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PubMed2004

The fundamental thumb-tip force vectors produced by the muscles of the thumb.

A rigorous description of the magnitude and direction of the 3D force vector each thumb muscle produces at the thumb-tip is necessary to understand the biomechanical consequences to pinch of a variety of paralyses and surgical procedures (such as tendon transfers). In this study, we characterized the 3D force vector each muscle produces at the thumb-tip, and investigated if these thumb-tip force vectors scaled linearly with tendon tension. In 13 cadaver specimens, we measured the output 3D thumb-tip force vector produced by each tendon acting on the thumb, plus two common tendon transfers, as a function of input tendon tension. After fixing the hand to a rigid frame, we mounted the thumb by configuring it in standardized key or opposition pinch posture and coupling the thumb-tip to a rigidly held 6 degree-of-freedom force/torque sensor. Linear actuators applied tension to the distal tendons of the four extrinsic thumb muscles, and to six Nylon cords reproducing the lines of action of (i) the four intrinsic thumb muscles and (ii) two alternative tendon transfers commonly used to restore thumb opposition following low median nerve palsy. Each computer-controlled linear actuator ramped tendon tension from zero to 1/3 of predicted maximal muscle force expected at each tendon, and back to zero, while we measured the 3D force vector at the thumb-tip. In test/re-test trials, we saw thumb-tip force vectors were quite sensitive to mounting procedure, but also sensitive to variations in the seating of joint surfaces. We found that: (i) some thumb-tip force vectors act in unexpected directions (e.g., the opponens force vector is parallel to the distal phalanx), (ii) the two tendon transfers produced patently different force vectors, and (iii) for most muscles, thumb-tip force vectors do not scale linearly with tendon tension--likely due to load-dependent viscoelastic tendon paths, joint seating and/or bone motion. Our 3D force vector data provide the first quantitative reference descriptions of the thumb-tip force vectors produced by all thumb muscles and two tendon transfers. We conclude that it may not be realistic to assume in biomechanical models that thumb-tip force vectors scale linearly with tendon tensions, and that our data suggest the thumb may act as a "floating digit" affected by load-dependent trapezium motion.

Aged↗

PubMed1995

Control of thumb movements: EMG analysis of the thumb and its application to functional electrical stimulation for a paralyzed hand.

This paper describes the control of thumb movements by functional electrical stimulation (FES). In order to determine stimulation data of thumb muscles, activities of nine thumb muscles and the palmaris longus were analyzed in normal subjects by averaging their EMGs. In this analysis, it was found that well coordinated contractions of these thumb muscles were required for finer movements and precise positioning of the thumb. Based upon this analysis, several standard stimulation data for the thumb muscles were programmed and stored into a computer-controlled FES system. Input of the threshold and maximum stimulating voltages for individual thumb muscles of normal subjects to the system enabled automatic creation of stimulation data for each subject. The thumb movements of the normal subjects induced by these data were very smooth and their trajectories were reproducible. In addition, precise thumb positioning and joint stability were easily obtained. These standard stimulation data for the thumb muscles were also applied to FES control of a C4 quadriplegic. The controllability of the thumb movements was improved and the reliability of hand tasks achieved by FES was increased.

Adult↗

PubMed2006

Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues.

