AN ANALYSIS OF PARALYTIC THUMB DEFORMITIES

liv J. LEONARD Gd)LDNER’, M.D., AND C. E. IRWIN, M.D., W.-’sHM SPRINGS, GEouwn.-

Frwn Georgia ll’arm -Springs Fooo miation

Paralysis of the opposition unit of the thumb is a major- disability. The degree of
deformity d!epend!s primarily upon the ant-en-ion--hsonn cells affected, a-nd (lie treatment
hinges upon (lie resulting deformity. Furthermore, the status of the thumb is not- constant,
and the secondary changes ‘svhich occunr in bones, joints, and soft tissunes make an ideal
end result difficult-. The factors of nerve supply, munsclc stuengthi, joins( contractures,
joint- st-ability, and vascular statuns munsf- all be d-o)nsidlcu’ed. The interval fn-om onset of
disease, the occupation, the general physical condition, and the stability of (lie remainder
of f-he arm and forearm must he c’s-alurated before reconstruction is attempteti. The treat-
ment of each thumb ‘s’s-ill vary according to the pathological changes present. With these
facts in mind, a general classification ‘s’s-ill be oln(linc(l, and the var’iations in tr-eatmcnt
‘s’s-ill l)c Olis(Insse(l.

EARLY TREATMENT

(‘hildi’en

The -hild ‘s’s-it-h ‘sveakness of the hand follo’sving clestruction of motor- cells in tIre con’(l
must he treated in preparation for the future. Evens ‘s’s’hile rout-inc care and mtrscle re-
education are being carried out, the patient is fitted with a .sphirit to hold (he thumb in

FIG. 1-A FIG. 1-13

S9linits useol for sVeSLknseSS of op)osition1.
Fig. 1-A : The plexiglas splint hobois the thiunib in abductions ; it will niot o’onstrol a thiunsb with coIl-
tractures. If is used best by adults.
Fig. 1-B: Basic aluminum splint with wrist attachment. Thisis worni prior to o)perat-ion to prevent
t-ontractures and to increase function. It is used postoperatively to 1)rotect trsonssplanted tendons. This
splint- is more durable for children than the plastic kind. It helps l)revenit joust SUI)luXatiofl, joint con-
fractures, and faulty habits. Adjustment should be niade every few nssonsths for ohsibolren, since the child
sill discard the splint if it does not fit properly.

the position 0)f fusnction (Figs. 1-A and 1-B). A proper selection of splint is necessau-y.
If the (leformit.y is already se’s-crc or the hand is rigid, a plastic splint ‘s’s-ill not hold (lie
metacarpal in position. Then the metal splint, with or ‘s’s-it-hout- ‘s’s’rist a(tachment, may
he necessary (Fig. 1-B). Home care, particularly in the form of stretching and diversional
therapy, shoinid be given.
The time for’ any operative procedun-e on the tendons of the hand ‘s’s-ill dlepend upon
the size and, to some extent-, upon the intelligence of the patient. In general, it is ‘s’s’isc
to ‘svait until the bone structure is fairly mature and until (-he child can actively participate
in muscle re-education. The minimum age is about twelve to fourteen ycal’s.
* Aided by a fellowship from the National Foundation for Inifanstile Paralysis, lute., New ork, N. Y.

VOL. 32-A. NO. 3. JULY 1950 627

 628 .1. L. GOLDXER AND C. 1. IH’sVIN

- I (101115
r1l pu’iniCi)le 0)1 nsain(ainsinig a full 1-anige of nisotions in 1115(1 about (he thumb applies

for aciinlts as ivell as for (hil(lren. Splinting in the position of function, stretching, and
resistance exencises for’ increase in muscle strength an(l coordination should be pursired
a(-(ivcly hefore sunn-gery is considered.

CL.-SSIFICATION AND SURGICAL TREATMENT

Thse one fac-(ou co)niTimo)ni to) all (lie hands to he considered is partial or complete loss
of (lie lun(-tion of (rue opposition. Tlsere are variations in degree from almost unnoticeable
(lcfor’mity to (lie completely useless hand. To he in (rue opposition, (-he thumb must be
opposite (lie fingers, ‘svitls the punlp of (he thumb facing (he radial pulp of the fingers and
(-lie thumb nail almost parallel ‘svitli the palm. Merely touching the fingers or palm ‘svith
the thumb is not opposition. This is “false” opposition, or apposition. The thumb must
al)(lu(-t, pn’oniat-e, ant! flex fee’ opposition.

A classification based Oh (ire (r-eatment necessary for (-he best end result ‘s’s-ill be pre-
sented. This (-lassiho-ation emphasizes (lie fact- (-hat a single proccc!uire, or even a combina-
fio)n 0)f pu-oceoluures, (-ansno( be sterco(-ypc(l for- any ‘sveak thumb.

