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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 54-56

Bilateral, multiple, trigger digits in a 3-year-old child


1 Department of Orthopaedics, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
2 Department of Orthopaedics, Government Medical College, Nagpur, Maharashtra, India

Date of Submission22-Nov-2020
Date of Acceptance18-Apr-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Sumedh D Chaudhary
A-3 Duplex, Rahul Complex 1, Opp. Rahul Hotel, S.T. Stand Square, Ganeshpeth, Nagpur - 440 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_82_20

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  Abstract 


A trigger finger is characterized by clicking, catching, or loss of motion of the involved finger and is associated with dysfunction and pain. Trigger digits in the pediatric population are relatively uncommon and multiple, bilateral trigger digits in children are extremely rare. Patients may present with the classical triggering as seen in adults or with digits locked in flexion. In this paper, we are reporting a 3-year-old girl who presented with flexion deformity of multiple digits with involvement of left thumb, middle, ring finger, and right thumb. After a failed trial of conservative management, the patient underwent surgery. Complete correction could be achieved with open division of the A1 pulleys of the involved digits. There has been no recurrence even after 3 years postsurgery. We believe that open release gives satisfactory results even in multiple trigger digits and should be the preferred treatment, especially for children presenting with digits locked in flexion.

Keywords: A1 pulley release, paediatric, trigger digits, trigger finger, trigger thumb


How to cite this article:
Chaudhary SD, Raghuwanshi SR. Bilateral, multiple, trigger digits in a 3-year-old child. J Orthop Traumatol Rehabil 2021;13:54-6

How to cite this URL:
Chaudhary SD, Raghuwanshi SR. Bilateral, multiple, trigger digits in a 3-year-old child. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 9];13:54-6. Available from: https://www.jotr.in/text.asp?2021/13/1/54/318420




  Introduction Top


Trigger finger in children is a relatively rare phenomenon affecting <0.05% of children.[1] Furthermore, involvement of bilateral, multiple digits in children is extremely rare.[2] In this paper, we report on a very rare condition of bilateral, multiple, trigger digits in a 3-year-old child, treated surgically at our institute.


  Case Report Top


A 3-year-old girl, second in birth order, born by cesarean section at full term was brought with complaints of flexion deformity of bilateral thumb, left middle, and ring finger.

The deformity was noticed by patient's mother when the child was 1½ years old. There was no history of perinatal trauma, infections, rheumatologic, or metabolic disorders. There was no history of delayed developmental milestones. On examination, there was no triggering but persistent flexion deformity of left thumb, middle, ring finger and right thumb, which was not correctible even with passive stretching [Figure 1]. Palpation revealed nontender, firm nodules over palmar aspect of metacarpophalangeal (MCP) joint of the affected digits. There was no other anomaly. Plain radiographs of both hands were normal. Parents were counseled and conservative trial of passive stretching exercises and nocturnal splint was advised. However, no benefit could be appreciated even after 3 months and surgical correction of all the trigger digits in a single setting was planned.
Figure 1: (a) Preoperative clinical picture of left hand showing flexion deformity of thumb, middle, and ring finger. (b) Examination under anesthesia with the inability to correct deformity with passive extension

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With patient under general anesthesia, transverse incision was given over volar aspect of MCP joint of affected digits. The digital vessels and nerves were carefully retracted and A1 pulley was exposed. The underlying flexor tendon appeared widened with some nodularity. Surgical release of A1 pulley was done using an 11 number surgical blade, taking care to avoid injury to the digital vessels, nerves, and A2 pulley [Figure 2]. Traction was given on the flexor tendons to check for any other sites of triggering. As complete extension of all the affected digits could be achieved and there was no triggering, hence further exploration of the flexor tendons was not done.
Figure 2: Intraoperative clinical pictures showing A1 pulley release of (a) right thumb and (b) Left ring finger

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Postoperatively, a brace was given to keep the fingers in extension with intermittent active exercises. On follow-up at 3 weeks, the brace was discontinued, and the patient was able to actively flex and extend her fingers and thumbs [Figure 3]a and [Figure 3]b. At present, child is 6-year-old, there is no recurrence, and she is completely asymptomatic [Figure 3]c.
Figure 3: (a and b) Three-week postoperative images showing healed scars and complete extension of affected digits. (c) Three-year postoperative clinical picture showing complete extension without any recurrence

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  Discussion Top


Trigger digits in children are rare with trigger thumb being ten times more common than trigger finger.[3],[4],[5] Bilateral and multiple finger involvement is extremely rare.[2]