OBJECTIVE: To introduce a new technique of 1-stage reconstruction for thumb loss complicated by thumb-index web space contracture and to report its clinical effectiveness. METHODS: From November 1994 to September 2004 there were 11 patients with thumb loss and contracture in the thumb-index web space who had a combined transplantation of free tissues to reconstruct the missing thumb and to rebuild the web space. The reconstructive procedure used the second toe and the anterolateral thigh flap in 5 patients, the second toe and the scapular flap in 2, the big toe wraparound flap and the anterolateral thigh flap in 3, and the big toe wrapround flap and the scapular flap in 1. The 2 independent free tissues were connected together by a vascular combination to form an assembly with 1 common vascular pedicle, which then was anastomosed to the selected vessels in the recipient hand. In this vascular series the dorsalis pedis artery and the greater saphenous vein served as the common vascular pedicle of the flap transfers and the radial artery and the cephalic vein provided the recipient vessels. The outcomes of the reconstructions were evaluated using the Michigan Hand Outcomes Questionnaire. RESULTS: The flaps survived completely in all patients except 1. In this patient a small area in the distal part of the transplanted anterolateral thigh flap became necrotic but healed after dressing changes without the need for further surgical intervention. A mean follow-up period of 3.6 years showed a mean increase of 4.3 cm in the width of the thumb-index web space and a considerable improvement in overall hand function was noted on the Michigan Hand Outcomes Questionnaire with effect sizes of greater than 3 (large effect) in all domains. CONCLUSIONS: Combined transplantation of the second toe or the big toe wraparound flap and a free skin flap is suitable to reconstruct a missing thumb and repair the associated skin defect in the adjacent thumb-index web space. We found good functional recovery and an acceptable appearance in this series of patients. Type of study/level of evidence: Therapeutic, Level IV. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Activities of Daily Living↗

PubMed2003

Video-computer quantitative evaluation of thumb function using workspace of the thumb.

This study develops the basis for video-computer quantitative evaluation method for measuring degree of thumb impairment. The system evaluates the three-dimensional space (workspace) within which the thumb-tip moves and computes its surface area. This study is intended to be the basis of a subsequent study which will compute the percentage of actual use compared to the "ideal" value for the given thumb length. Based on this quantitative measurement, the movement function of the impaired thumb can be identified objectively. Repeatability testing confirms that the video motion analysis system is a reliable tool for measuring the workspace of thumb-tip motion. It is also shown experimentally that there is a linear correlation between the surface area of thumb-tip motion workspace and the square of the thumb length. Accordingly, this method may be used to evaluate the functional abnormalities and deformities of the thumb.

Adolescent↗

PubMed2000

Combined free toe and free deep inferior epigastric perforator flap for reconstruction of the thumb and thumb web space.

To repair a complexly injured hand with composite loss of the thumb and the thumb web space in one stage, the combined transfer of a free second toe and a free deep inferior epigastric perforator flap was designed. It was used to simultaneously reconstruct the thumb and thumb web space of the injured hand in five cases. All flaps survived and there were no complications at any donor site after the reconstructions. In follow-up averaging 35.6 months, the final functional and cosmetic outcomes of the reconstructed thumbs and thumb web spaces were satisfactory. Results demonstrated that the combined transfer of a free second toe and a free deep inferior epigastric perforator flap is a valid method for simultaneous reconstruction of the thumb and the thumb web space of the injured hand.

Abdominal Muscles↗

PubMed2006

Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures.

Pain is common in the thumbs of physiotherapists. The purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain. One hundred and twenty-nine physiotherapists who attended the Musculoskeletal Physiotherapy Association Conference (2003) participated. After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed. There was an association (p<0.05) between work-related thumb pain and alignment of the thumb during performance of PA pressures: participants who were able to maintain their MP and IP joints in extension were less likely to report pain. These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.

Adult↗

PubMed1991

Triphalangism in thumb polydactyly: an anatomic study on surgically resected thumbs.

Surgically resected thumbs in preaxial polydactyly were submitted to anatomic dissection to detect a triphalangeal thumb. Radiologically, two particular categories of thumbs with duplication at the metacarpophalangeal joint were seen. The surgically excised thumbs of either the radial or the ulnar member were preserved for dissection. Depending on the number of phalanges as well as on osteocartilaginous structures, the thumbs were classified into three groups. In the first group, the thumbs consisted of three phalanges but had absent joint formation between the phalanges and metacarpal. The second group consisted of three phalanges with two well-formed joints between them. The third group of thumbs also had three phalanges but had only one interphalangeal joint between them. In all three groups, morphologic features and clinical criteria are discussed.

Humans↗

PubMed1999

The effect of maintaining a constant preload or a constant degree of thumb abduction in the isometric twitch force of the thumb.

