Friday, August 23, 2013

Trigger Thumb/ Trigger Finger

Trigger digits are common in the adult population.  It can be called different things including stenosing tenosynovitis but we really do not understand who gets it and why they get it.  The only population that seems to get trigger fingers more than everyone else are diabetics.  Adults with trigger finger (and it really can be all the fingers and/ or the thumb) have pain at the location where the fingers meet the palm and sometimes can feel a catching when they bend the finger.  It is classically worse in the morning and gets better over the course of the day.  We know it is caused by the tendon rubbing at the anatomical entrance to the canal- the A1 pulley.  Again, we just don't know why.  Treatment is straightforward.  Splints and braces don't work in most cases and treatment is either a steroid injection or a surgery.  Steroid injections work about 60% of the time but we don't repeat the injection over and over.  Surgery is very effective and has only rare complications (but it is surgery so we try to avoid).

There are multiple websites which detail trigger finger diagnosis and treatment.  The AAOS (American Academy of Orthopaedic Surgeons) is a great site and the following link is as good as any.

Trigger digits in kids are very different and again, we don't know why.  A couple of thoughts.

1) Most importantly, it is almost always a trigger thumb.  Trigger fingers are rare in kids but trigger thumbs are "common," at least in my world.
2) The term congenital (meaning present at birth) is often used in describing trigger digits/ thumbs in kids.  This is not accurate.  There are several (at least 3) studies which look at a large number of newborns and trigger thumbs just don't exist.  The appear later.  So the best term is pediatric trigger thumb.
3) Kids almost always present with the thumb in a bent or flexed position at the distal joint- the IP joint. Typically it is stuck in that position.  Occasionally, kids can straighten the thumb but usually it is just stuck.
4) It doesn't hurt.  Because it is stuck, there is no pain.
5) Function is usually pretty good but we worry about function over time- in school with writing and scissorts, etc.

For those who see kids with trigger thumbs or fingers, the diagnosis is clear.  The thumb is stuck in a bent position and sometimes there is swelling at the base of the thumb (MCP joint).  We call this a "Notta's node" and it is where the tendon gets stuck in the sheath.  We don't need x-rays or MRIs.

Treatment for trigger thumbs or fingers.
There are 3 options for treatment.
1)  Ignore it as it might get better.  This is not unreasonable given that it doesn't hurt but in our experience, rarely does this go away on its own.  But, a 6- month trial of watchful waiting is certainly a reasonable plan.  This is the recommendation from Korea with a good study supporting that it will help.  Dr Baek is an extremely well respected surgeon who has written on many topics in kids hand surgeries.    In his study, 4 years after the first visit, about 60% of kids had resolved and another 20% were improved.  These are impressive numbers but obviously require some patience from the patient, family, and surgeon.
2) Stretch and splint.  There is little data to support splinting of the thumb but there is actually good data to support considering a splint and/ or stretching for trigger finger.
3) Surgery.  Surgery works for pediatric trigger thumb.  It is a small surgery, it is outpatient and takes less than 10 minutes.  Patients have little pain after and most heal uneventfully with a cure.  Complications are rare and include a risk of infection (likely around 1/200) and scarring.  It does require a general anesthetic but again, minimal risks.  Trigger finger surgery may be more complicated as it can require a more extensive operation compared to trigger thumb.  It is just less predictable.  Still effective and reliable.
The decision of when to go to surgery is not easy.  It depends on the family perspective, the time that the trigger finger has been present, and the surgeon's beliefs.  For me, a conversation between the family and myself helps to bring all the issues out and guide the decision.  In the USA, we tend to be more aggressive than our Asian counterparts about the decision of when to go to surgery.

This is a case of a pediatric trigger finger.  Again, much less common than trigger thumbs.  This case had a swelling or "Notta's node" at the A1 pulley which limited extension.  At surgery, the A1 pulley was released and the finger extended.  Additional surgical dissection was not required and the patient's condition resolved.

Pediatric trigger finger which is more rare than trigger thumb.  Not the flexed position of the finger.    It could not be straightened.
I am trying to straighten the finger but it is blocked in this pediatric trigger finger.

Bilateral trigger thumb.  Photos courtesy of my partner, Dr Wall.

Trigger thumb.  We are trying to straighten the thumb but it is locked.  Photo courtesy of Dr Wall.

Saturday, August 17, 2013

Mild Camptodactyly

Camptodactyly comes in different types based on age and severity.  I have written several times about camptodactyly including

While there are different ways to consider camptodactyly, there are three basic types: infantile, adolescent, and camptodactyly associated with a syndrome (i.e., athrogryposis, etc.).  For most patients, camptodactyly affects the small fingers on both sides but may be different on each side.  Syndromic kids may have any finger affected.  When, for example, the long finger is affected, it tends to be more of a problem compared to the small finger and get in the way of grasp.  Upton and others have done a nice job breaking down these 3 types with the results of treatment.

I certainly see all three types of camptodactyly patients and each has its challenges.  Pain is rare but with a worsening deformity (i.e., worsening position of flexion), functional issues increase.  This includes difficulties with playing musical instruments, typing on the computer, sports, among others. Different patients are bothered at different levels of contracture.  We, as surgeons and doctors, try to define the point at which camptodactyly becomes a problem but the reality is that we can assign numbers like 30 degrees or 45 degrees or others but, again, it is really about the patient.

