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Hand & Microsurgery
Case Report
Original
Article
Hand
Microsurg
2016;5:29-31
Hand Microsurg 2014;X:X-X
doi:10.5455/handmicrosurg.189904
doi:10.5455/handmicrosurg.163944
Enhancement of Palmar Advancement Flap:
A Simple Modification
Oguz Kayiran1, Ercan Cihandide2
Isolated bilateral absence of abductor
ABSTRACT pollicis brevis and opponens
Background: Distal fingertip amputations
exposed bone is
for the surgeon to manage. In order to repolliciswithmuscles:
Achallenging
case report
construct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar
1
2
advancement flap, firstCihan
described
by Moberg
in 1964,
comprises
oneTekeli
of the3,most
popular options.
Sahin
, Serkan
Aribal
, Hakan
Celalettin
Sever1
Methods: Thirteen patients (11 male, 3 female) with fingertip injuries were operated. Following the elevation of Moberg
flap, proposed modifications were carried out. Joint mobility and pulp sensitivity were recorded as well and advancement
scores were noted before and after the modification. These
scores were assessed statistically.
ABSTRACT
Results:
No
complications
were
noted
and
there
was
no
need
surgery.
Excellent
joint mobility
andmuspulp
We report a rare case of a 21-year-old man with a bilateral absenceforofadditional
abductor pollicis
brevis
and opponens
pollicis
sensitivity
maintained.
This modification
showed
a statistically
significant
improvement
in the
(p<0.05).
cles,
whichwere
has not
been previously
reported. He
presented
with weakness
in both
of his hands.
Onadvancement
physical examination
Conclusions:
Moberg
flap
is
a
good
option
for
the
closure
of
fingertip
defects.
Some
simple
modifications,
as
described
there was atrophy on the thenar eminences of both of his hands and there was an absence of gross functional impairmentin
can enhance
the
while securing
theabductor
entire advantages
of the
flap.
inhere,
his hand
functions.
Onadvancement
magnetic resonance
imaging,
pollicis brevis
and
opponens pollicis muscles were bilat-
erally
absent. Enhancement, Moberg flap, modification
Key words:
Key words: Abductor pollicis brevis, opponens pollicis, agenesis, absence
Introduction
Introduction
The hand
is a unique
in the
body ininand
plays
Thenar
atrophy,
whichpart
is often
observed
median
important
and often
functions.
In thecan
innerve
disorders,
suchirreplaceable
as carpal tunnel
syndrome,
dustrialized
world,
occupational
handorinjuries
need to
also
be seen in
congenital
syndromes
as an isolated
be healed as
soon[1,2].
as possible.
Meanwhile,
several
healcongenital
defect
Although
congenital
absence
ingthe
techniques
various
options
areflexor
being pollicis
applied
of
abductorwith
pollicis
brevis
(APB),
to hundreds
patients
experienced
brevis
(FPB), of
andthousands
opponensofpollicis
hasby
been
reported
practitioners.
previously [2-6], bilateral congenital absence of the
other hand
injuries,
amputations
APB Unlike
and opponens
pollicis
has yetfingertip
to be reported.
needCase
additional
Reportattention in order to establish a normal
pulpAsensibility
maximum
rangetoofour
motion,
and
21-year-oldand
man
was referred
clinic belike others
to maintain
the upmost
level ofeminences.
hand funccause
of a flattening
of both
of his thenar
tioning.
Examination
of his hands revealed bilateral atrophy of
In
1964,
the volar(Figure
advancement
was impairfirst dethe thenar eminences
1). No flap
sensory
scribed
Moberginfor
reconstruction
pulpdisdement
wasbypresent
thethe
median
and ulnar of
nerve
fects of the thumb (1). This flap is a pedicled advanceAuthor affiliations
ment flap of
proximally
based
on an
intact
skin pedicle
tributions
both hands.
Both
hand
functions
were
including
both
neurovascular
bundles.
This
technique
normal, and passive and active ranges of motions of his
establishes
a successful
neurosensation
of the
pulpOnly
with
wrist
and other
fingers were
within normal
limits.
a limited
advancement
as well.and
However,
a simple
mild
impairment
of abduction
opposition
wasmodnotification
as
described
here,
and
never
been
reported
ed. The remaining physical examination was normal.
elsewhere,
enhance
The gripcan
strength
of additional
the patientadvancement.
and plain X-rays of
Patients
and
Methods
both hands were normal. Electromyography (EMG),
study was
performed
with informed
consents
whichThe
included
motor
and sensory
conduction
studobtained
from
all
participants.
ies and a needle EMG, revealed that the supra-maximal
Technique
compound
muscle action potential (CMAP) was very
Thirteen
patients
(11 was
males,
females)
with finlow in the APBs,
and there
no 3gain
in potential
bigertip
injuries
were
operated
under
regional
anaeslaterally during the needle EMG. There was no entrapthesia.neuropathy
Palmar advancement
flap was
overresthe
ment
or polyneuropathy.
