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Resumen Antecedentes y objetivo Las infiltraciones de corticoides son efectivas en el tratamiento de los dedos en gatillo pero el dolor percibido por el paciente durante la inyeccion es un efecto acompanante siempre presente. El objetivo de este estudio fue evaluar la efectividad y el dolor percibido durante una infiltracion corticoidea depositada fuera de la vaina tendinosa utilizando la tecnica comisural dorsal. Material y metodo Se incluyeron 126 pacientes consecutivos. Se realizo una infiltracion esteroidea subcutanea (fuera de la vaina) a traves de la comisura dorsal. En los casos en que los signos o sintomas persistieron, se ofrecio una segunda infiltracion. Se registro el dolor percibido durante la infiltracion mediante la escala visual analogica, el cuestionario DASH antes del tratamiento y al final de seguimiento, la tasa de exito y las complicaciones. Resultados Fueron 86 mujeres y 40 hombres con una edad media de 61 anos. La puntuacion media del dolor durante la infiltracion fue de 3,8. Doce pacientes se perdieron durante el seguimiento. El exito global fue del 68% y el exito tras una unica inyeccion fue del 54%. El mejor resultado se obtuvo en el dedo anular. Los pacientes que no habian sido operados previamente del sindrome del tunel carpiano respondieron mejor. No se objetivaron complicaciones. Conclusiones La infiltracion esteroidea fuera de la vaina tendinosa y utilizando la tecnica comisural dorsal es efectiva y segura en el tratamiento de los dedos en resorte. Parece ser menos dolorosa que los resultados publicados para la tecnica palmar sobre la linea media, aunque esto debe evaluarse en un estudio disenado para ello.

Anomalies of the thumb development are not uncommon and may be associated with a number of syndromes also. These anomalies range from total absence to duplication. Reconstructive surgery for the creation of an opposable thumb is the most rewarding aspect of Hand Surgery and also the most challenging. Classification systems have been modified for better description. A number of procedures have been introduced to improve the functionality of the hand in anomalies and age old concepts are undergoing a metamorphosis to further this. A brief description of the common conditions and their treatment are discussed here and highlighted by selected clinical cases.

Purpose To quantify the long-term success of repeat injections for trigger fingers and to identify predictors of treatment outcomes. Methods This retrospective case series analyzed 292 repeat corticosteroid injections for trigger fingers administered by hand surgeons at a single tertiary center between January 2010 and January 2013. One hundred eighty-seven patients (64%) were female, 139 patients (48%) had multiple trigger fingers, and 63 patients (22%) were diabetic. The primary outcome, treatment failure, was defined as receiving a subsequent injection or surgical treatment. Patients without either documented failure or a return office visit in 2015 or 2016 were surveyed by telephone to determine if they had required subsequent treatment. Kaplan-Meier analyses with log-rank testing assessed the median time to treatment failure and the effect of demographic and disease-specific characteristics on injection success rate and predictors of injection outcome (success vs failure) were assessed with multivariable logistic regression. Results Second injections provided long-term treatment success in 39% (111 of 285) of trigger fingers with 86 receiving an additional injection and 108 ultimately undergoing surgical release. Thirty-nine percent (24 of 62) of third injections resulted in long-term success, with 22 receiving an additional injection, and 23 ultimately undergoing surgery. Median times-to-failure for second and third injections were 371 and 407 days, respectively. Success curves did not differ significantly according to any patient or disease factor. Logistic regression identified that advancing patient age and injection for trigger thumb were associated with success of second injections. Conclusions Thirty-nine percent of second and third corticosteroid injections for trigger finger yield long-term relief. Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief. Repeat injections of trigger fingers should be considered in patients who prefer nonsurgical treatment. Type of study/level of evidence Therapeutic IV.

Congenital thumb anomalies are common and have a major impact given the specific functional role of the thumb. They may occur alone or as part of a multiple congenital anomaly syndrome. The primary goal of surgical management is to improve or restore pincer grip. In patients with 'congenital' trigger thumb, the A1 pulley must be released if the interphalangeal joint remains in fixed flexion. Thumb duplication is generally managed by reconstruction of the thumb from the predominant (ulnar-based) digit; the accessory (radial-based) digit is excised after collection of its tissue components needed for the reconstruction programme. Thumb aplasia requires pollicisation of the index finger by island flap transfer of the second ray to give it the shape, position, and function of a thumb. Among patterns of digital hypoplasia, some require reconstruction of the existing thumb and others excision of the rudimentary thumb followed by pollicisation. In patients with aplasia of multiple hand digits, a toe transfer may be considered when there is no natural tendency to develop digital prehension at the hand.

