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Thumb-in-Palm

Exams and Signs

Historical Overview

  • Thumb-in-palm deformity is associated with cerebral palsy (CP), which was first described by William John Little in 1853 as cerebral spastic palsy or Little’s Disease.1

Description

  • CP may contribute to the development of thumb-in-palm deformity and swan neck deformity in children.2
  • If CP is suspected, the patient’s parents or guardians should consult with a neurologist as soon as possible.3

Pathophysiology

  • The thumb-in-palm deformity test can help to diagnose CP.
  • If the patient presents with thumb-in-palm deformity, there will be little or no function in his/her hand.

Instructions

  1. Obtain an accurate and complete patient history. Ask the patient to rate on a scale from 1 to 10 how much pain s/he usually experiences in the affected thumb, hand, and wrist.
  2. Observe whether the patient’s thumb is positioned inside of his/her palm.2
  3. Check the patient’s grasping and pinching abilities.
  4. Examine the contralateral thumb and hand, to verify that the patient understands the doctor’s requests.

Variations

  • When examining the hand for thumb-in-palm deformity, evaluate the surrounding skin for color and the presence of scars.4
  • Also check wrist range of motion (ROM), active and passive.5

Related Signs and Tests

  • ROM, active
  • ROM, passive
  • Grip strength6
  • Muscle test
  • Neurovascular exam4
  • Tenderness and crepitus
  • Proprioception5

Diagnostic Performance Characteristics

  • To improve reliability, the thumb-in-palm deformity test must be used in conjunction with active, gross, and fine motor tests to help diagnose CP.3,5
  • The grip-strength test, performed with a Jamar dynamometer, also improves reliability.6
Definition of Positive Result
  • A positive result occurs when the patient’s thumb is positioned inside of his/her palm, without ability to move from this position. 
Definition of Negative Result
  • A negative result occurs when the patient’s thumb is not positioned inside of his/her palm.
Comments and Pearls
  • Depending on the severity of contractures, operative procedures may be used in childhood or adolescence to improve stiffness and ROM.4 Some operative treatments may have to be postponed until the patient reaches skeletal maturity.5
  • Operative treatments for thumb-in-palm deformity include release of the adductor pollicis muscle from the middle metacarpal origin. To help prevent relapse, use tendon transfer to improve extension and abduction of the thumb metacarpal.7
Diagnoses Associated with Exams and Signs
References
  1. Siegel IM. Historical vignette #9. Little big man: the life and genius of William John Little (1810-1894). Orthop Rev 1988;17(11):1161-6. PMID: 3060808
  2. Rayan G, Akelman E. The Hand: Anatomy, Examination and Diagnosis. Philadelphia: Lippincott Williams & Wilkins, 2012
  3. Bhardwaj P, Sabapathy SR. Assessment of the hand in cerebral palsy. Indian J Plast Surg 2011;44(2):348-56. PMID: 22022045
  4. Seruya M, Dickey RM, Fakhro A. Surgical treatment of pediatric upper limb spasticity: the wrist and hand. Semin Plast Surg 2016;30(1):29-38. PMID: 26869861
  5. Koman LA, Smith BP. Surgical management of the wrist in children with cerebral palsy and traumatic brain injury. Hand (NY) 2014;9(4):471-7. PMID: 25414607
  6. Dekkers KJ, Rameckers EA, Smeets RJ, et al. Upper extremity strength measurement for children with cerebral palsy: a systematic review of available instruments. Phys Ther 2014;94(5):609-22. PMID: 24415772
  7. Van Heest AE. Surgical technique for thumb-in-palm deformity in cerebral palsy. J Hand Surg Am 2011;36(9):1526-31. PMID: 21816546
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