Management of a Thumb-In-Palm Deformity in Adult Patients With Upper Motor Neuron Syndrome

Published:September 01, 2022DOI:
      The thumb-in-palm (TIP) deformity in adults with upper motor neuron syndrome results from an imbalance of extrinsic and intrinsic muscular forces. Traditionally, the thumb is adducted against the index ray, and flexed to varying degrees at the metacarpophalangeal and interphalangeal joints. However, not all TIP deformities result from the same underlying imbalances. The severity of the deformity ranges over a spectrum dependent upon the involved muscle groups and underlying spasticity, myostatic contracture, and/or joint contractures. Surgical procedures for correcting a TIP deformity can be classified broadly as procedures used for functional, present volitional motor control, versus nonfunctional, absent motor control. Techniques include tenotomies, tenodeses, tendon lengthenings, tendon transfers, tendon reroutings, neurectomies, and joint releases. A focused physical examination is key in developing a patient-specific treatment algorithm.

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        • Matev I.
        Surgery of the spastic thumb-in-palm deformity.
        J Hand Surg Br. 1991; 16: 127-132
        • Botte M.J.
        • Keenan M.A.
        • Gellman H.
        • Garland D.E.
        • Waters R.L.
        Surgical management of spastic thumb-in-palm deformity in adults with brain injury.
        J Hand Surg Am. 1989; 14: 174-182
        • Keenan M.A.
        Management of the spastic upper extremity in the neurologically impaired adult.
        Clin Orthop Relat Res. 1988; 233: 116-125
        • Rhee P.C.
        Surgical management of upper extremity deformities in patients with upper motor neuron syndrome.
        J Hand Surg Am. 2019; 44: 223-235
        • Photopoulos C.D.
        • Namdari S.
        • Baldwin K.D.
        • Keenan M.A.
        Decision-making in the treatment of the spastic shoulder and elbow: tendon release versus tendon lengthening.
        JBJS Rev. 2014; 2 (01874474–201410000-00004)
        • Pomerance J.F.
        • Keenan M.A.E.
        Correction of severe spastic flexion contractures in the nonfunctional hand.
        J Hand Surg Am. 1996; 21: 828-833
        • Pappas N.
        • Baldwin K.
        • Keenan M.A.
        Efficacy of median nerve recurrent branch neurectomy as an adjunct to ulnar motor nerve neurectomy and wrist arthrodesis at the time of superficialis to profundus transfer in prevention of intrinsic spastic thumb-in-palm deformity.
        J Hand Surg Am. 2010; 35: 1310-1316
        • Manske P.R.
        Redirection of extensor pollicis longus in the treatment of spastic thumb-in-palm deformity.
        J Hand Surg Am. 1985; 10: 553-560
        • Tonkin M.A.
        • Hatrick N.C.
        • Eckersley J.R.
        • Couzens G.
        Surgery for cerebral palsy part 3: classification and operative procedures for thumb deformity.
        J Hand Surg Br. 2001; 26: 465-470
        • Alewijnse J.V.
        • Smeulders M.J.
        • Kreulen M.
        Short-term and long-term clinical results of the surgical correction of thumb-in-palm deformity in patients with cerebral palsy.
        J Pediatr Orthop. 2015; 35: 825-830