Congenital limb deficiencies in Alberta-a review of 33 years (1980-2012) from the Alberta Congenital Anomalies Surveillance System (ACASS)

Associated Anomalies in Radial Ray Deficiency

Radial ray deficiency (RRD) may be isolated, without other congenital anomalies or co-occurring with other, non-RRD, congenital anomalies. The prevalence and the types of co-occurring anomalies are variable in the reported studies. The aim of this study was to obtain the prevalence and the types of co-occurring congenital anomalies among cases with RRD in a geographically well-characterized population of 387,067 consecutive births in northeastern France from 1979 to 2007 including live births, stillbirths and terminations of pregnancy. During the study period 83 cases with RRD were ascertained (prevalence of 2.14 per 10,000 births), 63 cases (75.9%) had co-occurring anomalies. Cases with co-occurring anomalies were divided into chromosomal anomalies (18 cases, 22%), syndromic conditions (syndromes and associations, 23 cases, 28%), and multiple congenital anomalies (MCA) (22 cases, 26%). Trisomies 18 and autosomal deletions were the most common chromosomal abnormalities. Thrombocytopenia absent radii syndrome, VACTERL association, Fanconi anemia, Roberts syndrome, and Holt-Oram syndrome were the most common syndromic conditions. Anomalies in the musculoskeletal, the cardiovascular, the urinary, and the orofacial system were the most common co-occurring anomalies in cases with MCA. As cases with RRD have often co-occurring congenital anomalies, a multidisciplinary checkup of these cases is recommended.

Development and Production of a Children's Upper-Limb Cycling Adapter Using 3D Printing

The research described in this study focuses on the development of an innovative upper-limb adapter for young children aged 1-3 years who have congenital upper-limb defects. The objective was to create a functional and affordable solution that allows children to engage more safely and actively in physical activities such as cycling. The adapter was designed within the DESIGN+ project at the University of West Bohemia in Pilsen in collaboration with the German company Ottobock. The development included a detailed analysis of hand movements during cycling, modelling using CAD software (NX 1888), prototype manufacturing through 3D printing, and subsequent testing. The result is an adapter that allows 360° rotation around the arm axis, provides natural hand movement while turning, and is made of soft material to enhance safety. Despite initial challenges and necessary prototype adjustments, a functional and reliable design was achieved. This adapter will contribute to improving the quality of life for children with upper-limb disabilities, supporting their coordination, strength, and confidence in daily activities.

Demographic and clinical characteristics of children with limb loss in Saudi Arabia: A retrospective study

PURPOSE

The aim of this study was to describe the demographic and clinical characteristics of children with limb loss in Saudi Arabia.

METHODS

This is a retrospective study on children attending a limb loss clinic in a tertiary hospital in Riyadh, Saudi Arabia, between July 2012 and June 2020. Descriptive statistics were computed to describe the sample characteristics. A Chi-Squared test was conducted to explore the relationship between a child's sex with the type of limb loss (congenital or acquired) and extent of limb loss (major and minor) and the association between child's age and the mechanism of injury in traumatic limb loss.

RESULTS

A total of 122 children aged 2-16 years were included of whom 52% were boys. Congenital limb loss represented 57% of the sample with upper extremity loss accounting for 63.7% of all limb loss in this type. Trauma-related limb loss represented the most frequent etiology (88.2%) in the acquired limb loss group. Road traffic accidents accounted for 51.7% of the mechanism of injuries in trauma-related limb loss. Child's sex was not associated with the type of limb loss nor the extent of limb loss ( p > 0.05). In addition, child's age was not associated with the mechanism of injury in traumatic limb loss ( p > 0.05).

CONCLUSION

Child's sex was not a determinant of type nor the extent of limb loss. Most of the acquired limb loss was trauma-related with road traffic accidents as the most common mechanism of injury. The findings of this study illuminate the importance of ongoing prosthetic care for children with a limb loss because young children may require multiple prostheses as they grow in age and size.

Introduction to Limb Deficiency for the Pediatrician

Owing to the lack of trained professionals in amputee care, the pediatrician is often required to assist in the care of children with limb deficiencies. An overview of the causes and epidemiology of limb deficiency is provided, as well as an evaluation and diagnostic workup. Important considerations for surgical interventions are discussed and an introduction to prosthetic prescribing and care of the amputee is described. Common overuse syndromes and mental health issues are also reviewed. Finally, resources for funding of prosthetic devices, as well as support and education for clinicians and families are provided.

Intellectual Characteristics in Children With Congenital Unilateral Upper Limb Deficiencies

Introduction Some children with motor disabilities show low cognitive levels. However, the influence of motor disabilities on children's intelligence remains to be fully elucidated. This study aimed to clarify the intellectual characteristics of children with upper limb deficiencies and the influence of upper limb impairments on intelligence. Methods The participants were 10 children from four to six years of age with congenital unilateral transradial or transcarpal limb deficiencies who received prosthetic interventions. The children's intelligence and adaptive behaviors, including motor skills, were examined using the Wechsler Preschool and Primary Scale of Intelligence and the Vineland Adaptive Behavior Scale, respectively. Results There were no significant characteristics or discrepancies in cognitive level in children with upper limb deficiencies. The Adaptive Behavior Composite Score of the Vineland Adaptive Behavior Scale was significantly positively correlated with the Full-Scale Intelligence Quotient of the Wechsler Preschool and Primary Scale of Intelligence. Conclusions The children with congenital limb deficiencies showed average cognitive levels. Expansion of adaptive behaviors, including appropriate complementation of disabilities, may promote intellectual development in children with motor disabilities.

