Tuesday, December 6, 2011

Preparing for Trigger Thumb Surgery: Before, During, After

After my initial post on my first daughter's trigger thumb surgery, I received more responses than I had expected.  Now, two and a half years and one more trigger thumb surgery later (on another daughter, not the same one!), I wanted to share the more details about the surgery with those of you who have expressed so much interest.

The Surgery
Trigger thumb release surgery involves an incision being made near the base of the thumb where the bump or nodule on the tendon is.  The surgeon cuts the sheath that the tendon goes through, making it big enough that the enlarged spot on the tendon can easily slide through the sheath to straighten the thumb.  The surgeon sews up the incision and bandages it up either with a hard cast or a soft bandage, depending on preference.  This surgery is a minor one (though when it's your child, it doesn't sound minor), taking only 15-20 minutes per thumb. Though, when you factor in anesthesia, it's more like a 2-3 hour ordeal.  In the end, it's really quite magical, the things that modern medical advances can do!

Hard Cast or Soft Bandage?
I had two daughters that have had bilateral trigger thumb release surgery (surgery to fix both right and left trigger thumbs).  One daughter's Orthopedic surgereon perferred using hard casts while the other perferred using a soft bandage. The reason the one surgeon liked the hard casts: with a cast on for 2-3 weeks, it gives ample time for the incision to heal, and since kids can be pretty rambucious, this can make sense.  The other surgeon's reason for using the soft bandage: with a bandange, it can be removed after two days and the child can go straight to using his/her new thumbs.

Having the rare chance of expeiencing both the hard cast and the soft bandage, I'll share the pros and cons.  If your surgeon gives you the choice, hopefully this can help you make your decision.

Hard Cast
Pros
  • 3 weeks gives wound time to heal, letting the swelling go down and the incision to close up.
  • If you have a very accident prone child, this might be a very safe option, because it wouldn't be fun to break open a freshly stitched up job.
Cons
  • Parents will invest plenty of time helping their child eat, dress, and wipe after up after the bathroom.
  • Getting the cast cut off can be a bit of a traumatic experience for a child. 
  • Child doesn't get to realize the benefits of their new, working thumbs until weeks after the surgery.
  • Bath time is crazy for a few weeks.  Plastic bags on casts...
Soft Bandage
Pros
  • Only needs to be on for a couple of days, so I only had to spoon feed my daughter for a couple of days as opposed to three weeks.
  • No need to schedule an appointment to have them removed.  You can remove them yourself after a couple of days.
  • Child can start using thumbs as soon as bandage comes off, though he/she may not want to for a day or two.  Remember, they've been locked in place for months.  
Cons
  • Parents have to help the child take care of their incision while the wound is healing, keeping it clean and not playing too rough.  We put band-aids on each thumb to remind our daughter.
Tips for Before, During and After Surgery

Because there have been enough questions, I'd like to address some of my thoughts about preparing your child and yourself (the parent) for the surgery.

1.  Schedule the entire day for surgery:  Though the surgery will only take 2-3 hours, schedule the entire day.  I had my husband take off work to help me out.  It is nice to have someone to help out, especially if you have other children at home. Can you do it on your own?  I think so, but it would be more stressful.

2.  Talk to your child in simple terms about the surgery:  You know your child best.  If you think they need a couple of weeks to allow the idea of getting their thumbs fixed to sink in, talk to them early about it.  For most of us, we'll be taking in little children between the ages of 2-4 for surgery.  Typically, they don't need the worry of knowing about a looming surgery date. With my kids, I didn't tell them about it until 3-5 days before.  We all know that kids get scared of anything that has to do with cutting.  I was very careful not to use the word "cut" when I told my kids what would happen.  I explained it something like this:  "When we take you to the doctor to fix your thumbs, they will want you to get in some doctor pjs first.  You will get to put on your own clothes again after the doctor is done.  First the doctor will help you go to sleep so that he can work on your thumbs.  The nurses will put a funny plastic thing on on your mouth to help you sleep.  Then, when you wake up, your thumbs will be fixed!  You will have bandages on your hands to protect your thumbs."  I didn't want to go into a lot of detail about the bandages and how to take care of them until we actually got to that point.   It turned out to be wise.

