Notta's nodules and trigger digits.

Proc (Bayl Univ Med Cent) 2007;20:143–145 I n 1850 Dr. A. Notta, an “internè” in Paris, described four adult patients between the ages of 20 and 60 who had a nodule on a flexor tendon of a finger, thereby inhibiting its normal movement (1). This publication in the Archives Générales de Médecine led to these “nodules” being named “Notta’s nodules,” but a multitude of subsequent papers have largely ignored his claim to fame. Trigger digit occurs from infancy to old age. In infants it usually occurs in the thumb but is not often diagnosed at birth. The flexed position of the thumb is often recognized sometime after the first 3 months of life. About 30% of these thumbs will gradually gain a full range of motion, and early attempts to passively straighten the thumb often cause significant pain. Some recommend splinting the thumb in full extension, but the reported results vary considerably and I have not usually employed this treatment. The reported rate of spontaneous relief from the flexed posture varies from 0% to 49% but is probably in the area of 30%. This rate drops to 10% to 12% between 6 months and 3 years of age. Beyond age 3 the standard surgical release of the A1 pulley is a definitive treatment. Surgical release can be done earlier but should certainly be done by age 3. Occasionally the thumb is not fixed in flexion, but it clicks on motion. It has rarely been reported as being in interphalangeal joint extension or even extension of the metacarpophalangeal joint. In all postures, if movement is possible, a click may be heard and can certainly be felt on the palmar surface of the thumb, usually in the region of the metacarpophalangeal joint. Dobyns (2) has emphasized the importance of differentiating a true trigger thumb from other palm-clutched thumb conditions. Anomalies such as spastic thumb, arthrogryposis, and varieties of hypoplastic thumbs should all be excluded before treatment is undertaken. A trigger finger at birth is about one tenth as common as a trigger thumb, and there is a high rate of abnormalities of the flexor tendons that are often diagnosed only after a standard release of the A1 pulley fails to give complete relief (3). In adult men and women, the most common age for the triggering of digits is between 50 and 60 years. Bonnici and Spencer (4) reviewed their operative results in 37 patients. Multiple digits were involved in one third. Hereditary factors are said to be very rare, but these authors reported a nurse with all five digits involved on her right hand and a similar condition in her sister’s hand. Repeated minor trauma is probably the most likely cause of trigger digit, but heavy manual labor with the direct palmar pressure of power grasp may precipitate the symptoms at any adult age. Even ordinary use of the hand is associated with a higher incidence of trigger digit in the dominant right hand. The ring finger is most commonly affected; next in involvement is the long finger, then the small finger, while the index finger is rarely involved. For some inexplicable reason, trigger thumb is far more common in women. The fundamental etiology of a trigger digit is a size mismatch between the flexor tendon and the proximal end of the digital tendon sheath, particularly at the A1 pulley (Figure 1). Hueston Notta’s nodules and trigger digits