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Hand Microsurgery OriginalCase Report Article HandHand Microsurg Microsurg 2016;5:29-31 2014;X:X-X Hand & Microsurgery doi:10.5455/handmicrosurg.189904doi:10.5455/handmicrosurg.163944 Enhancement of Palmar Advancement Flap: A Simple Modification Oguz Kayiran1, Ercan Cihandide2 Isolated bilateral absence of abductorABSTRACT pollicis brevis and opponens Background: Distal fingertip amputationspollicis with muscles: exposed bone Ais challengingcase report for the surgeon to manage. In order to re- construct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar advancement flap, firstCihan described Sahin by1, SerkanMoberg in Aribal1964, comprises2, Hakan oneTekeli of the3 ,most Celalettin popular options.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. ABSTRACTThese scores were assessed statistically. WeResults: report aNo rare complications case of a 21-year-old were noted man and with there a bilateral was no absence need for of additional abductor pollicissurgery. brevis Excellent and opponens joint mobility pollicis and mus pulp- cles,sensitivity which werehas not maintained. been previously This modification reported. He showed presented a statistically with weakness significant in both improvement of his hands. in Onthe physicaladvancement examination (p<0.05). thereConclusions: was atrophy Moberg on the flap thenar is a eminencesgood option of for both the ofclosure his hands of fingertip and there defects. was an Someabsence simple of gross modifications, functional asimpairment described in inhere, his handcan enhance functions. the On advancement magnetic resonance while securing imaging, the abductor entire ad pollicisvantages brevis of the and flap. opponens pollicis muscles were bilat- erallyKey words:absent. Enhancement, Moberg flap, modification Key words: Abductor pollicis brevis, opponens pollicis, agenesis, absence IntroductionIntroduction tributionsment flap of proximally both hands. based Both on handan intact functions skin pediclewere ThenarThe hand atrophy, is a unique which partis often in the observed body in inand medianplays normal,including and both passive neurovascular and active rangesbundles. of Thismotions technique of his nerveimportant disorders, and often such irreplaceableas carpal tunnel functions. syndrome, In the can in- wristestablishes and other a successful fingers neurosensationwere within normal of the limits. pulp withOnly alsodustrialized be seen inworld, congenital occupational syndromes hand or injuries as an isolated need to milda limited impairment advancement of abduction as well. and However, opposition a simple was mod not-- congenitalbe healed asdefect soon [1,2].as possible. Although Meanwhile, congenital several absence heal- ed.ification The remaining as described physical here, examination and never wasbeen normal. reported ofing the techniques abductor with pollicis various brevis options (APB), are flexor being appliedpollicis elsewhere,The grip can strength enhance of additional the patient advancement. and plain X-rays of brevisto hundreds (FPB), ofand thousands opponens of pollicis patients has by been experienced reported both Patientshands were and normal. Methods Electromyography (EMG), previouslypractitioners. [2-6], bilateral congenital absence of the whichThe included study motorwas performed and sensory with conductioninformed consents stud- APB Unlikeand opponens other hand pollicis injuries, has yet fingertip to be reported. amputations iesobtained and a needle from all EMG, participants. revealed that the supra-maximal needCase additional Report attention in order to establish a normal compoundTechnique muscle action potential (CMAP) was very pulpA sensibility21-year-old and man maximum was referred range to of our motion, clinic beand- low inThirteen the APBs, patients and there (11 was males, no gain3 females) in potential with bifin-- causelike others of a flattening to maintain of the both upmost of his level thenar of hand eminences. func- laterallygertip injuries during thewere needle operated EMG. under There regional was no entrapanaes-- Examinationtioning. of his hands revealed bilateral atrophy of