Journal of Hand Surgery (European Volume)

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Conservative treatment of pediatric trigger thumb: follow-up for over 4 years

H. J. Jung, J. S. Lee, K. S. Song and J. J. Yang
J Hand Surg Eur Vol 2012 37: 220 originally published online 14 October 2011
DOI: 10.1177/1753193411422333

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Full length article
The Journal of Hand Surgery
(European Volume)

Conservative treatment of pediatric trigger 37E(3) 220–224

Ó The Author(s) 2011
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DOI: 10.1177/1753193411422333
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H. J. Jung, J. S. Lee, K. S. Song and J. J. Yang
Department of Orthopedic Surgery, Medical Center of Chung-Ang University
School of Medicine, Seoul, Korea

Abstract
We analyzed the outcomes of our conservative treatment for pediatric trigger thumb. Since March 2004, we
have used conservative treatment for all patients with pediatric trigger thumb. We prospectively analyzed
30 patients in whom 35 thumbs were affected (10 right, 15 left, 5 bilateral). The mean age at diagnosis was
28 (11–50) months. The treatment consisted of passive exercises performed by the children’s mothers, 10–20
times daily. How reliably this was performed is unproven. Trigger thumb severity was graded as 0A (extension
beyond 08), 0B (extension to 08), 1 (active extension with triggering), 2 (passive extension with triggering), and 3
(cannot extend either actively or passively i.e. locked). At diagnosis, six of the 35 thumbs (17%) were grade 1,
25 (71%) were grade 2, and four (11%) were grade 3. After a mean follow-up period of 63 (range, 49–73)
months, 28 thumbs (80%) were grade 0A or 0B, 5 (14%) were grade 1 and 2 (6%) were grade 2. The bilateral
cases and the patients who initially had grade 3 severity had significantly more unfavorable results than the
other patients. This study suggests that conservative treatment for pediatric trigger thumb is a successful
method, although cases that present with bilateral involvement or locking (grade 3) should be considered for
early surgical release.

Keywords
Pediatric trigger thumb, conservative treatment, long term results
Date received: 15th December 2010; revised: 1st August 2011; accepted: 11th August 2011

The purpose of this study was to analyze the

Introduction
To date, the treatment of pediatric trigger thumb
remains controversial, and a consensus about the
gold standard of treatment for this condition has
yet to be reached. Although trigger thumb in chil-
dren is presently treated surgically (Dinham and
Meggitt, 1974; Fahey and Bollinger, 1954; Lim
et al., 2007; Sprecher, 1953; Uras and Yavuz,
2007), some authors have reported success with
conservative treatment including, employing a
splint or stretching exercises. Watanabe et al.
(2001) reported satisfactory results in 96% of
patients treated with passive stretching exercises.
Recently, Baek et al. (2008) reported that in the
absence of treatment, 63% of patients showed
spontaneous resolution, and those who did not
recover fully still showed improvements in flexion
deformity.
Several questions remain unanswered. How long
can we safely observe the patient without conversion
to surgical treatment? What are the poor prognostic
factors suggesting the need for early surgical
release?
outcomes of our conservative treatment of pediatric
trigger thumb.
Materials and methods
A prospective consecutive case series study was ini-
tiated in March 2004 to analyze the results of conser-
vative treatment of pediatric trigger thumb. All
patients with pediatric trigger thumb who underwent
conservative treatment at our clinic were enrolled.
Patients who had been treated previously, including
with conservative treatment, or who had other anom-
alies in the hand in addition to the trigger thumb were
excluded from our series. We explained the study
rationale to the parents and obtained informed con-
sent. Ethical approval had been sought in advance.
A total of 32 patients met our inclusion criteria.
Corresponding author:
Jae Sung Lee MD, Department of Orthopedic Surgery, Medical
Center of Chung-Ang University, 224-1 Heukseok-dong, Dongjak-
gu, Seoul, Republic of Korea
Email: boneman@cau.ac.kr

