Treatment alternatives of congenital hand differences with thumb hypoplasia involvement

Surgical Reconstruction for the Triphalangeal Thumb

The triphalangeal thumb poses a complex reconstructive challenge to the congenital hand surgeon due to its rarity and variable anatomy. We discuss the available evidence, reporting clinical characteristics and outcomes of surgical reconstructive procedures of triphalangeal thumb alongside a representative case. The congenital hand surgeon must approach each patient with triphalangeal thumb individually to optimize the use of available tissues to maximize functional and aesthetic outcomes.

[Spare-parts concept in pediatric hand: About one bilateral syndactyly]

INTRODUCTION

The spare-parts concept is well described in traumatology of the hand. Tissues of a scarified ray are used to reconstruct another damaged finger. We will detail an application in pediatric hand through a clinical case.

MATERIALS AND METHOD

We describe a patient presenting a bilateral complete and non-complex syndactyly of the third web space associated with a bilateral hexadactyly classified as type B according to the Temtamy and Mc Kusick's classification. The treatment of the syndactyly was performed with a dorsal flap for the web space and with longitudinal zigzag incisions in mirror. Skin loss of the lateral sides of the fingers was covered by the full-thickness graft taken on the supernumerary finger which was treated in the same surgical time.

DISCUSSION

This application of the spare-parts concept allows only one surgical site with absence of scar on the donor site and a skin graft close to the skin loss on the finger.

CONCLUSION

The spare-parts concept can be applied in some cases of pediatric hand and must be a tool for the surgeon.

Long term functional outcomes after early childhood pollicization

STUDY DESIGN

Retrospective Cohort

INTRODUCTION

Important outcomes of polliciation to treat thumb hypoplasia/aplasia include strength, function, dexterity, and quality of life.

PURPOSE OF THE STUDY

To evaluate outcomes and examine predictors of outcome after early childhood pollicization.

METHODS

8 children (10 hands) were evaluated 3-15 years after surgery. Physical examination, questionnaires, grip and pinch strength, Box and Blocks, 9-hole pegboard, and strength-dexterity (S-D) tests were performed.

RESULTS

Pollicized hands had poor strength and performance on functional tests. Six of 10 pollicized hands had normal dexterity scores but less stability in maintaining a steady-state force. Predictors of poorer outcomes included older age at surgery, reduced metacarpophalangeal and interphalangeal range of motion, and radial absence.

DISCUSSION

Pollicization resulted in poor strength and overall function, but normal dexterity was often achieved using altered control strategies.

CONCLUSIONS

Most children should obtain adequate dexterity despite weakness after pollicization except older or severely involved children.

LEVEL OF EVIDENCE

IV.

Quantitative assessment of dynamic control of fingertip forces after pollicization

Dexterity after finger pollicization (reconstruction to thumb) is critical to functional outcomes. While most tests of hand function evaluate a combination of strength, coordination, and motor control, the Strength-Dexterity (S-D) paradigm focuses on the dynamic control of fingertip forces. We evaluated 10 pollicized and 5 non-pollicized hands from 8 participants ages 4-17 years (2 female, 6 male; 10.6 ± 4.5 years). Participants partially compressed and held an instrumented spring prone to buckling between the thumb and first finger to quantify dynamic control over the direction and magnitude of fingertip forces. They also completed traditional functional tests including grip, lateral pinch, and tripod pinch strength, Box and Blocks, and 9-hole peg test. Six of 10 pollicized hands and all non-pollicized hands had S-D scores comparable to typically developing children. However, dynamical analysis showed that pollicized hands exhibit greater variability in compression force, indicating poorer corrective action. Almost all pollicized hands scored below the normal range for the traditional functional tests. The S-D test Z-scores correlated moderately with Z-scores from the other functional tests (r = 0.54-0.61; p = 0.02-0.04) but more weakly than amongst the other functional measures (r = 0.58-0.83; p = 0.0002-0.02), suggesting that the S-D test captures a different domain of function. A higher incidence of radial absence in the hands with poor S-D scores (3/4 vs. 0/6 in hands with normal S-D scores, p = 0.03) was the only clinical characteristic associated with S-D outcome. Overall, these results suggest that while most pollicized hands can control fingertip forces, the nature of that control is altered.

Constriction band syndrome

Constriction band syndrome is an uncommon congenital abnormality with multiple disfiguring and disabling manifestations. Early amnion rupture with subsequent entanglement of fetal parts by amniotic strands is currently the primary theory for the development of this syndrome. Management of constriction band syndrome is focused on improving function and development while providing a more acceptable esthetic appearance. The treatment should be tailored to the individual. Timing of repair and surgical planning are important to provide the best functional results for affected hands.