Finger Deformities trigger digits

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.
http://orthoinfo.aaos.org/topic.cfm?topic=a00024

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.  http://www.ncbi.nlm.nih.gov/pubmed/18451388  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.  http://www.ncbi.nlm.nih.gov/pubmed/22624785
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.

132 Comments

  1. Hi doctor we already see the doctor today her surgery not successful he said maybe the problem is the bones she will have an x ray after 6 weeks.do u know anything about bones problem?? Thanks

  2. Thank you for this post. My son is 8 years old. He has left hand trigger thumb and right hand trigger pinky finger. These are from birth. Do I need to do surgery or it will be corrected automatically?

  3. Mahen,
    Thank you for the question. It is rare to have trigger thumb and finger on the same hand. Clearly, your son has done reasonably well at age 8 without surgery. However, I would not expect either condition to notably improve over time. If bothersome, surgery might be helpful. This is certainly something that a pediatric hand surgeon could help to evaluate and consider options. Good luck.

  4. Thanks for continuing to respond to questions! My 2 1/2 year old has been diagnosed with trigger thumb and we have been advised to simply observe until he is 4. Am I right in thinking, from your other comments, that even if his thumb is stuck in permanent flexion for a few months, this isn't going to cause any longterm problems? At what point should we begin to be worried if it continues to be permanently stuck? Thanks!

  5. Leslie,
    My experience has been that the thumb will do fine despite being stuck in flexion for a few additional months. While I would not disagree with waiting at least some time, my personal feeling is that if the thumb has not improved after 6 months or so, it likely will not. The literature suggests that most of these locked trigger thumbs do improve at least to some degree but, the the US, many surgeons offer a surgical release if the patient is not improved over time. That is my philosophy as well. Good luck.

  6. Hi Doctor! My son is almost 4, he was diagnosed with trigger thumb last December. We have tried stretching his thumb and it popped up once but immediately flexed back down. He does have the nodules at the base of his thumb and he says his thumb hurts a lot. We have been advised to have the surgery to correct his trigger thumb. Just worried about the possible complications and wondering if we should wait longer ?

  7. Thank you for the question. While it is possible that the thumb may extend more over time, my honest opinion is that surgery is reasonable. Surgery is very safe and effective. Complications are unlikely.

    Good luck.

  8. My son is now 30 months and is still having the similar issues. He is unable to stretch his pointer, ring, and pinky finger out independently. He can outstretch all fingers as a whole (about 75% of the way), but he can not isolate them. The only finger that he can isolate on his right hand is his middle finger. He uses it to point, swipe the screen on his tablet, etc. His pointer finger triggers occasionally. Lately, his thumb on has been triggering a few times a week. It will stay bent anywhere from several minutes to several hours. Sometimes he is able to pop it out on his own, but most often, he uses his other hand to pop it out. He complains that it hurts when it first locks.

    We had an appointment with a pediatric orthopedic specialist at Children's when he was 17 months and were told not to worry that he was probably just preferring to use his middle finger to point, etc. He had a few months of occupational therapy around that time, but it did not help. His pediatrician said to wait it out until he is 3 because he likely wouldn't be eligible for any surgical intervention until after then due to his age.

    We are concerned about congenital issues because looking back at photographs from his birth on– his right hand has always been clenched. We aren't for sure how to request a congenital hand surgeon appointment as we thought that was who we were seeing at his last appointment, but maybe it was just a general specialist? We are worried how this will affect him in the long run as his right hand is his dominant hand and he struggles with utensils, holding crayons, etc.

  9. I believe my 5 year old daughter has just recently developed a trigger thumb. The other night she demonstrated to me that she can bend her thumb at the joint and make it stick and then pop it back straight again using her other hand. I thought this was strange but didn't think much of it. The following evening (last night) I noticed her left thumb was not as straight as her right thumb and was slightly bent at the joint. I immediately thought about a child that I worked with a few years ago who presented with a trigger finger. So I began massaging my daughter's thumb to see if I could straighten it out. I finally was able to 'POP' it back straight but it caused her quite a bit of pain. This morning she woke up and again her thumb was slightly bent at the joint, I again had to massage the joint until it was free to "POP" back into a straight position. Whenever she bends her thumb ever so slightly, like to turn up volume on a phone or grasp something, the thumb again locks in a bent position. As long as she catches it right away, she can easily pop her thumb back into a straight position with little discomfort; however, if she goes an extended period of time with the thumb in a locked position, straightening it is very painful for her. She can not tell me how long she has been experiencing it but she says she just figured out her thumb can do this.

    I did submit a request to schedule an appointment with her pediatrician to. What might cause a trigger thumb to suddenly appear in a 5 year old and what might the prognosis be?

  10. Wendi,
    Thank you for the question. A trigger thumb can appear in any age group. While 5 years of age is a bit older than the age we typically see this issue (2 years, or so), it is not uncommon. And the most common presentation is a thumb stuck in a bent (flexed) position. However, again, this presentation certainly happens. One option might be to splint the thumb in extension (ie, straight) and check to see if this helps. Otherwise, and especially given the pain, surgery could be a reasonable step. Good luck.

  11. My son is 3.5 month old and we just recognized his left ring finger has trigger finger. We checked the previous photos and we found out it just started when he was 1 month old.
    I am wondering if finger splint helps? Also is it enough to use finger splint just during night?
    Thanks for your help

  12. Shawn,
    Congratulations on the birth of your son. The brief answer is yes- splints can absolutely help trigger finger. I would recommend that you see a hand surgeon who treats kids commonly and a hand therapist is likely to be involved as well. Night time only splinting may be effective but there are different considerations.