Pediatric trigger thumb presents not at birth but early in childhood. Most evidence suggests that it is caused by a developmental size mismatch between the flexor pollicis longus tendon and its sheath. Patients generally present with the thumb interphalangeal joint locked in flexion. Surgical reviews report near universally excellent outcomes after open release of the A1 pulley. However, recent reports indicate that there may be a role for nonsurgical treatment for families that are willing to wait several years for possible spontaneous resolution of the deformity. Triggering in digits other than the thumb in children is generally associated with an underlying diagnosis including anatomic abnormalities of the tendons, and metabolic, inflammatory, and infectious etiologies. Although some have advocated nonsurgical treatment, surgery is often necessary to address the underlying anatomic etiology. More extensive surgery beyond simple A1 pulley release is often required, including release of the A3 pulley and resection of a slip of the flexor digitorum superficialis tendon.

Trigger fingers are common tendinopathies representing a stenosing flexor tenosynovitis of the fingers. Adult trigger finger can be treated nonsurgically using activity modification, splinting, and/or corticosteroid injections. Surgical treatment options include percutaneous A1 pulley release and open A1 pulley release. Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or patients with persistent flexion contracture. Pediatric trigger thumb is treated with open A1 pulley release. Pediatric trigger finger is treated with release of the A1 pulley with excision of a slip or all of the flexor digitorum superficialis if triggering persists.

Research on congenital hand anomalies continues to slowly advance the field via retrospective investigations and surgical technique improvements. This manuscript reviews progress in the field over the last 4 years regarding an assortment of common congenital hand anomalies. We have also highlighted a few key manuscripts regarding upper extremity anomalies.

Purpose The anatomical arrangement of the thumb pulley system continues to be revised through ongoing investigative research, changing our previous assumptions. This study demonstrates the components and anatomical features of this pulley system in an effort to improve surgical outcomes and to clarify current misconceptions. Methods Researchers procured 75 hand specimens from 41 adult cadavers through our institution's anatomical donations program. Dissections of the thumb and thenar compartment identified the various pulleys. A detailed analysis of the thumb pulleys was performed through various measurements. Results Four different pulley categories were identified: type I (n = 5), type II (n = 29), type III (n = 29), and type IV (n = 12). The variable annular pulley was present in 70 of 75 hands (93%) in 1 of 3 arrangements: transverse, oblique, or fused with the A1 pulley. Conclusions The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3. Along with the A1 pulley, the additional variable annular pulley might contribute to stenosis in trigger thumb. This might necessitate a more extensive surgical incision and its partial release to relieve triggering. Clinical relevance Understanding the anatomical configuration of the thumb pulley system will aid in the surgical attempt to resolve triggering while avoiding complications such as bowstringing of the flexor pollicis longus tendon and iatrogenic nerve injury.

Infection complicates approximately 5% of open trigger digit releases. Both superficial and deep infections may occur. We present a unique case of a cactus farmer who underwent an uneventful thumb trigger finger release and subsequently developed pyogenic flexor tenosynovitis and acute carpal tunnel syndrome resulting from Nocardia nova infection.

Purpose Pediatric trigger thumb is regarded as an acquired condition characterized by flexion deformity of the interphalangeal joint of the thumb. However, the exact etiology and pathoanatomy of this condition remain unknown. The purpose of this study was to evaluate cross-sectional configurations of the flexor pollicis longus (FPL) tendon and the area under the A1 pulley quantitatively using ultrasonography. Methods In this study we enrolled 43 patients, 23 boys and 20 girls, with unilateral pediatric trigger thumb. We measured the anteroposterior (AP) diameter, radioulnar diameter, and cross-sectional area of the FPL tendon at the level of the greatest AP diameter of the FPL tendon proximal to the A1 pulley and those of the inner dimensions of the A1 pulley using ultrasonography. The measurements were repeated on the contralateral side. Average age at the time of the measurements was 32 months. Results Average AP and radioulnar measurements of the FPL tendon were 13% and 55% larger than those of the inner dimensions of the A1 pulley in the trigger thumb. The average AP measurement in the area under the A1 pulley was notably larger in the trigger thumb than on the normal side. Conclusions Using ultrasonographic measurements, we were able to identify enlargement of the FPL tendon proximal to the A1 pulley in the symptomatic thumb, compared with the area under the A1 pulley in the symptomatic thumb or FPL tendon on the contralateral side. Developmental mismatch between the FPL tendon and the area under the A1 pulley is a possible cause of pediatric trigger thumb. Type of study/level of evidence Diagnostic IV.

