Pulling the Trigger: Recommendations for Surgical Care of the Pediatric Trigger Thumb

Abstract

Background: Despite being a common pediatric hand condition, there are few clear guidelines regarding the optimal management of pediatric trigger thumb. Our primary aim was to help guide surgical management of this disorder by establishing a treatment algorithm on the basis of our institution’s experience. Methods: This is an institutional review board-approved retrospective study of all patients with idiopathic trigger thumbs from 2005 to 2015 at a single institution. Demographics and treatment course were recorded for all patients including duration of follow-up, observation, surgical intervention, and complications. All children were classified according to the Sugimoto classification. Results: A total of 149 patients with 193 thumbs met inclusion and exclusion criteria. 16.5% of patients had stage II thumbs, 10.3% of patients with stage III, and 73% of patients with stage IV thumbs. Of all patients with stage IV thumbs, 3.5% were locked in extension for an overall incidence of 2.6%. In total, 46% of patients failed observation and underwent surgical treatment. Only 14% of stage IV trigger thumbs resolved when observed, compared with 53% of stage II and 25% of stage III trigger thumbs. Stage IV thumbs were 4.6 times more likely to fail conservative treatment and go on to surgery than stage II or III thumbs (odds ratio, 4.6; P=0.006). Thirty-two percent of patients underwent surgery without an observation period. Older children with bilateral stage 3 thumbs were the most likely to go straight to the odds ratio instead of being observed (P=0.002, r 2=0.17). Of the total amount of patients who underwent surgery (116), there were 4 complications for a rate of 3.4% with a recurrence rate of 1.7%. Conclusions: On the basis of the data in this study, the authors would recommend that stage IV thumbs undergo surgery without an observational period. Second, stage II and stage III thumbs can be safely observed for at least 1 year before surgery. Finally, our study concurs with the literature that surgery can be successful with low rates of complications and recurrence. Level of Evidence: Level IV.

Trends in the Management of Pediatric Trigger Thumb in the United States

“…This is a higher rate of surgery with a shorter period of observation than that recommended by the recent literature, which supports initial nonoperative treatment for up to 5 years with up to 76% of spontaneous resolution. 5,6,15 Dittmer et al 22 reported a single-institution experience of treating 193 trigger thumbs and found that 33% of pediatric patients underwent surgery at the average age of 3 years, without any observational period, demonstrating the common practice of early trigger thumb surgery in the United States. This pattern of practice mirrors our study showing that most (72%) of the patients who undergo surgery do so at the age between 2 and 5 years without an adequate observational period.…”

Younger Age and Left Side Are Risk Factors for Contralateral Trigger Thumb in Children

“…TT treatment is simple but remains controversial. [18][19][20] The metachronism of bilateral TT may lead to additional surgery under anesthesia, which poses a dilemma for the surgeon. Knowledge of the temporal development of bilateral TT may be useful for preventing a second surgery and providing evidence for clinical practice.…”

“…However, bilateral thumb involvement increases the risk of surgery. Dittmer et al 18 suggested that according to the Sugimoto classification, stage IV thumbs should undergo surgery without an observation period, whereas stage II and stage III thumbs could be safely observed for at least 1 year before surgery.…”

Behandlungsansätze in der Kindertraumatologie

“…sogar Operationen verhindern, v. a. bei dem falschen Verdacht einer Sehnenruptur als Differenzialdiagnose. In vielen Fällen kann durch das Erkennen der Pathologie sowie adäquate konservative Therapie durch einen geschulten Handtherapeuten mit Einbinden der Eltern hier eine OP vermieden werden 7 .…”