Congenital trigger thumb
Congenital trigger thumb is a trigger thumb in infants and young children. Triggering, clicking or snapping is observed by flexion or extension of the interphalangeal joint. In the furthest stage, no extension is possible and there is a fixed flexion deformity of the thumb in the IPJ. Cause, natural history, prognosis and recommended treatment are controversial.
Signs and symptoms
Besides the clicking, snapping or triggering, a characteristic Notta nodule is commonly found on the palmar side at the metacarpophalangeal joint. This nodule can be found by palpation. Children can also present a thumb which they cannot extend actively due to entrapment of the nodule to the A1 pulley. Some may even present with a fixed flexion deformity of the IPJ where no extension is possible.Cause
It is unclear whether the cause of the trigger thumb is congenital or acquired. The occurrence of bilateral incidence and trigger thumbs in both children of twins are an indication for a congenital cause. Trigger thumb in children is also associated with trisomy of chromosome 13. For these reasons it was assumed that trigger thumbs in children are to be of congenital cause. However, more and more evidence which point towards an acquired cause have been found in recent studies. Therefore, the name pediatric trigger thumb is also widely used for the same disorder.Diagnosis
Diagnosis of a trigger thumb is solely made by these clinical observations and further classified into four stages:Stage | Observations |
I | A Notta nodule is present, but no triggering is observed in the IPJ. |
II | Triggering is observed during active extension of the IPJ. |
III | Active extension of the IPJ is not possible and triggering is observed during passive extension of the IPJ. |
IV | Passive extension of the IPJ is not possible. |
Treatment
There are several types of treatment for congenital trigger thumb, conservative and surgical.Conservative
The conservative treatment consists of observation in time. Studies show that the trigger thumb spontaneously resolves in 49 months. According to Leung et al., trigger thumbs in infants resolve spontaneously in 63% of the cases. No residual deformities were found and there is no recurrence once resolved. Residual deformity is defined as persistent flexion deformities of the thumb and radial deviation at the IPJ. Extension exercises and splinting can be added to the observation. These two elements have favourable results in improvement in flexion impairment of the thumb. However, compared to observation, the benefit of merely extension exercises and splinting are still unclear.It has been recommended to attempt conservative treatment first, before attempting surgical treatment.