Relationship between degree of disability, usefulness of assistive devices, and daily use duration: an investigation in children with congenital upper limb deficiencies who use upper limb prostheses

Upper limb prostheses can help children with congenital upper limb deficiencies (ULDs) perform activities of daily living. Although the degree of disability and prosthesis usefulness may be related to becoming accustomed to wearing a prosthesis, these relationships have not been confirmed. This study was aimed at investigating the relationship between motor function, the usefulness of prostheses in everyday activities, and daily duration of prosthesis use in children with congenital ULDs. Eleven children with congenital transcarpal or transradial ULDs and their caregivers participated in this study. The caregivers were asked to complete a questionnaire concerning their children's everyday activities and the daily duration of prosthesis wearing. The adaptive behavior scale was used to measure motor function prior to intervention. Correlations analyses revealed no significant correlation between the children's adaptive behavior, including motor skills before intervention, and daily duration of prosthesis wearing, but revealed a positive correlation between the number of activities that the children performed more effectively with their prostheses and the daily use duration. To ensure that children with congenital ULDs become accustomed to wearing their prostheses, the prostheses should meet the requirements of everyday activities.

Congenital limb deficiency: Genetic investigation of 44 individuals presenting mainly longitudinal defects in isolated or syndromic forms

Congenital limb deficiency (CLD), one of the most common congenital anomalies, is characterized by hypoplasia/aplasia of one or more limb bones and can be isolated or syndromic. The etiology in CLD is heterogeneous, including environmental and genetic factors. A fraction remains with no etiological factor identified. We report the study of 44 Brazilian individuals presenting isolated or syndromic CLD, mainly with longitudinal defects. Genetic investigation included particularly next-generation sequencing (NGS) and/or chromosomal microarray. The overall diagnostic yield was 45.7%, ranging from 60.9% in the syndromic to 16.7% in the non-syndromic group. In TAR syndrome, a common variant in 3´UTR of RBM8A, in trans with 1q21.1 microdeletion, was detected, corroborating the importance of this recently reported variant in individuals of African ancestry. NGS established a diagnosis in three individuals in syndromes recently reported or still under delineation (an acrofacial dysostosis, Coats plus and Verheij syndromes), suggesting a broader phenotypic spectrum in these disorders. Although a low rate of molecular detection in non-syndromic forms was observed, it is still possible that variants in non-coding regions and small CNVs, not detected by the techniques applied in this study, could play a role in the etiology of CLD.

Treatment approaches for congenital transverse limb deficiency: Data analysis from an epidemiological national survey in Japan

BACKGROUND

Congenital limb deficiency is a rare anomaly that impairs limb function. Transverse deficiency accounts for approximately half of congenital limb deficiency cases. In Japan, there have been no detailed data of clinical features, especially treatment approaches, of this disorder. The present study aimed to investigate the status of treatment approaches of congenital transverse limb deficiency in Japan.

METHODS

From the national epidemiological survey of congenital limb deficiency undertaken in Japan in 2016, all the data of 200 patients with congenital transverse limb deficiencies were extracted. These data were analysed to reveal the treatment approaches of congenital transverse limb deficiency and its basic clinical features.

RESULTS

Surgical treatments and prosthetic or orthotic intervention had been implemented or planned for about one-quarter of patients, respectively. In the upper limb deficiencies, prosthetic or orthotic intervention was likely chosen in cases of deficiency at the metacarpal or proximal to metacarpal level. Surgical treatment was chosen only in cases of deficiency at the carpal or distal to carpal level. Although the number of patients with transverse lower limb deficiencies was small, prosthetic or orthotic intervention was likely chosen in proximal deficiencies, and surgical treatment was likely chosen in distal deficiencies.

CONCLUSIONS

Herein, we revealed the status of treatment approaches for congenital transverse limb deficiency in Japan. Approximately half of the patients had no history of-and no plans for-surgical, prosthetic, or orthotic interventions. Further treatment advances may enable patients with congenital limb deficiencies to increase their participation in daily activities.

STUDY DESIGN

Cross-sectional survey.

Maternal risk factors for congenital limb deficiencies: A population-based case-control study

BACKGROUND

Risk factors for congenital limb deficiencies are poorly understood.

OBJECTIVE

To investigate risk factors for congenital limb deficiencies.

METHODS

We conducted a nationwide population-based case-control (1:5) study in Finland, using national registers on congenital anomalies, births, and induced abortions, cross-linked with data on maternal prescription medicine use obtained from the registers on Reimbursed Drug Purchases and Medical Special Reimbursements. Five hundred and four children with limb deficiencies (241 isolated, 181 syndromic, and 82 other associated anomalies) were identified, and 2,520 controls were matched to cases on residence and year of pregnancy. Non-syndromic cases (n = 323) were subdivided into longitudinal (n = 120), transverse (n = 123), intercalary (n = 24), mixed (n = 18), and unknown (n = 38) deficiencies.