Gi-o UJ) I . Tin so-innb Req uiring only Transplantalio a

of 1/re Flexor J)igiloi-u in 0S’ubliinis

Transplantation of (lie flexor digitorunm sublimis of the ring finger to the proximal
phalanx of the thumb is the most physiological method and, in general, gives the best
uesinlt in cases of inn(-omphicated! opponens ‘svcakness. It fulfills the principles established
by Bunnell in that (1) (-he tenc!on passes subcutaneously from its insertion in the direction
0)f (he pisiform l)one, and (2) a tn-ansplanted tendon is inserted on the dorsal ulnar aspect
0)f the
proximal phalanx of the thumb.
Many pren-cqunisites aie necessary for an excellent postoperative result ; their absence
‘svill cause (-he nesinlts to be innsatisfact-on-y. These prerequisites arc:
1. A strong flexor pollicis longuns.
2. A strong extensor pollicis longins and abductor pollicis longus.
3. A good ou l)e(ter flexor (!igitorum sul)limis of one of f-he fingers, preferably the
n-ing finger’.
4. A good 0)i’ hetten flexor- can-pi ulnaris, for use as a pulley.
5. No bone, joint, on’ soft-fissure (leformity present about the thumb.
6. Gooc! s(nenigth in (lie fingers and a good palmar arch.
7. Adequate coorclinat ion and minimal tremor.

A. (seal J)eformily

Figirres 2-A and 2-B sho’sv the unsunal deformity in a hand from ‘svhich an excellent
postoperative result can he expected. There is weakness and atrophy of the intrinsic
thenar munsclcs, bunt good strength in the extrinsic muscles. There are no contractures
of (he thumb unit, and the Iemaifld!el of the hand is strong (Fig. 2-A). “False” opposition,
lio’svever (Fig. 2-B), is the result of ‘sveak intrinsic thunmb muscles. The first metacarpal
hone cannot he elevated. The flexor pollicis longus and adductor pollicis pull the thumb
across (he palm and the entire cffon’t of the hand is used, as can be seen by flexion at the
interphalangeal joints of all the fingers. The easier the action of opposition, the less
“forced “ is the appearano-e of the remainder of the hand.

B. Tieatmeiit

Treatmenit (Olisists in keeping the ent-in-e hand well stretched, using an opponens
splint, and regaining all possible strength and coordination. Then the flexor digitorum
sublimis of the ring finger should be transplanted (Figs. 2-C and 2-D). The flexor carpi

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 PA R. nxnno nun t M ui DEFOtIMIlI t5 629

unlnat-is pulley must I)e St n-ong, to pn-e’s-enst uaolial deviat ions 0)! t htt hanoI and ‘s’sn’ist artol
stnctclsing of (lie tn’anisplaiit. Follo’sving (Iris l)I’o)d((hllre, fIre mt uiussic niiusc-les list’s-c been
ueplacecl l’ t lie tencloni of (lie sunl)linsis aniol its niiuus-le niot or’. Figinu’es 3-A, 3-B, 3-( ‘, soniol
3-I) shso’sv the o)l)enat ive teo-hsnsiciine inset! in I lie sul)innsiis I n’ansplanit at ions.
rflse ease ‘s’s-itls ‘s’s-hsicls tu’une opposition nitty be j)eufOu’flieol affeu opeI’a(ion is ini(iicate(l
by the coor’dinate(l adtio)ni of (lie fist burn- finger’s ani(l t Iso- clevat ions of (lie fift h finiger’
(Fig. 2-D). -

(Aroo1p II. 7’/i u Fill) I?(’(/uirill(J I?einfoi’cemenl of Its L.i’tl’itISl( ‘-11c1l(/1/l l)(1fO1’(’ 1/ic bl(.tO1

1)#{252}jiloi’u iiO Subilin is ( ‘a a BC Tic ios’pla ,it’(1

A. Usual Defoi’mily

In this gu’oinp (lie inu-insic musc-les ar-c weak. The o’s-er--all stu’(-nigthi of tlse palm ans(l
finger-s is good : (-oo)r’chnat ions is good : t lseu’e a u’e Ii 0 soft -t issue to )l5 ( ua(-t in u-es o)I I l5( ole-
formitics. One extrinsic- nsunsc-le, for’ exaniple, (lie extenison- l)o)IIio-is lonsguns, nates ‘‘ fsoiu’

minuns’’ (40 per- ceni(.) . If the flexor’ stnl)liniis transplant at ioni is olo)nse ‘svithoirt aolding
strengths to) (lie weak long extensor’, (Ise r’esiulf ‘s’s-ill riot he sat isfactouv. This thumb is

FIG. 2-A FIG. 2-B

(;roin I
Fig. 2-A: The extrinssic nsiuscles allow a good pinsch hctveenr tire tlounsib arid insobo-x finiger.
Fig. 2-B: “ False’’ opl)osit-ion. Tht tlounssb caisnsot be abobuCte(l or proniatetb. Extrenso- effort is tvio1enst
ins attemptinsg opposition. There are no co)nt-racfures and there is good strensgth ins the hsond, exco-pt for
the thenar grout). The palnsaris lonsgus, flexor l)olliciS brevis, andjlexor carpi radialis all are beirsg uSed
for substitution. The pinch bet-weeni the thumb and little finger is at lo-aSt 50 per cent-. less thsoni betweens
the thumb and index finger, and the flsunssl) tensds td) roll into an cxternutl position whit-ni the psoticnot i-nc-s
to pinch againsst slight rrsistance.

2-C
1’ig. 2-( : Aftei’ O)1)(1’SIt ions, tlso- t-hsuniih esons lx- sobolucto-ol . ‘l’hso ilo-xon oligitononnis sub )linssis goo-s unsobo-r t hso
flexor d-aI’I)i ulnaris, the l)Lnlbt sot t lie vrist-, and! is insserteo I o )I5 t iso- don’ssol ul nsson 505h)e(t Of t hoe l)rxinissol
Phis-olarsX of tise thumb, tO) the volsin’ SidlO of the nsset-socsorpopissohsonsgesol joinit.
Fig. 2-1) : Tn-ut- o))po)sitions is 150W 1)OSsiblO’ without o-ffort . Psotio-nst Issos ‘inll fonnot-t ionssil csopsso’it.y sinsol cx-
cellenst strensgtls. Note the ahxluction, proniat-ions, 505(1 flexiono of the thnnnb. .\.. o’ast vsss iisool for onse week
softer operations, followed by a S1)linst for fotnr weeks. (Conspsmne with Fig. 2-13.)

