TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfers for Thumbin-Palm Deformity

Michelle Gerwin Carlson, MD, and Catherine Brooks, OT, CHT

Cerebral palsy is a musculoskeletal deformity caused by a static perinatal brain

injury. The extent of involvement of motor function and sensibility is variable.
Motor involvement may take the form of spasticity, accidity, or athetosis (uctuating between spasticity and accidity). Frequently, spastic involvement of a muscle is
accompanied by accidity of its antagonist, often necessitating not only release of
the spastic muscle but transfers to augment the antagonist.
Identication of upper limb dysfunction usually is noted by 1 year of age. At
this point normal infant achieves a rened pinch with opposition of the thumb tip
to the index nger. Infants with cerebral palsy do not reach this milestone, although
they may have a more primitive key pinch (thumb to side of index nger).

Work for this article was supported by a grant from the Tow Foundation and the Farbman Foundation.
From The Hospital for Special Surgery; and The Cornell University Medical College, New York, New
York

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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The thumb is responsible for 40% of the function of the hand, and the thumbin-palm deformity seen in cerebral palsy signicantly affects the function of the
hand. There are two important aspects of thumb-in-palm deformity: (1) the position
of the thumb in the palm during sting, and (2) the inability to abduct the thumb
when opening the hand. This inability to get the thumb out of the palm, with loss
of the rst web space, when trying to grasp an object is the true obstacle to use of
the hand (Fig. 1).

Figure 1. Thumb adduction during grasp prevents this patient from being
able to hold a bottle. (Courtesy of Michelle Gerwin Carlson, MD, New York,
New York)

Even in the setting of an adequate web space, abduction of the thumb is necessary
to allow for visualization of the thumb, especially if the forearm is pronated. Visualization is important to assist function in a sensory or functionally limited hand.
Abduction of the thumb requires strength in the abducting muscles and relaxation
of the adducting muscles. Additionally, the skin of the rst web space must be
redundant enough to allow abduction. The primary muscle responsible for abduction of the thumb is the extensor pollicis brevis (EPB). This muscle abducts the
thumb carpometacarpal (CMC) joint and the metacarpophalangeal (MP) joint. The
extensor pollicis longus (EPL) tendon is responsible for extension of the terminal
phalanx in this abducted position. EPL ring alone will produce adduction of the
thumb ray owing to its line of pull around Listers tubercle.7 For full thumb abduction, the EPL and EPB must function. The abductor pollicis longus (APL), although
named an abductor, has little thumb abduction function and actually is more responsible for wrist radial deviation than thumb abduction.
The adducted posture of the thumb is caused by spasticity in the adductor
pollicis and the rst dorsal interosseous muscle. In most cases, release of these
muscles is necessary to improve abduction of the thumb. Additionally, the skin of
the rst web space contracts over time and usually needs to be released. The exor
pollicis longus (FPL) muscle may also be spastic and should be checked for tightness.

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY

EXAMINATION OF THE THUMB

Physical examination of the spastic upper extremity can be difcult. Despite
their best efforts, patients often have difculty cooperating with the examination.
Often, it is helpful for the patient to perform the requested activities with both
extremities simultaneously to ensure that the patient understands the requested
task.
There are four keys to evaluating the adducted deformity of the thumb: (1)
spasticity of the exors and adductors, (2) accidity of the extensors and abductors,
(3) hypermobility of the MP joint, and (4) web space skin contracture. The exors
and adductors are the FPL, the exor pollicis brevis (FPB), the adductor pollicis,
and the rst dorsal interosseous. With use, the thumb metacarpal will assume an
adducted position if there is spasticity of the adductor and rst dorsal interosseous,
and the MP joint will ex with spasticity of the FPB. These muscles can be palpated
in the rst web space. FPL spasticity should be evaluated with the wrist at neutral
and the thumb held radial to the index nger. If the interphalangeal (IP) joint of the
thumb sits in a xed exed position, the FPL will need to be lengthened also.
Extension and abduction of the thumb are performed by the EPB and EPL.
Often, the EPL will function well with the thumb in the adducted position, creating
IP joint hyperextension.
Passive or active MP joint hyperextension should be identied and addressed at
the time of surgery; otherwise, tendon transfers to abduct the thumb ray may
produce unwanted MP joint hyperextension. Additionally, the skin in the rst web
space may similarly become contracted and need to be addressed at the time of
surgical correction.

