Orthopedics

Case Reports 

Sonographic Evidence for the Absence of Abductor Pollicis Longus, Extensor Pollicis Longus, and Brevis

Mustafa Kürklü, MD; Serkan Bïlgïç, MD; Mahmut Kömürcü; Levent Özçakar, MD

Abstract

Complete absence or variations of extensor pollicis brevis and abductor pollicis longus; absence of the extrinsic extensors, abductor pollicis longus, thenar muscles along with congenital hypoplasia of the thumb; absence of flexor pollicis brevis and abductor pollicis brevis; and bilateral absence of extensor pollicis have been reported previously. Those cases mainly comprised absence/variations of the first extensor compartment either with or without thumb anomalies. This article presents a case of a patient in which the constituents of the first and third compartments (extensor pollicis brevis, abductor pollicis longus and extensor pollicis longus) were absent unilaterally. Herewith, we also highlight the role of static/dynamic sonography for prompt imaging in this regard.

A 24-year-old man presented with difficulty using the left thumb. He reported no trauma and had not used the affected thumb since childhood. On physical examination, the left thumb was observed to be in flexion and opposition. He was unable to perform active extension and abduction but passive motion was free. Neurological examination of the left upper extremity was unremarkable. No organ anomaly was present on systemic examination. Radiographs of the left hand revealed no joint problems or hypoplasia. Ultrasonographic evaluation was consistent with absence of the first and third extensor compartment tendons. Tendon transfer was recommended but the patient refused surgery.

Congenital absence of the extensor tendons of the hand can be seen in various forms.1-5 Herein, the absence of the first and the third compartments in a young man is reported, to the best knowledge of the authors, for the first time in the literature. Moreover, the role of musculoskeletal ultrasonography in clearly visualizing such pathologies is also emphasized.

A 24-year-old man presented with difficulty in using the left thumb. He reported no trauma and had not used his thumb since childhood. Past medical and parental history was noncontributory.

On physical examination, the left thumb was observed to be in flexion and opposition (Figure 1). He was unable to perform active extension and abduction but passive motions were free. Neurological examination of the left upper extremity was unremarkable. No organ anomaly was present on systemic examination. Radiographs of the left hand revealed no joint problems or hypoplasia. Ultrasonographic evaluation was consistent with absence of the first and third extensor compartment tendons (Figures 2-4). Tendon transfer was recommended but the patient refused surgery.

Figure 1: Photograph demonstrating the left thumb in the flexed position.

Figure 2: Longitudinal view of the extensor side of the first metacarpophalangeal joint. White arrows demonstrate the intact extensor pollicis brevis tendon on the left side and the white star indicates the absent right extensor pollicis brevis tendon. Figure 3: Axial view of the first and second extensor compartments at the wrist level. White arrows demonstrate the intact tendons on the left side and the white star indicates the absent extensor brevis and abductor pollicis longus tendons. Figure 4: Axial view of the third and fourth extensor compartments at the wrist level. White arrows (from left to right) demonstrate the intact extensor digitorum and extensor pollicis longus tendons, the Lister’s tubercle (L) on the left side; and the Lister’s tubercle (L), extensor digitorum tendons on the right side with white star indicating the absent extensor pollicis longus tendon.

To our knowledge, isolated absence of the first and the third extensor compartments has not been previously reported in the literature. Complete absence or variations of extensor pollicis brevis and abductor pollicis longus1,2; absence of the extrinsic extensors, abductor pollicis longus, thenar muscles along with congenital hypoplasia of the thumb3; absence of flexor pollicis brevis and abductor pollicis brevis4 and bilateral absence of extensor pollicis5 have been…

Abstract

Complete absence or variations of extensor pollicis brevis and abductor pollicis longus; absence of the extrinsic extensors, abductor pollicis longus, thenar muscles along with congenital hypoplasia of the thumb; absence of flexor pollicis brevis and abductor pollicis brevis; and bilateral absence of extensor pollicis have been reported previously. Those cases mainly comprised absence/variations of the first extensor compartment either with or without thumb anomalies. This article presents a case of a patient in which the constituents of the first and third compartments (extensor pollicis brevis, abductor pollicis longus and extensor pollicis longus) were absent unilaterally. Herewith, we also highlight the role of static/dynamic sonography for prompt imaging in this regard.

A 24-year-old man presented with difficulty using the left thumb. He reported no trauma and had not used the affected thumb since childhood. On physical examination, the left thumb was observed to be in flexion and opposition. He was unable to perform active extension and abduction but passive motion was free. Neurological examination of the left upper extremity was unremarkable. No organ anomaly was present on systemic examination. Radiographs of the left hand revealed no joint problems or hypoplasia. Ultrasonographic evaluation was consistent with absence of the first and third extensor compartment tendons. Tendon transfer was recommended but the patient refused surgery.

Congenital absence of the extensor tendons of the hand can be seen in various forms.1-5 Herein, the absence of the first and the third compartments in a young man is reported, to the best knowledge of the authors, for the first time in the literature. Moreover, the role of musculoskeletal ultrasonography in clearly visualizing such pathologies is also emphasized.

Case Report

A 24-year-old man presented with difficulty in using the left thumb. He reported no trauma and had not used his thumb since childhood. Past medical and parental history was noncontributory.