RESULTS

Pregestational diabetes was associated with all limb deficiencies (adjusted odds ratio [OR] 12.71, 95% confidence interval [CI] 2.37, 68.25) and with isolated (OR 11.42, 95% CI 2.00, 64.60) deficiencies. Primiparity was associated with increased risk of congenital limb deficiencies among all cases (OR 1.49, 95% CI 1.15, 1.93), isolated cases (OR 1.46, 95% CI 1.09, 1.96), and among cases with longitudinal (OR 1.90, 95% CI 1.24, 2.90) and transverse deficiencies (OR 1.75, 95% CI 1.13, 2.70). Young maternal age (<25 years) was associated with all congenital limb deficiencies (OR 1.40, 95% CI 1.02, 1.90) and transverse deficiencies (OR 1.76, 95% CI 1.05, 2.96). Advanced maternal age (≥35 years) was associated with syndromic (OR 1.82, 95% CI 1.19, 2.78) and transverse deficiencies (OR 1.94, 95% CI 1.06, 3.57). Maternal antiepileptic medication was associated with all (OR 5.77, 95% CI 1.75, 19.04) and with isolated cases (OR 3.83, 95% CI 1.02, 14.34).

CONCLUSIONS

It is important that pregnant women taking medications, especially antiepileptics, or women with pregestational diabetes are carefully monitored with regard to the occurrence and risk of limb deficiencies in the fetus.

Gastroschisis in Ontario, Canada: 2012-2018

BACKGROUND

Gastroschisis is a congenital anomaly of the abdomen in which the intestines are found outside of the body at birth. While no clear causative factors have been identified, it is strongly associated with young maternal age. Other reported associations include low maternal socioeconomic status, low maternal body mass index (BMI), and smoking.

METHODS

This is a retrospective review of epidemiologic data relating to cases of gastroschisis in Ontario from 2012-2018 in the Better Outcomes Registry & Network (BORN) Ontario database, which is the province's prescribed maternal-newborn registry. We describe the epidemiology of gastroschisis in Ontario with respect to birth prevalence, maternal age, health, exposures, and geography.

RESULTS

The birth prevalence of gastroschisis is 2.31 cases/10,000 births. There was no apparent change in birth prevalence over the study period and there was no difference between male and female infants. Gastroschisis was associated with younger maternal ages and was inversely correlated with maternal BMI. Gastroschisis was associated with first completed pregnancy. Maternal diabetes was associated with a lower birth prevalence of gastroschisis than average. Mothers of babies with gastroschsis were more likely to report use of tobacco, alcohol, and drugs during pregnancy than those without gastroschisis, with marijuana use showing the largest increase in birth prevalence of gastroschisis. Mothers living in rural areas were more likely to have a baby with gastroschisis than those in urban centers, even after controlling for maternal age.

CONCLUSIONS

This Ontario registry study reveals that mothers with babies with gastroschisis are more likely to be young and thin, live in rural areas, and report prenatal smoking, alcohol use, and drug use than women whose pregnancies do not have gastroschsis.

Rehabilitation Approach for a Child with Cerebral Palsy and Upper Limb Deficiency

Background

Congenital limb deficiency is a rare and intractable anomaly of the limbs; however, prostheses can partially complement the motor function and appearance of the missing limbs. The first prosthesis is usually prescribed for children with upper limb deficiencies at approximately 6-8 months of age. In affected children with additional problems associated with motor function, such as limb paralysis, the age for initiating prosthetic therapy and the benefit of prostheses in promoting and expanding their motor function and activities is unknown.

Case

In this case presentation, we describe a 25-month-old boy with cerebral palsy and left unilateral congenital upper limb deficiency caused by congenital constriction band syndrome. The patient could stand with assistance and crawl on his hands and knees. However, he was unable to walk with assistance or to stand on his own. A forearm prosthesis with a passive hand was prescribed and issued, and rehabilitation therapy for wearing and using the prosthesis was performed. At 34 months of age, the patient was able to walk forward using a walker with the prosthesis. Without the prosthesis, he still could not walk using a walker. The upper limb prosthesis also improved other movements such as sitting, standing, and tasks performed on a desk or on the floor.

Discussion

The prosthesis was apparently effective in improving motor function. Prosthesis prescription should be considered at an appropriate and early age considering individual developmental stages and needs, regardless of the existence of additional problems associated with motor function.

Maternal Risk Factors Associated with Limb Reduction Defects: Data from the Polish Registry of Congenital Malformations (PRCM)

Data from the Polish Registry of Congenital Malformations (PRCM) suggest that the prevalence of limb reduction defects (LRDs) in some Polish regions is significantly higher in comparison to that reported in the European Surveillance of Congenital Anomalies (EUROCAT) registry, but specific risk factors are still unknown. The objectives of this study were two-fold: to detect risk factors linked to isolated LRDs among Polish natives and to search for geospatial clusters of isolated LRDs to identify high-risk areas across the country. Among the 2,939,001 births accounted for in the PRCM, we determined that there were 852 children with distinct LRDs. Our data demonstrate that lower birth weight, prematurity, and maternal smoking history are strongly associated with isolated LRDs. Furthermore, our investigation pointed to various additional risk factors for isolated LRDs, including paternal education, gestational hypertension, upper respiratory tract infections, and exposure to anti-inflammatory drugs in the first trimester of pregnancy. We did not recognize statistically significant spatial or spatiotemporal clusters over the area of Poland using Kulldorff’s scan. Our study strengthens the hypothesis that maternal factors have an integral role in the etiology of isolated LRDs.