OPERATIVE PROCEDURES
Operative treatment is directed at the four causes of deformity previously
described. Spasticity of the thumb intrinsics is present in almost all thumb-in-palm
deformities. Attention should primarily be addressed to the adductor pollicis and
rst dorsal interosseous muscles; less frequently, the FPB is involved. Release of the
adductor can be performed at its origin1,46,8,11,13 or its insertion.2,46,8,12 The FPL
should be lengthened or released if it is spastic.
Augmentation of thumb abduction has been performed using a variety of tendon transfers, including brachioradialis,9 palmaris longus,6 exor carpi radialis and
exor carpi ulnaris,6,11 extensor carpi radialis longus and brevis,8 and exor digitorum supercialis.1,3 Rerouting of the EPL, FPL abductorplasty, and APL and EPB
imbrication also have been described.1,3,710 Rerouting of the EPL allows the tendon
to become a thumb abductor instead of an adductor and extensor. Of these procedures, the author has found rerouting of the EPL tendon, or a brachioradialis to
EPB transfer to be the most effective. If the EPL is strong and if good extension of
the IP joint is possible with the wrist in netural, EPL rerouting is performed as
described in the following sections. If the EPL is not strong, brachioradialis to EPB
transfer is performed. One must examine the thumb MP joint prior to transfer;
otherwise, the transfer may produce unwanted MP joint hyperextension. A capsulodesis of the MP joint can be performed at the time of the procedure if necessary.

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Adductor Release and MP Joint Capsulodesis

Adductor Release
Release of the adductor is performed at its insertion on the ulnar thumb sesamoid and metacarpal through the rst web space. Through a double opposing Zplasty of the rst web space (Fig. 2), the adductor tendon and muscle are released
from their insertion on the metacarpal, extensor hood, and sesamoid, and reattached
proximally to periosteum in the midshaft of the metacarpal with a 4-0 nonabsorbable braided suture (Fig. 3).

Figure 2. The rst web space is opposed through a double opposing

Z-plasty incision. This allows for excellent visualization of the adductor
and rst dorsal interosseous and improvement of the skin contracture
in the web space. (Courtesy of Michelle Gerwin Carlson, MD, New
York, New York)

Figure 3. The adductor is taken down from its insertion on the

thumb metacarpal and sesamoid. (Courtesy of Michelle Gerwin
Carlson, MD, New York, New York)

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY

Subperiosteal release of the rst dorsal interosseous from the thumb metacarpal is
performed proximally. Care is taken to avoid injury to the princeps pollicis artery as
it ascends from the base of the web space along the ulnar border of the rst
metacarpal. After release of the rst dorsal interosseous, the FPL tendon should be
checked with the wrist in a neutral position. If full abduction and extension of the
thumb is not possible, the FPL tendon will need to be released, usually by fractional
lengthening.
MP Joint Capsulodesis
If there is passive hyperextension of the thumb MP joint of more than 20
degrees, a capsulodesis can be performed through this incision. The volar capsule is
taken down from its origin on the metacarpal along its ulnar side, leaving it
attached to the ulnar sesamoid. The capsule is then pulled down securely and
sutured more proximally to the periosteum of the rst metacarpal. Performing this
capsular advancement only on the ulnar side of the MP joint is secure enough to
prevent MP joint hyperextension after tendon transfer. The MP joint should be held
in 10 degrees of exion for 4 weeks after surgery with a 0.035-inch Kirschner wire.

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Abduction Augmentation
Abduction augmentation is primarily accomplished by one of two procedures.
If the EPL can fully extend the thumb IP joint with the wrist in neutral (either held
actively or passively), it is rerouted to become an abductor. If the EPL is not
functional with the wrist in neutral, the brachioradialis is transferred to the EPB or
rerouted EPL.
EPL Rerouting
Through a transverse incision over the third dorsal compartment, proximal to
Listers tubercle, the retinaculum of the third dorsal compartment is incised. The
EPL is removed from its tunnel and allowed to migrate radially (Fig. 4A and B).

Figure 4. The third dorsal compartment is opened over the extensor pollicis longus tendon to
allow it to migrate radially. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY

Through a second transverse incision just distal to the rst dorsal compartment, a
distally based slip of APL is harvested (Fig. 5).

Figure 5. A and B, The most volar slip of the abductor pollicis longus (APL) tendon is transected
distally to create a radial pulley for the extensor pollicis longus (EPL) tendon. EPB extensor
pollicis brevis. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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A radial pulley is created with the abductor slip as it is wrapped around the EPL
tendon, pulling it radially. The abductor slip is sutured to the most volar aspect
of the retinaculum of the rst dorsal compartment, or radial periosteum (Fig. 6A
and B).