OBJECTIVE: To investigate the effects of maintaining a constant preload and of maintaining a constant degree of thumb abduction on the isometric twitch force during mechanomyography of the thumb, we monitored neuromuscular function in patients anaesthetized without the use of a neuromuscular blocking agent. In addition, we studied the relationship between the degree of thumb abduction, twitch force and preload. METHODS: Fourteen patients were divided randomly into two groups, determining the sequence of the experiments in respect of correcting the preload and maintaining a constant degree of abduction after allowing the twitch forces to stabilize. Both experiments lasted 15 minutes. In both groups the relationship between the degree of thumb abduction, twitch force and preload was studied. RESULTS: We found a progressive increase in twitch force both with (6.6%; CI: 3.7-9.3%; p < 0.001) and without (1.9%; CI: 0.4-3.5%; p = 0.020) continuous correction of the thumb preload. A significant greater increase in twitch force was seen when the preload had been corrected than when it was not (4.7%; CI: 0.8-8.7%; p = 0.023). In addition, both twitch force and preload appeared to depend on the degree of thumb abduction both before and at the time of measurement. CONCLUSIONS: Changes in length of the contracting muscle fibres and creep phenomena in the connective tissue of the muscles, both leading to changes in the sarcomere length of the muscle fibres, may explain the observations in this study. In general, a stabilized preload at a constant degree of abduction seems to be required in order to obtain a stable twitch force.

Adult↗

PubMed2004

[Application of the dorsoulnar arterial retrograde flap of the thumb to repair of soft tissue defect at the distal thumb].

OBJECTIVE: To introduce the surgical procedure and indication of the dorsoulnar arterial retrograde flap of the thumb in repair of soft tissue defect. METHODS: From March 2000 to March 2001, 12 cases of soft tissue defect with exposed bone at the distal thumb were involved. Ten flaps were pedicled distally at the proximal rotation point, 2.5 cm proximal to the cuticule. Two flaps were pedicled distally at the distal rotation point, 1.0 cm proximal to the cuticule. The flaps harvested in this study were 1.1 cm x 1.3 cm to 1.8 cm x 2.5 cm. RESULTS: All the flaps survived. After an follow-up of 2 to 14 months postoperatively, the appearance of the thumbs were satisfactory, except those of 2 thumbs repaired by the flaps transferred at the distal rotation point, which were bulkiness because of the uncovered pedicle. In 6 cases, the defect of finger pulp was repaired, and the 2-point discrimination was measured 8-10 mm. The same range of motion of the thumb IP joint were observed in both sides in all cases. CONCLUSION: The optimal indication of the procedure is soft tissue defect at the distal thumb.

Adult↗

PubMed1999

[Post-traumatic palmar instability of the thumb metacarpophalangeal joint. The "other skier's thumb"].

"Passive" and "active" stabilizers give the thumb metacarpophalangeal (MP) joint the necessary palmar stability. It is possible to temporarily stabilize the joint by means of the flexor muscles in cases where there is an injury to the palmar ligaments due to hyperextension trauma. However, sudden severe or prolonged strain may lead to palmar instability and/or stress-related pain. In an experimental study, the MP joints of 40 specimen thumbs were hyperextended to varying degrees. The extent of tissue damage was evaluated during dissection. Between 1984 and 1992, in 72 cases with acute hyperextension injury of the thumb MP joint, we X-rayed the thumb under stress during primary examination. Habitual instability was excluded by comparing X-ray films under stress of the opposite uninjured thumb. The treatment of the lesion depends on the degree of instability documented by the X-ray films. Experimentally, we found only partial lesions or ruptures with only slight dislocation of the ligament ends in cases where the MP joint was hyperextended up to 30 degrees. In cases with hyperextension of 60 degrees or more, there was usually a complete rupture of the ligaments or a fracture of the sesamoid bones with dislocation of the ligament ends as well as partial rupture of the thenar muscles. This injury pattern was also observed in clinical cases during surgery. Partial lesions of the palmar ligaments of the thumb MP joint can be treated conservatively with good results. In cases of complete palmar instability due to trauma, we saw better results after surgical reconstruction of the ligaments particularly in manual workers.

