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Classification and surgical treatment of the thumb-in-palm deformity in cerebral palsy and spastic paralysis
Classification and Surgical Treatment of the Thumb-in-Palm Deformity in Cerebral Palsy and Spastic Paralysis Harilaos T. Sakellarides, MD, Mohinder A. Mital, MD, Richard A. Matza, MD, Panagiotis Dimakopoulos, MD, Boston, MA Over a 20-year period, 59 children with spasticity mainly due to cerebral palsy underwent surgery for correction of a thumb-in-palm deformity. A classification of the deformity based on the functional anatomy of the thumb divided the problem into four different types. A retrospective analysis of the results has shown the classification to be helpful in selecting a surgical option for treatment. In addition, the classification helps to keep accurate records, predict patient progress, and coordinate postoperative treatment. (J Hand Surg 1995; 20A:428~31 .)
Hand deformities are a major handicap and a difficult treatment problem in patients with cerebral palsy or spastic hemiplegia. Pinch and grip are compromised by a thumb-in-palm deformity (Fig. 1). Not only is the thumb function lost, but the other fingers are obstructed by the thumb's physical presence in the palm. Thumb function is estimated to be 50% of hand functionJ Preoperative evaluation of the family as well as the patient is important to determine suitability for treatment. In our experience, a patient 5 years or older with an intelligence quotient of 70 or higher, without a rejected extremity, with reasonable stereognosis and who has plateaued with therapy is a good surgical candidate.
From Franciscan Children's Hospital, Department of Hand Surgery and Orthopaedics, Brighton, MA, and Boston University School of Medicine, Boston, MA. Received for publication Sept. 5, 1991; accepted in revised form July 11, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Harilaos T. Sakellarides, MD, 3 Hawthorne Place, Suite 105, Boston, MA 02114.
428
The Journal of Hand Surgery
Classification and Treatment Type 1 In type 1 thumb-in-palm deformity, the deformity is secondary to a weak or paralyzed extensor pollicis longus (Fig. 2A). To treat type 1 deformity, the palmaris longus or flexor carpi radialis is transferred to the extensor pollicis longus. Bowstringing of the rerouted tendon is prevented by constructing
Figure 1.
Thumb-in-palm deformity.
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
429
Figure 2. (A) Preoperative type 1 deformity of the thumb showing weakness of the extensor pollicis longus. (B) Same thumb 3 months after rerouting of extensor pollicis longus around the radial styloid, and tendon transfer of the flexor carpi radialis.
Figure 3. (A) Right thumb of a patient with type 2 deformity, contracture of adductor pollicis. (B) Same thumb 2 months postoperatively with good pinch following release of the adductor pollicis, abductor pollicis brevis, and opponens.
a pulley from the proximal half of the fibrous sheath of the abductor pollicis longus and extensor pollicis brevis tendon (Fig. 2B). Type 2 A spastic or contracted adductor pollicis, flexor pollicis brevis, and abductor pollicis brevis with or with-
out first dorsal interosseous involvement characterizes a type 2 deformity. Contracture of the thumb web is occasionally present (Fig. 3A). In such cases, the treatment is release of the thenar muscles and the first dorsal interosseous with carpal tunnel release. If the thumb-index web space is contracted, release is required (Fig. 3B).
43,0 Sakellarideset al./Thumb-in-Palm-Deformity
Figure 4. (A) Right thumb of a patient with type 3 deformity before surgery. (B) Same patient showing the thumb with improved position. The abductor pollicis longus was routed around the flexor carpi radialis. One half of the tendon reinforced the lax carpometacarpal joint capsule and the other half of the tendon was advanced distally along the thumb metacarpal and sutured closed to the metacarpophalangeal joint.
Figure 5. (A) Right thumb of patient with type 4 deformity from contracture of flexor pollicis longus before surgery. (B) Same thumb 5 months postoperatively with good correction of the thumb-in-palm deformity after the lengthening of the
Type 3 A type 3 deformity defines the case of a weak or paralyzed abductor pollicis longus (Fig. 4A). Treatment is as follows: abductor pollicis longus power is augmented by rerouting it around the flexor carpi radialis and advancing its insertion distally. If the carpometacarpal joint is unstable, the capsule is plieated and augmented with part of the abductor pollicis longus. Web space release may also be required.
Type 4 A type 4 deformity is defined as a spastic or contracted flexor pollicis longus (Fig. 5A). Z-lengthen-
ing of the contracted flexor pollicis longus proximal to transverse carpal ligament is the appropriate treatment (Fig. 5B).
Multiple Deformities If the patient has more than one of these conditions, the most disabling deformity is initially corrected along the foregoing guidelines. The residual deformity is reassessed and corrected appropriately after a period of observation.
