Mirror-image trigger thumb in dichorionic identical twins

The congenital vs acquired etiology of pediatric trigger thumb is the subject of considerable debate. Existing case reports of bilateral presentation in identical twins and first-degree familial association support the congenital hypothesis. However, prospective studies have yet to report a neonate presenting with this anomaly at birth. This article describes the first known set of dichorionic, monozygotic identical twins with unilateral trigger thumbs, affecting contralateral (mirror-image) hands and with asynchronous age at presentation (11 months and 18 months, respectively).Pediatric trigger thumb is caused by a mismatch between the flexor pollicis longus tendon and its A1 synovial pulley. Four sets of twins have been previously reported in the literature with trigger thumb. Of these, 3 sets were monozygotic twins who had bilaterally affected thumbs. Together with the absence of trauma, a congenital etiology was suggested. The fact that pediatric trigger thumb is generally seen several months after birth was felt to be due to infants holding their thumbs clutched in their palms until 6 months. However, no confirmed cases of trigger thumb have been diagnosed at birth in several large prospective studies of newborns.In the current case, the asynchronous presentation of unilateral trigger thumbs in identical twins does not support a solely congenital cause. Furthermore, the mirror-image presentation contradicts current embryological understanding of the temporal course of twinning and the determination of laterality. Thus, a multifactorial etiology is supported with both a genetic and acquired component affecting the development of this condition.     

The management of trigger thumb in children

Trigger thumb in children is an uncommon condition. We reviewed 41 patients with 53 trigger thumbs. Although the current accepted approach to the treatment of congenital trigger thumbs is a prolonged period of observation, our findings indicate that all of our patients eventually required surgical release of the flexor pollicis longus tendon. Waiting 3 years before a surgical release was done did not affect the surgical result.     

Extension splint for trigger thumb in children

Sixty-two reducible trigger thumbs in 50 children with age from 0 to 4 years (mean, 1 year 11 months) were reviewed to study the effect of splinting. Thirty-one thumbs in 24 children received splinting for a mean of 11.7 weeks. The other 31 thumbs in 26 children were only observed. The results were categorized as cured, improved, or nonimproved. Follow-up was conducted after a mean of 20 months (age, 43 months). Result in the splinted group showed cured in 12 thumbs, improved in 10 thumbs, and nonimproved in 9 thumbs, whereas in the observed group, result showed 4, 3, and 24, respectively. Splinting results in 71% trigger thumbs cured or improved that is better than observation alone. The subsequent surgical release for the nonimproved trigger thumbs after splinting still had excellent results. Because surgical release for trigger thumb is not urgent, we suggest extension splinting to be a treatment option before the elective surgery.     

儿童拇指扳机指局部封闭治疗的疗效分析

目的 分析局部封闭治疗儿童拇指扳机指的疗效.方法 2007年8月至2009年2月,对41例(47指),年龄20个月至5岁,病程时间为1周至4年的儿童拇指扳机指,按照Sugimoto分期,其中Ⅱ期27指、Ⅲ期17指、Ⅳ期3指,均采用局部封闭治疗,每周1次,共2～3次.结果 2例Ⅱ型拇指扳机指失访,其余39例45指获得随访,时间为12～18个月,平均14个月.局部封闭治疗后平均2周症状缓解,总有效率为82.2%.注射局部无后遗症.结论 局部封闭治疗儿童拇指扳机指起效快,是安全有效的保守治疗方法.     

Conservative treatment for trigger thumb in children

Conservative treatment was performed for 60 trigger thumbs (19 right, 17 left, 12 bilateral) in 48 children (19 boys, 29 girls); the age at initial diagnosis ranged from 0 to 48 months old (mean 26 months). In this approach, only passive exercise of the affected thumb was performed by the mother. As a result, two patients (two thumbs) dropped out of treatment. Fifty-six thumbs out of 58 showed a satisfactory result (96%). Sixteen thumbs (in stage 2) and eight thumbs (in stage 3) showed completely recovery. Four thumbs (in stage 3) have not yet improved. In conclusion, we suggest that conservative treatment is effective for trigger thumbs in stage 2, while surgical therapy was thought to be indicated for stage 3 before the age of 3 years to avoid flexion deformity.     