Athletic Injuries↗

PubMed1992

[Thumb reconstruction with cryopreserved autogenous thumb skeleton and microneurovascular flap].

This paper describes a procedure for thumb reconstruction using autogenous cryo-conserved bone from the thumb itself. In a case of severe explosion injury, the thumb and index finger were amputated at the carpometacarpal joint level and the remaining fingers at the distal interphalangeal joint level. Severe soft tissue damage and lesion of both the superficial and deep palmar arterial arches rendered customary surgical procedures for thumb reconstruction impossible. The cryo-conserved bone was replanted following soft tissue healing and then covered with a free radial forearm flap. This procedure resulted in a stable and painfree thumb and provided satisfactory grip.

Adult↗

PubMed2006

[Thumb duplication: an analysis of 72 thumbs].

OBJECTIVES: The aim of this study was to evaluate patients who were operated on for a duplicated thumb. METHODS: Sixty-seven patients (41 females, 26 males; mean age 2.5 years; range 6 months to 20 years) underwent surgery for a total of 72 duplicated thumbs between 1982 and 2003. Five patients had bilateral involvement. The anomaly was on the right in 39 cases, and on the left in 33 cases. Clinical and radiographic evaluations were made according to the Wassel classification. The Bilhaut-Cloquet technique was used in 13 symmetrically duplicated thumbs, while simple excision of the unserviceable part was performed in the remaining. Patient satisfaction was assessed with the use of a visual analog scale after a mean follow-up period of 3.6 years (range 1 to 10 years). RESULTS: Nail deformity was present in all cases treated by the Bilhaut-Cloquet technique. These thumbs did not exhibit growth retardation, but interphalangeal joint motion was limited in five, while seven had a larger size compared to the normal side. Limited range of motion was detected in eight cases (11.9%), affecting the metacarpophalangeal joint in one, and the interphalangeal joint in the others. Seventeen patients (25.4%) developed an angulation of more than 10 degrees in the alignment of the thumb. Secondary procedures were necessary in 25 cases (37.3%), including collateral ligament reconstruction (n=12; 17.9%), tendon rerouting (n=3; 4.5%), corrective osteotomy (n=5; 7.5%), and arthrodesis of the interphalangeal joint (n=5; 7.5%). Patient satisfaction with the surgical outcome was 85% (n=57). CONCLUSION: It is important to evaluate and treat the skin, nail, bone, and the ligaments in a simultaneous manner in order to obtain a good reconstruction and to decrease both the complications and the need for subsequent operations.

Adolescent↗

PubMed1996

Acquired thumb flexion contracture in children: congenital trigger thumb.

We examined prospectively 4719 newborn infants to determine the congenital incidence of trigger thumb. No cases were found. Fifteen other children aged from 15 to 51 months had surgery for this condition. The anomaly had not been seen at birth and all thumbs presented with a flexion contracture without triggering. The condition is usually seen after birth as a flexion contracture of the interphalangeal joint. The term 'congenital' is a misnomer because patients acquire the deformity after birth. The term 'trigger' is inaccurate as most thumbs show a fixed-flexion contracture without triggering. We suggest that rather than 'congenital trigger thumb' a more appropriate description of this disorder is 'acquired thumb flexion contracture in children'. If the contracture persists after one year of age, treatment by dividing the A-1 pulley is simple and effective.

Child, Preschool↗

PubMed1999

Alternatives to thumb replantation in three cases of traumatic amputation of the thumb.

Three cases of complete amputation of the thumb are reported in which the amputated distal parts were not suitable for replantation. In all cases there were either complete or incomplete amputations of other digits. Two different techniques were used for thumb reconstruction: 1) pollicization of a partially amputated digit with transposition microsurgery in case 1; and 2) replantation of a less important amputated digit to the thumb stump for cases 2 and 3. These microsurgical efforts successfully restored thumb function in all three patients.