Etiological diagnosis in limb reduction defects and the number of affected limbs: A population-based study in the Northern Netherlands

Limb reduction defects (LRDs) that affect multiple limbs are considered to be more often heritable, but only few studies have substantiated this. We aimed to investigate if an etiological diagnosis (genetic disorder or clinically recognizable disorder) is more likely to be made when multiple limbs are affected compared to when only one limb is affected. We used data from EUROCAT Northern Netherlands and included 391 fetuses and children with LRDs born in 1981–2017. Cases were classified as having a transverse, longitudinal (preaxial/postaxial/central/mixed), intercalary, or complex LRD of one or more limbs and as having an isolated LRD or multiple congenital anomalies (MCA). We calculated the probability of obtaining an etiological diagnosis in cases with multiple affected limbs versus one affected limb using relative risk (RR) scores and Fisher's exact test. We showed that an etiological diagnosis was made three times more often when an LRD occurred in multiple limbs compared to when it occurred in one limb (RR 2.9, 95% CI 2.2–3.8, p < 0.001). No genetic disorders were found in isolated cases with only one affected limb, whereas a genetic disorder was identified in 16% of MCA cases with one affected limb. A clinically recognizable disorder was found in 47% of MCA cases with one affected limb. Genetic counseling rates were similar. We conclude that reduction defects of multiple limbs are indeed more often heritable. Genetic testing seems less useful in isolated cases with one affected limb, but is warranted in MCA cases with one affected limb.

Effect of prostheses on children with congenital upper limb deficiencies

BACKGROUND

Individual weaknesses in motor skills are a characteristic of children with congenital upper limb deficiencies. These weaknesses increase with age. In Japan, however, prosthetic prescription and subsequent rehabilitation approaches for children with upper limb deficiencies are insufficient and often delayed. This study aimed to elucidate whether rehabilitation approaches, including prostheses prescription and occupational therapy, improve these children's adaptive behaviors, especially their motor skills.

METHODS

The study included nine children, aged 0-6 years, with unilateral transradial or transcarpal upper limb deficiencies. We measured their adaptive behaviors and motor skills at the beginning of prosthetic therapy and after 1.5 years, using the Vineland Adaptive Behavior Scales - Second Edition.

RESULTS

The score for the motor skills domain was significantly lower than the median score of the domains at the beginning of prosthetic therapy. The motor skill weaknesses significantly improved after 1.5 years of prosthetic therapy.

CONCLUSIONS

Although children with congenital upper limb deficiencies have individual weaknesses in their motor skill behavior, it was shown that these weaknesses can be improved through rehabilitation approaches, including occupational and prosthetic therapies. Issuing the appropriate prostheses and implementing the appropriate training to use the prostheses for congenital upper limb deficiencies are reasonable and meaningful interventions to improve quality of life.

Radial Longitudinal Deficiency: Severity Differences Between U.S. and Japanese Cohorts

PURPOSE

Radial longitudinal deficiency (RLD) presents on a spectrum of severity and associated diagnoses. The literature is limited in describing patient presentation without comparative data between countries. In a study comparing 2 cohorts of patients, 1 in the United States and 1 in Japan, we hypothesized that there would be a similar presentation of forearm deficiency severity, thumb hypoplasia severity, and associated syndromes between the 2 cohorts.

METHODS

Patients with RLD were identified via a comprehensive chart review at 2 pediatric hospital cohorts, 1 in the United States and 1 in Japan, capturing patients presenting over 15 years. We assessed RLD and thumb hypoplasia severity via a modified Bayne and Klug and modified Blauth classifications. The relationship between these 2 diagnoses and the presence of common medical conditions were evaluated and correlated.

RESULTS

A total of 194 Japanese patients with 290 involved extremities were compared with 107 U.S. patients with 174 involved extremities. The U.S. cohort had a significantly more severe RLD, and a higher rate of bilaterality (63% vs 50%, respectively). A total of 131 Japanese patients (68%) and 41 U.S. patients (38%) had associated medical syndromes/associations, most frequently vertebral abnormalities, anal atresia, cardiac abnormalities, tracheoesophageal fistula and/or esophageal atresia, renal agenesis and dysplasia, and limb defects (VACTERL; 46 Japanese, 14 U.S.), Holt-Oram (44 Japanese, 5 U.S.), and thrombocytopenia absent radius syndrome (0 Japanese, 12 U.S.). Correlation analysis showed that increased RLD severity was associated with increased thumb hypoplasia severity in both groups, with 95% of modified Bayne and Klug III, IV, or V patients having severely affected thumbs (type IIIb, IV, or V).

CONCLUSIONS

The U.S. patients had a more severe RLD and a higher rate of bilaterality. Japanese patients had a higher incidence of associated syndromes and radial polydactyly. Both cohorts showed that increased forearm severity was associated with more severe thumb hypoplasia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Differential diagnosis/symptom prevalence study III.

