22: Intrinsic Muscle Release for Thumb-in-Palm Deformity

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Procedure 22 Intrinsic Muscle Release for Thumb-in-Palm Deformity

Harry A. Hoyen, Patrick J. Messerschmitt

image See Video 19: Intrinsic Muscle Release for Thumb-in-Palm Deformity and Adductor Release Using a Thenar Incision

Indications

image Spastic contracture of the thumb adductor muscle results in excessive thumb metacarpal adduction and thumb-in-palm deformity.

image In mild or moderate degrees, grasp and pinch are affected when other intrinsic and extrinsic contractures result in compromise of skin care and hygiene.

image This procedure is often combined with other surgical release procedures for the thumb, fingers, and wrist.

Examination/Imaging

Clinical Examination

image Examination of the hand demonstrates an adducted position of the thumb metacarpal across the palm of the hand (Figs. 22-1 and 22-2).

image Additional deformities of the wrist and hand frequently can coexist with the thumb-in-palm deformity (Fig. 22-3).

image Evaluate for flexion deformities of the thumb metacarpophalangeal joint and/or thumb interphalangeal joint, which would require concomitant releases of the flexor pollicis brevis or flexor pollicis longus, respectively.

image

FIGURE 22-1

image

FIGURE 22-2

image

FIGURE 22-3

Surgical Anatomy

image Thenar muscles, flexor pollicis longus, adductor pollicis, lumbricals, and interosseous muscles

image Recurrent motor branch of the medial nerve and the common digital nerves

image Superficial and deep palmar arterial arches

Positioning

image The patient is positioned supine with the arm extended onto a surgical arm board.

image A nonsterile tourniquet is placed high on the arm before surgical preparation to allow better visualization during the procedure.

Exposures

image A palmar incision is made paralleling the thenar crease (Fig. 22-4).

image The long finger flexor tendons are the next most dorsal structure after the palmar fascia has been divided. Retract the flexor tendons ulnarly.

image Identify the lumbrical muscle and common digital artery and nerve.

image Gently retract the lumbrical muscle and the neurovascular bundle ulnarly to visualize the enveloping thumb adductor muscle fascia. The thumb adductor muscle, with transverse muscle fibers beneath, originates on the radial side of the long finger metacarpal (Fig. 22-5).

image

FIGURE 22-4

image

FIGURE 22-5

Pearls

Severe adduction contractures may require Z-plasty exposure of the first web space, which facilitates release of both skin contracture and involved spastic muscles.

Procedure

Step 1

image Sharply release the origin of the thumb adductor muscle from the long finger metacarpal.

image Passively abduct the thumb, allowing the thumb adductor musculature to pull radially and ensure complete release (Fig. 22-6).

image

FIGURE 22-6

Step 1 Pearls

Preserve the deep ulnar nerve branch to the adductor pollicis.

Preserve the deep palmar vascular arch.

Step 2

image If necessary, proceed to release of thenar muscle contracture.

image Origins of both heads of flexor pollicis brevis, opponens pollicis, and abductor pollicis brevis muscles are identified on the volar carpal ligament and sharply sectioned with care (Fig. 22-7).

image Again, passively abduct and extend the thumb, allowing the muscles to retract.

image

FIGURE 22-7

Step 2 Pearls

Preserve the motor branch of the median nerve to the thenar muscles.

The first dorsal interosseous muscle can be released from the thumb metacarpal base if residual contracture remains; however, this is usually not necessary.

Pin the thumb metacarpal in abduction with smooth K-wires if tightness persists.

Step 2 Pitfalls

Avoid injury to the perforating branch of the radial artery.

Obtain meticulous hemostasis after tourniquet deflation before wound closure.

Postoperative Care and Expected Outcomes

image The postoperative thumb-spica splint is applied with the thumb metacarpal positioned in extension and abduction. This permits the fibrosis that bridges the muscle defect to incorporate in a better anatomic position. Avoid thumb metaphalangeal hyperextension.

image After 4 weeks, the patient is converted to a full-time fabricated C-splint between the index metaphalangeal joint and the thumb proximal phalanx. This holds the thumb in extension and abduction and maintains opening of the first web space. The splint is removed for bathing and exercises.

image Eight to 10 weeks postoperatively, the patient is advanced to wearing the splint at night only. If the patient is skeletally mature, the splint can be discontinued 3 to 6 months postoperatively.

Acknowledgment

We would like to give a special thanks to the author of this chapter in the previous edition, Ann E. Van Heest, as her work served as an excellent foundation for and contribution to this chapter.

Evidence

House J, Gwathmey F, Fidler M. A dynamic approach to the thumb-in-palm deformity in cerebral palsy. J Bone Joint Surg [Am]. 1981;63:216-225.

This classic article described the spastic thumb-in-palm deformity secondary to cerebral palsy. It also highlighted the Upper Extremity Functional Use Classification as an outcome tool to use after surgery. (Level IV evidence)

Inglis AE, Cooper W, Bruton W. Surgical correction of thumb deformities in spastic paralysis. J Bone Joint Surg [Am]. 1970;52:253-268.

This classic article described the spastic thumb-in-palm deformity secondary to cerebral palsy. Surgical methods and outcomes are presented. (Level IV evidence)

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