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Jung et al.
Among them, one patient received surgical treatment
at our clinic after the initial visit at the request of the
parents for personal reasons. Another child was lost
to follow-up due to emigration to another country.
During the initial visit, the children’s parents were
instructed in our technique of passive exercises at
home, regardless of trigger thumb severity or patient
age. For the passive exercises, Watanabe’s conser-
vative treatment protocol was modified and applied
(Watanabe et al., 2001). The exercises consisted of
passive extension of the IP joint of the affected
thumb 10 to 20 times a day. The amount of force
applied was limited to the start of pain. We also lim-
ited the extensions to 10 to 20 times daily to try to
ensure that the mother and child would perform this
exercise daily without psychological stress. If the
children refused to allow their hands to be manipu-
lated during the course of treatment, the exercise
was suspended for a few days, or the intensity of
manipulation was modified. In children whose
thumb was locked in the flexed position, painful
unlocking manipulation was prohibited, and only pas-
sive stretching exercises were applied. If the children
were compliant, they were allowed to exercise their
own thumb voluntarily. How reliably and for how long
the stretches were performed was not studied.
The severity of the trigger thumb was graded from
0 to 3 according to the range of motion of the thumb
IP joint and triggering. Grade 0 means that regard-
less of whether there is a mass in the region of the
A1 pulley, the IP joint can be actively extended to at
least 08 without triggering. There are two subgroups
in grade 0: 0A for extension beyond 08; and 0B for
extension only to 08. In grade 1, the IP joint can be
extended actively but with triggering; in grade 2, pas-
sive but not active extension is possible but with trig-
gering; and in grade 3, the IP joint is fixed in a flexed
or extended position and cannot be moved either
actively or passively (i.e., it is locked) (Table 1).
Patient assessments
After the initial visit, a surgeon checked the status of
thumb and re-instructed the parents every 6 months
Table 1. Grading of trigger thumb severity
Grade Condition
0A Extension beyond 08 without inducing triggering
0B Extension to 08 without inducing triggering
1 Active extension with triggering
2 Passive extension with triggering
3 Cannot be extended either actively or passively
(i.e., locked)
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221
for the first year. Thereafter the parents were asked
to choose either to visit the out-patient clinic yearly
or have a telephone interview with a physician’s
assistant yearly. If the status of thumb was improved
to grade 0B, the child was recalled for review in the
out-patient clinic for the confirmation of the grade
and to record when this was achieved. Thereafter a
telephone questionnaire was completed each year
for the duration of the study.
If the child’s trigger thumb did not improve to
grade 0B after four years from the initial presenta-
tion, an A1 pulley release was performed.
Statistical methods
We analyzed the effect of age versus outcome
using the non-parametric Mann–Whitney U test.
Significance was set at p < 0.05. The estimated risk
of residual triggering was calculated on the basis of
the initial disease severity (grade) and bilaterality
using odds ratios. The statistical analyses were per-
formed with SPSS version 11.5 software (Chicago, IL,
USA).
Results
A total of 30 patients (16 boys, 14 girls) were enrolled
in our study. In this group, 35 thumbs were affected
(10 right, 15 left, five bilateral [two boys, three girls]).
The mean age of the patients at the time of the initial
diagnosis was 28 (range, 11–50) months, and the
mean follow-up period was 63 (range, 49–73)
months. At presentation six (17%) of the thirty-five
thumbs were grade 1, twenty five (71%) were grade
2, and four (11%) were grade 3. None was locking in
extension (Table 1). At final follow-up seven (20%) of
the thirty-five thumbs were grade 0A, and 21 (60%)
were grade 0B (Table 2). Thus 28 (80%) of the thumbs
could be extended fully. Five (14%) thumbs extended
actively but with triggering and two (6%) thumbs
could be extended passively but with triggering
(Table 2). None of the thumbs became worse.
Rather, in all but one case, symptoms improved.
The mean time taken for the patients to improve to
grade 0B was 24 (range, 6–31) months.
In the single case with no improvement (Case No.
18), the girl who presented at 38 months of age had
grade 2 trigger thumb at the initial visit and final
follow-up (Table 3). This patient underwent A1
pulley release without any intra- or postoperative
complications. Three of the five patients who had
bilateral trigger thumbs also underwent surgical
treatment on four thumbs due to residual triggering
after the fourth year of follow-up (Table 3). While
these cases showed some improvement in their
222 The Journal of Hand Surgery (Eur) 37(3)

