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The natural history of adult trigger thumb
THE NATURAL
HISTORY
OF ADULT
TRIGGER
THUMB
C. B. SCHOFIELD and N. D. CITRON From the Nelson Hospital, Wimbledon, London, UK
30 consecutive adult patients presenting with trigger thumb (31 thumbs) were entered prospectively into a study to determine the natural history of the condition. Five patients insisted on treatment and could not be followed to resolution, but the rest resolved spontaneously after an average duration of symptoms of 6.8 months (range 2-15). There was a small but non-functional reduction in movement of the thumb in some of the patients: six lost an average of 7” of abduction and ten had an average loss of opposition of 1.4 (Kapandji grade). The remaining patients made a full recovery.
Journal of Hand Surgery (British and European Volume, 1993) 18B: 247-248 Adult trigger fingers and thumbs have been treated by a variety of methods, including steroid injection, surgical release and splinting. Recently percutaneous tendon sheath division has again been advocated (Eastwood et al, 1992). In order to evaluate the effectiveness of a treatment, the natural history of the condition should be known. We have attempted to discover this for adult trigger thumb.
required the use of their thumbs at work. Another patient insisted on immediate steroid injection and was withdrawn, The remaining 25 patients (26 thumbs) were followed for an average of 14 months (range 5-36). The presenting symptoms spontaneously resolved in all these patients after an average duration of symptoms of 6.8 months (range 2- 15 months). In the group who had spontaneous resolution, clinical reduction of movement as assessed by restriction of abduction of the thumb was found in six patients, the average loss of abduction being 7”. A difference in the Kapandji score was found in ten patients, in whom the average loss of grade was 1.4. Only one patient had loss of both opposition and abduction. No patient with spontaneous resolution of symptoms complained of any functional loss.
METHOD 30 consecutive adult patients presenting to a hand clinic with 31 trigger thumbs were prospectively studied in order to determine the natural history of adult trigger thumb. Patients whose thumbs were completely locked in flexion or extension were excluded from the study. The aim of the study was explained and the patients reassured that spontaneous resolution would occur. They were also instructed not to try and exercise the thumb but to use it normally. A standard proforma was completed for all subjects to obtain information on age, occupation, sex, hand dominance and symptoms. Patients were reviewed at varying intervals after the first examination. The review included an examination of both thumbs to allow a comparison to be made with the unaffected side. Thumb abduction was measured directly using a finger goniometer. Thumb opposition was assessed using the scoring method of Kapandji (1986). This method grades opposition according to the patient’s ability to touch the fingertips and ulnar border of the hand with the thumb pulp. Grade 1 represents the least and grade 8 the most opposition.
DISCUSSION
There are previous reports of spontaneous recovery of untreated trigger thumb (Lapidus and Fenton, 1952; Fahey and Bollinger, 1954). Series of so-called “conservative” treatment usually consist of steroid injection or splinting. Splinting appears particularly ineffective in treating trigger thumb, altering the natural history in an unfavourable way (Evans et al, 1988; Pate1 and Bassini, 1992). Lambert et al (1992) in their study found that only 16% of patients, 30% of whom had trigger thumb, had spontaneous resolution. However, the follow-up was only 1 month with a mean duration of pre-existing symptoms of 6.5 months, so it is possible that not all spontaneous resolutions would have been observed. Also their control group received an injection of Lignocaine into the tendon sheath which may have altered the natural history. It remains unclear why trigger thumbs should resolve and trigger fingers not. It may be that only one tendon is involved and that the thumb can function well when almost fully extended. The swelling in the tendon can thus recover spontaneously. We are not advocating benign neglect as a treatment for adult trigger thumb. Some patients want a rapid
RESULTS
Six patients were male and 25 female. The average age at presentation was 63 years (range 47-86). The dominant hand was affected in 60% of subjects. Presenting symptoms reported by the patient included triggering in 97%, pain in 91% and intermittent locking in 27%. Three patients insisted on immediate surgery and another had surgery following an immediate steroid injection. These four withdrew from the study as they 241
THE JOURNAL
cure or are not prepared to risk a very slight loss of movement, although no patient who spontaneously recovered complained of any functional loss. Nevertheless, in this cost-conscious age it is reasonable to question the need for treatment in all cases. References EASTWOOD, D. M., GUPTA, K. J. and JOHNSON, D. taneous release of the trigger finger: An office procedure. Surgery, 17A: 1: 114-117. EVANS, R. B., HUNTER, J. M. and BURKHALTER, W. E. tive Management of the Trigger Finger: A New Approach. Therapy, 13: 1: 59-68.
P. (1992). PercuJournal of Hand (1988). ConservaJournal of Hand
OF HAND
SURGERY
VOL. 18B No. 2 APRIL
1993
FAHEY, J. J. and BOLLINGER, J. A. (1954). Trigger-finger in adults and children. Journal of Bone and Joint Surgery, 36A: 6: 1200-1218. KAPANDJI, A. (1986). Cotation clinique de l’opposition et de la contreopposition du pouce. Annales de Chirurgie de la Main, 5: 1: 67-73. LAPIDUS, P. W. and FENTON, R. (1952). Stenosing tenovaginitis at the wrist and fingers. Archives of Surgery, 64: 475-487. LAMBERT, M. A., MORTON, R. J. and SLOAN, J. P. (1992). Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb. Journal of Hand Surgery, 17B: 1: 69-70. PATEL, M. R. and BASSINI, L. (1992). Trigger fingers and thumb: When to splint, inject or operate. Journal of Hand Surgery, 17A: 1: 110-l 13.
