Redirection of extensor pollicis longus in the treatment of spastic thumb-in-palm deformity

Twenty patients with the thumb-in-palm deformity associated with cerebral palsy were treated surgically by redirecting the extensor pollicis longus (EPL) tendon through the first dorsal retinacular compartment in association with releasing the spastic intrinsic thenar muscles at their origin. The redirected EPL tendon augmented extension-abduction of the thumb in all patients; 18 patients were able to grasp with the thumb outside the clenched fist and noted improvement in functional activities. Augmentation tendon transfer that uses the EPL is an ideal surgical treatment for patients with cerebral palsy who have a thumb-in-palm deformity, since the procedure relieves an adduction deforming force and augments the weak extension-abduction by means of a musculotendon transfer that is known to function during digital extension. Consequently, postoperative reeducation of the transfer is minimal.     

Trapezio-metacarpal arthritis. Trapezium excision and ligament reconstruction not including the LRTI arthroplasty

For trapeziometacarpal arthritis, trapezium excision and ligament reconstruction that is distinct from the ligament reconstruction tendon interposition (LRTI) arthroplasty has a distinct role. Emphasis is placed on the use of the abductor pollicis longus for tendon interposition and "suspensionplasty" for the arthritic thumb carpal metacarpal joint. The advantages of the abductor pollicis longus techniques as originally advocated by Thompson, and modified by Diao, are reviewed. The surgical technique for this procedure, clinical results and biomechanical cadaver analysis comparing abductor pollicis longus suspensionplasty done with two techniques, as they compare to the LRTI procedure, are included. The abductor pollicis longus suspensionplasty is an excellent treatment choice both for index procedures for carpometacarpal (CMC) thumb arthritis, and for salvage of the failed thumb CMC arthroplasty.     

Reconstruction of the rheumatoid thumb.

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.     

Osteotomy versus tendon arthroplasty in trapeziometacarpal arthrosis 17 patients followed for 1 year

We evaluated 2 consecutive cohorts of patients with primary trapeziometacarpal arthrosis 1 year after either first metacarpal osteotomy or trapezial excision with abductor pollicis longus tendon arthroplasty. At follow-up, 4 of 7 patients treated with osteotomy had pain at rest and/or with light activities and were dissatisfied with the results of surgery, all 4 had advanced (stage III) preoperative trape ziometacarpal arthrosis. 1 of 10 patients (5 having stage III arthrosis) treated with abductor pollicis longus arthroplasty had pain with light activities, and no patient was dissatisfied. Our findings indicate that first metacarpal osteotomy as a surgical option in trapeziometacarpal arthrosis should be limited to patients with early disease.     

Management of the spastic upper extremity in the neurologically impaired adult

Spasticity that interferes with upper extremity function is common in adults following stroke, brain injury, or anoxia. During the period of neurologic recovery definitive surgical procedures are avoided. Techniques to temporarily reduce spasticity include the implantation of a MicroPort reservoir and catheter for repeated branchial plexus blocks and phenol nerve blocks, which provide longer lasting relief of noxious muscle tone. Percutaneous blocks of the musculocutaneous and recurrent median nerves and motor point blocks of the pectoralis major, the brachioradialis, and forearm flexor muscles are easily performed at bedside. The motor branch of the ulnar nerve can be injected surgically with phenol to diminish intrinsic spasticity. When neurologic recovery has plateaued, hand placement can be improved in many patients following proximal release of the brachioradialis muscle and lengthening of the biceps and branchialis tendons. Hand function is enhanced by fractional lengthening of spastic wrist and finger flexors. Intrinsic spasticity must be addressed at the same time by phenol block or intrinic release. When extensor function is lacking, a tenodesis of the wrist extensors is helpful. The thumb-in-palm deformity requires proximal release of the thenar muscles as well as lengthening of the flexor pollicis longus. Contracture releases in the nonfunctional arm improve hygiene and ease care.     

