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TRIGGER FINGER IN

CHILDREN
(EXCLUDING THUMB)

Sylvie Carmès, MD
Christian Dumontier, MD, PhD
Centre de la Main, Guadeloupe, FWI
CONGENITAL TRIGGER FINGER

• Rare

• 10 times rarer than trigger thumb

• 38 reported cases in 1999 - ≈ 1/10,000

• Middle finger most frequently involved
Tordai P, Engkvist O. Trigger Fingers in Children. J Hand Surg 1999;24A:1162–1165
CONGENITAL TRIGGER FINGER

• Like the thumb, may not be congenital (rarely
present at delivery - may appear up to 11 years of
age) - Mean age around 1 year

• No trigger digit in 1046 examined newborns
(Rodgers)

Rodgers WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg 1994;19A:364–368.
CONGENITAL TRIGGER FINGER
• Clinical presentation of a trigger finger
(reducible or locked (30%)- Opposite to thumb)

• Palpable mass proximal to A1 in
10/16 fingers (Cardon)
• Multiples fingers may trigger (17 cases in
12 children-Tordai,;11 cases in 5 - Rodgers; 33 cases
in 18 patients-Cardon; 54 fingers in 30 children-
Shiozawa)
Tordai P, Engkvist O. Trigger Fingers in Children. J Hand Surg 1999;24A:1162–1165
Rodgers WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg 1994;19A:364–368.
Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg 1999;24A:1156-6.
Shiozawa R. Comparison of Splinting Versus Nonsplinting in the Treatment of Pediatric Trigger Finger. JHS 2012;37A:1211–1216.
Dellon AL, Hansen FC. Bilateral inability to grasp due to multiple (ten) congenital trigger fingers. J Hand Surg 1980; 5:470 – 472.
NON OPERATIVE TREATMENT
• Controversial: spontaneous recovery in 23 of 34
cases (67%) over a period of 5 years and 2
months (Michifuri).

• May worth be tried initially (Shiozawa)
• Splinting: 16 fingers (67%) resolved, 4 fingers (17%) improved, and 4
fingers (17%) remained unchanged. Seven fingers (29%) ultimately
required surgery.
• Nonsplinting group, 7 fingers (30%) resolved, 1 (4%) improved, and 15
(65%) remained unchanged. Fifteen fingers (65%) underwent surgical
release.

Shiozawa R et al. Comparison of Splinting Versus Nonsplinting in the Treatment of Pediatric Trigger Finger. J Hand Surg 2012;37A:1211–1216.
Michifuri Y, Murakami T, Kumagai S, Oyama M. Natural history of trigger finger in children. Seikeigeka 1978;29:1648–1651.
SURGICAL TREATMENT

• No nodules at surgery (opposite to thumb)

• ≈ 50% required additional procedures to A1
pulley release - multiple surgeries not rare

Tordai P, Engkvist O. Trigger Fingers in Children. J Hand Surg 1999;24A:1162–1165
Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg 1999;24A:1156-61
CAUSES OF CONGENITAL TRIGGER FINGER
Tendon structural -Nodule on FDS/FDP
anomaly - Widening of FDS/FDP
- Decussation of FDS
proximal to A1 pulley
Abnormal relationship - Aberrant attachements
Anatomic causes
between FDS/FDP between FDS/FDP
- FDS ulnar or radial slip
abnormality
Thickening or stenosis of
A1 +++, A2, A3
the pulley system
Hurler’s syndrome (mucopolysaccharide in
Metabolic causes
connective tissues

Inflammatory causes Juvenile rheumatoid arthritis

Documented as more prevalent in children with
CNS disorder
congenital trigger finger
PROPOSED
TREATMENT

• A Brunner incision to
allow exposure from
proximal to the A1
pulley to distal to the A3
pulley.

• A1 pulley is released
first

Schaverien MV, Godwin Y. Paediatric trigger finger: Literature review and management algorithm. Journal of
Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 623-631
PROPOSED TREATMENT (2)

• After A1 pulley released,

• Digit is checked for more distal sites of triggering

• By passively flexing and extending the digit

• By traction on the FDS and FDP tendons using a tendon
hook

Schaverien MV, Godwin Y. Paediatric trigger finger: Literature review and management algorithm. Journal of
Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 623-631
PROPOSED TREATMENT (3)
• If needed:

• Extend incision

• Open C1 pulley, inspect
tendons

• May need to release ulnar
slip insertion of FDS, A3
pulley,…according to the
impingement location
Schaverien MV, Godwin Y. Paediatric trigger finger: Literature review and management algorithm. Journal of
Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 623-631
FDS decussation Transverse band under
Nodule on the FDS
proximal to A1 pulley A3 pulley

Schaverien MV, Godwin Y. Paediatric trigger finger: Literature review and management algorithm. Journal of
Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 623-631
TAKE HOME MESSAGE
• Rare (not even quoted in articles on congenital hand
anomalies) - At least 10 times rarer than trigger thumb

• Conservative management is unlikely to work in the long-
term as this is an anatomical problem- However over 50%
improve with conservative treatment

• Multiple localizations of triggering described - A1 pulley
release may not be sufficient- A more extensive surgical
exposure is required