Figure 6. A and B, The extensor pollicis longus (EPL) tendon is rerouted radially and volarly
through the abductor pollicis longus (APL) pulley. (Courtesy of Michelle Gerwin Carlson, MD, New
York, New York)

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY

The adequacy of the radial pulley is checked intraoperatively by traction on the EPL
at the wrist, producing thumb abduction instead of extension and adduction (Fig.
7A and B).

Figure 7. A, Traction on the EPL in its anatomic position produces extension and adduction of the thumb. B, After rerouting of the EPL, traction produces abduction of the thumb.
(Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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If hyperextension of the MP joint is noted preoperatively, a capsulodesis of the MP

joint is concurrently performed. The rst web space is held in abduction with a
percutaneous 0.045-inch Kirschner wire, and a nonremovable thumb spica splint is
applied for 4 weeks.
Postoperatively at 4 weeks, the Kirschner wire is removed, the thumb is placed
in a removable thumb spica splint, and therapy is begun. Thumb position in the
splint is midante/retropulsion and not pure opposition in an attempt to encourage
more radial abduction. The splint is worn at all times with the exception of bathing
and therapy. Silicone scar management is placed in the web space of the splint for
nighttime wear. Scar massage is recommended for 3 to 5 minutes daily for 6 weeks.
Therapy lasting 3 months postoperatively is recommended. The initial postoperative therapy goal is an active attempt by the patient to inhibit any thumb adduction during the performance of proximal exercises. This action is assessed and
achieved before active EPL/EPB ring is attempted, usually within 2 weeks after
splint removal. Therapy then progresses to include light cylindrical grasp and lateral or opposed light pinch of 1-inch size objects, with a focus on the use of
balanced palmar and radial abduction. Squeezing and tight pinch are avoided for
the rst 3 weeks of therapy to avoid the thumb adduction pattern. If the patient
cannot inhibit involuntary adduction, squeezing and tight grasp are limited in the
therapy program but included as needed for activities of daily living. Three weeks
after cast removal, activities of daily living are encouraged, including tasks with
pinch and grasp. Activities of daily living are then progressed as tolerated, and the
splint is discontinued 4 weeks after cast removal.
Brachioradialis to EPB Transfer
A 2-cm transverse incision is made 3 cm proximal to the tip of the radial
styloid. The subcutaneous tissues are spread bluntly with care taken to avoid injury
to the supercial branches of the radial nerve. The brachioradialis tendon is identied and released from its insertion on the distal radius as distal as possible. The
EPB tendon is identied in the distal aspect of the wound as the more ulnar of the
tendons in the rst dorsal compartment. Its identity can be conrmed with retraction of the two tendons. The APL will only abduct the rst metacarpal at the CMC
joint, with no effect at the MP joint. The EPB tendon will extend the MP joint. The
EPB tends to be a small tendon. If it is too small, the rerouted EPL described
previously can be used instead. The EPB is transected as proximal as possible, and
the tendon is woven into the brachioradialis tendon in a Pulvertaft fashion (Fig. 8A
and B).

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY

Figure 8. A and B, The brachioradialis tendon is transected distally and the EPB proximally and woven in
a Pulvertaft fashion into the brachioradialis. (Courtesy of Michelle Gerwin Carlson, MD, New York, New
York)

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Maximum tension is placed on the two tendons with the wrist in neutral during the
weave. The tension can be checked after repair. Wrist dorsiexion should allow the
thumb to rest on the radial aspect of the index nger, and wrist volar exion
should abduct the thumb.
The postoperative regimen is the same as for EPL rerouting.

SUMMARY
Treatment of the thumb-in-palm disorder usually requires release of the pathologic adduction and augmentation of thumb abduction. Release of the thumb adductor and rst dorsal interosseous along with EPL rerouting or brachioradialis to EPB
transfer reliably provide excellent results in improvement of grasp of the hand (Fig.
9A and B).

Figure 9. Release of the adductor and rst dorsal interosseous and

rerouting of the EPL. A, Preoperatively attempted abduction of the
thumb produces adduction of the rst metacarpal. B, Postoperatively
a 60 web space is maintained actively. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY

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Address reprint requests to

Michelle Gerwin Carlson, MD
Hospital for Special Surgery
523 East 72nd Street
New York, NY 10021

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