Abductor pollicis longus tendon division with swan neck thumb deformity

Swan neck thumb deformity can be caused by osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, tendon transfers and paralytic diseases. Abductor pollicis longus is one of the major stabilizing tendon of the carpometacarpal joint of thumb. To the best of our knowledge, swan neck thumb deformity owing to division of abductor pollicis longus tendon is rare. In this article, we describe a case of isolated division of abductor pollicis longus tendon presenting with swan-neck deformity of thumb and discuss the mechanism, management and outcome. The patient was treated by repair of the divided tendon using palmaris longus tendon graft. At approximately 107 weeks following treatment, the patient was having full range of thumb movement and the deformity completely disappeared. We also describe the unusual mechanism whereby an isolated division of abductor pollicis longus tendon results in swan neck thumb deformity. Level of clinical evidence IV.     

No correlation between trapeziometacarpal arthritis and abductor pollicis longus insertion

The primary hypothesis of this study is that supernumerary slips of the abductor pollicis longus (particularly those slips inserting distal to the trapeziometacarpal joint) increase the risk of trapeziometacarpal osteoarthritis on account of increased transarticular forces. Other hypotheses surmised that age and female gender were directly correlated with severity of arthritis. We did cadaveric dissection of the distal first dorsal compartment in 61 specimens, noting the cadaveric age, gender, and number and insertion sites of abductor pollicis longus tendon slips. Each variable was statistically correlated with visual grade of trapeziometacarpal arthritis. The median number of abductor pollicis longus tendon slips in these cadaveric hands was three (range, 1-4). Seventy-nine percent of the hands had a digastric-type insertion into the abductor pollicis brevis. Ninety percent had an insertion into the trapezium. All hands possessed an insertion into the base of the first metacarpal. Age and female gender were directly correlated with severity of arthritis. No other correlations existed. We conclude that trapeziometacarpal joint arthritis progresses with age and occurs independently of any aspect of abductor pollicis longus insertion. Based on our results, we do not recommend surgical release of these supernumerary abductor pollicis longus tendon slips for the treatment of trapeziometacarpal osteoarthritis.     

Bilateral subluxation of the base of the thumb secondary to an unusual abductor pollicis longus insertion: a case report

Bilateral subluxation of the trapeziometacarpal joint was related to abnormal insertion of the abductor pollicis longus (APL) tendon and an atrophic extensor pollicis brevis tendon. The APL tendon had four slips, all of which inserted into the fascia of the abductor pollicis brevis muscle distal and palmar to the trapeziometacarpal joint. Active pinch of the thumb resulted in subluxation of the trapeziometacarpal joint. To prevent reciprocal distal deformity, the proximal thumb was held in dynamic balance by attaching two slips of the APL tendon to the radiodorsal base of the first metacarpal. One tendon slip supplemented the tendon of the extensor pollicis brevis muscle. The lax capsule of the trapeziometacarpal joint was reinforced with the remaining tendon slip. The patient retains excellent bilateral function without subjective weakness after surgery.     

A new modification of trapeziectomy and soft tissue interposition arthroplasty with abductor pollicis longus advancement

A new modification of trapeziectomy, soft-tissue interposition arthroplasty with a one-half slip of the flexor carpi radialis tendon and advancement of the abductor pollicis longus tendon for treatment of thumb carpometacarpal degenerative arthritis and instability is presented. This procedure facilitates tenodesis of the flexor carpi radialis slip at the first metacarpal and realigns and rebalances the thumb posture by using and advancing the abductor pollicis longus tendon. Therefore, this new modification eliminates the need for perioperative pin fixation of the first metacarpal, offers better soft tissue tenodesis of the ligament reconstruction component of the procedure, and results in improved intraoperative thumb alignment.     

Trapezometacarpal ligamentoplasty: personal technique

We describe a new procedure of trapeziometacarpal ligamentoplasty. This ligamentoplasty is both passive and active. The operation is performed in three stages: (1) Transfert of part of the abductor pollicis longus in a posterior and distal direction; (2) Transfert of the radial part of the extensor carpi radialis longus into the proximal first metacarpal; (3) Forming a loop around the flexor carpi radialis tendon with a distally inserted slip of abductor pollicis longus.     

