Congenital Clasped Thumb

The term congenital clasped thumb implies a  spectrum of thumb anomalies ranging from mild deficiencies of the thumb extension  to severe abnormalities of the thenar muscles, web space, and soft tissues. It is also called congenital contracted or clenched thumb.

Congenital clasped thumb is rare anomaly. Involvement is almost always bilateral.

Males are more commonly affected than females and familial incidence has been observed.

Classification of Congenital Clasped Thumb

Following is an old classification and no longer used as it was clinically not relevant.

Group I

Deficient extension only. Extensor pollicis brevis is hypoplastic or absent. Sometimes the extensor pollicis longus muscle may also be involved.The tendons of these thumb extensors are not completely absent.They are attenuated into thin thread-like tendinous structures which narrow proximally and terminate into fibrofatty tissue and there is no real muscle attached to them. There is no fixed contracture and there are no other finger or hand anomalies.

Group II

Deficient extension combined with flexion contracture.There is flexion contracture of the thumb.There are significant flexion contracture of the other digits and, occasionally, mild flexion contracture of elbows and knees.

Group III

Hypoplasia of the thumb associated with deficiencies of muscles and tendons.The involvement is more severe and diffuse.

The thumb is small, the first metacarpal and its phalanges are hypoplastic, and the metacarpophalangeal joint is unstable.

There is partial or complete absence of the extensor tendons of the thumb, thenar muscles, and abductor pollicis longus.This group probably represents a mild form of longitudinal deficiency of the radial ray.

Group IV

The few cases not falling in the first three groups. Cases usually represent varying degrees of polydactyly with associated musculotendinous weakness.

Therefore following classification was proposed by McCarroll and expanded by Mih. This classification is more useful than previous one.

This  initial classifications attempted to subdivide the anomaly into individual types had  not been useful in the clinical setting.

congenital clasped thumb

congenital clasped thumb, Image Credit: Wustl.edu

Type I Congenital Clasped Thumb

Type I Congenital Clasped thumb is usually supple, and the extensor mechanism is either absent or hypoplastic.

Type II Congenital Clasped Thumb

Type II congenital clasped thumb is complex with additional findings of joint contracture, abnormality of collateral ligament , contracture of first web space , and abnormality of thenar muscle .

 Type III Congenital Clasped Thumb

Type III congenital clasped thumb, clasped thumb is associated with arthrogryposis or its associated syndrome, the extensor mechanism may have minimal or no abnormality.

Presentation

It must be noted that the first three to four months of infancy, grasp reflex is normal-the thumb is flexed across the palm and the fingers are flexed over the clutched thumb. Spontaneously and upon stimulation, the infant will actively extend his fingers and thumb.This normal grasp posture should be distinguished from congenital clasped thumb.

At initial evaluation, the thumb rests in flexion with an extension lag. Hypoplasia of the extensor pollicis brevis, extensor pollicis longus and abductor pollicis longus may be present resulting in various positions of thumb.

Imaging

Xrays of bilateral hands and upper limbs should be done to find any bony abnormality and associated syndromes.

Treatment

Type I congenital clasped thumbs are treated wit splinting of the affected  joints in extension so as to prevent additional further weakening of  hypoplastic extensors. Surgery is required for patients in who splinting has failed or are seen when their age is more than 2 years.

The degree of problem guides for the treatment and it  must be considered during formulation of a treatment plan.

An extension that interferes with grasp  or  associated thumb MP joint or thumb–index finger web space contracture  require surgery.

In a type I clasped thumb, skin and subcutaneous tissue release is usually enough to correct the contracture. Z plasty or dorsal rotation advancement flap  may be required.

Palmar skin deficiency requires a rotational flap into the palmar aspect of the thumb MP joint.

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Comments

  1. Lloyd says

    Hi Dr Singh,

    My wife recently delivered a baby boy who has a duplicated thumb (polydactyly). Although the thumb has one stem, it has two thumbs at the top forming a Y. Both have bones and nails. We wish to have one of the thumbs surgically removed.

    I would really appreciate if you could provide us with some valuable information on the same and how much it usually costs to have the surgery done. What is the recovery time and what special care is needed during and after surgery.

    Thanks for your time and advise.

    Regards,

    Lloyd

  2. Dr Arun Pal Singh says

    @Lloyd,

    Please go through the article on Polydactyly

    It would help you. If there is any further query, please let me know/

  3. anthony says

    my son has hypoplastic thumbs and the doctor has told us that pollicization is the best option would tendon replacement be a better option

  4. Dr Arun Pal Singh says

    @anthony,

    The treatment is based on the severity and it may be possible that tendon transfers are not helping. Did you discuss it with your doctor.

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