The FPL has its own separate sheath within the carpal tunnel (the radial bursa) that is distinct from the ulnar bursa enclosing the other flexor tendons. This thenar bursa communicates with the ulnar bursa in 50% of individuals. FPL triggering in the thumb A1 pulley (trigger thumb) is the most common form of trigger finger, producing painful thumb IP joint locking.
Thumb IP joint flexion force transmission through the thenar sheath
Trigger thumb from FPL nodular tenosynovitis catching at the A1 pulley produces locking of the thumb IP joint in flexion. Corticosteroid injection into the A1 pulley sheath resolves 50-70% of cases. Surgical A1 pulley release under local anaesthesia provides definitive cure for refractory trigger thumb. Congenital trigger thumb from a FPL nodule (Notta's node) at the A1 pulley resolves spontaneously in 30% by age 1.
FPL nodule catching at the A1 pulley producing thumb IP locking managed with injection and A1 pulley release.
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