Congenital limb reduction defects in 1.6 million births in Argentina

The objectives of this study were to describe the birth prevalence of limb reduction defects (LRD) in Argentina, their clinical features, and to review the literature on this topic. The data source was the National Network of Congenital Anomalies of Argentina, a surveillance system that has been operative since 2009. Data were collected from November 1, 2009 to December 31, 2016. 1,663,610 births and 702 affected patients were registered during this period. The prevalence of LRD was 4.22/10,000 births (CI 95%: 3.93-4.54). In 15,094 stillbirths, prevalence was 30.80/10,000 (CI 95%: 22.31-40.65). Perinatal mortality (stillbirths plus early neonatal deaths) was 24.6%, mostly explained by postnatal deaths. LRD were classified according to different variables, including Gold's anatomic classification. Then, 41.0% of patients had transverse terminal defects and 50.2% had longitudinal defects. We found multiple and syndromic clinical presentation to be associated with both preaxial LRD and lethality. The prevalence of LRD was lower and perinatal mortality was higher in our study compared to that of previously published studies. Because there is heterogeneity in the inclusion and exclusion criteria among publications, a greater effort should be made in order to include similar populations and to use a unified anatomic classification and nomenclature.

Perinatal outcomes of infants with congenital limb malformations: an observational study from a tertiary referral center in Central Europe

Background

Congenital limb malformations are rare, and their perinatal outcomes are not well described. This study analyzed the perinatal outcomes of infants with congenital limb malformations.

Methods

All infants with congenital limb malformations who underwent prenatal assessment and delivery at our tertiary referral center from 2004 through 2017 were retrospectively identified. Neonatal outcome parameters were assessed, and the predictors of worse perinatal outcomes were determined.

Results

One hundred twenty-four cases of congenital limb malformations were identified, of which 104 (83.9%) were analyzed. The upper limb was affected in 15 patients (14.4%), the lower limb in 49 (47.1%), and both limbs in 40 (38.5%) patients. A fetal syndrome was identified in 66 patients (63.5%); clubfoot and longitudinal reduction defects were the most frequent malformations. In total, 38 patients (36.5%) underwent termination, seven (6.7%) had stillbirth, and 59 (56.7%) had live-born delivery. Rates of preterm delivery and transfer to the Neonatal Intensive Care Unit were 42.4 and 25.4%, respectively. Localization of the malformation was a determinant of perinatal outcome (P = .006) and preterm delivery (P = .046).

Conclusions

Congenital limb malformations frequently occur bilaterally and are associated with poor perinatal outcomes, including high rates of stillbirth and preterm delivery. Multidisciplinary care and referral to a perinatal center are warranted.

Perinatal post-mortem ultrasound (PMUS): radiological-pathological correlation

There has been an increasing demand and interest in post-mortem imaging techniques, either as an adjunct or replacement for the conventional invasive autopsy. Post-mortem ultrasound (PMUS) is easily accessible and more affordable than other cross-sectional imaging modalities and allows visualisation of normal anatomical structures of the brain, thorax and abdomen in perinatal cases. The lack of aeration of post-mortem foetal lungs provides a good sonographic window for assessment of the heart and normal pulmonary lobulation, in contrast to live neonates.In a previous article within this journal, we published a practical approach to conducting a comprehensive PMUS examination. This covered the basic principles behind why post-mortem imaging is performed, helpful techniques for obtaining optimal PMUS images, and the expected normal post-mortem changes seen in perinatal deaths. In this article, we build upon this by focusing on commonly encountered pathologies on PMUS and compare these to autopsy and other post-mortem imaging modalities.

Epidemiology of limb reduction defects as registered in the Medical Birth Registry of Norway, 1970-2016: Population based study

Background

Following the Thalidomide disaster, the Medical Birth Registry of Norway (MBRN) was established in 1967, with epidemiological surveillance of congenital anomalies as one main aim. Limb reduction defects (LRD) constitute a rare and heterogeneous anomaly group, where correct registration and classification is important for surveillance and research. We aimed at reviewing and recoding LRD cases in the MBRN using the same classification system for all years, and evaluate time trends, characteristics and risk factors, 1970–2016.

Methods

After reviewing and recoding LRD cases using International Classification of Diseases (ICD), 10^th version, for all years, time trends, association with major anomalies, risk factors and infant outcomes were calculated. Generalized linear models for the binomial family with log link gave relative risks (RR) with 95% confidence intervals (CI). Classification of LRD as suggested by European surveillance of congenital anomalies (EUROCAT) was attempted.

Results

Overall LRD prevalence, 1970–2016, was 4.4 per 10 000, slightly increasing during 1970–1981, followed by relatively stable rates. There were more defects in upper than lower limbs. Defects in hands/fingers were most common, but unspecific descriptions prevented classification of LRD according to EUROCAT. A majority of cases had associated anomalies, the most common being other limb defects, followed by cardiac defects and anomalies in the nervous and digestive systems. From 1999, 26% of LRD cases were terminated, more than 90% of these had associated major anomalies. Stillbirth, neonatal and infant mortality were higher among infants with LRD, also related to associated anomalies. Pre-gestational diabetes was associated with a more than three times increased risk of offspring total LRD, while no association with maternal epilepsy was found. Taking folate/multivitamin supplements before and/or during pregnancy was associated with lower risk of offspring LRD (adjusted RR 0.7; 95% CI 0.6–0.9), while daily smoking did not significantly increase the risk.

Conclusion

The MBRN now has information on LRD coded by ICD-10 from 1970, but information is not specific enough to use other recommended classification systems. Collecting radiographic descriptions and/or more details from hospital records would improve the quality of the registry data. Taking folate supplements before/during pregnancy may reduce the risk of offspring LRD.

Body knowledge in children with congenital lower limb deficiency

BACKGROUND

In order to effectively improve motor function, a sound understanding of one's body - for example, relative spatial position, relationships, names and functions of body parts - is essential. The aim of this study was to explore how children with congenital lower limb deficiency (LLD) perceive their bodies, particularly their legs.