Adult↗

PubMed2000

Are triphalangeal thumb-polysyndactyly syndrome (TPTPS) and tibial hemimelia-polysyndactyly-triphalangeal thumb syndrome (THPTTS) identical? A father with TPTPS and his daughter with THPTTS in a Thai family.

We report on a Thai man who had triphalangeal thumb-polysyndactyly syndrome (TPTPS, MIM *190605) and his daughter who had tibial hemimelia-polysyndactyly-triphalangeal thumb syndrome (THPTTS, MIM *188770). The father had polysyndactyly of triphalangeal thumbs, syndactyly of fingers, duplicated distal phalanx of the left great toe, brachymesophalangy of toes, and the absence of middle phalanges of some toes. He was diagnosed as having TPTPS. His daughter was more severely affected, having complete syndactyly of five-fingered hands in rosebud fashion (Haas-type syndactyly), hypoplastic tibiae, absent patellae, thick and displaced fibulae, preaxial polysyndactyly of triphalangeal toes, and cutaneous syndactyly of some toes, the manifestations being consistent with THPTTS. Having two different syndromes in the same family suggests that they are actually the same disorder. A literature survey showed that there have been several families where THPTTS occurred with TPTPS or Haas-type syndactyly (and/or preaxial polydactyly type 2, PPD2). In addition, all loci for TPTPS, THPTTS, and PPD2 (and/or PPD3) have been assigned to chromosome band 7q36. These findings support our conclusion that TPTPS, PPD2 (and/or PPD3), and Haas-type syndactyly are a single genetic en-tity (THPTTS). We propose to call the condition "tibial hemimelia-polysyndactyly-triphalangeal thumbs syndrome."

Adult↗

PubMed1987

Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint.

Amputation of the thumb, including the basal joint, is a disabling injury that leaves limited reconstructive options. Three cases of multiple digit amputation including the thumb and basal joint are presented in which a second toe transfer was used to reconstruct the thumb. All patients have functional pinch with an average pinch strength of 27% of the opposite uninjured extremity. The average grip strength for two patients is 44% of the opposite hand. Average motion of the transfer at the MP, PIP, and DIP is 25 degrees, 37 degrees, and 9 degrees, respectively. Adduction and abduction are obtained, the degree depending on the site of proximal bony fixation. No patient has morbidity at the donor site and all are happy with their reconstruction. In selected cases we feel second toe transfer is an excellent choice to reconstruct the thumb amputated at a proximal level.

Adult↗

PubMed2004

"Floating thumb metacarpal" or complete dislocation of the thumb metacarpal: a case report and review of the literature.

We present a case of a patient with a simultaneous dislocation of the metacarpophalangeal (MP) and the carpometacarpal (CMC) joint of the thumb as an isolated injury, and we review the relevant literature. We found only three previous reports in the literature, two reports as an isolated injury and another similar injury combined with a carpometacarpal fracture-dislocation of all four fingers. A closed reduction of both joints followed by an open repair of the torn ulnar collateral ligament of the MP joint and Kirschner-wire (K-wire) stabilization of the CMC joint led to a good result at 1 year. This rare injury has been described as a "complete dislocation of the thumb metacarpal" or as a "simultaneous dislocation of the MP and CMC joints of the thumb". We suggest it is a "floating thumb metacarpal".

Adult↗

PubMed1991

Thumb duplication and contralateral thumb hypoplasia in infant of mother with diabetes.

Uncontrolled maternal diabetes frequently results in congenital anomalies. This report describes an infant of a mother with diabetes born with thumb hypoplasia and contralateral thumb duplication without other associated anomalies. Maternal diabetes should be part of the etiologic differential diagnosis of thumb anomalies. The concomitant occurrence of thumb duplication and hypoplasia, apparently as a result of the same systemic insult, suggests a close relationship between hypoplasia and duplication.

Adult↗