Saving Thaxton’s Thumb: Treatment for Thumb Hypoplasia

Thaxton and his mom with Dr. Shah Rachael researched her son’s condition and possible treatments available across the United States, then reached out to top experts in Pennsylvania, Ohio and Texas. She shared her son’s story with Maribeth Magarity, MSN, RN, a nurse navigator in the Division of Orthopaedics at Children’s Hospital of Philadelphia (CHOP).

Rachael explained that Thaxton could hold things with his thumb – he just couldn’t move it. Were there alternatives to removal? Magarity consulted with Apurva S. Shah, MD, MBA, an orthopaedic surgeon who specializes in pediatric hand surgery, and reported back to Rachael: They believed CHOP could help.

CHOP’s Hand and Arm Disorders Program is one of the largest and most recognized centers in the country dedicated to treating children with congenital deformities, injuries and tumors of the hand and arm.

Coming to Philadelphia

When Thaxton was 9 months old, he and his family were on a plane to Philadelphia.

“I was really impressed by how the whole experience went. It was so thorough,” Rachael says. Thaxton had X-rays and an ultrasound of his hand that showed one promising sign: Thaxton’s thumb carpometacarpal (CMC) joint was stable. The thumb CMC joint forms where the ends of the metacarpal bone (at the base of the thumb) meets the trapezium bone in the wrist. Cartilage covers the ends of both bones and allows them to glide easily during motion.

After Dr. Shah performed a careful physical examination, he suggested that Thaxton’s thumb curled into his palm because of weakness in his extensor tendon. Thaxton also appeared to have difficulty with pinch. Dr. Shah noted that the thumb muscles in Thaxton’s palm were weaker than normal and that his metacarpophalangeal joint (MCP) was unstable.

Dr. Shah described the two possible treatment options for Thaxton’s thumb hypoplasia:

• Pollicization, removing the hypoplastic thumb and reconstructing the hand by converting the index finger into a functional thumb, or
• Reconstruction, by replacing the weak extensor tendon and thumb muscles with tendon transfers from the index finger and ring finger, with potential to improve function and preserve the typical 5-finger appearance of the hand.

Based on the ultrasound, which showed a stable CMC joint, Dr. Shah felt Thaxton was a better candidate for reconstruction, and the family agreed. “We wanted to try the reconstruction,” Rachael says. “We wanted him to have the most functional – and normal appearing – hand as possible.”

Dr. Shah agreed to do the surgery, but first Thaxton would need time to grow and develop more fully.

Thumb reconstruction surgery

The family flew from their home in Baton Rouge, Louisiana, to CHOP for a check-up in September 2017, and then for surgery in November 2017. Thaxton was 18 months old.

During surgery, Dr. Shah detached an extensor tendon from Thaxton’s index finger and a flexor tendon from his ring finger and transplanted them both to his thumb. The ring finger tendon was also used to stabilize his MCP joint. A protective cast was applied after surgery. Thaxton spent one night in the hospital, another night at a Philadelphia hotel and then was cleared to return to Louisiana.

“When we went home, Thaxton had a cast on his whole left arm – from the tips of his fingers to a little past his elbow,” Rachael says. It took some time for Thaxton to get used to the cast, but within days, he was back to exploring his home. Crawling was a bit more difficult with the cast, but soon Thaxton took his first steps and became unstoppable. “The cast didn’t slow him down for long,” Rachael says with a laugh.

After Christmas, the cast was removed and Thaxton began hand therapy to increase his functional motion. In March, the family again met with Dr. Shah.

“Dr. Shah said everything looked great and was healing well. Thaxton’s range of motion was improving day by day,” Rachael says.

Hand tune-up

The family returned to CHOP in August 2020 so Dr. Shah could again examine Thaxton and recommend next steps. Dr. Shah believed a second minor surgery – to widen the webspace between Thaxton’s thumb and index finger – would give him greater flexibility and make it easier for him to grasp objects.

Outpatient surgery was performed at the end of September, and the family returned home the next day. Again, Thaxton needed a cast, but this time it was only for three weeks and Rachael was able to safely remove it at home.

Once the cast came off, Thaxton wiggled his thumb a few times then took off to play with his brother. A few days later, Thaxton climbed up on his mom’s lap, holding a ball in his left hand.

“I looked down and it hit me: That was the first time he’d ever held a ball in his left hand and really gripped it. It was the first time he could physically do that,” Rachael says, tearing up. She took a picture to savor the memory and shared it with Dr. Shah via email.

“I am so excited to see how he adapts and grows with this,” Rachael wrote. “Every trip to see y’all is absolutely worth it.”

Looking to the future

Today, Thaxton is an active little boy who likes school and loves superheroes. He enjoys playing with his siblings and making his parents laugh. “Thaxton is a very sweet little boy and he’s smart,” his mom says. “He can tell you all his letters and he’s been reading sight words since he turned 4.”

The family won’t have to return to CHOP until Thaxton is 10, when doctors may need to perform another procedure to lengthen the metacarpal bone in Thaxton’s left thumb to ensure it is similar to his non-affected right thumb.

“We have complete faith in Dr. Shah’s ability and are beyond grateful for his talents. He is absolutely brilliant,” Rachael says. “After meeting him four years ago during Thaxton’s initial consultation, I didn’t think we needed to go anywhere else – and he’s proven me 1,000% right.”