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TRIGGER THUMB PEDIATRIC

Introduction

Pediatric trigger thumb is characterized by interphalangeal (IP) joint contracture and the presence of a flexor tendon nodule at the metacarpal head (Notta’s nodule). The pathophysiology is stenosing tenosynovitis of the flexor pollicis longus (FPL) tendon.1 Although there is debate as to whether the condition is present at birth, observational studies suggest that it is more likely to develop early postnatally.2,3 If a case does not resolve spontaneously, within the child’s first year, the open A1 pulley release technique is recommended and highly effective, with excellent long-term outcomes.4  Trigger thumb is not known to affect the development of a child’s gross or fine motor skills.5,6,7 

Related Anatomy

  • Thumb IP joint

  • Thumb metacarpal head and neck

  • FPL tendon with Notta’s nodule

  • A – 1 Pulley

  • Oblique Pulley

  • Volar Plate MP joint8

Pathophysiology

  • Abnormal collagen degeneration and synovial proliferation cause the FPL tendon to thicken relative to the A1 pulley, and this disrupts normal tendon gliding. Biopsies have consistently shown large amounts of fibroblasts and mature collagen without degenerative or inflammatory changes, arguing against an infectious, inflammatory, or degenerative etiology.9

Incidence and Related Conditions

  • Pediatric trigger thumb is a separate entity from adult, acquired trigger thumb. It is difficult to determine if trigger thumb is present from birth, because infants tend to close their hands for much of the time.

  • Incidence has been estimated to be 3.3 cases per 1000 live births; boys and girls are affected equally; approximately 25% of cases are bilateral.2

  • Pediatric trigger thumb has been associated with trisomy-13 syndrome, polydactyly of other digits, triphalangeal thumbs, broad thumbs, retroflexible thumbs, radial ray defects, syndactyly and clenched hand syndrome.10,11 

  • Bilateral thumb involvement occurs in approximately 23-30% of cases.  Patients with bilateral involvement are more likely to undergo surgery, have poorer prognosis for spontaneous resolution and may demonstrate sequential involvement.12,13,14 

Differential Diagnosis

  • Congenital hypoplastic or absence thumb extensors

  • Congenital clasped thumb15

  • Thumb fracture

  • Thumb dislocation

  • Arthrogryposis

ICD-10 Codes

  • TRIGGER THUMB

    Diagnostic Guide Name

    TRIGGER THUMB

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    TRIGGER THUMB M65.312M65.311 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Congenital Trigger Thumb
    Congenital Trigger Thumb
Symptoms
Lump or nodule under first flexion crease of the thumb (Notta’s node)
Limited painful passive thumb range of motion
Flexion contracture of the IP joint at the tip of the thumb
Painful clicking, snapping, catching, triggering or temporary locking of thumb with motion
When examined, tenderness near the base of the thumb on palm side of the metacarpophalangeal (MP) joint
When not being examined, usually painless because child doesn't move thumb
Typical History

A three-year-old male child presents with a right flexed thumb IP joint and a lump on the palm side of the thumb MP joint. The child cannot straighten the thumb. The mother notes that a few weeks ago the thumb would straighten but when it did extend, the thumb would "click" and the child would occasionally cry and complain that the thumb hurt.

Exams, Signs and Tests

  • Presentation is typically noticed by parents as a lack of full thumb extension, with the thumb interphalangeal (IP) joint held in flexion.

  • Active triggering (clicking/popping with reducible flexion) may or may not be present.

  • A baseline IP joint flexion contracture ≤30° is associated with spontaneous resolution. 

  • The majority of pediatric patients present with locked trigger thumbs.

  • Assess for bilateral involvement at every visit, as bilateral thumb involvement is associated with increased need for surgery. 

  • MCP joint hyperextension should be assessed but is not a reliable indicator for surgical intervention. 

  • Tenderness and functional limitation are often minimal. 13,17
Exams, Signs and Tests Links
Work-up Comments
  • No imaging or laboratory work-up is typically required for diagnosis because pediatric trigger thumb is a clinical diagnosis based on history and physical examination
  • Routine X-ray maybe indicated if there is a history of a specific trauma associated with the onset of triggering.
Work-up Links
Images (X-Ray, MRI, etc.)
  • Normal Pediatric Thumb. Note open growth plates at arrows.
    Normal Pediatric Thumb. Note open growth plates at arrows.
Treatment Options
Treatment Goals
  • Stop the pain, catching, and/or finger locking
  • Return hand to normal active range of motion with a normal pain-free grip
Conservative

  • First-line options include passive extension exercises and observation.

  • IP joint flexion contracture greater than 30 degrees is strongly predictive that spontaneous resolution will not be successful.

  • Extension splinting as adjunct to extension exercise regimen in which the IP joint hyperextended for 6–12 weeks16 

Operative

  • Surgery should be considered if not spontaneously resolved in the child’s first year and is advised between ages 2 and 3 years. Early surgical intervention is a highly successful option for patients with stage IV trigger thumbs who can safely have anesthesia.17,18 

  • Some doctors recommend delaying surgery if trigger thumb is affecting both thumbs. If the condition does not resolve spontaneously, families can decide for the child to have operative treatment on both hands at the same time. This can help the child to avoid being anesthetized twice; anesthesia carries extra risks in young children.6,12 

  • For children, open A1 pulley release is a better and safer option than percutaneous trigger thumb release. With the percutaneous option, there is a greater risk of neurovascular iatrogenic injury or incomplete A1 pulley release.19

  • Five years after surgery, 95-100% of patients have full range of motion in their thumb(s), with no neurovascular complication?