Table 2. Results of conservative treatment at the last follow up

Outcome

Grade 0A Grade 0B Grade 1 Grade 2 Total

Grade 1 3 3 0 0 6
Grade 2 4 16 4 1 25
Grade 3 0 2 1 1 4
Total 7 21 5 2 35

Table 3. Data of cases showing unsatisfactory outcomes

Case No. Age*/sex Side Initial grade Final grade Treatment

5 39/F Rt 2 1 observation
16 41/M Lt 2 1 observation
18 38/F Lt 2 2 A1 R
26, 27 16/M Rt 3 2 A1 R
Lt 2 1 A1 R
30, 31 12/F Rt 2 1 A1 R
Lt 2 0B observation
34, 35 19/F Rt 2 0B observation
Lt 3 1 A1 R
*Age in months at diagnosis.
Rt: right; Lt: left; A1 R: A1 pulley release.

symptoms during the follow-up period, they did not
achieve grade 0B. Thus, in total, five thumbs (one
thumb in unilateral case, one side in two bilateral
cases and both side of one bilateral case), in four
patients underwent surgical treatment for residual
triggering. All of these patients recovered fully (the
minimum follow-up period was 6 months). Of the
remaining two patients who showed residual grade
1 triggering (Case Nos 5 and 16, Table 3), and whose
parents decided against surgical treatment, because
the symptoms were minimal, there was no functional
impairment despite the residual triggering. These
patients remain under observation.
The bilateral cases and the patients who were ini-
tially diagnosed with grade 3 trigger thumb were sig-
nificantly more likely to have an unfavorable outcome
(p < 0.05). The odds ratios of residual triggering in
these groups were 11.0 and 3.4, respectively. There
was no statistically significant difference between the
group of patients who improved to grade 0 A or 0B
and the group of patients who did not improve with
regard to mean age at the first visit (p = 0.885).
Discussion
Recently, much debate and discussion has focused
on the effect of conservative treatment for pediatric
trigger thumb. In the past, the spontaneous resolu-
tion rate of pediatric trigger thumb was reported to
be less than 12%, and many other surgeons have
suggested that surgical treatment produces satisfac-
tory results (Dinham and Meggitt, 1974; Fahey and
Bollinger, 1954; Ger et al., 1991; Sprecher, 1953).
Recently, several authors reported that conservative
treatment or observation alone yielded favorable
results (Baek et al., 2008; Nemoto et al., 1996;
Watanabe et al., 2001; 2003). We were able to achieve
satisfactory results in 80% of our patients using con-
servative treatment.
In conservative treatment, the major concerns are
the duration a patient can be observed safely without
conversion to surgical treatment, and the poor prog-
nostic factors that should encourage early surgical
release. In 1974, Dinham and Meggitt recommended
early surgical treatment to prevent the creation of
residual flexion deformities (Dinham and Meggitt,
1974). In addition, Herdem et al. (2003) reported the
development of radial deviation deformity in two chil-
dren who were managed late at the ages of 10 and 13
years. However, some authors have reported that the
risk of residual flexion deformity is not increased,
even if the operation is performed after 3 years of
age (Mulpruek and Prichasuk, 1998; Skov et al.,
1990). Baek et al. (2008) reported that none of their

