Youngleson, J.H.

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716 S.A. MEDICAL JOURNAL 28 August 196556. Ishizaki, Y. and Belter. L. F. (1960): AlDer. J. Obstet. Gynec., 79.1074.57. Sundberg, R. D. (1956): Anat. Rec., 124, 368.58. Franklin, J. W., Zavala, D. C. and Radclilfe, C. E. (1952): Blood,7. 934.59. Johnsson, U. and Rundles, R. W. (1957): Jbid., 6, 16.60. Briining, E. G. H. (1964): Dennatologica (Basel), 128, 271.61. Van der Wait, J. J. (1965): Personal communication.62. Borghesan, E. (1964): Acta oto-Iaryng. (Stockh.), 57, 288.63. Billingham, R. E. and Silvers, W. K. (1960): Quart. Rev. BioI.,35, 1.64. Ikeda, S. (1962): Jap. J. Derm.. 72. 836.65. Mason, P. (1948): Ann. N. Y. Acad. ScL, 4, 28.66. Wintrobe. M. M. (1961): Clinical Haematology, 5th ed., p. 246.Philadelphia: Lea & Febiger.67. Wassermann, H. P. (1964): Blood. 24. 668.68. Idem (1965): Arch. Environm. Hlth. (in the press).69. Forbes. W. H., Johnson, R. E. and Consolazio, F. (1941): Amer. J.Med. Sci., 201, 407.70. Casley-Smith, J. R. (1959): Aust_ J. Exp. BioI. Med. 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Kikkawa, H., Ogita, Z. and FujilO, S. (1955): Science, 121, 43.87. Cope, F. W., Sever, R. J. and Polis, B. D. (1963): Arch. Biochem.,lOO. 171.88. Sever, R. J .. Cope. F. W. and Polis, B. D. (1962): Science, 137. 128.89. Gerritzen, T. and Walker, A. R. P. (1953): S. Afr. Med. J .. 27. 577.90. BothweH. T. H. and Isaacson, C. (1962): Brit. Med. J., I, 522.91. Perdrup, A. and Poulsen, H. (1964): Arch. Derm.. 90, 34.92. Salm, R. and Swinburne, L. M. (1963): J. Path. Bact.. 85, 297.93. Hedinger, C. (1953): Helv. med. Acta. 20. suppl. 32. I.94. Heilmeyer, L. (1954): Acta I·aemat. (Basel), 11, 137.95. Politzer. W. M. and Tucker, B. (1958): Lancet, 2. 778.96. Barnicot, . A. and Wolffson, D. (1952): Ibid., I, 893.97. Parkinson, L., Ghyoot. E .. Van Vlierberghe. R. and Bone. G. (1960):Trans. Roy Soc. Trop. Med. Hyg .. 54. 366.98. Higgin. D. and Wolffson, D. (1958): J. Trop. Med. Hyg., 61, 62.99. Satanove. A. (1965): J. Amer. Med. Assoc .. 191, 263.lOO. Engel. R. L. and Koprowska. I. (1959): Amer. J. Med.. 26. 965.101. Forbes. W., Steel, M. H. and Munro. H. W. (1964): Brit. J. Nutr..18. 55.102. Ephraim. A. J. (1959): Arch. Denn. Syph. (Chic.), 79, 228.103. Gail. D. (1957): Frankfurt. Z. Path .. 68. 64.104. Yoffey, J. M. (1960): Quantitative Cellular HemalOlogy. iIIinois:Charles C. Thomas.105. Arens. L. and Brock. J. F. (1954): S. Afr. J. Clin. Sci .. 5, 20.106. Van Heerden. P. D. R. and Brink, A. J. (1962): S. Afr. J. Lab. Clin.Med .. 8. 118.THE MANAGEMENT OF THE CONTRACTED FIRST WEB SPACEJ. H. YOUNGLESON,* M.B., CH.B. (CAPE TOWN), F.R.C.S. (EDIN.), ER.C.S. (ENG.), Plastic Surgeon, DurbanThe function of the thumb is usually assessed at between40 and 60% of the total function of the hand. The useful-ness of the hand as a whole depends on variations of thepinch grip and the power grip. The thumb forms one limbof the pinch grip, and of the radral component of thepower grip, as in holding a screwdriver-the ulnar com-ponent of the power grip is used as in holding a golf club.The position of the metacarpal determines the positionof the thumb tip for the pinch grip; when the metacarpalis fully abducted and extended it determines the 'span' ofthe hand, and so the grasp for the power grip. Hence theneed for a fully mobile thumb metacarpal with an adequatefirst web space to allow free movement of the thumb. Inboth the pinch grip and the power grip the metacarpal ofthe thumb swings across the palm as a gate which ishinged at the carpo-metacarpal joint.FUNCTIONAL ANATOMY OF THE FIRST WEB SPACEAllafomy of the Skill alld Subcutaneous TissuesAs shown in Fig. I, the distal free margin of the normalskin fold runs in a gentle curve from a point just distal to themetacarpo-phalangeal joint of the thumb to a point oppositethe metacarpo-phalangeal joint of the index finger. The distaledge of this fold is a supple margin formed by the fusion ofthe dorsal and palmar skin.The dorsal skin is relatively lax and separated from themuscles of the first web space by loose connective tissue inwhich run the dorsal digital nerves to the index finger, theorigin of the cephalic vein, and the terminal branches of theradial artery. These are the princeps pollicis artery, and theradialis indicis artery, with the terminal portion of the radialartery divi ng between the 2 he;;.ds of origin of the first dorsalinterosseus muscle to enter the palm and form the radial com-ponent of the deep palmar arch. These arteries of the first webspace commonly run a variable course. Should it prove neces-sary to divide one of these during operation, both ends shouldbe ligated.