Open Release of Pediatric Trigger Thumb

Abstract

Background: Open release of a trigger thumb has been shown to be the most reliable option to restore full interphalangeal (IP) joint extension and thus normal thumb-joint motion in children 1 . The aim of this procedure is to restore free gliding of the flexor pollicis longus (FPL) tendon in its canal in children with fixed IP joint flexion contractures or those in whom nonoperative treatment modalities have failed. Description: The surgical procedure is easy to perform and straightforward; however, attention must be given to several details in order to avoid surgical failure and complications. General anesthesia is required for this procedure. The extremity is prepared and draped in a sterile fashion with the patient in the supine position, and a tourniquet is utilized to facilitate surgical dissection. A transverse incision is gently made just adjacent to the thumb metacarpophalangeal (MP) flexion crease, above the so-called Notta nodule. The ulnar neurovascular bundle is retracted to the side, and the Notta nodule, a local enlargement of the FPL tendon 2 , is visualized at the A1 pulley. The pulley is incised longitudinally to allow for full IP joint extension. After verification of full passive motion, the tendon is inspected for any further abnormalities. Then, the tourniquet is released, and the wound is closed with absorbable sutures. We recommend the use of local anesthetics for postoperative pain control. In cases of a trigger thumb stuck in extension, full tenodesis flexion of the IP joint combined with smooth, full passive extension confirms a complete release. Alternatives: Nonoperative treatment modalities mainly include watchful waiting for spontaneous resolution 3 , occupational therapy (i.e., passive exercising) 4,5 , and splinting therapy 6 . However, prolonged stretching and splinting may move the nodule to a point distal to the stenotic pulley, thus resulting in a trigger thumb locked in extension with a loss of IP flexion. Alternative surgical treatment techniques involve percutaneous trigger thumb release or open release with alternative surgical approaches (e.g., an oblique or Brunner incision) 7,8 . Rationale: Several reports have shown that open release of a trigger thumb leads to the most reliable outcomes in terms of achievement of range of motion and complications 1,9,10 . The main advantage of this procedure is the perfect visualization of the FPL tendon beneath the stenotic A1 pulley, which allows for a complete A1 release with clear vision. Such visualization cannot be provided with use of percutaneous techniques, which position the neurovascular Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJSEST/A366).