METHODS

Six children with congenital LLD and 14 controls, aged 5-12 years, were recruited for this study. They drew self-portraits and answered questions about names of body parts. These body part-related questions consisted of a production test, in which an examiner pointed to body parts on each child and asked the child to name them, and a comprehension test, in which the examiner mentioned body parts and asked the child to point to them on their own body.

RESULTS

No differences were found between the self-portraits of children with LLD and those of the control children. In the verbal tests, children with LLD responded correctly at lower rates to questions on body trunk, upper limbs, arms, hands and feet than the control children.

CONCLUSION

Children with LLD have diminished lexical-semantic body knowledge of the upper limbs and feet compared with children without LLD.

Congenital limb deficiency in Japan: a cross-sectional nationwide survey on its epidemiology

Background

Congenital limb deficiency is a rare and intractable disease, which impairs both function and appearance of the limbs. To establish adequate medical care, it is necessary to reveal the actual conditions and problems associated with this disease. However, there have been no extensive epidemiological surveys in Japan addressing this disease. This is the first nationwide epidemiological survey of congenital limb deficiency in this country.

Methods

With the cooperation of epidemiology experts, we performed a two-stage nationwide survey to estimate the number of patients with congenital limb deficiency and reveal basic patient features. We targeted orthopaedic surgery, paediatric, and plastic surgery departments. Hospitals were categorized according to the institution type and the number of hospital beds; hospitals were randomly selected from these categories. We selected 2283 departments from a total 7825 departments throughout Japan. In this study, we defined congenital limb deficiency as partial or total absence of the limbs, proximal to the proximal interphalangeal joint of the fingers/lesser toes or interphalangeal joint of the thumb/great toe. We distributed the first survey querying the number of initial patient visits from January 2014 to December 2015. Targets of the second survey were departments that reported one or more initial patient visits in the first survey.

Results

In the first survey, 1767 departments responded (response rate: 77.4%). Among them, 161 departments reported one or more initial patient visits. We conducted the second survey among these 161 departments, of which 96 departments responded (response rate: 59.6%). The estimated number of initial visits by patients with congenital limb deficiency was 417 (95% confidence interval: 339–495) per year in 2014 and 2015. The estimated prevalence of congenital limb deficiency in Japan was 4.15 (95% confidence interval: 3.37–4.93) per 10,000 live births. The sex ratio was 1.40. Upper limbs were more affected than lower limbs.

Conclusions

We revealed the estimated number of initial patient visits per year and birth prevalence of congenital limb deficiency in Japan. Our results will contribute to establishing the disease concept and grades of severity of congenital limb deficiency.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2195-3) contains supplementary material, which is available to authorized users.

Prenatal limb defects: Epidemiologic characteristics and an epidemiologic analysis of risk factors

To analyze prenatal ultrasound data for fetal limb deformities in high-risk pregnant women and the risk factors for prenatal limb defects in high-risk pregnant women.This was a retrospective study of high-risk pregnant women at the multidisciplinary consultation center from January 2006 to December 2015. When deformities were definitively diagnosed in the first trimester by ultrasound, patients were recommended to undergo an abortion, and fetal abnormalities were confirmed by pathological examination (both gross anatomic examinations and fetal chromosome and genetic tests). The risk factors for fetal limb deformities and other congenital malformations were analyzed by multifactor analysis.Of the 4088 fetuses recorded, 144 (3.52%) were diagnosed with limb abnormalities. The abnormalities included 70 (48.61%) clubfoot/clubhand cases, with 5 polydactyly, 5 syndactyly, 4 flexion toe, 4 split hand/foot malformation, 3 overlapping fingers, and 49 congenital talipes equinovarus. A total of 6 (4.17%) and 13 (9.02%) fetuses had phocomelia and imperfect osteogenesis, respectively; 22 (15.28%) cases showed achondrogenesis; 19 (13.19%) and 12 (8.33%) had partial limb deletion absence and joint movement malfunction, respectively.In the high-risk population with limb deformities (144 patients), 19 (13.19%) were ≥35 years old, 6 (4.17%) had family history of congenital malformations, 14 (9.72%) had abnormal reproductive history, 21 (14.6%) had harmful chemical exposure, 6 (4.2%) had early TORCH infections, 16 (11.1%) had gestational diabetes, 9 (6.3%) had hypertension, 3 (2.1%) took glucocorticoid, 9 (6.3%) took sedatives.In the high-risk population with other congenital malformations except limb deformities (3766 patients), 144 pregnant women were randomly selected. In the high-risk population with other congenital malformations (144 patients), 9 (6.25%) were ≥35 years old, 7 (4.86%) had family history of congenital malformations, 10 (6.94%) had abnormal reproductive history, 22 (15.28%) had harmful chemical exposure, 5 (3.47%) had early TORCH infections, 12 (8.33%) had gestational diabetes, 11 (7.64%) had hypertension, 4 (2.78%) took glucocorticoid, 11 (7.64%) took sedatives.Ultrasound can provide adequate evidence for fetal limb deformities evaluation in most patients. Fetal limb deformity cases showed a significantly higher rate than other congenital malformations for advanced maternal age (≥35 years old).

Adaptive behaviour and motor skills in children with upper limb deficiency

BACKGROUND

The dysfunction of individuals with upper limb deficiencies affects their daily lives and social participation.