-Late Registrar. Det"artment of Plastic. Maxillo-F3cial and Oral Surgery.University of the Witwatersrand. Johannesburg.The palmar skin is thick 'gripping skin' which is attachedto the palmar fascia by vertical fibrous bands running throughthe palmar fat. There is a skin crease running obliquely acrossthe web ~kin of the thenar eminence where the skin foldswhen the thumb is brought across the palm. The neurovascularbundles to the adjacent sides of the index finger and the thumbemerge from under the palmar fascia and run along theadductor pollicis muscle into the index finger and thumb.Anatomy of the MusclesThe first dorsal interosseus muscle runs obliquely across thefirst web space from the base of the first metacarpal to theradial wing tendon of the extensor expansion of the indexfinger. The muscle belly is covered by a substantial fascialenvelope. The action of this muscle is important in stabilizingthe index finger for counter-pressure to the thumb in the pinchgrip. It is always supplied by the deep branch of the ulnarnerve.The adductor pollicis muscle arises by 2 heads which areseparated from the palmar surface of the first dorsal interos-seus muscle by loose areolar tissue.The fan~shaped transverse head arises from the distal two-thirds of the palmar surface of the shaft of the third metacar-pal. It is inserted by a common tendon from the obliquehead to form the ulnar wing tendon of the extensor expansionof the thumb.The oblique head arises from the bases of the second andthird metacarpals and the surrounding bones and ligaments ofthe carpus.The nerve supply to both heads is from the deep branch ofthe ulnar nerve. The oblique head at least may occasionally besupplied by the median nerve.'The action of this muscle is to adduct the thumb and tostabilize the metacarpo-phalangeal joint of the thumb bypulling on the wing .tendon. Hence its importance in both thepinch and the power grip. This action is opposed by long andshort abductor muscles; and by the long and short extensorpollicis muscles.First palmar illterosseus muscle (also called the deep headof flexor pollicis brevis) arises from the proximal half of thepalmar surface of the first metacarpal and is inserted with the28 Augustus 1965 S.A. TYDSKRIF VIR GENEESKUNDE 717adductor pollicis tendon. It is supplied by the deep branch ofthe ulnar nerve.MECHANISM OF CONTRACTURE OF THE FIRST WEB SPACEAs is shown in Fig. I, the normal thumb in the fullyabducted position forms an angle with the index finger of90°. In the normal adult the 'span' measures 6 - 7 in.from the tip of the thumb to the tip of the index finger.Any reduction of this means there is some degree of con-tracture of the first web space.The skin itself may be contracted as is seen in scarringfollowing burns. For relief of this contracture all scartissue must be excised, the secondary soft tissue contrac-tures must be corrected, and the resulting skin defectmust be covered by healthy pliable skin, using local flapsby preference. If no local flaps are available, free skingrafts, either full-thickness or thick split-skin may be used,but the grafts will always contract to some degree. Rarely,a flap from a distance may be required.The muscles of the first web space may be primarily orsecondarily involved in the contracture:(a) Prolonged incorrect splintage, with the thumb inthe adducted position, is probably the commonest cause ofa contracted first web space. The muscle fibres of theadductor pollicis and the first dorsal interosseus becomeshortened and more especially there appears to be athickening and contracture of the fascia over the firstdorsal interosseus muscle.(b) Infection of the first web space may cause contrac-ture due to scar formation.(c) In an ulnar nerve palsy the muscles of the first webspace are paralysed, the muscle fibres shorten and arepartially replaced by fibrous tissue.(d) With a radial nerve palsy causing paralysis of theabductor pollicis longus muscle and the extensor pollicislongus and brevis muscles, the adductor pollicis musclebecomes unopposed. If the 'span' of the first web space isnot maintained by splints, the fibres of the adductorpollicis muscle become shortened and there is fibroustissue laid down to cause a permanent contracture.