On physical examination, the left thumb was observed to be in flexion and opposition (Figure 1). He was unable to perform active extension and abduction but passive motions were free. Neurological examination of the left upper extremity was unremarkable. No organ anomaly was present on systemic examination. Radiographs of the left hand revealed no joint problems or hypoplasia. Ultrasonographic evaluation was consistent with absence of the first and third extensor compartment tendons (Figures 2-4). Tendon transfer was recommended but the patient refused surgery.

Figure 1: The left thumb in the flexed position

Figure 1: Photograph demonstrating the left thumb in the flexed position.


Figure 2: Longitudinal view of the extensor side of the first metacarpophalangeal joint
Figure 3: Axial view of the first and second extensor compartments
Figure 4: Axial view of the third and fourth extensor compartments

Figure 2: Longitudinal view of the extensor side of the first metacarpophalangeal joint. White arrows demonstrate the intact extensor pollicis brevis tendon on the left side and the white star indicates the absent right extensor pollicis brevis tendon. Figure 3: Axial view of the first and second extensor compartments at the wrist level. White arrows demonstrate the intact tendons on the left side and the white star indicates the absent extensor brevis and abductor pollicis longus tendons. Figure 4: Axial view of the third and fourth extensor compartments at the wrist level. White arrows (from left to right) demonstrate the intact extensor digitorum and extensor pollicis longus tendons, the Lister’s tubercle (L) on the left side; and the Lister’s tubercle (L), extensor digitorum tendons on the right side with white star indicating the absent extensor pollicis longus tendon.

Discussion

To our knowledge, isolated absence of the first and the third extensor compartments has not been previously reported in the literature. Complete absence or variations of extensor pollicis brevis and abductor pollicis longus1,2; absence of the extrinsic extensors, abductor pollicis longus, thenar muscles along with congenital hypoplasia of the thumb3; absence of flexor pollicis brevis and abductor pollicis brevis4 and bilateral absence of extensor pollicis5 have been reported previously. Those cases mainly comprised absence/variations of the first extensor compartment either with or without thumb anomalies.

In our case, the constituents of the first and third compartments (extensor pollicis brevis, abductor pollicis longus and extensor pollicis longus) were absent unilaterally. Any other musculoskeletal anomalies (including those of the left thumb) were not present. We found no embryological basis to substantiate the selective absence of these 3 muscles. However, possible tendon transfers to extensor pollicis longus could have been performed either from extensor indicis proprius for extension of the first interphalangeal joint,6 or from palmaris longus for both radial abduction and interphalangeal joint extension.7 Flexor carpi radialis tendon could have also been transferred to abductor pollicis longus and extensor pollicis brevis for thumb radial abduction.7 However, our patient refused surgical intervention.

In addition to the general advantages of ultrasonography, being convenient as well as inexpensive, noninvasive, repeatable, and accurate, musculoskeletal ultrasonography displays 2 other advantages. These include dynamic imaging and comparability. Dynamic imaging provides exquisite details especially in tendon pathologies, eg, rupture vs adhesion. Further, as seen in our patient, comparison with the normal side or in the case of symmetric involvement, the chance to compare with a normal subject is advantageous. Herewith, it is also noteworthy that congenital absence of the aforementioned extensor compartments could be visualized substantially with ultrasonography in our case.

References

  1. Nayak SR, Krishnamurthy A, Pai MM, et al. Multiple variations of the extensor tendons of the forearm. Rom J Morphol Embryol. 2008; 49(1):97-100.
  2. Muller T. Variations in the abductor pollicis longus and extensor pollicis brevis in the South African Bantu. S Afr J Lab Clin Med. 1959; 5(1):56-62.
  3. Neviaser RJ. Congenital hypoplasia of the thumb with absence of the extrinsic extensors, abductor pollicis longus, and thenar muscles. J Hand Surg Am. 1979; 4(4):301-303.
  4. Iyer KM, Stanley JK. Congenital absence of flexor pollicis brevis and abductor pollicis brevis. Hand. 1982; 14(3):313-316.
  5. Allaria A. Bilateral congenital absence of extensor pollicis [in Italian]. Chir Organi Mov. 1956; 43(5):423-426.
  6. Giessler GA, Przybilski M, Germann G, Sauerbier M, Megerle K. Early free active versus dynamic extension splinting after extensor indicis proprius tendon transfer to restore thumb extension: a prospective randomized study. J Hand Surg Am. 2008; 33(6):864-868.
  7. Sammer DM, Chung KC. Tendon transfers, I: Principles of transfer and transfers for radial nerve palsy. Plast Reconstr Surg. 2009; 123(5):169e-177e.

Authors

Drs Kürklü and Bïlgïç and Mr Kömürcü are from the Department of Orthopedics and Traumatology, Gülhane Military Medical Academy; and Dr Özçakar is from the Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey.

Drs Kürklü, Bïlgïç, and Özçakar and Mr Kömürcü have no relevant financial relationships to disclose.

Correspondence should be addressed to: Levent Özçakar, MD, Hacettepe Üniversitesi Tip Fakültesi Hastaneleri FTR AD, Sihhiye, Ankara, Turkey (lozcakar@yahoo.com).

doi: 10.3928/01477447-20100225-29

10.3928/01477447-20100225-29

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