The Development of Trigger Thumb in the Contralateral Thumb in Pediatric Patients Presenting Initially With Unilateral Involvement

Background: Pediatric trigger thumb is a common condition that can occur bilaterally. There have been reports of a metachronous relationship between trigger thumbs developing in both extremities. Surgeons might consider delaying operative treatment of unilateral trigger thumb due to the concern that contralateral symptoms may develop later in childhood, requiring a second procedure and anesthetic event. Methods: We retrospectively reviewed patients diagnosed with pediatric trigger thumb from 2008 to 2016 at a large pediatric hospital. Data collected included age at presentation and onset, laterality, age and timing of onset of contralateral symptoms, time of index procedure and subsequent procedure (if any), severity of symptoms, previous treatments, range of motion, and birth history. Results: There were 198 patients with pediatric trigger thumb, with 55 patients (28%) presenting with or developing bilateral involvement. Fifty patients (25%) had bilateral involvement upon initial presentation. Five patients (3%) were subsequently diagnosed with contralateral trigger thumb after initial presentation of unilateral trigger thumb. Average time to contralateral trigger thumb development was 12 months after presentation in unilateral patients. Most patients presented with locked flexion contracture with palpable Notta’s nodule. Of the 5 patients who developed contralateral trigger thumbs, three required a second surgery after the index procedure. Conclusions: The vast majority of patients with bilateral trigger thumbs had bilateral involvement upon initial presentation to the pediatric hand clinic. Given the rarity of bilateral symptoms after initial unilateral presentation, we do not recommend delayed surgical intervention for patients with unilateral disease in children over 3 years of age.     

Efficacy of cortisone injection in treatment of trigger fingers and thumbs

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.     

Percutaneous trigger thumb release in children

The objective of this study was to determine whether percutaneous release of the A1 pulley is an adequate treatment of trigger thumb in children. Twenty-three children under the age of 6 years with 27 trigger thumbs fixed in flexion were evaluated prospectively. All were treated with a percutaneous release of the A1 pulley in an ambulatory setting and followed for at least 1 year. Interphalangeal and metacarpophalangeal joint range of motion, pinch strength, static two-point discrimination sensibility, and triggering were examined and compared with the unaffected thumb at the end of follow-up. After a mean follow-up of 3 years, 25 of the thumbs had an excellent result without residual triggering. Two of these thumbs had mild metacarpophalangeal extension deficit 1 month after surgery that resolved completely with specific exercises. One thumb relapsed and required subsequent open release and was considered a poor result. One child was lost to follow-up. There were no sensibility defects, strength loss, interphalangeal motion loss, or metacarpophalangeal hyperextension deformities. Percutaneous release of the A1 pulley is an effective and safe option in the treatment of trigger thumb in children.     

The outcome of treatment of trigger thumb in children

Our aim was to determine the outcome of the treatment of trigger thumb in children. There was a rate of spontaneous recovery of 49% in those children whose thumbs were observed before a final decision to operate was made. Spontaneous recovery occurred more commonly in children over 12 months old. All patients treated by operation had a satisfactory outcome with few complications. The overall rate of recurrence was 4.0% and it was more common in younger children. Our results suggest that a conservative approach to surgery for this condition could be adopted.     

Epiphyseolysis capitis femoris (ECF) in monozygotic twins

AIM: The frequency of bilateral slipped capital femoral epiphysis (SCFE) is 5-80%. A set of boy twins developed left-sided SCFE within 2 years. We tried to find a relationship between SCFE and HLA typing. METHOD: We obtained the HLA typing and compared it to previously reported cases. RESULTS: By comparing 14 gene loci we made sure that they are identical twins. In our patients as well as in may of previously reported cases of sets of boy twins HLA phenotype A2 were found, while in the sets of girl twins HLA phenotype A11 and B12 were found. CONCLUSIONS: HLA phenotyping is needed in a larger number of SCFE twin cases to evaluate phenotypic patterns for coincidence to provide a basis for the genetic expression of this condition.     

A prospective clinical study of the A1 pulley in trigger thumbs

A prospective study was performed in 19 patients with trigger thumbs to define the anatomy of the A1 pulley of the thumb in this condition and to evaluate biomechanical parameters of the thumb after complete division of the A1 pulley. Pre- and postoperatively, flexion of the interphalangeal and metacarpophalangeal joints, key pinch strength and tip pinch strength were measured and compared with these measurements on the contralateral thumb. We identified three types of A1 pulley. The clinical data showed that there is no deficit with respect to motion and strength of the thumb after completely sectioning any of the three types of A1 pulley.     

Incidence and development of trigger thumb in children

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.     

Trigger thumb in adults after hyperextension injury

Three cases of trigger thumb in adults developing after hyperextension injury are described. The similarity of the mode of injury in the cases and its possible role in the production of initial stenosis in the tendon sheath is discussed. Trauma alone may not cause triggering in the fingers, for there are other important factors such as rheumatoid disease, which with trauma may play a part. Trauma may however be the sole initiating factor in other cases of adult trigger thumbs.     