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630 J. L. GOLDNER AND C. E. IR’sVIX

\\ k

Flexor

- . - --

FIG. 3-A
Fo’o’lsnsioiuc of usinsg t ho’ flexor’ oligito)runsi sublinnis for sins opponeris tr’anosplantt.
Fig. 3-A: Thse slips t)f the fld-xor digitorunsi subliussis aro- isolated sot- the volar crease of tise iiso-tstcar-
pophalanigesol jo)iIit O)f the ring finsger. The flc-xor csorpi ulnssoris is isolato-tb for the l)ulley, also! the subhimis
is pulled out at thoo- wrist.

/
Flexor Dig/forum Sub/imis
Flexor Corpi Ulnoris ] ,/

- . _
FIG. 3-B
f1oe flexor digitorunso ‘otnh,hinsiis is PuSStol unsder, thoenn over, the flexor curpi ulnoanis. A subeutalidous
t unsnso-l is-; nusoolt- fronsi t Iso- oborso-ulnsan’ sin be of the Pro)xinsisol phnstlanx of t hoe- thumb to t hoe- wrist incision
The thinnish is held its sohthuo-tion anti full notsotioni.

55j}#{149}
Jo)URNAn. O)F’ BONE AND JOINT SURGERY
 PAR. LYTIC TH U M B DEFORMITIES 631

Flexor Digitorurn Sub//rn/s

FIG. 3-C
The tranisplautted tendon is niow in its nto.-s locations. It is split insto two so-guisents: ouse will be strsolrored
ins bone turd the other in periosteum. The ss-rist is flexed anti thot- t-hunsb is hick! ins oppositions.

FIG. 3-D
A thrill hole, about one-eighth of an inch ins diameter,
in the proxiniial is made
l)hialansx, bt-insg olireotetb
to)ward the pisiform bone. A piece of medium silk
over one segment is looped
of the tentlo)ns, arid tenssio)ns
is made with a hemostat on the other. A needle is passed through the drill hole; one silk loop with f-Isv
tossdon in it follows, the tendon being allowed to double on itself. When the doubled tendon is passed ens-
tirely through the hole, the tendon is secure and the thunib stays in the position of oppositions. A buttons
is used to anchor the silk. The second segment of tendons is sutureol to the penio)Steum for additionsstl
support-. The wrist is insnsol)ilized in flexion nonscl ulnar deviation (o keep the tr:onsh)lanst unsober tenssions.

sinuila-i irs appean-ance to that- in (1roup I. If tire r-ountinic ussusclc test is riot olonse, (lie
‘s’s-cakncss of (lie long extensor- may be overlooked.

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632 J. L. GOLDNER AND C. E. IRWIN

Il-i

Group III
Fig. 4-A: The thensar muscles are weak; there has beers lit)
splinting or stretching for many i-ears; and contractures have
tieveboped, including flexion-constracture at the metactorpo-
phalangeal joint-. The palm is moderately flat. There is nsodl-
crate subluxation of the car)o)metacsorpsol joinit toward thst,
volar side.
Fig. 4-B: In extenision, the t-liunsib has a typidal “coc-keol-
b:ock “ appearance. The skin and fascia bet-weeni the first arid
seconsd metacarpals are contracted, a.s is the adductor pol-
licis arsd it-s fascia. The dorsal capsule of the earx)metacsorpsol
joint is constract.etb. Three years before, ins the presence of
these deformities, the sublimis fenidons was transsplantetl to
the head of the first nsetacarpal. Funiction (lid! riot insprove.
Surgical procedures should be carried out to correct all soft-
tissue deformities arid joint- defornoities, after which a sub-
limis transplantation to the proximal phalanx 0-an be donit-.
A svnostosis between (he first ant! second metsocarpals
would take away too much motion and strength.
Figs. 4-C and 4-D: From the muscle test arid from these
V I isofographs, it would seem that a flexor sublimis transplans-
FrG. 4-1) tsotion could be done. There is, however, flexioni contracturo’
sot the metao’arpophalangeal joint. Not until this joinst con-
trsu-tur-, as we-lb as thoo.s skin o-onotrsocture bo-tween the first and second metsocsorpals, ha.s beeni o-o)rrd-cteob,
cans so good nt-suIt bo- expecteol following tensdoni trsonssplsonstationi.

B. Ti’ealnunl

}d)I’ weakness 0)f the extensor pollicis lorigus, the extensor carpi radialis longuss croni
be sutuned to the long extensor of (lie thusmh, just as is done for late rupture of f-he cx-
tenson polhicis longuns follo’svinig Colles’s frac(urr’c. fh technique of Frederick Smith ca-n
be used. If the flexor’ l)olhicis longus is ‘sveak, the flexor digiforurm sunblimis from the index
fiisger- or long finigen can be suturn’ed to (his tendon at- the ‘svrist for a sunhstitut-e.