(e) With a median nerve palsy and paralysis of theopponens muscle, the long muscles supplied by the radialnerve are in themselves capable of securing full abductionand extension of the thumb.The joint capsule of the saddle-shaped carpo-metacarpaljoint of the thumb often becomes secondarily contracted.If this has occurred, a capsulotomy of this joint may berequired to secure full release of the thumb metacarpal.TREATMENTProphylaxis of Conlracture of the First Web SpaceThe hand may require splinting for lesions of the handitself, e.g. in the case of trauma or burns; or it may besplinted for lesions of the forearm, e.g. in the case offractures of the forearm bones or for nerve paralysis.If the thumb requires immobilization-as with a fractureof the scaphoid bone, or if the muscles acting upon thethumb are paralysed-the position of the thumb in thesplintage should always be in the fully abducted positionand with the metacarpal of the thumb in the position offull opposition.If the thumb is to be left free, and it has normal motorfunction, the splintage must be cut away from the thenareminence to allow the thumb to perform a full rangeof movement.Trealment of ConrraClure of the First Web SpaceIf the contracture is caused by scar tissue, this scar mustbe excised and the skin defect covered by healthy pliableskin. This skin may be supplied by a local flap of skinfrom the dorsum of the hand, if this is available. Morecommonly a free skin graft is required. All free skingrafts will contract, and so tend to cause a relapse of thecondition, but this may be minimized by using a thickgraft, either a full-thickness (Wolffe) graft, or a thick split-thickness graft (Dermatome). Occasionally, it may benecessary to fill the skin defect with a pedicle flap (usuallyfrom the abdomen).Paul Brand, writing in 1959' on the problem of the con-tracted first web space in patients suffering from leprosy,makes two important observations:I. That the skin incisions', made on the Z-plasty princi-ple, should have unequal flaps.2. That where the contracture had been present forsome time, even with normal structures within theweb space, that release of the skin alone usuallydid not provide adequate release of the contracture.The fascia and muscles of the first web space mustalways be explored for thickened bands that binddown the first metacarpal.This paper sets out the various stages for the operationof release of a contracted first web space as advocated byPaul Brand, but with some modifications. All the stagesmay not be necessary to correct the deformity. In factwith a thumb of normal length, it may be undesirable todeepen the first web space too much, since this leaves avery ugly hand without necessarily improving function.Fig. J. Span of normal first web space. Fig. 2. Dorsal skin incision for Z-plasty firstweb space.Fig. 3. Palmar skin incision for Z-plasty firstweb space.718 S.A. MEDICAL JOURNAL 28 August 1965Case 3, with a short thumb, demonstrates that this opera-tion carried to its limit will provide adequate phalangiza-tion of the first metacarpal.THE OPERATION FOR RELEASE OF THE FIRST WEB SPACESkin IncisionsUnder a bloodless field the skin incisions are made onthe Z-plasty principle, using unequal flaps as shown inFigs. 2 and 3. When the wound is closed the large dorsalflap is brought through into the palm. This leaves a skindefect over the dorsum of the index metacarpal which iscovered by a thick split-thickness graft.The Deeper StructuresThe dissection is carried out from the dorsum throughto the palm. The first dorsal interosseus muscle is usualJyshortened with a contracted first web space. Often incisionof the fascia covering this muscle alone wilJ provideadequate release. If this does not occur as expected, thenthe origin of this muscle is stripped off the periosteum ofthe base of the first metacarpal.The transverse head of the adductor pollicis muscleusually requires some degree of release. The degree towhich this muscle is.: released will determine the ultimatedepth of the new first web space. This muscle is releasedeither by dividing the muscle fibres in the centre of theweb space at right-angles to the line of the fibres, or bystripping the origin of the muscle from the third metacar-pal. If the oblique head of the adductor polJicis muscle isnormal, one may strip the distal two-thirds of the trans-verse head without causing material weakening of thepower of adduction of the thumb.The palmar fascia is divided in the line of the palmarskin incision as far proximally as is necessary to securerelease of the first metacarpal. Care is obviously taken notto divide the motor branch of the median nerve to thethenar muscles, or the neurovascular bundles to the indexfinger or the thumb. The carpo-metacarpal joint of thethumb may be held by secondary contracture of thecapsule. This is released if necessary by a capsulotomy.CASE HISTORIESThe following clinical cases show some of the defonnities thatcan be improved by this operation.Case JThe patient was a right-handed White male of 58 years, whohad cut himself across the right wrist in a suicide attempt 3years before. He had had a primary repair of all the flexordigitorum profundus tendons, the flexor pollicis longus tendon,and the median and ulnar nerves. As shown in Figs. 4 and 5,his present position was that all his long flexor tendons werepulling adequately, he had protective sensation over the wholeof his hand, the opponens pollicis muscle had a fair function,but no re-enervation