ON THE FORM AND FUNCTION OF THE ABDUCTOR POLLICIS BREVIS MUSCLE

The abductor pollicis brevis muscle acts In conjunction with the palmaris longus and the abductor pollicis longus to abduct the first metacarpal in the sagittal plane. Segments of the abductor pollicis brevis which arise from the tendons of the palmaris longus and/or the abductor pollicis longus and are inserted into the extensor expansion are the lumbricals of the thumb. The lateral border of the abductor pollicis brevis presents an important muscular (in four cases out of ten neurovascular) hilum. The tendinous slip to the abductor pollicis brevis from the palmaris longus presents near its origin an orifice which the palmar branch of the median nerve traverses to become superficial.     

On the form and function of the abductor pollicis brevis muscle.

The abductor pollicis brevis muscle acts in conjunction with the palmaris longus and the abductor pollicis longus to abduct the first metacarpal in the sagittal plane. Segments of the abductor pollicis brevis which arise from the tendons of the palmaris longus and/or the abductor pollicis longus and are inserted into the extensor expansion are the lumbricals of the thumb. The lateral border of the abductor pollicis brevis presents an important muscular (in four cases out of ten neurovascular) hilum. The tendinous slip to the abductor pollicis brevis from the palmaris longus presents near its origin an orifice which the palmar branch of the median nerve traverses to become superficial.     

Surgery of the spastic thumb-in-palm deformity

A twenty-year experience with a surgical procedure, previously described, for dynamic correction of spastic thumb-in-palm deformity in cerebral palsy is reported. The procedure includes lengthening of the long flexor of the thumb, proximal thumb intrinsic release and augmentation of abduction-extension of the thumb. Bone-stabilising operations are not performed. 56 patients have been followed up for an average period of 4 years and 11 months after the treatment (range 2 to 15 years). Correction of the deformity is recorded in 82% of the patients.     

The extensor sling procedure for an unstable carpometacarpal joint

An unstable carpometacarpal joint of the thumb may present with pain and interfere significantly with normal function. Weakness of the intermetacarpal ligament may result in partial or complete dislocation. A procedure that reinforces this ligament more accurately than those previously published is described. A sling is made by routing part of the extensor carpi radialis longus tendon through the interspace between the second and third metacarpals and around the base of the first metacarpal. The ligament returns to its point of entry where it is sutured to itself. The entire ligament is situated deep to the adductor pollicis longus and restores stability without interfering with the first metacarpal excursion. All 10 patients who had this procedure had full metacarpal excursion and could oppose to the base of the small finger.     

Problems with the metacarpophalangeal joint in the surgical treatment of osteoarthritis by inserting an ARPE type joint prosthesis

Progressive ankylosis of the trapeziometacarpal joint in flexion-adduction with closure of the first web in advanced trapeziometacarpal osteoarthritis gradually leads to compensatory dislocation of the metacarpophalangeal joint with hyperextension in the sagittal plane and abduction in the frontal plane. This deformity of the MP joint, initially reducible, but subsequently irreducible, results in the classical 'Z' deformity of the thumb in the sagittal plane. A less well known 'Z' deformity can also occur in the frontal plane due to distension of the medial collateral ligament. Surgical treatment of trapeziometacarpal osteoarthritis by arthroplasty must correct this secondary deformity of the MP joint to obtain an optimal result. The classical sagittal 'Z' deformity of the thumb can be easily corrected while this deformity is still reductible by releasing the fist metacarpal by tightening the abductor pollicis longus. When it is irreducible, this deformity can only be treated by MP arthrodesis, which contraindicates insertion of the ARPE trapeziometacarpal implant. Correction of the frontal 'Z' deformity of the thumb requires repair of the medial collateral ligament of the MP joint by ligamentorraphy (retightening) or ligamentoplasty.     