(;1-011J) III. T/noiiiib Requii’iiig Rel(’ase of (‘ontraclures Follonved by Transplantation

of the I1’lexoi’ Di#{231}jitoi’uin Sublimis

A. (seal I)eforinily

This group, for- (lie risost pan’t, coniprises tiiuinshs which ha’s-c bceni weak in (-he funt’-
tioni of opposition for maniy year’s. There lists been DO splinting, no stretching, and lid)

at (erupt to nsains(aini jo)ints ‘s’s-itls a finll range of motion or so)ft tissues ‘s’s’itliourt (-on(rad-t-ur-es.
A typi(-al fliunrnh (-sun l)c (lcscribedl as having a ‘‘ cockeol-back ‘‘ soppeau-anso-e : the intli’s-idiusol
olefon’mities causing this an’e risany (Figs. 4-A to 5-B).
The acldinc(ions (lefornsitv is the nestnlt of son adclunc’fion couitrad-(un’e i)ltns tIre act ion

THE JOURNAl. OF noxn; ANI JoINS’ surt;n;nov

 PARALYTIC THUMB DEFORMITIES (1:33

FIG. 5-A FIG. s-B

Group IV
Fig. 5-A: Before operation, the carponsietacarpstl joint is relaxed! alodi liypennsiobile, and tire extrinsic
nsuscle strength is only 50 er cent-. It- is necessary to stabilize this joinst.
Fig. 5-B : The l)alniaris lorsgus ha-s I)een t-ransplanited to the flexor carpi ulnianis anic! the carl)onset-ao-sor-
l)al joint has I)eeIs fused. The flexor digit-orum sublimis has been transplanted to the l)roxinlssol phalanx of
the thunsb. The nietsocarpal is fused in abduction ansc! Pronssotion. Function arid appearance sore iniil)rOVe(b.

of the long anc! short extensor tendons against- the ‘sveak intiinisic munscles, causing (lie
metacarpal to be adchircted and externally rotated. Subluxation or cont-r-acture of the
carpometacaspal joint follo’svs ‘svhcn f-he thumb lies at the side of the hanc! continunally
in the position of external rotation and adduct-ion, or ‘s’s-hen the patient is doing muds
crutch ‘svalking oi resting on f-he hand while sitting. The capsule on the volar side of (he
carpometacarpa! joint stretches and relaxes, arid the ligaments on (he dorsum shot-tens
and coritn’act (Figs. 4-A and 4-B) ; on- the ‘s’s-hole unit of f-he greater- multangular- and (he
metacar-pal may he pantially relaxed and hypermobile in all dir’ections (Fig. 5-A) . Flcxion
con(rac(un-e at the mctacarpophalangcal joint resislts from tight adductors and fn’eqtnent
use of the hand! in “false” opposition (Fig. 4-C), leading to contract-us-c of the collaten’al
ligaments and (he capsule at this joint (Figs. 4-A and 4-B). When the patient attempts to
extend the thumb (Fig. 4-D), the unit as a ‘s’s-hole moves into extension, but- (he metacarpo-
phalangeal joint. iemains flexed. This fixec! flexion contnacture nsay measurre 45 degrees.

13 . Coi-rectivc Procedures

\Vitli a metal thumb splint, the metacarpal is elevated and! held! in enough abd!urction
to allo’sv for- a stronger pinch between (he thumb and finges’s. A better grasp of large anscl
small objects is accomplished by use of this splint. A plastic splint, however-, ‘svill not
aid this patient, for if ‘s’s-ill not hold f-he metacarpal in ahd!uction. Neither splint ‘s’s-ill acId
much o (lie action of rotation. If the splint improves fusnction, the correct su.nrgical pr’o-
cedures should do the same.
If, hso’sve’s-cn, a sul)limis transplantation is done on the hand! sho’svn in Figuires 4-A
and 4-B ‘s’s-ith the expectation of improvement in function or appearance, the patient arid
(lie open-at-on- ‘s’s-ill be disappointed. The thumb already has fixed deformities. Inserting a
tendon into the proximal phalanx ‘svihl fend to increase the flexion confracture at f-he
metacarpophalangeal joint. A subhimis transplantation ‘svill not a!lo’sv abduction, because
of the skin and fascial cont-rac(urcs between f-he first and second metacarpals. If the sub-
limis is inser’tcc! into the distal end of f-he mctacaspal, “false” opposition ‘s’s-ill still be
pr’escnt. There may be slight improvement in the depth of the carpal arch; but, becaurse
of the existing contractures, there ‘s’s-ill not be true opposition. This is seen in Figures
4-A and 4-B; in this patient a subhimis transplantation to f-he distal end of the fin-sf
me(-acanpal has already been done, the flexor carpi ulnaris being ursed as a pulley. On
examination the t-ransplant can be felt and seen to move.

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(134 J. I._. d;oLDNEn .ND 0. U. IRWIN

