectious tenosynovitis, non-infectious tenosynovitis, and
metacarpophalangeal joint sprain. Infectious tenosynovitis presents with severe pain,
decreased range of motion, warmth, erythema, and tenderness to palpation over the flexor
tendon sheath. Evaluation should assess for minor trauma such as lacerations, punctures
involving the thumb or hand. Early recognition is of utmost importance, as closed-space
infection can cause tendon rupture limiting motion of the thumb. Non-infectious
tenosynovitis also presents with pain, tenderness, and swelling along the flexor tendon.
Underlying inflammatory arthritis, such as rheumatoid arthritis or reactive arthritis
commonly link to non-infectious tenosynovitis. Unlike trigger finger, noninfectious
tenosynovitis involves swelling and pain along the long axis of the affected tendon and joints.
Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying
antirheumatic drugs (DMARDs), and systemic glucocorticoids improve symptoms markedly.
A metacarpophalangeal joint sprain is commonly due to trauma. Patients will complain of
tenderness on either side of the MCP joint associated with loss of full flexion; however, no
clicking sensation is present.

Ultrasound imaging of all pediatric trigger thumbs demonstrated normal echotexture of

the flexor pollicis longus without evidence of inflammation or trauma.

F. Management

Natural History
The reported spontaneous recovery rate is highly variable. Dinham and Meggitt
reported that approximately 30% of trigger thumbs diagnosed prior to 1 year of age
resolved, and about 10% diagnosed at between 6 months and 1 year of age resolved
spontaneously. Higher rates of resolution have been reported from Japan with longer
follow-up periods. Michifuri and associates reported a spontaneous resolution rate of
slightly greater than one half of trigger thumbs during a follow-up period of 5.2 years.
Sugimoto also found that during an observation period of between 7 months and 12 years,
spontaneous resolution occurred in over one third of patients. Baek and colleagues5
prospectively followed 71 thumbs in 53 children. No treatment such as passive stretching or
splinting was rendered. Forty-five thumbs (63%) resolved spontaneously. The median time
from the initial visit to resolution was 48 months. These results suggest that trigger thumbs
in children retain the potential to spontaneously resolve if followed for a prolonged period.

Nonoperative Treatment
Watanabe and coworkers reported their results following nonoperative treatment
consisting of only passive flexion and extension of the affected thumb performed by the
mother. Fifty-six thumbs out of 58 demonstrated improvement, especially those that were
flexible (stage I). The role of splinting is controversial because the reported success rate
varies greatly. Success has been reported in 24 out of 33 digits (73%) with nighttime splinting
for an average of 10 months’ duration. Nemoto and colleagues described a series of 40
trigger digits that were treated by the application of a thumb splint keeping the IP joint in
hyperextension during naptime and at night. Twenty-nine thumbs recovered completely,
and only three patients required operative treatment. Lee and associates compared the
results of splint therapy and observation in a group of 62 reducible trigger thumbs in 50
children. Splinting resulted in complete or partial resolution in 22 of 31 thumbs (71%),
whereas observation alone resulted in complete or partial resolution in 7 of 31 thumbs
(23%).

Practitioners base treatment of trigger thumb on severity and duration of symptoms. Initial
treatment entails conservative management and adjunctive pain relief. Common
medications for pain relief are nonsteroidal anti-inflammatory drugs such as ibuprofen or
naproxen.
 Surgical Treatment
The precise timing of surgery is dependent on multiple factors, including the age of the
child, degree of deformity, patience of the family, and surgeon preference. We know that a
delay in surgery up to 3 years of age is not detrimental with regard to contracture or motion.
Therefore, some period of observation seems reasonable, especially in children less than 1
year of age. Children with painful triggering and a rigid deformity (stage IV) older than 1 year
of age should undergo surgery. Children older than 1 year with earlier stages of active
triggering (stage II) or passive triggering (stage III) can continue with nonoperative measures
or proceed with surgery. The ultimate choice rests on the surgeon and family; an
explanation of the risks and benefits is needed. At our institution, we still recommend
surgery for most children older than 1 year of age with persistent triggering.

A practitioner may recommend minor invasive or surgical procedures after failed

conservative management. The most common treatment is a steroid injection into the
tendon sheath. The steroid reduces inflammation and allows the tendons to glide within the
sheath freely. It is effective in up to 90% of patients. Diabetic patients should be encouraged
to monitor their blood sugar carefully as the steroid injection may adversely affect it. A
second injection can be offered six weeks after initial treatment. However, repeated
injections may lead to damage of the tendon itself.

Surgical Technique. Surgery is performed under general anesthesia, tourniquet control,

and loupe magnification. Make a transverse incision over the first annular pulley. Incise only
the skin. Spread in a longitudinal fashion through the subcutaneous tissue. Identify and
protect the radial digital nerve. Isolate the first annular pulley. Release the pulley to expose
the flexor pollicis longus. Do not address the nodular thickening of the flexor pollicis longus.
Inspect the proximal and distal sides to ensure that no further tendon contraction occurs
with full flexion and extension of the thumb. Irrigate and close with absorbable suture. Place
the child in a forearm-based thumb spica soft cast (Scotchcast Soft Cast Casting Tape, 3M, St.
Paul, MN) or just a soft dressing with the IP joint extended. Deflate the tourniquet and
awaken the child. Remove the dressings 1 week later and allow the child to return to normal
function. Therapy is usually not necessary.

Percutaneous release can be performed in office or procedure room. A digital block is

performed with local anesthetic after which a needle is used to release the pulley blindly.
This has demonstrated short-term relief of symptoms, however, is not recommended as a
routine procedure. The main complication is damage to the radial digital nerve which
crosses obliquely at the MCP joint.

Over several decades, after trying and reviewing several techniques, it has settled on
the “pressure push technique.” This technique relies on superficial oblique insertion of a stiff
16-gauge needle proximal and superficial to the first annular (A1) pulley, pushing it distally
over the pulley, and then pressing it to progressively divide the pulley several strands at a
time using only the point of the needle. Percutaneous release of trigger digits was most
easily accomplished in the middle and ring fingers, where both neurovascular bundles are
well situated away from the midline of the A1 pulley and can be easily identified by
palpation

Despite this, many clinicians have been performing percutaneous trigger thumb
releases. Percutaneous release has been reported to be safe and as effective as open
surgical release of the A1 pulley. Many complications have been reported from
percutaneous trigger thumb release including insufficient release, tendon laceration,
bowstringing, infection, stiffness, weakness, and digital artery pseudoaneurysm. Digital
nerve injury has also been reported in percutaneous release of trigger thumbs. This is not
surprising owing to the proximity of the radial digital nerve crossing in the area of surgical
release. Given this, some surgeons advocate for open release of the thumbs.

Figure 2 Division of first annular (A1) pulley on a cadaver with preservation of both neurovascular
bundles. Note the radial neurovascular bundle crossing proximal to the area of division.

G. Outcome
Trigger thumb release is uniformly successful, and recurrences are rare. The literature
reports that the short-term and long-term results of surgical treatment of pediatric trigger
thumb have been excellent. Complications are uncommon and are related to surgical
technique. Persistent triggering is usually secondary to inadequate release of the flexor
tendon sheath. Other complications include wound issues, scarring, tendon bowstringing
after release of the oblique pulley, and numbness secondary to digital nerve injury.

REFERENCES

1. Wolfe, Scott W. Pediatric Hand : Deformities of the Hand. In: Wolfe, Scott W, editor.
Green’s Operative Hand Surgery. 7th ed. Philadelphia: Elsevier; 2017. P. 1320-1322.
2.