Onraised
magnetic
parathenon
(1) (Figure
1a).
Both neurovascular
bunonance
imaging,
APB and
opponens
pollicis muscles
dles bilaterally
were included
in (Figure
the flap2).
soThere
that neurosensible
were
absent
was minimal
coverage is accomplished (Figure 1b). To increase the
: 1Department of Plastic, Reconstructive and Aesthetic Surgery, 2Department of Radiology, 3Department of Neurology, Gulhane Military Medical
Academy, Haydarpasa Training Hospital, Istanbul, Turkey
Correspondence
: Cihan Sahin, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Gulhane Military Medical Academy, Haydarpasa Training
Author affiliations : Department of Plastic, Reconstructive and Aesthetic Surgery,1 Izmir University, Izmir/Turkey, 2 Bahcesehir University, Istanbul/Turkey
Hospital, Istanbul, Turkey. e-mail: [email protected]
Correspondence
: Oguz Kayiran, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Izmir University, Izmir/Turkey. E-mail: [email protected]
Received / Accepted : May 27, 2015 / June 08, 2015
Received / Accepted : July 08, 2014 / August 12, 2014
© 2016 Turkish Society for Surgery of the Hand and Upper Exremity
© 2014 Turkish Society for Surgery of the Hand and Upper Exremity
www.handmicrosurgeryjournal.com
www.handmicrosurgeryjournal.com
Sahin C et al.
A
A
B
B
C
Figure 1. View of thenar eminence flattening of both hands. (A) Volar
view. (B) Lateral view.
disability in hand function and the patient did not complain of limitations to activities of daily living. Therefore, surgical treatment was not considered.
Discussion
Abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, and adductor pollicis are the intrinsic
muscles of the thumb. Three of these four muscles (abductor pollicis brevis, opponens pollicis, and flexor
pollicis brevis) form the thenar eminence [7], which
flattens if one or more of these muscles are lacking or in
atrophy. Thenar atrophies, or thumb hypoplasias, are
rare conditions and are often observed with median
nerve disorders, such as carpal tunnel syndrome. In addition, thenar atrophies or thumb hypoplasias sometimes occur as congenital syndromes or as an isolated
congenital defect [1,2,4,5]. These syndromes include
Fanconi syndrome (pancytopenic anemia), TAR
30
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Hand and Microsurgery
Figure 2. Axial magnetic resonance image of the patient’s wrist along
with a normal hand. (A) Normal anatomic magnetic resonance image
of the wrist. (B) Right hand. (C) Left hand. *The yellow arrow shows
the absence of APB and OPP muscles in Figures A and B.
(thrombocytopenia and absent radius), VACTERL
(vertebra, anal, cardiovascular, tracheo-esophageal,
renal and limb defects), Holt-Oram (congenital heart
defects), Cornelia de Lange syndrome (dwarfizm),
Okihiro syndrome (Duane anomaly of the eyes and
deafness), and Cavanagh’s syndrome (hypodevelopment of the thumb phalanges and adjacent carpal
bones) [2-5,8]. We examined our patient systematicalYear 2016 | Volume 5 | Issue 1 | 29-31
Bilateral absence of APB and OP muscles
ly and had necessary consultations from other clinics
and observed no anomaly other than bilateral thenar
atrophy.
We searched the Pubmed database and google
academic, but found no previous report of an isolated
bilateral abductor pollicis brevis and opponens pollicis
agenesis. Hong et al. reported a case with an anomalous
course of extensor pollicis longus muscle, with absence
of abductor pollicis brevis, opponens pollicis, abductor
pollicis longus, and extensor pollicis brevis muscles.
However, as a unilateral case, our patient differs from
this finding [3].
The patient that we present here had mild dysfunction in opposition and abduction, but no complaints
nor limitations of activities of daily living. Opposition
is accomplished with the combined motions of flexion, pronation, and palmar abduction of the thumb
metacarpal [7]. The flexor pollicis brevis muscle primarily flexes the thumb metacarpophalangeal joint.
Flexion is the action of moving the thumb in an ulnar
direction within the plane of the palm. Additional actions of the FPB muscle include extension of the distal
phalanx and pronation of the thumb metacarpal [9].
As a result, only the FPB muscle can achieve sufficient
opposition for performing daily living tasks, as in our
patient. Therefore, no surgery was considered for this
patient, which would only have achieved cosmetic improvements. Muscle agenesis should be considered in
thenar atrophies, especially in bilateral cases. In addition, these patients should be evaluated systematically,
since thumb hypoplasias can arise from various syndromes.
www.handmicrosurgeryjournal.com
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Conflict of interest statement
The authors have no conflicts of interest to declare.
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