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The Management of the Contracted First Web Space

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The Management of the Contracted First Web Space 716 S.A. MEDICAL JOURNAL 28 August 1965 56. Ishizaki, Y. and Belter. L. F. (1960): AlDer. J. Obstet. Gynec., 79. SO. ScOlt. J. G. (1949): S. Air. Med. J .. 23, 1054. 1074. 81. Schlir, P. H. (1964): J. Trop. Med. Hyg.. 67. 260. 57. Sundberg, R. D. (1956): Anat. Rec., 124, 368. 82. Fortier, C. (1962): Ann. Rev. I·hysiol.. 24. 223. 58. Franklin, J. W., Zavala, D. C. and Radclilfe, C. E. (1952): Blood, 83. Bowness, J. M. and Morton, R. A. (1952): Biochem. J .. SI, 530. 7. 934. 84. Flesh. P. (1949): Proc. Soc. Exp. BioI. (N.Y.), 70, 79. 59. Johnsson, U. and Rundles, R. W. (1957): Jbid., 6, 16. 85. Cotzias, G. C. and Dole, V. P. (1951): J. BioI. Chem.. 190, 665. 60. Briining, E. G. H. (1964): Dennatologica (Basel), 128, 271. 86. Kikkawa, H., Ogita, Z. and FujilO, S. (1955): Science, 121, 43. 61. Van der Wait, J. J. (1965): Personal communication. 87. Cope, F. W., Sever, R. J. and Polis, B. D. (1963): Arch. Biochem., 62. Borghesan, E. (1964): Acta oto-Iaryng. (Stockh.), 57, 288. lOO. 171. 63. Billingham, R. E. and Silvers, W. K. (1960): Quart. Rev. BioI., 88. Sever, R. J .. Cope. F. W. and Polis, B. D. (1962): Science, 137. 128. 35, 1. 89. Gerritzen, T. and Walker, A. R. P. (1953): S. Afr. Med. J.. 27. 577. 64. Ikeda, S. (1962): Jap. J. Derm.. 72. 836. 90. BothweH. T. H. and Isaacson, C. (1962): Brit. Med. J., I, 522. 65. Mason, P. (1948): Ann. N. Y. Acad. ScL, 4, 28. 91. Perdrup, A. and Poulsen, H. (1964): Arch. Derm.. 90, 34. 66. Wintrobe. M. M. (1961): Clinical Haematology, 5th ed., p. 246. 92. Salm, R. and Swinburne, L. M. (1963): J. Path. Bact.. 85, 297. Philadelphia: Lea & Febiger. 93. Hedinger, C. (1953): Helv. med. Acta. 20. suppl. 32. I. 67. Wassermann, H. P. (1964): Blood. 24. 668. 94. Heilmeyer, L. (1954): Acta I·aemat. (Basel), 11, 137. 68. Idem (1965): Arch. Environm. Hlth. (in the press). 95. Politzer. W. M. and Tucker, B. (1958): Lancet, 2. 778. 69. Forbes. W. H., Johnson, R. E. and Consolazio, F. (1941): Amer. J. 96. Barnicot, . A. and Wolffson, D. (1952): Ibid., I, 893. Med. Sci., 201, 407. 97. Parkinson, L., Ghyoot. E .. Van Vlierberghe. R. and Bone. G. (1960): 70. Casley-Smith, J. R. (1959): Aust_ J. Exp. BioI. Med. Sci., 37, 481. Trans. Roy Soc. Trop. Med. Hyg.. 54. 366. 71. Ramalingaswami, V. and Venkatachalam, P. S. (1950): Ind. J. Med. 98. Higgin. D. and Wolffson, D. (1958): J. Trop. Med. Hyg., 61, 62. Res., 38. 17. 99. Satanove. A. (1965): J. Amer. Med. Assoc.. 191, 263. 72. Kirkeby, K., Haugaard. G. and Lingjaerde, P. (1963): Acta med. lOO. Engel. R. L. and Koprowska. I. (1959): Amer. J. Med.. 26. 965. scand.. 174. 257. 101. Forbes. W., Steel, M. H. and Munro. H. W. (1964): Brit. J. Nutr.. 73. Johnsson. S. and Hogberg, B. (1952): Nature (Land.). 169. 286. 18. 55. 74. Najjar. S. and Jarrah, A. (1964): Amer. J. Dis. Child., IOS. 198. 102. Ephraim. A. J. (1959): Arch. Denn. Syph. (Chic.), 79, 228. 75. Dahlberg, B. (1963): Ann. N.Y. Acad. Sci., 100. 631. 103. Gail. D. (1957): Frankfurt. Z. Path.. 68. 64. 76. McGuinness. B. W. (1963): Ibid., lOO, 640. 104. Yoffey, J. M. (1960): Quantitative Cellular HemalOlogy. iIIinois: 77. Nicol. T .. SneH, R. S. and Bilbey. D. L. J. (1956): Brit. Med. J., Charles C. Thomas. 2. 800. 105. Arens. L. and Brock. J. F. (1954): S. Afr. J. Clin. Sci .. 5, 20. 78. SneH. R. S. and Nicol, T. (1956): Nature (Lond.). 177. 578. 106. Van Heerden. P. D. R. and Brink, A. J. (1962): S. Afr. J. Lab. Clin. 79. Roberts, J. I. (1948): J. Trop. Med. Hyg., SI, 228. Med.. 8. 118. THE MANAGEMENT OF THE CONTRACTED FIRST WEB SPACE J. H. YOUNGLESON,* M.B., CH.B. (CAPE TOWN), F.R.C.S. (EDIN.), ER.C.S. (ENG.), Plastic Surgeon, Durban The function of the thumb is usually assessed at between The palmar skin is thick 'gripping skin' which is attached 40 and 60% of the total function of the hand. The useful­ to the palmar fascia by vertical fibrous bands running through the palmar fat. There is a skin crease running obliquely across ness of the hand as a whole depends on variations of the the web ~kin of the thenar eminence where the skin folds pinch grip and the power grip. The thumb forms one limb when the thumb is brought across the palm. The neurovascular of the pinch grip, and of the radral component of the bundles to the adjacent sides of the index finger and the thumb power grip, as in holding a screwdriver-the ulnar com­ emerge from under the palmar fascia and run along the adductor pollicis muscle