Freiberg’s Infraction in Identical Twins: A Case Report

Freiberg's infraction is an ostechondrosis of a lesser metatarsal head resulting in degeneration of the metatarsophalangeal joint. Several mechanisms have been suggested in its pathenogenesis. Freiberg first described the entity and believed single impact trauma was the underlying cause. Repetitive biomechanical microtrauma is the most widely accepted etiologic theory. Other factors contributing to its development include aseptic necrosis, ischemia, and a congenital predisposition. We present a case report of Freiberg's infraction occurring in identical twins involving multiple metatarsals in various stages of degeneration. One of the twins was affected unilaterally whereas the other twin was affected bilaterally. Both twins had involvement of the second metatarsal on the same side extremity. The occurrence of Freiberg's infraction in identical twins suggests that an underlying congenital predisposition to the condition may play more of a role than previously considered.     

The treatment outcome of trigger thumb in children

Our objectives were to determine the treatment outcome of trigger thumb and to identify its possible cause. One hundred and thirty-eight thumbs from 115 children were reviewed. There was an overall success rate of 66% following conservative treatment and the success rate appears to be higher in the younger age group and in those treated with splint therapy, which includes wearing a splint and regular therapy exercises. The outcome of the children who underwent surgery was good with a recurrence rate of 1.4% and a wound infection rate of 2.8%. Our results suggest that a more conservative approach to this problem should be adopted. Our data also suggest that this condition may be acquired rather than congenital.     

Congenital trigger digit.

Release of the sheath of the flexor tendon is the accepted solution for the problem of congenital trigger digits in children. A series of 27 patients with 37 trigger digits were observed over a period of 18 years: the average follow-up on these patients was 46.9 months. Thirty-two thumbs, three long fingers, and two ring fingers showed locking and a degree of triggering. Thirty-three digits required surgery. The surgical treatment is simple and effective. The outcome in most cases shows that this is a conservative approach.     

Conservative treatment of pediatric trigger thumb: follow-up for over 4 years

We analyzed the outcomes of our conservative treatment for pediatric trigger thumb. Since March 2004, we have used conservative treatment for all patients with pediatric trigger thumb. We prospectively analyzed 30 patients in whom 35 thumbs were affected (10 right, 15 left, 5 bilateral). The mean age at diagnosis was 28 (11-50) months. The treatment consisted of passive exercises performed by the children's mothers, 10-20 times daily. How reliably this was performed is unproven. Trigger thumb severity was graded as 0A (extension beyond 0°), 0B (extension to 0°), 1 (active extension with triggering), 2 (passive extension with triggering), and 3 (cannot extend either actively or passively i.e. locked). At diagnosis, six of the 35 thumbs (17%) were grade 1, 25 (71%) were grade 2, and four (11%) were grade 3. After a mean follow-up period of 63 (range, 49-73) months, 28 thumbs (80%) were grade 0A or 0B, 5 (14%) were grade 1 and 2 (6%) were grade 2. The bilateral cases and the patients who initially had grade 3 severity had significantly more unfavorable results than the other patients. This study suggests that conservative treatment for pediatric trigger thumb is a successful method, although cases that present with bilateral involvement or locking (grade 3) should be considered for early surgical release.     

Trigger digits in children

Seven thousand, seven hundred newborn children were examined prospectively to determine the congenital incidence of trigger thumb and finger. No cases were found. The case histories of 43 trigger digit cases (35 trigger thumbs and eight trigger fingers) noted in 40 children diagnosed at our center between 1995 and 1998 were reviewed with special reference to the spontaneous recovery rate, treatment outcome, and age at presentation. Of the 35 thumb cases, 23 underwent surgical release and all responded satisfactorily to surgical treatment. Spontaneous recovery was noted in 12 trigger thumb cases and in all eight trigger finger cases. Trigger finger developed earlier in life than trigger thumb and the spontaneous recovery rate was higher in trigger finger than trigger thumb.     

Transmission electron microscopic pathoanatomy of congenital trigger thumb.

Previous studies of trigger digits in children have been limited to gross morphology and light-microscopic histology. Nine children with 11 trigger thumbs formed a preliminary study group for electron-microscopic evaluation of tendon nodules and A-1 pulleys. This pathoanatomic investigation was not previously reported. Comparison was made with light-microscopic sections. Large amounts of mature collagen was observed. Fibroblasts with prominent rough endoplasmic reticulum were present. No degenerative or inflammatory changes were noted in either tendon or sheath. We believe that although the etiology of trigger digits is still uncertain, an infectious, inflammatory, or degenerative process is unlikely.     

Multiple intracranial aneurysms in identical twins

Summary Familial intracranial aneurysms are well documented, with the highest association occurring among siblings. Five pairs of identical twins with subarachnoid hemorrhage have been previously reported. We present the sixth set of identical twins with multiple aneurysms. These cases represent the first report in the literature of multiple mirror aneurysms in identical twins. One twin presented with subarachnoid hemorrhage. Her sister, who was asymptomatic, had elective angiography which demonstrated multiple aneurysms in locations identical to her sister's aneurysms.In families in which a twin presents with subarachnoid hemorrhage, it is appropriate to recommend angiography to the asymptomatic twin.