Materials and Methods In a retrospective review, 59 patients, 23 male and 36 female, had 59 procedures for thumb-in-
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
Table 1. Functional Classification Excellent Good use of the hand. Effective grasp and release and with voluntary control. The patient could use the thumb in hand functions satisfactorily for everyday activities, such as combing hair, eating with utensils without assistance. There was no recurrence of the deformity. Good Helper hand. Effective grasp and release. Some satisfactory voluntary control. The patient could use the thumb and hand functions well and use utensils to eat, or grasp and pinch about 20-25% less than the opposite side. Fair Helper hand. Fair control of the thumb. The hand functions, grasp and pinch, are about 50% less than the opposite side. Minimal recurrence of the deformity requiring night splinting. However, the parent and patient were satisfied with the results due to the very substantial improvement in hand function. Poor Helper hand. Paper weight--absent grasp and release. No improvement from the preoperative status.
p a l m deformities and were followed f r o m 2 to 20 years. The diagnosis was spastic cerebral palsy in 42, traumatic e n c e p h a l o p a t h y in 8, spastic hemiplegia in 8, and spastic quadriplegia in 1. T h e y were all e x a m i n e d by the senior author (H.T.S.) at each follow-up visit. T w e n t y - f i v e of the 59 patients had type 1 deformity, 18 type 2, 8 type 3, and the remaining 8 patients type 4. Ten patients had two types o f deformities. The p r e o p e r a t i v e evaluation included functional and cognitive assessment, as well as testing of the muscles, range of motion, and sensibility. The function was graded according to the classification of G r e e n and Banks 2 as modified by Samilson and
431
Morris 3 (Table 1). T h e results w e r e classified as excellent, good, fair, or p o o r b a s e d on the functional outcome.
Results The functional outcome o f 59 patients was as follows: 8 excellent, 30 good, and 21 fair results. No patient's result was graded poor. The excellent and good results occurred in patients with cerebral palsy, and the fair results were most often found in the patients with gross traumatic encephalopathy. Our results were based on repeated clinical examinations; no electromyelography studies were used.
Discussion In all forms of spastic conditions involving the upper extremity, thumb-in-palm deformity is recognized as one of the more c o m m o n and disabling problems limiting hand function. Since it is rarely an isolated problem, its treatment is timed and integrated with the treatment of other deformities. T h u m b - i n - p a l m deformity m a y decrease the functional capacity of the hand by 50% and m a y be an important contributor to rejection of the extremity. In this patient group, early recognition of the deformity with treatment yielded the best results.
References 1. Inglis AE, Cooper W, Bruton W. Surgical correction of thumb deformities in spastic paralysis. J Bone Joint Surg
1970;52A:253-68. 2. Green WT, Banks HH. Flexor carpi ulnaris transplant and its use in cerebral palsy. J Bone Joint Surg 1962;44A: 1343-52. 3. Samilson RL, Morris JM. Surgical improvement of the cerebral palsied upper limb: electromyographic studies and results of 128 operations. J Bone Joint Surg 1960; 42A:951-64.
Hand deformities are a major handicap and a difficult treatment problem in patients with cerebral palsy or spastic hemiplegia. Pinch and grip are compromised by a thumb-in-palm deformity (Fig. 1). Not only is the thumb function lost, but the other fingers are obstructed by the thumb's physical presence in the palm. Thumb function is estimated to be 50% of hand functionJ Preoperative evaluation of the family as well as the patient is important to determine suitability for treatment. In our experience, a patient 5 years or older with an intelligence quotient of 70 or higher, without a rejected extremity, with reasonable stereognosis and who has plateaued with therapy is a good surgical candidate.
From Franciscan Children's Hospital, Department of Hand Surgery and Orthopaedics, Brighton, MA, and Boston University School of Medicine, Boston, MA. Received for publication Sept. 5, 1991; accepted in revised form July 11, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Harilaos T. Sakellarides, MD, 3 Hawthorne Place, Suite 105, Boston, MA 02114.
428
The Journal of Hand Surgery
Classification and Treatment Type 1 In type 1 thumb-in-palm deformity, the deformity is secondary to a weak or paralyzed extensor pollicis longus (Fig. 2A). To treat type 1 deformity, the palmaris longus or flexor carpi radialis is transferred to the extensor pollicis longus. Bowstringing of the rerouted tendon is prevented by constructing
Figure 1.
Thumb-in-palm deformity.
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
429
Figure 2. (A) Preoperative type 1 deformity of the thumb showing weakness of the extensor pollicis longus. (B) Same thumb 3 months after rerouting of extensor pollicis longus around the radial styloid, and tendon transfer of the flexor carpi radialis.
Figure 3. (A) Right thumb of a patient with type 2 deformity, contracture of adductor pollicis. (B) Same thumb 2 months postoperatively with good pinch following release of the adductor pollicis, abductor pollicis brevis, and opponens.
a pulley from the proximal half of the fibrous sheath of the abductor pollicis longus and extensor pollicis brevis tendon (Fig. 2B). Type 2 A spastic or contracted adductor pollicis, flexor pollicis brevis, and abductor pollicis brevis with or with-
out first dorsal interosseous involvement characterizes a type 2 deformity. Contracture of the thumb web is occasionally present (Fig. 3A). In such cases, the treatment is release of the thenar muscles and the first dorsal interosseous with carpal tunnel release. If the thumb-index web space is contracted, release is required (Fig. 3B).