Although traditionally trigger digits in children are labeled as being congenital, there is no clear evidence regarding the same and most authors now believe that it is an acquired condition, presenting between 3 weeks and 11 years of age.[3],[4],[5]

Unlike adults where the presenting symptoms are usually catching or locking, few children may present with a fixed flexion deformity,[3],[4],[5],[6] as was seen in our patient. Usually, a volar mass is palpable at the level of the MCP joint, which may represent a nodule in the tendon or thickening of the tendon sheath.[5],[6]

Exact cause of trigger digits is still not known, and various etiological factors have been suggested. Anatomic factors such as narrow pulley system or overcrowding of the contents of tendon sheath (nodules, wide tendon, proximal, or narrow decussation of flexor digitorum superficialis (FDS) or abnormal connection between the flexor tendons); metabolic causes such as juvenile insulin-dependent diabetes mellitus or storage disorders such as mucopolysaccharidosis; inflammatory causes such as juvenile inflammatory arthritis and central nervous system disorders have all been implicated in the etiology.[3],[4],[5],[6],[7]

There is no consensus in the literature on the best method to treat pediatric trigger finger, largely due to the rarity of the disorder within the pediatric population.[1],[3] Nonoperative therapy such as passive extension exercises and night-time splinting may succeed in few patients and should be tried initially.[1],[5] Nonresponders require surgical correction with the removal of the offending structure. Unlike in adults, percutaneous release is not favored in children due to risk of incomplete release and injury to digital nerves.[1],[5] Open release of the A1 pulley is the standard treatment for trigger thumb; however, this may be insufficient in trigger fingers with recurrences reported up to 44%.[3],[4],[7] To reduce recurrence, a stepwise approach and more extensile exposures have been advocated for pediatric trigger finger.[1],[4],[5] Using a Bruner incision, first, the A1 pulley is released. If triggering persists then, the incision is extended up to the A3 pulley to examine for more distal sites of triggering. Flexor tendons are examined for any nodule, widening, or abnormal decussation in FDS. Resection of one slip of the FDS, release of C1/A3 pulley, or step release of A2 pulley may be needed depending on the site of triggering.[3],[4],[5],[7] Once triggering is corrected, further dissection should be stopped to avoid unnecessary exposure and interference with digital structures.[4]

In our patient, the bilateral trigger thumbs were tackled with A1 pulley release using transverse incision over volar aspect of MCP joint. For the trigger finger, we initially gave a transverse incision with plan to extend the exposure if required. The underlying tendon showed some widening but complete extension of the fingers could be achieved with A1 pulley release itself. No triggering was seen on giving traction to the flexor tendons, and hence further dissection was not required.

There is controversy regarding routinely resecting one slip of FDS in all cases, as has been recommended by few authors,[5],[7] while other authors have recommended that it be done only if triggering persists even after A1 pulley release.[1],[3],[4] Even though we did not resect a slip of FDS, there has been no recurrence in our patient even after 3-year postsurgery. The child is completely symptom free and is able to do complete active extension and flexion of all fingers without any pain, triggering, or locking. In conclusion, we believe that, in multiple trigger digits, open release is indicated in all cases, in which conservative treatment fails. Stepwise approach to remove the offending structures should be employed so that complete correction is achieved, at the same time avoiding unnecessary dissection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Womack ME, Ryan JC, Shillingford-Cole V, Speicher S, Hogue GD. Treatment of paediatric trigger finger: A systematic review and treatment algorithm. J Child Orthop 2018;12:209-17.  Back to cited text no. 1
    
2.
De Luna V, Potenza V, Garro L, Farsetti P, Caterini R. Multiple congenital bilateral trigger digits in a 2-year-old child: Case report. Open Orthop J 2013;7:75-7.  Back to cited text no. 2
    
3.
Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg Am 1999;24:1156-61.  Back to cited text no. 3
    
4.
Schaverien MV, Godwin Y. Paediatric trigger finger: Literature review and management algorithm. J Plast Reconstr Aesthet Surg 2011;64:623-31.  Back to cited text no. 4
    
5.
Shah AS, Bae DS. Management of pediatric trigger thumb and trigger finger. J Am Acad Orthop Surg 2012;20:206-13.  Back to cited text no. 5
    
6.
Paaske BP, Søe-Nielsen NH, Noer HH. Release of trigger finger in children. Long term results. Scand J Plast Reconstr Surg Hand Surg 1995;29:65-7.  Back to cited text no. 6
    
7.
Bae DS, Sodha S, Waters PM. Surgical treatment of the pediatric trigger finger. J Hand Surg Am 2007;32:1043-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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