Classification and Surgical Treatment

of the Thumb-in-Palm Deformity in

Cerebral Palsy and Spastic Paralysis
Harilaos T. Sakellarides, MD, Mohinder A. Mital, MD,
Richard A. Matza, MD, Panagiotis Dimakopoulos, MD, Boston, MA

Over a 20-year period, 59 children with spasticity mainly due to cerebral palsy underwent
surgery for correction of a thumb-in-palm deformity. A classification of the deformity based
on the functional anatomy of the thumb divided the problem into four different types. A ret-
rospective analysis of the results has shown the classification to be helpful in selecting a
surgical option for treatment. In addition, the classification helps to keep accurate records,
predict patient progress, and coordinate postoperative treatment. (J Hand Surg 1995;
20A:428~31 .)

Hand deformities are a major handicap and a diffi- Classification and Treatment
cult treatment problem in patients with cerebral palsy
or spastic hemiplegia. Pinch and grip are compro-
Type 1
mised by a thumb-in-palm deformity (Fig. 1). Not In type 1 thumb-in-palm deformity, the deformity
only is the thumb function lost, but the other fingers is secondary to a weak or paralyzed extensor polli-
are obstructed by the thumb's physical presence in cis longus (Fig. 2A). To treat type 1 deformity, the
the palm. Thumb function is estimated to be 50% of palmaris longus or flexor carpi radialis is trans-
hand functionJ Preoperative evaluation of the family ferred to the extensor pollicis longus. Bowstringing
as well as the patient is important to determine suit- of the rerouted tendon is prevented by constructing
ability for treatment. In our experience, a patient 5
years or older with an intelligence quotient of 70 or
higher, without a rejected extremity, with reasonable
stereognosis and who has plateaued with therapy is a
good surgical candidate.

From Franciscan Children's Hospital, Department of Hand Surgery

and Orthopaedics, Brighton, MA, and Boston University School of
Medicine, Boston, MA.
Received for publication Sept. 5, 1991; accepted in revised form July
11, 1994.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Harilaos T. Sakellarides, MD, 3 Hawthorne Place,
Suite 105, Boston, MA 02114. Figure 1. Thumb-in-palm deformity.

428 The Journal of Hand Surgery

 The Journal of Hand Surgery / Vol. 20A No. 3 May 1995 429

Figure 2. (A) Preoperative type 1 deformity of the thumb showing weakness of the extensor pollicis longus. (B) Same thumb
3 months after rerouting of extensor pollicis longus around the radial styloid, and tendon transfer of the flexor carpi radialis.

Figure 3. (A) Right thumb of a patient with type 2 deformity, contracture of adductor pollicis. (B) Same thumb 2 months post-
operatively with good pinch following release of the adductor pollicis, abductor pollicis brevis, and opponens.

a pulley from the proximal half of the fibrous
sheath of the abductor pollicis longus and extensor
pollicis brevis tendon (Fig. 2B).
Type 2
A spastic or contracted adductor pollicis, flexor pol-
licis brevis, and abductor pollicis brevis with or with-
out first dorsal interosseous involvement characterizes
a type 2 deformity. Contracture of the thumb web is
occasionally present (Fig. 3A). In such cases, the treat-
ment is release of the thenar muscles and the first dor-
sal interosseous with carpal tunnel release. If the
thumb-index web space is contracted, release is
required (Fig. 3B).
43,0 Sakellarideset al./Thumb-in-Palm-Deformity

Figure 4. (A) Right thumb of a patient with type 3 deformity before surgery. (B) Same patient showing the thumb with
improved position. The abductor pollicis longus was routed around the flexor carpi radialis. One half of the tendon reinforced
the lax carpometacarpal joint capsule and the other half of the tendon was advanced distally along the thumb metacarpal and
sutured closed to the metacarpophalangeal joint.