mentthesia. neuropathy Palmar advancement or polyneuropathy. flap was On raised magnetic over res the- the thenarIn 1964, eminences the volar (Figure advancement 1). No flapsensory was impair first --de onanceparathenon imaging, (1) (FigureAPB and 1a). opponens Both neurovascular pollicis muscles bun- mentscribed was by present Moberg in for the the median reconstruction and ulnar ofnerve pulp dis de-- weredles bilaterallywere included absent in (Figurethe flap 2). so There that neurosensiblewas minimal fects of the thumb (1). This flap is a pedicled advance- coverage is accomplished (Figure 1b). To increase the Author affiliations : 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 www.handmicrosurgeryjournal.com © 2014 Turkish Society for Surgery of the Hand and Upper Exremity 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 com- plain of limitations to activities of daily living. There- fore, surgical treatment was not considered. Discussion Abductor pollicis brevis, flexor pollicis brevis, op- ponens pollicis, and adductor pollicis are the intrinsic Figure 2. Axial magnetic resonance image of the patient’s wrist along muscles of the thumb. Three of these four muscles (ab- with a normal hand. (A) Normal anatomic magnetic resonance image of the wrist. (B) Right hand. (C) Left hand. *The yellow arrow shows ductor pollicis brevis, opponens pollicis, and flexor the absence of APB and OPP muscles in Figures A and B. pollicis brevis) form the thenar eminence [7], which flattens if one or more of these muscles are lacking or in (thrombocytopenia and absent radius), VACTERL atrophy. Thenar atrophies, or thumb hypoplasias, are (vertebra, anal, cardiovascular, tracheo-esophageal, rare conditions and are often observed with median renal and limb defects), Holt-Oram (congenital heart nerve disorders, such as carpal tunnel syndrome. In ad- defects), Cornelia de Lange syndrome (dwarfizm), dition, thenar atrophies or thumb hypoplasias some- Okihiro syndrome (Duane anomaly of the eyes and times occur as congenital syndromes or as an isolated deafness), and Cavanagh’s syndrome (hypodevelop- congenital defect [1,2,4,5]. These syndromes include ment of the thumb phalanges and adjacent carpal Fanconi syndrome (pancytopenic anemia), TAR bones) [2-5,8]. We examined our patient systematical- 30 | Hand and Microsurgery Year 2016 | Volume 5 | Issue 1 | 29-31 Bilateral absence of APB and OP muscles ly and had necessary consultations from other clinics Conflict of interest statement and observed no anomaly other than bilateral thenar The authors have no conflicts of interest to declare. atrophy. References We searched the Pubmed database and google 1. Dellon AL, Rayan G. Congenital absence of the academic, but found no previous report of an isolated thenar muscles. Report of two cases. J Bone Joint bilateral abductor pollicis brevis and opponens pollicis Surg Am 1981;63:1014-5. agenesis. Hong et al. reported a case with an anomalous 2. Koca K, Ekinci S, Ege T, Ozyurek S, Kurklu M, Bat- course of extensor pollicis longus muscle, with absence tal B, et al. Bilateral congenital absence of flexor of abductor pollicis brevis, opponens pollicis, abductor pollicis brevis and abductor pollicis brevis mus- pollicis longus, and extensor pollicis brevis muscles. cles with bilateral thenar atrophy: a case report. However, as a unilateral case, our patient differs from Clin Med Insights Arthritis Musculoskelet Disord this finding [3]. 2012;5:59-62. The patient that we present here had mild dysfunc- 3. Hong J, Kim DK, Kang SH, Seo KM. Anomalous tion in opposition and abduction, but no complaints course of the extensor pollicis longus with multi- nor limitations of activities of daily living. Opposition ple absences of thumb muscles. Ann Rehabil Med is accomplished with the combined motions of flex- 2013;37:151-5. ion, pronation, and palmar abduction of the thumb 4. Iyer KM, Stanley JK. Congenital absence of flexor metacarpal [7]. The flexor pollicis brevis muscle pri- pollicis brevis and abductor pollicis brevis. Hand marily flexes the thumb metacarpophalangeal joint. 1982;14:313-6. Flexion is the action of moving the thumb in
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