Since the nsiuscle test sho’svs gOo(l ext u’insic nsinsclcs, (lie following procedures may
l)e done:
1 A partial
. capsulofomy at the metacarpophalangeal joint.
2. An L-plasfy or’ Z-plast.y of (-he skin on the dorsum of the hand bet’sveen the first
a-no! second me(acarpals, to remove the skin contractures.
3. (1uttinsg of (he fascia bct’s’s-ccn the first and second metacarpals and stripping the
l)eniOstelnm fu-ons (lie first metacarpal, if ncccssar’y, to loosen the contracture bet’sveen the
mc(acar-pa-ls. Stu-ipping of (he acldinctors from the first and third metacarpals may also
l)e (lO)fle.
4. A capsunlo(onsy of the carpomctacan’pal joint on the c!orsinm, and placing f-he met a-
(arpal in (he p1-open- posit-ion to correct- f-he o-ontrac(-urc at (-his joint.
5. Following these procedures, ‘svhich can all be done at one o)perafiOfl, the thirmb
can be immobilized in a snug-fitting plaster
cast for- three weeks in the posit-ion of abduc-
(ion and pronation opposite the long finger.
After the plaster has been removed, a metal
opponens splint- can he applied ‘svith a rubber-
l)and cuff for rotation. Joint motion ‘s’s-ill be
restored. If the carpomct-acarpal joint. remains
n-easonably stable and f-he cont-ractures arc
eliminated, the sublimis can he transplanted
(0 (he proximal phalanx of the thumb. If the
can-pometacarpal joint- is hypermobile, but the
strength of the extrinsic thumb muscles and
the remainder of the hand is excellent-, a sub-
limis (ransplanat-ion ‘s’s-ill give enough support

l)ofl5tt(aIptlaIidm(ti(fl)ophtIaisg(ljolii5 to illo’s’s stable actron of this josnt Fusion of

Must-Ic strengths of the entire hansd is only 50 per the carpometacarpal joint- should be avoided
Oclit. The thunsb has a ‘o-o)cke(b-l)sock” appear- unless the o-ontra-tures cannot- he eliminated
ante because of \vesoknidsS, hut nio)t l)e(-sotnse of ,
tonit-rsootures. on’ thcic ns extreme hypermobility. Synostosis
l)e(’svccn the first and second metacarpals
sisounlcl not i)e clone in this type of hand, becaurse it takes away too much motion and
strength. if synostosis is clone, it is desirable that pundanthrosis develop, so that the
availal)le nsusc-le power’ will be utilized fully.

Gi-oup I V. Th otmb Requiiiiiq Correction- of Joint Hypei-inobility with oi without the Release of
-Joint and Skin Conti’act-ures, Followed by Ti-ansplantation of the Flexor Digitorum Subli-mis

A. (.Isital Deformity
Ins this grounp the thtnmb is a ‘sveak unit of a fair hand. The muscle strength of the hand
in general ‘s’s-mIld! rate only “ fair plus “ (60 per cent-.). Several deformities must be consid-
encc! and con-rec(ed.
I . Ilypeiinobility of the cai-pometacarpal joint ‘svith instability at the joint, relaxed col-
later-sob ligamcnt, and a stretched joint capsule constitute the main deformity. The meta-
canpal hone is externally rotated while at rest; it stands out clearly because of thenar
atrophy and flattening of the palm (Figs. 5-A and 7-A).
2. Adduction o,f the thumb is also present, although in Figure 5-A the skin and fascia
anc not particunlarly tight, whereas in Figure 7-A the dorsal skin and fascia are contracted.
3. Hypeimobility at the inetacarpophalangeal joint may be present. The metacarpo-
phalangeal joint is relaxed, and if- buckles when the patient attempts to pinch. It is hyper-
mobile in all directions.
4. Wrist weakness may he present. This ‘s’s-ill require that the flexor carpi ulnaris he
r-einfor’cedl befon’e it can be used as a pulley.

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 IA 1t.-’LYTIC THUMB DEFORM ITI ES 635

FIG. 7-A FIG. 7-B

Group IV
Fig.7-A: The palrss is flat and thid-rd- is partial subluxsotions 0)1 thso- (-son-po)rsseta(-sor)sol joinit of the thumb
011 the volar side. There is a t-ontrat-ture of f-he carpometacarpal joint on the dorstnnss. Tho- sobductor of
the little finger is weak. Tue fifth nietacarpa! cansnot- be elevated.
Fig. 7-B: Transplantation of the flexor digitorum sublimis to the proximal phalarsx of the thumb had
already been done, but the end result was not satisfactory. There is still adduction and external-rotation
deformity. Tendon transplantation will not correct joint deformity.

FIG. 7-C FIG. 7-D

Fig. 7-C: Consfracture on the dborsuni of tise ostnponsiefatsorpal joinst. list_s beers released sonid tisis joinit lists
l)een fused. The transplanted tenidons can 150W function, since the thunsli is sol)dlucted.
Fig. 7-D: There is good pinch between the thumb and insdex finsger. Mont- ussotio)Is is l)ossible. betweeni
the first sonsob SecoIs(! nsetacarpsols tissons if so synsostosis had i)eeIs t!onse.

B. Coirectiu’e Pi’oeedui-es

1 . The finst proccdunc is tiaiispiantation of the /)allna-l’is longus, near tire insertions
of the flexor- car-pi ulnanis, into) the pisiform bone. This can l)e used as an ulnar’ flexor’ as
‘svcll as an active pulley for (he sunhlimis tnansplan(.
2. Next- the greater maltangular is fused to the base of the first -metacarpal to) eliminate
all instability and motion at- (Isis joint. A moc!ciate amount of flexion and extension sf-ill
remain in the intercanpal joints, and pn-ona(ion is still pn’esent at the first metacarpo-
phalangeal joint after- funsion at (he base of the thumb. Following the tendon tn-ansplanta-
(ion and joint fusion, the thumb is immo)l)ilizcd in a sning cast in the furnctional position.
At founr ‘svccks the cast can he u-emoved, antI joint motion reston’eol, in preparation for the
second operation.
3. Two small Kii-schnei’ au-es ai-e insei-ted betu’een the first and second inetacarpals.
These ‘svircs allow frill mobilization following tendon tn’ansplantation.
4. A flexor subli-,nis transj)lan-tation is (lien clone, aliol ao-(ive motion is sta-ntcd in one
‘svcek.