The extensor sling procedure for the unstable carpo-metacarpal joint of the thumb

Surgical Principles The sling is made by routing part of the extensor carpi radialis longus, from its insertion, through the interspace between the second and third metacarpals, encircling the base of the first metacarpal and then suturing the tendon on itself at its point of entry between the second and third metacarpal. The entire procedure is carried out from the dorsal surface of the hand and deep to the adductor pollicis. Stability of the first carpo-metacarpal joint is restored without interfering with the excursion of the first metacarpal. During pinching great lateral forces act on the first carpo-metacarpal joint and tend to dislocate it laterally. This tendency is normally kept in check by the first intermetacarpal ligament [7]. As with all joints, instability in the carpo-metacarpal joint will promote the early onset of secondary degenerative changes. Increased stability would prevent the changes, or at least delay them, until the usual age of occurrence in the general population. However, no procedure carried out at the stage where significant cartilaginous degeneration is already present, will be able to control the process of arthritis. For the first metacarpal to move laterally the intermetacarpal ligament has to stretch [1]. Re-inforcing the ligament must, therefore, control this tendency. The extensor sling procedure provides a new ligament which lies in the coronal plane of the hand between the first and second metacarpal and prevents lateral subluxation. At the same time it does not interfere with circumduction of the first metacarpal provided that the ligament is sited at the base of the metacarpal.     

Traumatic boutonniere deformity of the thumb

We report three patients who presented 3 to 8 months after sustaining a closed injury to the dorsoradial aspect of the metacarpophalangeal joint of the thumb. All three patients had an extensor lag of the metacarpophalangeal joint and paradoxical hyperextension of the interphalangeal joint. There were no collateral ligament injuries. The patients required surgical treatment which included advancement and reattachment of the extensor pollicis brevis insertion and imbrication of the dorsoradial capsule to restore the anatomical alignment of the extensor pollicis longus. Surgical treatment of dorsoradial injuries to the thumb metacarpophalangeal joint may be required for injuries that result in subluxation of the extensor pollicis longus tendon and a boutonnière deformity of the thumb.     

Ulnar tendinous interconnection in type IIIA thumb hypoplasia--a pollex adductus

We present an anatomic variation of type IIIA thumb hypoplasia in which a tendinous interconnection between the flexor pollicis longus and the extensor pollicis longus occurred on the ulnar aspect of the thumb. Interconnection between extrinsic flexor and extensor systems is well known in type IIIA thumb hypoplasia and has been reported on the radial side (pollex abductus). In our patient the ulnar location of the interconnection remained unrecognized until recurrence of the deformity in adolescence.     

Surgical Correction of Checkrein Deformity after Malunited Distal Tibia Fracture: A Case Report

Checkrein deformities are rare and involve entrapment or tethering of the flexor hallucis longus and, occasionally, flexor digitorum longus tendons. The deformity has typically been secondary to traumatic fractures of the talus, calcaneus, or deep posterior compartment syndrome resulting from fractures of the tibia and fibula and most fractures of the ankle. These result in flexion contractures at the interphalangeal joint of the hallux. Because of the rarity of this deformity, no single surgical technique has been defined as the standard. Previous interventions have included release of adhesions with or without Z-plasty lengthening of the involved tendons. The present study reports a case of checkrein deformity secondary to a malunited distal tibia fracture, with flexion deformities to digits 1 through 3. The patient underwent successful surgical correction with flexor tenotomies to the affected digits with interphalangeal arthrodesis to the hallux.     

Acute rupture of extensor pollicis longus tendon due to avulsed fracture of the second metacarpal base: a case report.

Acute tendon rupture of the extensor pollicis longus (EPL) is rare. We present acute EPL tendon rupture associated with avulsed fracture of the second metacarpal at the insertion of extensor carpi radialis longus. Tendon rupture of the EPL was repaired with end-to-end suture and avulsed fracture of the second metacarpal base was treated with open reduction and internal fixation.