CPT Codes for Treatment Options

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Common Procedure Name
Trigger finger release
CPT Description
Tendon sheath incision trigger finger
CPT Code Number
26055
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Hand Therapy
Complications

  • Digital nerve injury

  • Wound complications such as scar contracture, abscess, or infection

  • IP flexion deficit 

  • Bowstringing of flexor tendon

  • If IP joint permanently locked in flexion and not released, there may be secondary skeletal deformities with growth

  • Recurrence – rare

  • Decreased IP joint range of motion

Outcomes

  • Spontaneous resolution: in one study, 75% of cases resolved after 5 years of follow-up.  In general, 30–60% of cases will resolve spontaneously before 12 months of age; <10% will resolve spontaneously after 12 months.6

  • Extension splinting: 50–60% resolution in all age groups; high drop-out rate.

  • A1 pulley release: 65–95% resolution in all age groups.5,13 

Video
Pediatric Trigger Thumb: Child demonstrating catching to his mother.
Pediatric Trigger Thumb after surgical release
YouTube Video
Pediatric Trigger Thumb
Key Educational Points

  • Congenital trigger thumbs are acquired, not congenital, and they do not necessarily trigger.

  • Several studies of newborn infants have found no cases of trigger thumb present at birth.2,3 

  • The condition usually develops between one and three years of age and presents as a flexion deformity without antecedent triggering.

  • Ultrasound can be used to verify the deformity of the flexor tendons, flexor tendon sheath, or volar plate but is not needed when making a routine diagnosis of trigger finger. 

  • Extension splinting is often ineffective, tedious, and requires the child’s cooperation.

  • Steroid injection not helpful only in the pediatric population.

  • The results of surgical treatment are uniformly excellent, and trigger thumb release is considered the most effective treatment option if observation does not result in spontaneous resolution.

References

  1. Goldfarb CA. Congenital hand differences. J Hand Surg Am 2009;34(7):1351-6. PMID: 19700077

  2. Kikuchi N, Ogino T. Incidence and development of trigger thumb in children. J Hand Surg Am 2006;31(4):541-3. PMID: 16632044

  3. Rodgers WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg Am 1994;19(3):364-8. PMID: 8056959

  4. Farr S, Mataric T, Kroyer B, Barik S. Paediatric trigger thumbs: patient-reported outcome measures over a minimum of ten years' follow-up. Bone Jt Open 2024.

  5. Kim SY, Lee H, Yoo H-N, et al. Association of trigger thumb with congenital malformations and developmental milestones among children in a nationwide birth cohort. Sci Rep 2025; 15(1):16952.

  6. Baek GH, Lee HJ. The natural history of pediatric trigger thumb: A study with a minimum of five years follow-up. Clin Orthop Surg 2011;3:157-60.

  7. Jones SM, Shannon BF, Gomez C, et al. Spontaneous Resolution of Early-Onset Pediatric Trigger Thumb: A Case Study. Cureus 2025.

  8. Bae DS. Pediatric trigger thumb. J Hand Surg Am. 2008;33(7):1189-1191.

  9. Buchman MT, Gibson TW, McCallum D, et al. Transmission electron microscopic pathoanatomy of congenital trigger thumb. J Pediatr Orthop. 1999;19(4):411-412.

  10. Carvalho M, Barreto MI, Alves C, Soldado F. Trigger thumb, trigger finger and clasped thumb. Children (Basel). 2024;11(3):294.
  11. Wong AL, Wong MJ, Parker R, Wheelock ME. Presentation and aetiology of paediatric trigger finger: a systematic review. J Hand Surg Eur Vol. 2022;47(2):192-196.
  12. Lin JS, Pettit R, Rosenbaum JA, et al. The Development of Trigger Thumb in the Contralateral Thumb in Pediatric Patients Presenting Initially With Unilateral Involvement. Hand (NY) 2021;16(3):316-20.

  13. Hutchinson DT, Rane AA, Montanez A. The natural history of pediatric trigger thumb in the United States. J Hand Surg Am. 2021;46(5):424.e1-424.e7.

  14. Moon WN, Suh SW, Kim IC. Trigger digits in children. J Hand Surg Br 2001;26(1):11-2. PMID: 11162006

  15. Ruland RT, Slakey JB. Acquired trigger thumb vs. congenital clasped thumb: recognize the difference: a case report. Hand (NY) 2012;7(2):191-3. PMID: 23730240

  16. Koh S, Horii E, Hattori T, et al. Pediatric trigger thumb with locked interphalangeal joint: can observation or splinting be a treatment option? J Pediatr Orthop 2012 Oct-Nov;32(7):724-6 

  17. Ray SB, Gibbs CM, Fowler JR. Trigger Thumb in Pediatric Patients: A 20-Year Update.

    Hand (NY) 2024;19(4):679-684.

  18. Dittmer AJ, Grothaus O, Muchow Riley S. Pulling the Trigger: Recommendations for Surgical Care of the Pediatric Trigger Thumb. J Pediatr Orthop 2020;40(6):300-303. 

  19. Masquijo JJ, Ferreyra A, Lanfranchi L, et al. Percutaneous trigger thumb release in children: neither effective nor safe. J Pediatr Orthop 2014;34(5):534-6.

  20. Hudock NL, Girgis MW, Glaun GD, Hennrikus WL. Paediatric trigger thumb: Diagnostic pearls. J Paediatr Child Health 2024;60(11):680-83.

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