Figure 5. (A) Right thumb of patient with type 4 deformity from contracture of flexor pollicis longus before surgery. (B)
Same thumb 5 months postoperatively with good correction of the thumb-in-palm deformity after the lengthening of the

Type 3 ing of the contracted flexor pollicis longus proximal

A type 3 deformity defines the case of a weak or
paralyzed abductor pollicis longus (Fig. 4A).
Treatment is as follows: abductor pollicis longus
power is augmented by rerouting it around the flexor
carpi radialis and advancing its insertion distally. If
the carpometacarpal joint is unstable, the capsule is
plieated and augmented with part of the abductor pol-
licis longus. Web space release may also be required.
Type 4
A type 4 deformity is defined as a spastic or con-
tracted flexor pollicis longus (Fig. 5A). Z-lengthen-
to transverse carpal ligament is the appropriate treat-
ment (Fig. 5B).
Multiple Deformities
If the patient has more than one of these condi-
tions, the most disabling deformity is initially cor-
rected along the foregoing guidelines. The residual
deformity is reassessed and corrected appropriately
after a period of observation.
Materials and Methods
In a retrospective review, 59 patients, 23 male
and 36 female, had 59 procedures for thumb-in-
 The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
Table 1. Functional Classification
Excellent Good use of the hand.
Effective grasp and release and with voluntary
control.
The patient could use the thumb in hand functions
satisfactorily for everyday activities, such as
combing hair, eating with utensils without assis-
tance. There was no recurrence of the deformity.
Good Helper hand.
Effective grasp and release.
Some satisfactory voluntary control.
The patient could use the thumb and hand func-
tions well and use utensils to eat, or grasp and
pinch about 20-25% less than the opposite side.
Fair Helper hand.
Fair control of the thumb.
The hand functions, grasp and pinch, are about
50% less than the opposite side.
Minimal recurrence of the deformity requiring
night splinting. However, the parent and patient
were satisfied with the results due to the very
substantial improvement in hand function.
Poor Helper hand.
Paper weight--absent grasp and release.
No improvement from the preoperative status.
p a l m deformities and were followed f r o m 2 to 20
years. The diagnosis was spastic cerebral palsy in
42, traumatic e n c e p h a l o p a t h y in 8, spastic hemiple-
gia in 8, and spastic quadriplegia in 1. T h e y were
all e x a m i n e d by the senior author (H.T.S.) at each
follow-up visit. T w e n t y - f i v e of the 59 patients had
type 1 deformity, 18 type 2, 8 type 3, and the
remaining 8 patients type 4. Ten patients had two
types o f deformities.
The p r e o p e r a t i v e evaluation included functional
and cognitive assessment, as well as testing of the
muscles, range of motion, and sensibility. The
function was graded according to the classification
of G r e e n and Banks 2 as modified by Samilson and
431
Morris 3 (Table 1). T h e results w e r e classified as
excellent, good, fair, or p o o r b a s e d on the func-
tional outcome.
Results
The functional outcome o f 59 patients was as fol-
lows: 8 excellent, 30 good, and 21 fair results. No
patient's result was graded poor. The excellent and
good results occurred in patients with cerebral palsy,
and the fair results were most often found in the
patients with gross traumatic encephalopathy. Our
results were based on repeated clinical examinations;
no electromyelography studies were used.
Discussion
In all forms of spastic conditions involving the
upper extremity, thumb-in-palm deformity is recog-
nized as one of the more c o m m o n and disabling
problems limiting hand function. Since it is rarely an
isolated problem, its treatment is timed and inte-
grated with the treatment of other deformities.
T h u m b - i n - p a l m deformity m a y decrease the func-
tional capacity of the hand by 50% and m a y be an
important contributor to rejection of the extremity. In
this patient group, early recognition of the deformity
with treatment yielded the best results.
References
1. Inglis AE, Cooper W, Bruton W. Surgical correction of
thumb deformities in spastic paralysis. J Bone Joint Surg
1970;52A:253-68.
2. Green WT, Banks HH. Flexor carpi ulnaris transplant and its
use in cerebral palsy. J Bone Joint Surg 1962;44A: 1343-52.
3. Samilson RL, Morris JM. Surgical improvement of the cere-
bral palsied upper limb: electromyographic studies and
results of 128 operations. J Bone Joint Surg 1960;
42A:951-64.