3. What to bring the day of surgery:  Usually the surgery is planned in the morning because there is a 12 hour fasting restraint.  Because it was early, I woke up my kids and took them in their pjs first thing.  Be sure to bring a change of clothes, paying attention to a shirt that will have wide sleeves to get over the bandage or cast.  (I forgot this both times I took my daughters for surgery!)  Normally, the hospital or surgical center is pretty mindful of having a little gift for the pint-sized patient, but if you aren't sure, have a back-up plan of a something soft and cuddly to give your child afterwards... because they will not feel well when they come of the meds...  And for you, the parent, the surgery wait is about 2.5 hours, so if you can focus on a book, bring one.  If not, they usually have TVs and magazines in the waiting rooms and chatty people too!

4. Parting:  Depending on where your child has surgery, there may be different rules about how long the parent can stay with the child before the surgery.  It's a good idea to check with the hospital or surgery center before hand to find out if you can be there until the child falls asleep or if you have hand them off to a nurse before the anesthesia.   We've gone through both scenarios and both went fine.  When the nurse had to take my daughter, I told my daughter that the nurse would take care of her like a babysitter and bring her back to me when the surgery was done.  I didn't hear any crying, and didn't ask about it afterward, so ignorance is bliss in this situation :)

5.  Be prepared for sadness after the surgery:  Even though as a parent, I was really excited for my daughters' thumbs to be fixed and really excited to see them both after their surgeries, the look on their faces reminded me that they were not yet in the mood to celebrate. Coming out of anesthesia is a pretty confusing thing for kids, plus they may be feeling pain from the surgery.  I remember when my daughter 2 (she was 3) went through surgery, I was escorted to her room as she was waking up.  I  held her in my arms, watching her eyes open and close.  At one point as her eye opened, she held up her hands so she could see them.  When she saw the bright pink bandages on them, her eyes got big, her mouth frowned, and she began to cry and cry.  She yelled "I wanna go home!  I want these off!" and started hitting me.  I'm really glad that the she didn't have hard casts at that point.  She pelted me for a good ten minutes until we could get the discharge papers taken care of and reassure her that we would go home and that the bandages would come off in a couple of days.  My daughter 1 (she was 4 and a half when she had surgery) woke and was very weepy and sad.  Even the Barbie doll the nurses gave her didn't make her smile.  For both my daughters, that original sadness only last 1 or 2 hours.  I found it helpful to rent some movies and have some good cuddle time for the rest of the day.  Order pizza or have dinner made in advance.  Take it easy!

Daughter 2 an hour after surgery, with soft bandages, watching a video.
Daughter 1, with hard casts, waking from anesthesia.
6.  Something for the Pain:  The surgeon will likely perscribe a pain medication to help control pain after surgery.  Neither of my daughters liked it.  We ended up throwing it away both times.  We got by just fine on a dose of children's tyenol or ibuprofen.  In fact, one dose was all they needed.  They didn't complain about pain.

7.  When the dressings come off:  Whether your child gets a cast or a bandage, there is some prepartion needed for you and your child when it is time to remove the dressing.  With a hard cast, there will very likely be fear of the cast saw, no matter how carefully you prepare your child.  And then there is an ick-factor of seeing the incision area that kids (and mommies don't like to see).  What I'm saying is, don't expect that everything will be "all better" once the dressing is off.  I warned my daughter 2 right before I took off her bandage that it wouldn't look all better.  She started crying when she saw her thumbs, not because it hurt, but because of how it looked.  Daughter 1, because she had hard casts, also had to deal with the yucky skin that's all flaky from being covered.  Both my daughters were totally disgusted with the stitches and the incision. We covered the incision with bandaids for a few days.  You can use alcohol to wash off any remaining idoine (yellow stuff) from the surgery...or you can let it slowly wash off with soap and water.  If after a week the ends of the stitches are sticking out and irritating your child, you can cut the ends off with nail clippers.
See, it looks yucky!

8.  Using those thumbs:  If your child isn't using his/her thumbs after dressing is off, don't be alarmed.  It will take a day or two.  And soon, they'll be using them quite adeptly.  It could take up to a month.  If you notice problems, it's a good idea to call the surgeon.  My daughter 1 had some therapy after her surgery, but this is generally not necessary.  It's only been about three weeks since daughter 2's surgery and she has been using them fine.

9.  Follow up with the surgeon:  You will likely visit the surgeon once or twice to check on the healing progress of the thumbs. Then, it's history!

I hope I've covered most aspects of the process of trigger thumb surgery.  My twins just finished making a mess in the kitchen and have moved on to the laundry room. I should stop.  I hope you have a good surgery experience!

Please, those of you who have had children undergo trigger thumb surgery, share your tips as well.  Let's bring some awareness to this seemingly obscure phenomenon of pediatric trigger thumb!