The good news about camptodactyly is that many patients will respond to therapy including stretching and splinting.  This depends, again, on the patient, but also on the degree of camptodactyly because once it is too severe, splinting and therapy become less effective.  Therapy and splinting may be a challenge in really young patients but is easier in adolescents (who really want their finger to get better).  Stretching during the day, specialized dynamic splints during the waking hours, and static splints at night all have a role.  Progress is typical.

Here is a recent patient with what I would consider mild camptodactyly.  He was excited to try therapy and I expect that he will improve.  I plan to post soon on the surgical options.

Bilateral small finger camptodactyly.  Note that the bottom hand, the right hand, is worse and was more of a problem.

Left small finger x-ray of camptodactyly.  Attempted full straightening.  The joint is well formed.

The more severely affected side in camptodactyly.  The joint is not quite normally formed but is generally satisfactory.

Tuesday, August 13, 2013

Partial Syndactyly

I have written several times on syndactyly, most recently about an unusual case of thumb- index syndactyly

I have also mentioned (but not discussed in great detail) partial syndactyly.  Partial syndactyly means that the fingers are joined together by a skin bridge without bony connection.  The skin bridge does NOT travel all the way to the fingertip (thus, partial).  Many times the skin bridge is short, only to the first knuckle (the PIP joint).  Partial syndactyly may or may not cause functional problems.  Often the partial syndactyly involves the long finger and the ring finger (also most common site for complete syndactyly- which is a joining of the skin to the fingertip).  Syndactyly between the long and ring finger can limit spread of the fingers and limits the ability to wear a ring (perhaps a wedding ring, one day). Partial syndactyly of the index and long finger can tether the index finger and affect pinch activities- patients/ families do complain about this aspect.  And, as always, there is the appearance issue which really does matter to patients and to families.

When I meet a patient/ family with a partial syndactyly, we discuss the nature of the syndactyly and I learn how it affects the child.  For some, the partial syndactyly is simply not a big deal and no intervention is recommended.  For others, the syndactyly limits function.  In those patients with functional limitations, surgery is discussed.  Surgery in those patients who simply want the syndactyly treated for appearance reasons is rare but does happen (in my mind, this discussion includes those who want to be able to wear a ring).  I frankly discuss the difficulties of surgery, the healing process, the risks, etc.  Some will chose surgery.

Surgical protocol.
Surgery is outpatient meaning you can go home that night.  I use a big, bulky but soft dressing for most patients but occasionally for the younger child will use an above elbow cast.  I typically leave the dressing on for about 3 weeks.  I use dissolving sutures so nothing to remove.  Depending on the appearance of the wound, sometimes we use a dry dressing and sometime we use an odoform support at night (and splint at night).  Scar massage is instituted when the sutures start to dissolve.

Partial syndactyly between the index and long fingers.  Not severe but functionally limiting.

Partial syndactyly view from palm

After syndactyly reconstruction with dorsal commissural flap.

Another case demonstrating the box flap technique.  This 3 flap technique is effective in covering the partial syndactyly is some patients.
Box flap design for recurrent syndactyly reconstruction. 
Corrected syndactyly with box flap

Box flap reconstruction with flaps in place.
Partial syndactyly of the long and ring fingers.  The first case is corrected by a dorsal first metacarpal artery flap.  See the diagram of the flap.
Partial syndactyly between long and ring fingers
Partial syndactyly flap reconstruction (without skin grafts)
 Other long and ring finger partial syndactyly.

Partial syndactyly past the PIP joint.  This is a longer than typical partial syndactyly.

Partial syndactyly from palm

Additional syndactyly 
Additional partial syndactyly

Tuesday, August 6, 2013

Thumb Index Syndactyly

I have posted a number of times about syndactyly.  The two basic posts include: and

The long and ring finger are most commonly involved in syndactyly whereas the thumb and index finger are uncommonly conjoined.  There are several important points to consider regarding thumb and index finger syndactyly:

1) The syndactyly between the thumb and index finger is functionally the most significant type of syndactyly as it limits pinch and large object grasp.  Without a wide, soft webspace between the thumb and index finger, function of the hand is difficult and will be frustrating to the child.

2) It is also notable as it should be correctly at a younger age to de- tether the index finger as otherwise, the index finger can deviate towards the shorter thumb with growth.  While long finger and ringer syndactyly may be corrected at any age (preferences vary, but we often aim to correct at 18 months), we correct the thumb and index finger syndactyly closer to 6 months of age, if not before.

3) Finally, thumb index syndactyly is a more difficult correction as the typical techniques are not applicable.  We like to use a dorsal flap to cover the web space to create a soft, function webspace.

Thumb and index finger syndactyly.  Note the large space between the index finger and the long finger (which is joined to the ring finger and is contracted).

Another view of both syndactylies- thumb/ index on the left and long/ ring finger in the center.

Here I isolate the thumb and index finger syndactyly.
This is an unusual correction of syndactyly as mentioned above.  In this case we borrowed skin between the index and longer finger and bring it over towards the new space between the thumb and index finger (with the zig- zag separation).