Clasped

(flexus adductus)
Thumb

Christian Dumontier MD, PhD

Centre de la Main, Guadeloupe, FWI
 Clasped thumb

• Very rare

• Attributed to Zadeck (1934)

• Tightly flexed and adducted

thumb under the fingers

• Normal up to 3-4 months of

age (should disappear during
Moro’s reflex)
 Pathology
• Extension is provided by the thumb extensors and
abductors :

• APL stabilizes the 1st metacarpal bone and

abducts the thumb out of the palm.

• EPB: extends and abducts the thumb at the MP

• EPL extends the interphalangeal joint

 Clinical presentation

• MP extension deficit (EPB

deficit)

• IP extension deficit
sometimes (EPL)

• Thumb adduction (APL

deficit +/- Adductor pollicis
retraction)
 Differential diagnosis

• Trigger thumb

• Spastic thumb deformity

 (Old) Classification
• Group 1: Deficit in • Group 1: without
extension only contracture of soft-
tissue
• Group 2: Flexion
contracture is noticed • Group 2:
contracture of the
• Group 3: Hypoplastic palmar side
thumb
• Group 3:
• Group 4: Other cases arthrogryposis

Weckesser EC, Reed JR, Heiple KG (1968). Congenital clasped thumb (congenital flexion-adduction deformity of the
thumb). JBJS Am, 50A: 1417-1428.
Tsuyuguchi Y et al. Congenital clasped thumb. A review of 43 cases. J Hand Surgr 1985;10A:613-618.
 Preferred classification

• Type 1: supple thumb, congenital absence of

extensors

• Type 2: Complex deformity with stiffness,

ligamentous anomalies, 1st web retraction,..

• Type 3: arthrogryposis or Syndromic

McCarroll Jr HR. Congenital flexion deformities of the thumb. Hand Clin 1985;1:567–75.
Mih AD. Congenital clasped thumb. Hand Clin 1998;14:77–84.
 Evaluation of results (Weckesser)
• Excellent (no limitation of active extension of either the
metacarpophalangeal or interphalangeal joint),

• Good (limitation of active metacarpophalangeal extension of

15° or less, active interphalangeal extension complete),

• Fair (limitation of active metacarpophalangeal extension of

15 to 30°, interphalangeal extension nearly complete),

• Poor (limitation of active metacarpophalangeal extension of

more than 30°, interphalangeal extension definitely limited).

Weckesser EC, Reed JR, Heiple KG (1968). Congenital clasped thumb (congenital ̄exion-adduction deformity of the
thumb). JBJS Am, 50A: 1417-1428.
 Non-operative treatment
• Splinting in extension and
abduction (in type 1 patients)

• Early results (2-6 months)

• 15/17 excellent results

• 70% good results if done before 1

year, 21% after 1 year, 0% after 2
years (Miura)

Lin SC et al. A simple splinting method for correction of supple congenital clasped thumb in infants. JHS Br
1999;24B(5):612-614.
Miura T. Flexion deformities of the thumb. In: Buck-Gramcko D, editor. Congenital malformations of the hand and
forearm. London: Churchill Livingstone; 1998. p. 425–9.
 Surgery is made stepwise

• Volar incision

• Web Z-plasty

• Thenar muscles release

• FPL lengthening
 Surgery is made stepwise
• Dorsal incision

• Chondrodesis for severe

MP instability

• Plication of the capsule in

mild laxity

• Reconstruction of APL
with a tendon graft

• Recontruction of extensors
using ECRL, FDS IV, EIP

⚠ If the EPL is hypoplastic, the EIP may be hypoplastic as well

 Flap reconstruction of the 1st web

Mahmoud M, Abdel-Ghani H, Elfar JC. New Flap for Widening of the Web Space and Correction of Palmar
Contracture in Complex Clasped Thumb. (J Hand Surg 2013;38A:2251-2256.)
 Conclusion

• Rare condition, mostly bilateral

• Type 1 can be treated non-operatively if seen early

• Type 2 will require surgery that includes 1st web

opening, MP joint stabilisation and tendon transfer
for the EPB deficiency at least