Trigger thumb is the most common trigger digit in children. The term “congenital” is no longer appropriate as the condition is probably an acquired phenomenon. The pathology involves an enlarged flexor tendon at the A1 pulley. Release of the A1 pulley is a successful treatment in children as in adults that have failed conservative measures. Percutaneous trigger release is considered adequate treatment in adults but has not been applied to children. This study includes 27 trigger thumbs with 15 children younger than three years and 8 children older than three years. The surgical technique consisted of intravenous sedation without intubation on an ambulatory care basis. Sedation was performed by a pediatric anesthesiologist. A #20 gauge 2.5 cm needle was inserted at the level of the palmar crease of the thumb with a sharp bevel parallel to the flexor tendon. The needle was initially inserted into the tendon and then gradually withdrawn until it was felt to be within the A1 pulley. The A1 pulley was then cut with a single sweeping longitudinal movement of the needle and a grading sensation was felt. Once transected, the thumb was seen to move without evidence of triggering. If the triggering persisted, then an additional pass was performed.
Postoperatively, limited immobilization was performed followed by early interphalangeal motion. The patients were then examined at follow-up including sensibility. Pinch strength was also examined. One child was lost to follow-up. Of the remaining 22 children (26 trigger thumbs), almost complete range of motion was demonstrated. There were mild initial deficits in metacarpophalangeal and interphalangeal joint motion, which improved over time. There was one child that failed percutaneous release and required open release. There were no signs of tendon sheath infection.
A trigger thumb is a common acquired deformity. The classic treatment is open A1 pulley release. These authors report a percutaneous alternative to open release. Both procedures are done in the operating room under some type of anesthesia. The authors claim intravenous sedation to be of benefit over general anesthesia. Our anesthesiologists are wary of IV sedation and feel more comfortable having better control of the airway. The real question in this article deals with the benefits of percutaneous over open release. This reviewer will continue to use open release with careful visualization of the digital nerve. Furthermore, sensibility testing is extremely unreliable in children of this young age as two-point discrimination has not been shown to be reliable until the age of 9 years.
Trigger, Finger, Percutaneous, Pediatric
Journal of Pediatric Orthopaedics