Surgery for Pediatric Trigger Finger.

Abstract

Background: Pediatric trigger finger (PTF) is an uncommon condition that is 10 times less common than trigger thumb. The Quinnell grade is utilized to quantify the extent of the triggering on a 4-point scale (0 = normal movement, 1 = uneven movement, 2 = actively correctable triggering, 3 = passively correctable triggering, and 4 = fixed deformity)¹. Less extensive triggering can be treated nonoperatively with use of monitoring or splinting; however, the reported resolution rates are low, with only 30% of PTF cases treated nonoperatively achieving complete resolution¹. Splinting has also been shown to not improve resolution rates in pediatric cases treated nonoperatively. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit^2,3. Overall, PTF has been shown to have significantly higher rates of resolution when treated operatively (97.1%) versus nonoperatively (30.0%)². PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single flexor digitorum superficialis (FDS) tendon slip. PTF treated with this technique predictably results in resolution with restoration of motion. The present video article demonstrates the surgical treatment of a 7-year-old with a locked right ring finger.

Description: Operative steps include (1) general anesthesia, (2) tourniquet control, (3) loupe magnification, (4) neurovascular identification, (5) A3 and A1 pulley release, (6) excision of the ulnar slip of the FDS, (7) and simple closure.

Alternatives: The primary alternative to this procedure is nonoperative treatment with continued monitoring and/or splinting.

Rationale: PTF differs from pediatric trigger thumb. Simple release of the A1 pulley may not resolve the triggering, requiring additional excision of the ulnar slip of the FDS.

Expected outcomes: Jia et al. reported that only 30% of nonoperatively treated cases of PTF achieved complete resolution, and splinting did not improve resolution rates³. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit. Overall, operatively treated PTF showed significantly higher rates of complete resolution compared with nonoperatively treated PTF (97.1% compared with 30.0%, respectively)³. Additionally, Cardon et al. reported residual triggering in 44% (8) of 18 cases of PTF treated with isolated A1 pulley release². Bae et al. reported a 91% success rate (21 of 23) when PTFs were treated uniformly with A1 pulley release combined with FDS slip excision¹. We conclude that PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single FDS tendon slip.

Important tips: General anesthesia will limit inadvertent patient movement for a safer surgery.Identify neurovascular bundles to prevent inadvertent injury.Utilize loupe magnification to aid in identification of neurovascular bundles.Perform a Bruner incision for wide exposure and excision of the ulnar FDS.

Acronyms and abbreviations: FDP = flexor digitorum profundusFDS = flexor digitorum superficialisDIP = distal interphalangeal joint.