C . I-rnpi’ovement in- Fe ii ction-

Wit-h the carpometacarpal joint fused, the transplanted sunblimis ‘s’s-ill assist only in
pronat-ion and ‘s’s-ill augment the flcxou po)llicis longins in flexion. (‘linit-ally I lie t n’anss-

Vd)L. 32-A. NO) 3. JILY 5950

(1:3(1 J. L. (JOLDNER AND C. E. It’sVIN

Pllonstedl to-nsolous 0sOIi 1)c l)stll)atetl ‘shtcis inniolengoiisg not ive nsso)t io)ii.Fhis t n’anisplant lists o)nsly
35 (0) 50 P#{176}”
o-enst . of floe strength 0)f tlsose ins ‘svlsi-hs the can’pometat-arpssl joint is freely
iiiO)V5Il)l( ( Figs. 5-B and 7-C).
Although (Isis pro)ced!unr’e is follo’sveo! by limitationi of motions, it appears to be l)c((-cn
than fonmsofioii t)f a svnostosis l)et’sVeefl the fir’st- and seoondl met-acarpals; ‘s’s’it-h the synos-
tO)sis, (lie oar’pometaoar’pal joint is still lsypenmobilc and the entire thumb frequently falls
bst(k mitt) exten’nal r-ot.afion, because (lie pne-exis(ilsg clefonmi(y of sublunxation has not-
i)dPI5 d-o)u’r’ed-feo!.

1). IIyJ)el-nbob-ility (it the TIetacai-pophaiangeal Joint

Its hiStlid!S with tnine hypes-mobility at- (he metacan’pophalangeal joint, the thumb
‘‘cocks back” (Fig. 6), lur( (lien-c is no contn’a-c(ure, as is seen in Figui-es 4-A and 4-B. The
irsinal external i’c)tation and! ao!dus-tioni o!eformity is present, and the hand in general is
‘svest.k, althoingh the first mefs-tcarpso-l can be elevated!. Surgical procedures on (his hand
will iiot iflci’et5S( finncfion s1)pn’edial)lV.

E. ( ompiete Obliteration- of the ( ‘alJ)al A. iilo

Iii (lie case exhibiting this o!efol-nsi(-y, the carpal arch, instead of having a concave
dOfl(Oili’, was convex (Fig. 7-A). The palm ‘svas flat, ano! this gave the appearance of a

FIG. 8-A FIG. 8-B

FIG. 8-C FIG. 8-I)

Group \-I
Jig. S-A : irs the l)1c-0l)0150tit phiotognsophi, there is wesoknsdss of tlse first dorssol iliteroSseUs as well sos
of the thereon IisUs(!ds. Shows 1)OsitiOli assunssed wheni ol)l)OSitio)Io is sottens!)te(b. The flexors of the index
finger and tI-sd- t.hunsh are insec! fan the n)inidls.
Figs. 8-B, 8-C, arid! 8-D : Postopo-rsttive result.. The d-xtenssor inidicis pnopnius has beeni proloniged with
51. graft of fascist lsota, and hsos beeni tnsonospkonted to the first into-rosseus insertions and dorsal aponeurosis.
The flexor digitorunsi sublinsis issis beens trsonisl)lant-e(l to the !)IOXiflsal phalanx of the thumb. Full abduc-
tio)ni sonsd t)!)l)OSitiOni of tise thunisb sore possible. Abductions against resistance and extension of the inter-
)hsalanigestl joints to 180 dbegro-es are evi(lenit. ins the ili(leX finger. The hand has excellent function.

nIlE J()URNAL OF BONE AND JO)INT SCR(;ERY

 PARALYTIC THUMB DEFORMITI ES 637

true “ape hand”. There ivas relaxation of the carpometacas-pal joint, external rotations
and adduefion, and cont-ractinrc of the skin, as- well as moderate relaxation of the mcta-
carpophalangeal joints as a groinp. The intrinsic aisti extrinsic muscles of the hanc! haol
only 50 per- oent. sts’cngth. A sublimis transplantatiori had alseady been done (Fig. 7-B),
and the poor resinl( ‘s’s-as evident. Following the tn’ansplanta(-ion, the proximal phalanx
‘s’s-as punlled slowly into flexion and (lie mctacan’pal dn’opped hack into external rotation
and adduct ion.
Fusion of the can-pometacarpal joint ‘s’s-as done, which stabilized the thumb in the
position of abduction and helped restore some concavity o (lie carpal arch (Figs. 7-C
and 7-D). The sunblimis transplant then augmented the flexor pollicis longins and adldleol
pronation at the metacarpophalangeal joint.

Group Thumb Requiring Synostosis between the First aini Second ilIetacai-pals or Fusion
of the First Carpo-metacai-pal ,Joint u’itho at Tell (Ion Ti-a nspla ii tation

With a genenal strength in (-he hand of only “poor” or “poor- plus” (20 per cent-.),
reconstrirctive surgery ‘s’s-ill not accomplish munch. Thumb sunrgery for- cosmetic reasons
only is usually not indicated, hut occasionally it may be necessary.
If the synostosis is done in the hand ‘svith “fair-” to “fair’ plus” (50 pen’ dent.) strength,
the development of pscindanthrosis iesunlts irs better’ function thiani if n’igio! innion haol
taken place between the fin-sf-- and second metacan-pals. This indicates that, if aoleoiuate
functional strength is cvk!cnt- in the initial evaluration of (-he hand, synostosis is not the
procedure of choice. Fusion of (he carpometac-au-pal joint ‘s’s-ill allo’sv nso)u’e mobility ansol
pn-obably gncatcn st-ability.
In genenal, formation of a synostosis hetivecri (lie fir-st and seconscl metacar’pals is
done too oft-en merely because of the presence of an ado!inctcol, ex(er-nally rotated thumb.
This operation should I)c used only on the weakest hands and those ‘svhio-hs have very little
function. Frequently, it takes a’s’s-ay ‘s’s-hatever- aolaptation the patient has already macic.