Accepted: 8 October 1992 C. B. Schofield and N. D. Citron, The Nelson Hospital, Wimbledon, London, UK. 0 1993 The British Society for Surgery of the Hand
HISTORY
OF ADULT
TRIGGER
THUMB
C. B. SCHOFIELD and N. D. CITRON From the Nelson Hospital, Wimbledon, London, UK
30 consecutive adult patients presenting with trigger thumb (31 thumbs) were entered prospectively into a study to determine the natural history of the condition. Five patients insisted on treatment and could not be followed to resolution, but the rest resolved spontaneously after an average duration of symptoms of 6.8 months (range 2-15). There was a small but non-functional reduction in movement of the thumb in some of the patients: six lost an average of 7” of abduction and ten had an average loss of opposition of 1.4 (Kapandji grade). The remaining patients made a full recovery.
Journal of Hand Surgery (British and European Volume, 1993) 18B: 247-248 Adult trigger fingers and thumbs have been treated by a variety of methods, including steroid injection, surgical release and splinting. Recently percutaneous tendon sheath division has again been advocated (Eastwood et al, 1992). In order to evaluate the effectiveness of a treatment, the natural history of the condition should be known. We have attempted to discover this for adult trigger thumb.
required the use of their thumbs at work. Another patient insisted on immediate steroid injection and was withdrawn, The remaining 25 patients (26 thumbs) were followed for an average of 14 months (range 5-36). The presenting symptoms spontaneously resolved in all these patients after an average duration of symptoms of 6.8 months (range 2- 15 months). In the group who had spontaneous resolution, clinical reduction of movement as assessed by restriction of abduction of the thumb was found in six patients, the average loss of abduction being 7”. A difference in the Kapandji score was found in ten patients, in whom the average loss of grade was 1.4. Only one patient had loss of both opposition and abduction. No patient with spontaneous resolution of symptoms complained of any functional loss.
METHOD 30 consecutive adult patients presenting to a hand clinic with 31 trigger thumbs were prospectively studied in order to determine the natural history of adult trigger thumb. Patients whose thumbs were completely locked in flexion or extension were excluded from the study. The aim of the study was explained and the patients reassured that spontaneous resolution would occur. They were also instructed not to try and exercise the thumb but to use it normally. A standard proforma was completed for all subjects to obtain information on age, occupation, sex, hand dominance and symptoms. Patients were reviewed at varying intervals after the first examination. The review included an examination of both thumbs to allow a comparison to be made with the unaffected side. Thumb abduction was measured directly using a finger goniometer. Thumb opposition was assessed using the scoring method of Kapandji (1986). This method grades opposition according to the patient’s ability to touch the fingertips and ulnar border of the hand with the thumb pulp. Grade 1 represents the least and grade 8 the most opposition.
DISCUSSION
There are previous reports of spontaneous recovery of untreated trigger thumb (Lapidus and Fenton, 1952; Fahey and Bollinger, 1954). Series of so-called “conservative” treatment usually consist of steroid injection or splinting. Splinting appears particularly ineffective in treating trigger thumb, altering the natural history in an unfavourable way (Evans et al, 1988; Pate1 and Bassini, 1992). Lambert et al (1992) in their study found that only 16% of patients, 30% of whom had trigger thumb, had spontaneous resolution. However, the follow-up was only 1 month with a mean duration of pre-existing symptoms of 6.5 months, so it is possible that not all spontaneous resolutions would have been observed. Also their control group received an injection of Lignocaine into the tendon sheath which may have altered the natural history. It remains unclear why trigger thumbs should resolve and trigger fingers not. It may be that only one tendon is involved and that the thumb can function well when almost fully extended. The swelling in the tendon can thus recover spontaneously. We are not advocating benign neglect as a treatment for adult trigger thumb. Some patients want a rapid
RESULTS
Six patients were male and 25 female. The average age at presentation was 63 years (range 47-86). The dominant hand was affected in 60% of subjects. Presenting symptoms reported by the patient included triggering in 97%, pain in 91% and intermittent locking in 27%. Three patients insisted on immediate surgery and another had surgery following an immediate steroid injection. These four withdrew from the study as they 241
THE JOURNAL
cure or are not prepared to risk a very slight loss of movement, although no patient who spontaneously recovered complained of any functional loss. Nevertheless, in this cost-conscious age it is reasonable to question the need for treatment in all cases. References EASTWOOD, D. M., GUPTA, K. J. and JOHNSON, D. taneous release of the trigger finger: An office procedure. Surgery, 17A: 1: 114-117. EVANS, R. B., HUNTER, J. M. and BURKHALTER, W. E. tive Management of the Trigger Finger: A New Approach. Therapy, 13: 1: 59-68.
P. (1992). PercuJournal of Hand (1988). ConservaJournal of Hand
OF HAND
SURGERY
VOL. 18B No. 2 APRIL
1993
FAHEY, J. J. and BOLLINGER, J. A. (1954). Trigger-finger in adults and children. Journal of Bone and Joint Surgery, 36A: 6: 1200-1218. KAPANDJI, A. (1986). Cotation clinique de l’opposition et de la contreopposition du pouce. Annales de Chirurgie de la Main, 5: 1: 67-73. LAPIDUS, P. W. and FENTON, R. (1952). Stenosing tenovaginitis at the wrist and fingers. Archives of Surgery, 64: 475-487. LAMBERT, M. A., MORTON, R. J. and SLOAN, J. P. (1992). Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb. Journal of Hand Surgery, 17B: 1: 69-70. PATEL, M. R. and BASSINI, L. (1992). Trigger fingers and thumb: When to splint, inject or operate. Journal of Hand Surgery, 17A: 1: 110-l 13.
Accepted: 8 October 1992 C. B. Schofield and N. D. Citron, The Nelson Hospital, Wimbledon, London, UK. 0 1993 The British Society for Surgery of the Hand