43,0 Sakellarideset al./Thumb-in-Palm-Deformity
Figure 4. (A) Right thumb of a patient with type 3 deformity before surgery. (B) Same patient showing the thumb with improved position. The abductor pollicis longus was routed around the flexor carpi radialis. One half of the tendon reinforced the lax carpometacarpal joint capsule and the other half of the tendon was advanced distally along the thumb metacarpal and sutured closed to the metacarpophalangeal joint.
Figure 5. (A) Right thumb of patient with type 4 deformity from contracture of flexor pollicis longus before surgery. (B) Same thumb 5 months postoperatively with good correction of the thumb-in-palm deformity after the lengthening of the
Type 3 A type 3 deformity defines the case of a weak or paralyzed abductor pollicis longus (Fig. 4A). Treatment is as follows: abductor pollicis longus power is augmented by rerouting it around the flexor carpi radialis and advancing its insertion distally. If the carpometacarpal joint is unstable, the capsule is plieated and augmented with part of the abductor pollicis longus. Web space release may also be required.
Type 4 A type 4 deformity is defined as a spastic or contracted flexor pollicis longus (Fig. 5A). Z-lengthen-
ing of the contracted flexor pollicis longus proximal to transverse carpal ligament is the appropriate treatment (Fig. 5B).
Multiple Deformities If the patient has more than one of these conditions, the most disabling deformity is initially corrected along the foregoing guidelines. The residual deformity is reassessed and corrected appropriately after a period of observation.
Materials and Methods In a retrospective review, 59 patients, 23 male and 36 female, had 59 procedures for thumb-in-
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
Table 1. Functional Classification Excellent Good use of the hand. Effective grasp and release and with voluntary control. The patient could use the thumb in hand functions satisfactorily for everyday activities, such as combing hair, eating with utensils without assistance. There was no recurrence of the deformity. Good Helper hand. Effective grasp and release. Some satisfactory voluntary control. The patient could use the thumb and hand functions well and use utensils to eat, or grasp and pinch about 20-25% less than the opposite side. Fair Helper hand. Fair control of the thumb. The hand functions, grasp and pinch, are about 50% less than the opposite side. Minimal recurrence of the deformity requiring night splinting. However, the parent and patient were satisfied with the results due to the very substantial improvement in hand function. Poor Helper hand. Paper weight--absent grasp and release. No improvement from the preoperative status.
p a l m deformities and were followed f r o m 2 to 20 years. The diagnosis was spastic cerebral palsy in 42, traumatic e n c e p h a l o p a t h y in 8, spastic hemiplegia in 8, and spastic quadriplegia in 1. T h e y were all e x a m i n e d by the senior author (H.T.S.) at each follow-up visit. T w e n t y - f i v e of the 59 patients had type 1 deformity, 18 type 2, 8 type 3, and the remaining 8 patients type 4. Ten patients had two types o f deformities. The p r e o p e r a t i v e evaluation included functional and cognitive assessment, as well as testing of the muscles, range of motion, and sensibility. The function was graded according to the classification of G r e e n and Banks 2 as modified by Samilson and
431
Morris 3 (Table 1). T h e results w e r e classified as excellent, good, fair, or p o o r b a s e d on the functional outcome.
Results The functional outcome o f 59 patients was as follows: 8 excellent, 30 good, and 21 fair results. No patient's result was graded poor. The excellent and good results occurred in patients with cerebral palsy, and the fair results were most often found in the patients with gross traumatic encephalopathy. Our results were based on repeated clinical examinations; no electromyelography studies were used.
Discussion In all forms of spastic conditions involving the upper extremity, thumb-in-palm deformity is recognized as one of the more c o m m o n and disabling problems limiting hand function. Since it is rarely an isolated problem, its treatment is timed and integrated with the treatment of other deformities. T h u m b - i n - p a l m deformity m a y decrease the functional capacity of the hand by 50% and m a y be an important contributor to rejection of the extremity. In this patient group, early recognition of the deformity with treatment yielded the best results.
References 1. Inglis AE, Cooper W, Bruton W. Surgical correction of thumb deformities in spastic paralysis. J Bone Joint Surg
1970;52A:253-68. 2. Green WT, Banks HH. Flexor carpi ulnaris transplant and its use in cerebral palsy. J Bone Joint Surg 1962;44A: 1343-52. 3. Samilson RL, Morris JM. Surgical improvement of the cerebral palsied upper limb: electromyographic studies and results of 128 operations. J Bone Joint Surg 1960; 42A:951-64.