Group TI. Group in which Miscellaneous Procedures on Parts of the hand ()thei- than the
Thumb A re Desirable before a Subli-mis Transplantation i-s Done

A. Limitation of Function
When the first dorsal interosseuns muscle is weak, ai)oitn(-tion and extension of (lie
index finger arc not- possible. If opposition is ‘s’seak also, an attempt to make a circle
‘s’s-ith f-he thumb and index finger gives the position seeni in Figur’e 8-A. in the case illins-
trated, there ‘s’s-crc no joint contractures, anol no contn-ao-tinn-es of (lie skin on- soft tissue. The
general strength of the hand ‘s’s-as good.

B. (‘ori-ectir’e Pi’ocedoiies

The extensor inolicis pn’oprius telidon was n-einiserteci, towan-ol the don-sou-adhial side of
the proximal phalanx of the index finger, into the inter’o)sseus tendon and dorsal aponeu-
rosis. A sublimis transplant to the proximal phalanx of the (hunmh, the flexon- carpi urlnaris
being used as a pulley, was applied four- weeks later. Figures 8-B, 8-C, and 8-I) show the
postoperative result.
If the flexor carpi ulnaris is weak, the palman’is longuns can he suntinned to (-lie flexou-
ulnaris near ifs insertion into the pisiform ; foirr ‘s’s-eeks later the sublimis can be trans-
planted around these tendons. If the finger extensors are of fair strength, one of the wrist
tendons may be inserted into the common extensor tendons. If the finger flcxors arc weak,
the problem is more difficult, since (-he other minsclcs in (lie hanoi arc usually ‘s’s-eak, also.

Pos’rOPEIIATIVE (ARE

.A. br-ief outliise of the post-openat i’s-c cane will be 1)ncscnrtct!

1. A light o-ast shiould be applied, ‘s’s-i(ls (-he ‘svnis( in nioclcrst(e flexiors anici ulnsan’ dlevia-

VOL. 32-A, NO. 3, JULY 1950

 638 J. L. GOLDNER AND C. E. IRWIN

tion. The thumb shounld he placed in (lie position of ftnll abduction and full rotation,
opposite the bug finger, ‘svithi (he tn-ansplanf under the proper amount of tension, (he
fingers l)eing left ourt to pen-mit aotive exercise. As soon as the patient a’s’s-akcns fn’om the
anaesthesia, ire is instn’irc(ed (0) at(eniip(- active motion. He can fcc! (he (cno!on move, c’s-en
(hoingli the thsunssb is immobilized in Plastei.
2. The metal splint (Fig. I-B) is applied one week after opcr-ation, ‘s’s-ifh a ‘s’s-nsf at-
t-achment and an extension to the proximal phalanx of the thumb if necessar-y. Tape slings
on light elastic traction on the thumb can he used in certain cases. Daily instructions are
given to (he patient l)\’ the sunrgeon. These vaiy, depending upon f-he postoperative con-
o!i(ion d)f (lie thumb.
3. Occupational and divensional therapy are started soon after the plaster has been
removeol. (1uintt-li ‘svalking is not- allowed for a fe’s’s- weeks, and the patient is taught to
support himself in ways which do not requrire use of the palm of the hand ; otherwise, the
transplant ‘s’s-ill l)e stretched.
4. ‘i’he buttons and the silk untinre are curt in four weeks.

STATISTICAL DATA

This study is based 015 an analysis of the end results in ninety-one thumbs operated
unpon in this Clinic during the past ten years. Then-c ‘s’s-en-c seventy-nine patients in the
group ; twelve had bilateral dcfon’mit-y of (-he thumb.
Transplantation of the flexor’ digitorium sublimis fn-om the ring finger ‘s’s-as done in
seventy-three cases. The results ‘s’s-en-cexcellent in fifty-nine of the seventy-three, in ‘svhich
only the flexor oligitorurm sublimis ‘s’s-as irsed as the motor. In the remaining fourteen cases,
f-he nesulfs ‘s’s-en-c fair- to poor for the following reasons:
1. Tcchnioiune not adapted for- deformity (insinfficicn( cxtninsic munsclc po’s’s-en- about
the thumb) in six patients.
2. Fault-v sinrgical techrsidlue (tendon placed unndcn insufficient- tension) in founr cases.
3. Tendon pullco! loose from its attachment in the thumb phalanx in one patient.
4. The pncscnce of ado!unc(ion contrac(-unre ahount the thumb (the contn-acfurre ‘s’s-as not
overcome pr’ior to tn-ansplantation) in three patients.
The rcnsaining eighteen thunmhs of the total of ninety-one ‘sverc tneated by miscellane-
ours opcnative proccdures, as follo’svs:
1. A sinhlimis 1i’ansplantation to the fhinmb, sunpplcmentcd by nedircction of other
tenidons to the thunmh, index finger’, or’ wrist, ‘svas done in eight cases. Two of these t-hinmbs
hiac! car’pometacar’pal fusion for- hypermobility, in addition to (he tendon transplant at ion.
The rcsunl(s ‘svenc excellent in six of this series.
2. A free gu’aft, the l)clonaeins longurs (cndlOfl ‘svi(hs (he flexoi caupi trlnai-is being used
as the nsoton, was applied in two cases. The rcsults ‘s’s-en-c excellent- in both.
3. Rotation os(cotomy of the proximal phalanx of (-he thumb toward the palm ‘s’s-ifh-
out (cndlon transplantation ‘s’s-as done t’svicc. A good “pincher-” niovement ‘s’s-as obtained
in each case, bust the appcanancc of (he thumb ‘s’s-as poor.
4. Synos(osis of the thumb and index-finger metacarpal ‘s’s-as performed in fourr cases.
The resinlt ‘s’s-as not good in any one, hurt the procedure cannot be condemned on this basis.
5. The Steindler tendon transplantation was olone on two thumbs. The end result
in neither of these ‘s’s-as satisfactor’v.