Objective Assess the differences between open and percutaneous release of trigger thumb in children. Material and methods We performed a retrospective study of all the patients operated on at our institution between January 2000 and February 2009. Our exclusion criteria were: patients with trigger fingers other than the thumb, that were being operated on simultaneously of another condition, admitted for other reasons or refused treatment. The surgical technique was left to the preference of the attending physician. Results We found 176 trigger thumbs (159 children), with a mean age of 2.58 years, the majority being unilateral (n=142). Statistically significant differences between the two treatments were only found regarding surgical time (p Conclusion Percutaneous release in children is a good, simple, cheap and fast alternative but it requires compliance of the parents in order to avoid recurrence and to obtain complete success.

Purpose To compare open versus percutaneous surgery in the treatment of stenosing tenosynovitis of the thumb (trigger thumb) in a pediatric population. Materials and methods A retrospective study was performed comparing both surgical techniques by reviewing 108 patients (135 thumbs) with a follow-up period of 24 months. Results Six patients out of 92 (6.52%) were incapable of complete extension of the interphalangeal joint of the thumb after open surgery. When percutaneous surgery was performed there was recurrence in 15 thumbs of the 43 that underwent surgery (34.8%). No complications were seen related to lack of sensitivity, residual pain, nor alterations of thumb mobility in any of the patients in the two compared series. Conclusions Due to the percentage of recurrences seen, percutaneous surgery for trigger thumb is not recommended in a pediatric population.

Resume Introduction Le pouce a ressaut realise un deficit d’extension du pouce secondaire a un conflit entre le long flechisseur propre du pouce et sa poulie de glissement osteofibreuse inextensible. L’etiologie exacte reste encore inconnue. Son traitement est habituellement chirurgical. Patients et Methodes Les auteurs rapportent a travers ce travail leur experience concernant la prise en charge de 52 patients soit 63 pouces a ressaut. L’âge de nos patients varie de 12 mois a cinq ans avec une moyenne de 32 mois. Vingt-neuf garcons et 23 filles, le cote droit 37, le cote gauche 26 et dans 11 cas l’atteinte a ete bilaterale. Tous ces patients ont ete traites par ouverture de la poulie A1 exclusivement par voie percutanee a l’aide d’une aiguille et suivis pour une periode superieure a une annee. Resultats Apres un recul moyen de 28 mois avec des extremes allant de 13 a 30 mois. Parmi les 50 pouces suivis, 48 pouces ont un bon resultat sans recidive. Deux cas de recidive ont ete notes lors de la consultation du respectivement des 15eme jour et du troisieme mois, traites a ciel ouvert avec succes. Aucun enfant n’avait une infection ou trouble vasculaire ou sensitif. Conclusion La chirurgie percutanee du pouce a ressaut qui est tres largement utilisee chez l’adulte avec d’excellent resultat peut etre utilisee avec securite et efficacite chez l’enfant a condition de la pratiquer par un chirurgien specialise dans la chirurgie de la main.

Purpose Whether trigger thumb is congenital or acquired remains controversial. The purpose of this study was to identify whether trigger thumb is present at birth and to clarify whether trigger thumb represents a developmental condition. Methods We examined 1,116 babies born at Yamagata Prefectural Nihonkai Hospital within 14 days after birth. All patients were examined by the author (N.K.), a hand surgeon. Patients were followed up to determine whether trigger thumb would present later even though it was not present at birth. We informed parents about the development of trigger thumb by providing informational sheets for neonatal screenings after hospital discharge. They were asked to check their child for a year or more to see if any flexion deformity of the interphalangeal joint of the thumb occurred. After discharge from the hospital, the family was responsible for noticing trigger thumb in their infant and seeking medical treatment. Results Trigger thumb was not identified in any patient at birth. Responses were obtained from 601 families. Trigger thumb manifested in 2 thumbs of 2 children in the screening group at 8 and 11 months after birth; however, 3 additional children developed trigger thumb at 15, 21, and 30 months of age. Conclusions The incidence of acquired trigger thumb in children 1 year of age was 3.3 per 1,000 live births. It is unlikely that this study identified all cases of trigger thumb in patients older than 1 year in the primary screening group. The results of this follow-up study, however, suggest that trigger thumb is not present at birth but develops with postnatal growth.

One hundred eight trigger fingers and thumbs in 74 consecutive patients were treated by injections of triamcinalone and followed for an average of 3 1/2 years. Minimum follow-up was 1 year. Eighty four percent of trigger fingers and 92% of trigger thumbs were cured with a single injection, and a repeat injection for treatment of recurrent symptoms raised these figures to 91% and 97%, respectively. All injections were done by one physician. There were no complications. We conclude that intrasynovial injection of a steroid compound is the appropriate initial treatment for trigger fingers and thumbs.

Triggering of the thumb due to de Quervain's Disease has not been reported in an adult, and only one case in a child has been documented in the literature. Two cases of trigger thumb that were due to stenosing tenosynovitis in which the extensor pollicis brevis tendon triggered in a separate fibro-osseous tunnel within the first dorsal compartment are cited.