OBJECTIVES

To clarify the adaptive behaviours and motor skills of children with upper limb deficiencies.

STUDY DESIGN

Cross-sectional survey.

METHODS

The subjects were 10 children ranging from 1 to 6 years of age with unilateral upper limb deficiencies at the level distal to the elbow who were using only cosmetic or passive prostheses or none at all. To measure their adaptive behaviour and motor skills, the Vineland Adaptive Behavior Scales, Second Edition was used. They were evaluated on the domains of communication, daily living skills, socialization and motor skills. We also examined the relationship of the scores with age.

RESULTS

There were no statistically significant scores for domains or subdomains. The domain standard score of motor skills was significantly lower than the median scores of the domains and was negatively correlated with age.

CONCLUSION

Children with upper limb deficiencies have individual weaknesses in motor skill behaviours, and these weaknesses increase with age. It may be helpful in considering approaches to rehabilitation and the prescription of prostheses to consider the characteristics and course of children's motor skill behaviours. Clinical relevance Even if children with unilateral upper limb deficiencies seem to compensate well for their affected limb function, they have or will experience individual weaknesses in motor skills. We should take this into consideration to develop better strategies for rehabilitation and prostheses prescriptions.

Congenital limb deficiencies and major associated anomalies in Alberta for the years 1980-2012

There is a wide range of the proportion of congenital anomalies associated with limb deficiencies reported in the literature. This variation is primarily attributed to methodology and classification differences. The distribution of associated anomalies among cases with congenital limb deficiencies in Alberta born between January 1, 1980 and December 31, 2012 is described. Of the 170 cases identified, most were live born (75.3%), male (61.8%), had longitudinal limb deficiencies (78.8%), and had associated anomalies outside the musculoskeletal system (77.6%). Significant associations between the preaxial longitudinal group and the central nervous, gastrointestinal, and cardiovascular systems are reported as well as between the postaxial longitudinal group and congenital hip and foot anomalies. Probable and possible syndrome diagnoses are described for cases with recognized malformation patterns.

Middle-aged individuals with thalidomide embryopathy have undergone few surgical limb procedures and demonstrate a high degree of physical independence

Background

Thalidomide is known to have induced thalidomide embryopathy (TE) in more than 10,000 live-born children worldwide between 1957–1962.

Aim

The aim of this study was to investigate the need for orthopaedic surgery and limb orthosis in relation to function and physical independence in middle-aged individuals with TE.

Methods

13 women/18 men with a mean age of 45.8 (SD 1.1) years were included. Information about limb surgery, the use of orthotic devices, jobs, accommodation, disability adjustments and personal assistants was collected. Physical function was measured by a modified general function score. The time needed for activities of daily living (ADL) was collected. Individuals with proximal focal femoral deficiency, PFFD, and participants in need of home or work adaptations were compared with the rest of the group.

Result

31 surgical procedures had been performed in the extremities. Three individuals were in need of personal assistance and seven had disability-adjusted homes. 28 individuals were working and 24 reported participation in exercises. Those with PFFD had significantly lower function score and needed a significantly longer time for ADL in the morning (p = 0.001 and p = 0.032). The group in need of home or work adjustments had significantly lower function score and needed longer time for morning ADL (p = 0.012 and p = 0.009).

Discussion

Few orthopaedic procedures had been performed. The TE individuals except the ones with PFFD and those in the need of disability adjustments, were mostly active workers, reported good physical function and participated in exercises, despite limb malformations.

Copy-number variants and candidate gene mutations in isolated split hand/foot malformation

Split hand/foot malformation (SHFM) is a congenital limb deficiency with missing or shortened central digits. Some SHFM genes have been identified but the cause of many SHFM cases is unknown. We used single-nucleotide polymorphism (SNP) microarray analysis to detect copy-number variants (CNVs) in 25 SHFM cases without other birth defects from New York State (NYS), prioritized CNVs absent from population CNV databases, and validated these CNVs using quantitative real-time polymerase chain reaction (qPCR). We tested for the validated CNVs in seven cases from Iowa using qPCR, and also sequenced 36 SHFM candidate genes in all the subjects. Seven NYS cases had a potentially deleterious variant: two had a p.R225H or p.R225L mutation in TP63, one had a 17q25 microdeletion, one had a 10q24 microduplication and three had a 17p13.3 microduplication. In addition, one Iowa case had a de novo 10q24 microduplication. The 17q25 microdeletion has not been reported previously in SHFM and included two SHFM candidate genes (SUMO2 and GRB2), while the 10q24 and 17p13.3 CNVs had breakpoints within genomic regions that contained putative regulatory elements and a limb development gene. In SHFM pathogenesis, the microdeletion may cause haploinsufficiency of SHFM genes and/or deletion of their regulatory regions, and the microduplications could disrupt regulatory elements that control transcription of limb development genes.