CONCLUSIONS

1 . Ins (he cauly treatment of paralytic o!cfonmitics of (he hand, (-he prevention of sof-
(issine cc)nfr-actuncs and! joint changes is important.
2. Tu’ansplant-ation of the flexon’ digitorum sublilnis of (he ring finger- to the proximal
phalanx of (lie tlsinmh has givens (lie niiost satisfacton’y s-esul(-s in this Clinio-, and has ful-
filled all the r’eoiunircment of opposition arid! increased strength.

THE JOURNAL OF BONE AND JOINT SURGERY

 PARALYTIC THUM B DEFORMITIES 639

3. Before operation is done, certain prerequisites must he fulfilled. The type of stir-
gical procedure used depends upon the existing anatomy of f-he hanoi. The result- ‘s’s-ill
depend upon the proper choice of procedures.

REFERENCES

1. ABBOTT, L. C.; SCHOTTSTAEDP, E. R.; SAUNDERS, J. B. DEC. M.; arid BOST, F. C.: The Evaluation of
Cortical arid Cancellous Bone as Grafting Material. A Clinical and Experimental Study. J. Bone and
Joint Surg., 29: 381-414, Apr. 1947.
2. BALDWIN, \\. I. : Orthopaedic Surgery of the Hand and Wrist-. In Orthopaedic Surgery of Insjuries, Vol.
1, Edited by Sir Robert Jones. London, Henry Frowde and Hodder & Stoughton, 1921.
3. BUNNELL, STERLING: Surgery of the Hand. Philadelphia, J. B. Lippincott Co., 1945.
4. EGGERS, G. W. N. : Chronic Dislocation of the Base of the Metacarpal of the Thunib. J. Bone and Joint
Surg., 27: 500-501, July 1945.
5. GRAHAM, W. C. : Flexor-Tendon Grafts to (-he Finger and Thunib. J. Boise and Joinit- Surg., 29: 553-559,
Jun13’ 1947.
6. HAYMAKER, WEBB, and WOODHALL, BARNES: Peripheral Nerve Injuries. Principles of Diagniosis.
Philadelphia, W. B. Saunders Co., 1945.
7. HOLLINSHEAD, W-. H., and MARKEE, J. E. : The Multiple Innervation of Limb Muscles in Man. J. Bone
and Joint Surg., 28: 721-731, Oct. 1946.
8. IRWIN, C. E. : Transplants to the Thumb to Restore Functions of Oppositioni : l-nid Results. Southern
Med. J., 35: 257-262, 1942.
9. KIRKLIIc, J. W., and THoMAs, C. G., JR. : Opponsens Transplsonst: An Analysis of the Met-hodls Employed
and Results Obtained in Seventy-five Cases. Surg., Gynec.. and Obstet., 86: 213-223, 1948.
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1 1. MAYER, LEO: Operative Reconstruction of (he Paralyzed Upper Extrensity. J. Boise sonid Joust Surg.,
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12. PHALEN, G. S., and MILLER, R. C. : The Transfer of Wrist Extenisor Muscles to Restore or Reinforce
Flexion Power of (he Fingers and Opposition of the Thumb. J. Bone sonid Joinst Surg., 29: 993-997, Oct.
1947.
13. ROYLE, N. D. : An Operation for Paralysis of the Intrinsic Muscles of the Tisunnib. J. Ann. Med. Assis.,
111: 612-613, 1938.
14. SLOCUM, D. B. : Stabilization of the Articulation of the Gresoter Multsongulsor 5015db the First Metacarpal.
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Surg., 1943.
15. SMITH, F. M. : Late Rupture of Extensor Pollicis Longus Tendon Following Colles’s Fracture. J. Bone
and Joint Surg., 28: 49-59, Jan. 1946.
16. STEINDLER, A. : Tendon Transplantation ins the Upper Extremity. Ans. 1. Sung., 44: 260-271, 1939.
17. THoitipsoN, C. F. : Fusion of Metacarpals of Thumb and Index Finsger to Msoinitsoins Funsctiorssol Position
of the Thumb. J. Boise and Joint Surg., 24: 907-911, Oct. 1942.
18. TH0MI’soN, T. C. : A Modified Operation for Opponenis Psoralysis. J. Bone 5011(1 Joinsi Sung., 24: (132-640,
July 1942.

VOL. 32-A. NO. 3, JULY 1950