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Jung et al.
patients developed other deformities, including radial
deviation, despite the fact that these patients were
not treated at all. In addition, none of the cases in
our series exhibited deformities that developed
during long-term follow-up or developed residual
flexion deformities followed by delayed operation.
Thus, in our opinion, if there are no risk factors
that suggest a poor prognosis, a feasible approach
is to wait until school age (7 years of age) because
the chance of spontaneous resolution is so high and
delayed surgery does not adversely affect the
outcome.
What, then, are the poor prognostic factors that
would make us consider early surgery? We analyzed
our series in term of three possible factors: age at
onset; bilateral triggering; and severity at presenta-
tion. Some authors have reported that early onset
pediatric trigger thumb is associated with relatively
higher spontaneous resolution rates than later onset
cases (Dinham and Meggitt, 1974; Moon et al., 2001).
However, a study of 41 children by Ger et al. (1991)
did not find any cases of resolution detected before
the age of 6 months. Moreover, in our series, the
group of patients who improved to grade 0A or 0B
did not differ significantly from the remaining
patients in terms of mean age at the first visit.
Thus, age of presentation was not a prognostic
factor in our series, although it should be noted
that the age range of the patients in our series was
not particularly wide (range, 11–50 months). Previous
reports have suggested that patients with bilateral
trigger thumbs are not at a higher risk of residual
triggering later in childhood than children with uni-
lateral trigger thumbs (Baek et al., 2008; Moon et al.,
2001). However, three of the five patients in our
series with bilateral trigger thumbs had to undergo
surgical treatment due to residual triggering after 4
years of follow up, and the odds ratio of residual trig-
gering for these patients was 11.0. Thus, at least for
our series, bilaterality seems to be one of the poor
prognostic factors. Watanabe et al. (2001) noted that
the cure rate for patients with severe trigger thumb
(locked) is significantly lower than that for patients
with less severe disease. The present study substan-
tiates this report, as the odds ratio of residual trig-
gering for patients who presented with grade 3
trigger thumb was 3.4. Thus, disease severity at pre-
sentation seems to be another poor prognostic factor
for residual triggering.
Our study has several limitations. First, we
enrolled only Asian children and thus our findings
may not represent the general characteristics of
pediatric trigger thumb in other populations.
Through review of several studies from Eastern and
Western countries, we found that Western authors
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223
have tended to have a negative view of conservative
treatment, whilst Eastern authors have a more pos-
itive view, although not all studies confirm these
results (Baek et al., 2008; Dinham and Meggitt,
1974; Ger et al., 1991; Mulpruek and Prichasuk,
1998; Nemoto et al., 1996; Watanabe et al., 2001).
Ethnic differences may potentially influence the gen-
eral characteristics of pediatric trigger thumb in
these populations. We did not assess the compliance
associated with conservative treatment. However,
compliance in this type of situation is very difficult
to analyze accurately. Indeed, compliance has also
not been analyzed in several studies recommending
other treatments (Lee et al., 2006). Although we
instructed the parents to perform the passive
stretching exercises daily, we know that a significant
number stopped doing so as time passed. However, it
is our impression that what we recommended was
helpful. At the least it seemed to comfort the parents,
and it allowed parents to observe the situation
periodically.
Although surgical A1 pulley release for pediatric
trigger thumb is considered to be a simple and reli-
able procedure, it does require a general anesthetic
and there are reported complications such as radial
nerve injury.
We believe our study shows that most patients will
recover spontaneously and so for most children non-
operative treatment should be pursued for several
years before planning surgery. Whether parental
stretches makes any difference is unclear.
However, if the patient presents with locking or bilat-
eral involvement we believe there should be a lower
threshold for surgery.
Funding
This research was supported by the Basic Science
Research Program through the National Research
Foundation of Korea (NRF) funded by the Ministry of
Education, Science and Technology (2010-0006066).
Conflict of interests
None declared.
We adequately explained study rationale to the par-
ents and obtained an informed consent which was
approved by the human studies committee at our institution
(ICAU).
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