Computer-aided training sensorimotor cortex functions in humans before the upper limb transplantation using virtual reality and sensory feedback

One of the biggest problems of upper limb transplantation is lack of certainty as to whether a patient will be able to control voluntary movements of transplanted hands. Based on findings of the recent research on brain cortex plasticity, a premise can be drawn that mental training supported with visual and sensory feedback can cause structural and functional reorganization of the sensorimotor cortex, which leads to recovery of function associated with the control of movements performed by the upper limbs. In this study, authors - based on the above observations - propose the computer-aided training (CAT) system, which generating visual and sensory stimuli, should enhance the effectiveness of mental training applied to humans before upper limb transplantation. The basis for the concept of computer-aided training system is a virtual hand whose reaching and grasping movements the trained patient can observe on the VR headset screen (visual feedback) and whose contact with virtual objects the patient can feel as a touch (sensory feedback). The computer training system is composed of three main components: (1) the system generating 3D virtual world in which the patient sees the virtual limb from the perspective as if it were his/her own hand; (2) sensory feedback transforming information about the interaction of the virtual hand with the grasped object into mechanical vibration; (3) the therapist's panel for controlling the training course. Results of the case study demonstrate that mental training supported with visual and sensory stimuli generated by the computer system leads to a beneficial change of the brain activity related to motor control of the reaching in the patient with bilateral upper limb congenital transverse deficiency.

Views on the Oberg-Manske-Tonkin Classification System for Congenital Anomalies of the Hand and Upper Limb

A new classification system was proposed by Tonkin et al as a replacement for the Swanson/International Federation of Societies for Surgery of the Hand system. We have reviewed their aims and have pointed out a number of problems that will make it difficult to be universally accepted.

The prevalence of amnion rupture sequence, limb body wall defects and body wall defects in Alberta 1980-2012 with a review of risk factors and familial cases

Prevalence rates of amnion rupture sequence, limb body wall defect, and body wall defects vary widely. Comparisons are difficult due to small case numbers and the lack of agreement of definition, classification, and pathogenesis. This study reports the prevalence of cases classified in five distinct categories. The Alberta Congenital Anomalies Surveillance System data on live births, stillbirths, and terminations of pregnancy (<20 weeks gestation) occurring between 1980 through 2012 with the ICD-10 Royal College of Paediatrics and Child Health Adaptation codes used for congenital constriction bands (Q79.80) and body wall complex (Q89.7) were reviewed. During the 33-year-study period, there were 153 eligible cases ascertained from 1,411,652 live births and stillbirths, giving a prevalence of 1.08/10,000 total births. There were more males (52%) than females (45%) and 3% were of unknown sex. The average maternal age, birth weight, and gestation was 27 years, 2,701 g, and 35 weeks, respectively. Limb deficiencies occurred in 78% of cases. Amniotic bands with limb deficiency was the most common phenotype (48%). Digital limb deficiency was the most frequent type (56%); however, cases with body wall defects had more severe types of limb deficiencies. The upper limbs only were affected more times (44%), and there was no side preference. Most cases are sporadic but a number of familial occurrences have been reported although some have insufficient documentation and others misdiagnosed. A review of putative risk factors gives conflicting results. © 2016 Wiley Periodicals, Inc.

Congenital limb deficiency classification and nomenclature: The need for a consensus

After the thalidomide epidemic in the early 1960s, many jurisdictions developed congenital anomaly surveillance systems. Congenital limb deficiencies can act as indicators of potential teratogens. The classification of congenital limb deficiencies is essential to determine the precise cause or causes of this anomaly. This article describes the different terminology and classification that have been used over time and the need for a consensus. While there are a variety of studies examining the epidemiology and etiology of congenital limb deficiencies, there is an inconsistent use of terminology and classification which makes comparisons between studies challenging. © 2016 Wiley Periodicals, Inc.

Children with congenital limb deficiency in Norway: issues related to school life and health-related quality of life. A cross-sectional study

PURPOSE

To describe clinical features, issues related to school life and health-related quality of life (HRQOL) for children with congenital limb deficiency (CLD) and compare these children to Norwegian school children on HRQOL.

METHOD

Cross-sectional study. In 2010, a postal questionnaire, designed for this study and the Paediatric Quality of Life Inventory (PedsQL), was sent to 154 eligible parents of children with CLD, aged 6-18 years and registered at TRS National Resource Centre for Rare Disorders in Norway.

RESULTS

Response rate 44% (n = 67), median age 11 years, 42% were girls. Of the total group, 46 had unilateral upper limb deficiency (UULD) and 21 had multiple/lower limb deficiency (MLD/LLD). The most common UULD was below-elbow deficiency, of these, 65% used grip-improving devices, and 35% used prostheses. Children with UULD-reported PedsQL score similar to Norwegian schoolchildren (NSC). The MLD/LLD group was heterogeneous; most had below-elbow/knee deficiency. In this group, PedsQL scores were reduced for physical and social functioning compared with NSC. Compared with children with UULD, more children with MLD/LLD were restricted in participation because of pain and fewer participated in physical education with peers.

CONCLUSIONS

Most children with CLD participated with their peers and managed well in everyday life. Children with MLD/LLD seemed to have more challenges than children with UULD. Approximately one-third of all the children had assistive devices and/or practical assistance in school. Implications for Rehabilitation Most children with upper-limb deficiency (UULD) in Norway manage well in everyday life and have HRQOL equal to other Norwegian children. Many choose grip-improving devices instead of prostheses. Their preferences should be respected and taken into account as the need for new assistive devices arise. For children with pronounced disabilities, access to, and use of, assistive devices, adaptions and practical assistance may be important for participation. Cooperation with the child and the parents is necessary to find useful measures. Physical education and practical subjects may provide special challenges, both for children and their teachers. Children themselves often find good solutions and the tasks should be planned ahead in cooperation with them.