into the index finger and thumb. ponent of the power grip is used as in holding a golf club. The position of the metacarpal determines the position Anatomy of the Muscles of the thumb tip for the pinch grip; when the metacarpal The first dorsal interosseus muscle runs obliquely across the is fully abducted and extended it determines the 'span' of first web space from the base of the first metacarpal to the the hand, and so the grasp for the power grip. Hence the radial wing tendon of the extensor expansion of the index need for a fully mobile thumb metacarpal with an adequate finger. The muscle belly is covered by a substantial fascial first web space to allow free movement of the thumb. In envelope. The action of this muscle is important in stabilizing the index finger for counter-pressure to the thumb in the pinch both the pinch grip and the power grip the metacarpal of grip. It is always supplied by the deep branch of the ulnar the thumb swings across the palm as a gate which is nerve. hinged at the carpo-metacarpal joint. The adductor pollicis muscle arises by 2 heads which are separated from the palmar surface of the first dorsal interos­ FUNCTIONAL ANATOMY OF THE FIRST WEB SPACE seus muscle by loose areolar tissue. Allafomy of the Skill alld Subcutaneous Tissues The fan~shaped transverse head arises from the distal two­ thirds of the palmar surface of the shaft of the third metacar­ As shown in Fig. I, the distal free margin of the normal pal. It is inserted by a common tendon from the oblique skin fold runs in a gentle curve from a point just distal to the head to form the ulnar wing tendon of the extensor expansion metacarpo-phalangeal joint of the thumb to a point opposite of the thumb. the metacarpo-phalangeal joint of the index finger. The distal edge of this fold is a supple margin formed by the fusion of The oblique head arises from the bases of the second and the dorsal and palmar skin. third metacarpals and the surrounding bones and ligaments of The dorsal skin is relatively lax and separated from the the carpus. muscles of the first web space by loose connective tissue in The nerve supply to both heads is from the deep branch of which run the dorsal digital nerves to the index finger, the the ulnar nerve. The oblique head at least may occasionally be origin of the cephalic vein, and the terminal branches of the supplied by the median nerve.' radial artery. These are the princeps pollicis artery, and the radialis indicis artery, with the terminal portion of the radial The action of this muscle is to adduct the thumb and to artery divi ng between the 2 he;;.ds of origin of the first dorsal stabilize the metacarpo-phalangeal joint of the thumb by interosseus muscle to enter the palm and form the radial com­ pulling on the wing .tendon. Hence its importance in both the ponent of the deep palmar arch. These arteries of the first web pinch and the power grip. This action is opposed by long and space commonly run a variable course. Should it prove neces­ short abductor muscles; and by the long and short extensor sary to divide one of these during operation, both ends should pollicis muscles. be ligated. First palmar illterosseus muscle (also called the deep head -Late Registrar. Det"artment of Plastic. Maxillo-F3cial and Oral Surgery. of flexor pollicis brevis) arises from the proximal half of the University of the Witwatersrand. Johannesburg. palmar surface of the first metacarpal and is inserted with the 28 Augustus 1965 S.A. TYDSKRIF VIR GENEESKUNDE 717 adductor pollicis tendon. It is supplied by the deep branch of TREATMENT the ulnar nerve. Prophylaxis of Conlracture of the First Web Space MECHANISM OF CONTRACTURE OF THE FIRST WEB SPACE The hand may require splinting for lesions of the hand As is shown in Fig. I, the normal thumb in the fully itself, e.g. in the case of trauma or burns; or it may be abducted position forms an angle with the index finger of splinted for lesions of the forearm, e.g. in the case of 90°. In the normal adult the 'span' measures 6 - 7 in. fractures of the forearm bones or for nerve paralysis. from the tip of the thumb to the tip of the index finger. If the thumb requires immobilization-as with a fracture Any reduction of this means there is some degree of con­ of the scaphoid bone, or if the muscles acting upon the tracture of the first web space. thumb are paralysed-the position of the thumb in the The skin itself may be contracted as is seen in scarring splintage should always be in the fully abducted position following burns.
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