    Good luck.

  13. Thank you for the article. My 2 year old has trigger finger of her left middle finger. It has been happening for about 2 months. I am planning on delaying surgery and trying a splint for a period of time.

    I'm just curious if there are any other underlying medical conditions besides MPS which are associated with trigger finger/thumb.

    Thank you kindly

  14. My son was born with cleft feet. When he was 3 months I noticed that he had trigger thumbs. He is now 8 months. He can barely stretch his thumbs. I have talked the doctor and she stated that his orthopedic doctor will have to refer him for genetic testing. I am concerned because when he grasp or grab anything he tries to stretch it but it does not straighten completely. Could think be genetic because his feet and thumbs are inward.

  15. Dr. Goldfarb,

    First, let me thank you taking the time to offer your advice and expertise free of charge to a bunch of strangers. That speaks to your character and provides an enormous amount of credibility to you and your organization.

    My 3 1/2 year old daughter was recently diagnosed with trigger thumb after we recognized it would not extend fully. You can also feel the little nodule at the base of her thumb. We took her to a local children's hospital and they recommended she have surgery, but we were floored with how much it was going to cost ($25k billed, $5k out-of-pocket) for a 10-15 minute procedure.

    After doing some online research and reading Dr. Baek's studies, I'm now inclined to wait and see if it resolves by itself over time. Would there be much, if any, risk in waiting until she's 5 or 6 to see if it resolves before having the release surgery? At that age, would she be able to do the surgery under local anesthesia instead of general?

    Thanks,

    Chuck Dukes

  16. Chuck- thank you for your kind words- it is a labor of love on subjects about which I am passionate. I too am shocked at the expense- impossible to justify! Given that this is a 5 minute surgery and incredibly safe (in the right hands), I really don't understand.

    Sorry. Off soapbox. Dr Baek's work is compelling and a friend in Utah has tried a similar approach with also reasonable results. My only concern is that this approach is rarely a "full" correction- of course, if the thumb is nearly straight, is there a problem? Finally, unfortunately, at 5 or 6 years, local only surgery is still not an option. The injection of local is very uncomfortable and poorly tolerated until teenage years (at best). But, certainly no harm in watching and waiting for a year or so. Good luck.

    1. Just stopping by for an update to let you know that our daughter’s trigger thumb has completely resolved around age 5 1/2. We took your advice after reading Dr. Baek’s work, and sure enough one day a few weeks ago we noticed her thumb was at full extension. So glad we didn’t elect to have it surgically repaired right out of the gate. Thousands saved on what would have been an unnecessary surgery!

      1. Thank you for sharing and I am so happy with your outcome. While many patients do not resolve their trigger, it is always great to see when the Nonoperative approach is successful.

  17. Hello! I just wanted to thank you for this blog. My 4 year old had bi-lateral trigger fingers (little fingers). The first ortho specialist we saw had said he was familiar with trigger thumbs in peds but had never seen any other digits in pediatrics, other than in his text book. He said it was a straight forward surgery to correct the issue. Having never operated on this particular condition did not sit well with me, especially after finding your blog and reading that trigger fingers in peds can require a more complex surgery. We decided to take our child for a 2nd opinion to our (somewhat) local Shriners hospital. That surgeon was familiar and knowledgeable on the condition. He did an amazing job on my sons hands and the care my son received from everyone at Shriners was better than we could have ever imagined. He has made a very quick recovery and now has full function of both hands! Thank you!!

  18. Good day.. My 3 year old son was born with normal fingers then all of a sudden when he was about 1 and half years old we noticed that both his thumbs have been bent and can't straighten it at all so its been like this for a while now

  19. Hello. This is a classic presentation. All seems fine until you notice that the thumbs are stuck in a bent position. Its always tricky to know how long the thumbs have been bent b/c younger kids function just fine.

  20. Hello! Messaging from Australia, Hope all is well for you over there during these chaotic times.
    I’m a registered cardiac nurse.
    I have 14 month old identical twin girls who have mirror image trigger thumb- both are always locked.
    A few questions- is this rare for both to have?
    Would this be congenital and or genetic even though there is no substantial evidence or documentation to suggest genetics are to blame nor a definitive reason of the cause?

    Any other advice or information would be super appreciated! 🙂 thank you!

  21. Hello Sheridan. That is super interesting. There are a few reports in the literature but it does the issue of a genetic component. There is no science confirming this but it makes sense (maybe a genetic predisposition). Thankfully, your girls will do great! As you can see from the blog, in the US, if the thumbs fail to improve (? 6 months), many will proceed to surgery which is safe and reliable.

  22. Hi Doctor,
    My 2 year old son was diagnosed with PTT this year in Jan. The doctor gave instructions to massage and asked us to wait and watch for 6 months. He was not much cooperative for the massage. However, twice during the last 2 months, the thumb became straight for a moment on its own and it would hurt him and he would cry. then in few minutes it goes back to the bent position. But he holds pencil and other stuff using this bent thumb and draws or scribbles normally. We are not sure if waiting will really help. Please suggest.

  23. Hello. There certainly remains a chance that the trigger digit will resolve. However, in the situation when there is pain as you describe, I tend to offer surgery sooner. The bottom line is that the surgery is safe and effective and it makes sense to me.

  24. Hi Doctor, my son is 2 years old. His right hand thumb gets bend (it happens three to four times during the last one month) and after some it becomes normal naturally. Sometimes we help to stretch and it gets normal again. What to do?

    1. Hello Nurul. It does seem like trigger thumb although most 2 year olds present with a thumb locked in a flexed/ bent posture. Time may help this improve. Surgery is also curative and safe. Good luck

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