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This patient has a painless, fixed flexion deformity of the thumb consistent with a trigger thumb and surgical treatment involves release of the A1 pulley. Trigger thumb is characterized by the presence of a flexible or fixed flexion deformity of the thumb IP joint and a painless nodule over the flexor tendon. Trigger thumb results from thickening of the FPL tendon causing an increase in tendon diameter relative to the A1 pulley, which results in abnormal tendon gliding. Diagnosis is usually based on clinical presentation and imaging is not required. Nonoperative treatment includes passive extension exercises with observation or intermittent extension splinting. Surgical intervention is indicated for fixed deformities after the age of 12 months or failed nonoperative treatment. Surgery involves release of the A1 pulley. Shah et al reviewed the natural history, clinical presentation and assessment, nonoperative treatment and surgical management of pediatric trigger finger. They recommend surgical release of trigger thumb for fixed flexion deformities in children older than 12 months given the prolonged period of nonsurgical management required for resolution of symptoms. They do note that nonoperative treatment is a reasonable alternative but recommend considering operative treatment after 2 years of age due to the unlikely spontaneous resolution of trigger thumb after this age. Marek et al conducted a retrospective study of 173 consecutive patients with 217 trigger thumbs treated surgically to review the surgical results and practice patterns. There were no major complications or recurrences at an average follow-up of 4.2 years. Five thumbs had minor skin complications and no second operations. 85% of surgeons would treated a locked thumb trigger in a 2-year-old with surgery and 52% would treat intermittent triggering of the thumb in a 2-year old nonoperatively. Figure A demonstrates the thumb pulley system. A is the FPL tendon. B is the A1 pulley. C is the Av pulley. D is the oblique pulley. E is the A2 pulley. Incorrect Answers Answer 1: FPL tendon should not be released as this would result in a loss of flexion of the thumb IP and MCP joint. Answer 3: The A1 pulley, not the Av pulley is where gliding of the thicken FPL tendon is impeded. Answer 4: Release of the oblique pulley should not be performed as this would result in bowstringing. Answer 5: The A2 pulley does not contribute to triggering of the thumb.
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