of the other small muscles of the handhad occurred, leaving him with a fixed claw hand with anadducted first web space.At the first operation he had an arthroplasty of the fixedmetacarpo-phalangeal joints of the index, middle, ring andsmall fingers perfonned; and in addition, the operation forrelease of his adducted first web space as described above.Fig. 4 Fig. 5 Fig. 6Fig. 4. Case I. Shows the thumb in adducted position before operation, at rest, with fixed hyperextension deformity of all metacarpo-phalangeal jointsof the fingers. Fig. 5. Case 1. Maximum assisted abduction of thumb. showing contracted first web space, before operation. Fig. 6. Case I. Showsthumb and index finger in pinch position after operation.Fig. 7. Case 2_ Thumb and index finger in maximum pinch positionbefore operation.Fig. 8. Case 2. Tight scar puHing index finger into ulnar deviationbefore operation.28 Augustus 1965 S.A. TYDSKRIF VIR GENEESKUNDE 719Fig. 9 Fig. 10 Fig. 11Fig. 9. Case 2. Postoperative view showing deepening of first web space with skin graft on the dorsum of the index finger. Fig. ID. Case 2. Post-operative view showing restorat!on of pinch grip_ Fig. 11. Case 2. Postoperative view showing position of power grip.tFig. 12. Case 3. Postoperative view showing flap repair of meta-carpal head. and how large dorsal skin flap has been broughtthrough into the palm.He has had his pinch mechanism restored with a reasonablyadequate span for power grip (Fig. 6). He has been offered atendon transfer operation to replace the missing intrinsicmuscle action of the hand.Case 2The patient was a right-handed Bantu male aged 28 years,who fell under a train and sustained an ulnar hemi-amputationof the right hand; taking the index finger through the distaltwo-thirds of the middle phalanx and the head of the middlefinger metacarpal (Figs. 7, 8). The scar on the ulnar border ofthe hand had contracted and pulled the shortened index fingeraway from the thumb, so that pinch grip was impossible. Thethumb and the first web space were normal.At one operation the scar along the ulnar border of theindex finger and palm remnant was released by 3 Z-plastyincisions. A rotation osteotomy was performed upon the shaftof the second metacarpal so that the pulp of the index fingerwas rotated in order to be able to pinch against the thumbtip. The first web space was deepened by the operationdescribed above. The improved function of the hand in hisability to carry out the pinch grip and the power grip areshown in Figs. 9 - 11.Case 3A right-handed Bantu male of 34 years had his left thumbneatly amputated through the metacarpo-phalangeal joint. Asa primary procedure the cartilage was removed from the endof the metacarpal and the bare bone was covered by anabdominal flap.As a second-stage operation, his first web space was deep-ened as described above to phalangize the metacarpal. Thespan of the hand and the position of the dorsal skin flap as itFig. 13. Case 3. Postoperative view showing phalangization offirH metacarpal.comes through the palm is shown in Fig. 12 and a photographof the dorsum shows how well the metacarpal can beabducted (Fig. 13), and also shows the large split-skin graftthat has been placed over the index metacarpal.SUMMARYThe diagnosis and aetiology of a contracted first web spaceis discussed.The functional anatomy of the first web space is described.The prevention and treatment of a contracted first web spaceis described. The Paul Brand operation for release of thiscontracture is detailed.Three clinical cases are presented, the first being a casewith a contracture of the first web space, while the second twocases are shown as examples of how this operation can beused to improve the function of the hand where parts aremissing but the first web space itself is normal.My thanks are due to Dr. C. Dreisenstock, Assistant Super-intendent, and to Mr. D. H. Walker, plastic surgeon in chargeof the 'Hand Clinic' of the General Hospital, Johannesburg,for permission to publish the first case. My thanks are also dueto Dr. W. H. Kenny, Superintendent, and Mr. S. Kleinot, chiefsurgeon, Baragwanath Hospital, Johannesburg, for permissionto publish the second and the third cases.I gratefully acknowledge the encouragement and assistanceaccorded to me by Mr. A. C. Boonzaier and Mr. I. Kaplanof the Hand Clinic, Baragwanath Hospital, in the preparationof this paper.REFERENCES1. Bunnell, S. (1956): Surgery of the Hand, 3rd ed. Philadelphia: J. B.Lippincott Co.2. Brand. P. in Cochrane, R. G .. ed. (1959): Leprosy in Theory andPractice. ch.pt. XXI. Bristol: John Wright & Son Ltd.

The management of the contracted first web space

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The management of the contracted first web space

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