The utility of prenatal ultrasound as a screening tool for upper extremity congenital anomalies

Fetal Hands: A Comprehensive Review of Prenatal Assessment and Diagnosis Over the Past 40 Years

Fetal skeletal dysplasias involving limbs and hands are rare congenital malformations. Prenatal two-dimensional ultrasound diagnosis of fetal limb defects has a sensitivity of about 30%; however, an increased detection rate may be obtained using three-dimensional (3-D) ultrasound in the rendering mode. 3-D ultrasound may be used as a complementary method providing additional information. Currently, magnetic resonance imaging (MRI), with the emergence of ultrafast imaging techniques and new sequences, allows for better diagnosis of several fetal skeletal dysplasias such as limb reduction defects and neuromuscular disorders. 3-D volumetric images from ultrasound or MRI scan data allow 3-D ultrasound reconstructions of virtual/physical models, and virtual reality can help researchers to improve our understanding of both normal and abnormal fetal limb/hand anatomy. In this article, we review the embryological development of fetal hands and their main anomalies including prenatal diagnostic methods, genetic counseling, the role of orthopedic and plastic surgery reconstruction, and new perspectives in fetal surgery.

Pre-natal and post-natal diagnosis of congenital upper limb differences: The first 3 years of the Australian Hand Difference Register

AIMS

Children with a congenital upper limb difference (CoULD) are a diverse group who often require multidisciplinary care and long-term support for functional and social impacts. The Australian Hand Difference Register (AHDR) provides a national database of children born with a CoULD and aims to facilitate research and improve health care for affected children. Using data from the first 3 years of its operation, we analysed the demographic and clinical features of participating families, including type of CoULDs and the frequency of pre-natal and syndromic diagnoses.

METHODS

Families were recruited from tertiary plastic surgery, orthopaedic and genetics clinics, as well as by self-referral. Hand differences were classified by the consulting physician according to the Oberg-Manske-Tonkin classification system. Primary carers were invited to complete an online questionnaire covering demographic information, pregnancy and newborn outcomes and diagnostic details.

RESULTS

Between August 2017 and September 2020, 822 families consented and 320 questionnaires were reviewed. CoULDs were detected pre-natally in 66 (20.6%) and post-natally in 248 children (77.5%); data for 6 (1.9%) children were missing. The most common CoULDs were radial polydactyly, symbrachydactyly with ectodermal elements and radial longitudinal deficiency, hypoplastic thumb. Twenty-seven children (8.4%) had an associated syndrome, 7 diagnosed pre-natally and 19 post-natally; the most common were VACTERL association, Poland anomaly, Holt-Oram and ectrodactyly-ectodermal dysplasia-clefting syndromes.

CONCLUSIONS

The AHDR is a valuable resource for understanding the relative frequencies of CoULDs. Participation will assist future research into the diagnostic journeys of children with CoULDs, including risk factors, diagnosis and psychosocial impacts.

Prenatal diagnosis of upper extremity malformations with ultrasonography: Diagnostic features and perinatal outcome

OBJECTIVE

The aim of this study was to assess the sonographic (US) characteristics, associated malformations, chromosomal status, and perinatal outcomes of fetuses with an upper extremity malformation (UEM) detected by US examination.

METHODS

The data of all patients evaluated in the Department of Obstetrics and Gynecology, Prenatal Diagnosis Unit between 2010 and 2015 were searched for UEM.

RESULTS

A total of 51 cases with UEM were detected. Eighteen cases (35.2%) had defects in the formation of body parts (absence of hand/forearm/digits); 25 cases (49%) had defects in differentiation (contractures, syndactyly), and 8 cases (15.6%) had duplication defects (polydactyly). The specificity of prenatal US for UEM was 96.2%. Ten cases (19.7%) had isolated UEM, and 41 cases (80.3%) had additional anomalies, most of which were cardiac, central nervous system, or facial malformations. Although chromosomal structure in isolated cases was normal in 9 of 10 cases (90%), 15 of 41 cases (36.5%) with multiple defects showed abnormal karyotypes. The chromosomal constituents of nine cases (17.6%) were not available. Although the postnatal outcome of isolated cases was favorable except for the presence of orthopedic problems, complex UEMs with or without abnormal karyotypes were always lethal (97.5%).

CONCLUSIONS

UEMs associated with other malformations are usually a sign of underlying severe chromosomal abnormalities, and the prognosis is poor. In contrast, chromosomal structure in isolated cases is normal, and the perinatal and postnatal outcomes are good. In general, US is an effective tool in differentiating fetuses with isolated UEM from those with UEM associated with additional malformations. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:267-276, 2017.

Prenatal diagnosis of congenital upper limb differences: a current concept review

Congenital upper limb differences are frequently associated with complex syndromes. Ultrasonography is considered as the first-line diagnostic modality, and fetal MRI can be useful to further evaluate ill-defined areas. Genetic and non-invasive prenatal testing help to identify the underlying genetic disorder. The diagnostic assessment is a multidisciplinary task that should involve early prenatal consultations with specialists involved in case management and treatment planning. Obstetricians, geneticists, radiologists, psychologists and dedicated surgeons are needed to provide good parental education, prenatal and postnatal care, and successful outcomes. The purpose of this review is to provide an overview of the clinicopathologic background, current diagnostic and imaging procedures in affected fetuses.

Prenatal Detection of Upper Limb Differences With Obstetric Ultrasound

PURPOSE

To determine the sensitivity, specificity, and predictive values of prenatal ultrasound detection of fetal upper extremity anomalies at a single tertiary care center in a large patient cohort. Our secondary purpose was to assess factors affecting prenatal detection including the presence of associated anomalies.

METHODS

We performed a retrospective review of prenatal ultrasound and postnatal clinical records from each pregnancy evaluated with a prenatal ultrasound at the Washington University Department of Obstetrics and Gynecology over a 20-year period. We searched for upper extremity anomaly diagnosis codes pre- and postnatally and correlated with clinical postnatal follow-up to determine prevalence, sensitivity, specificity, predictive values, and associated conditions.

RESULTS

A total of 100,856 pregnancies were evaluated by prenatal ultrasound, which included 843 fetuses diagnosed with a musculoskeletal anomaly (prevalence, 1 of 120) and 642 with an upper extremity anomaly (prevalence, 1 of 157). The postnatally confirmed sensitivity for prenatal ultrasound detection of an upper extremity anomaly was 42%. Sensitivity was lower in cases isolated to the upper extremity (25% vs 55%). Sensitivity was highest for conditions affecting the entire upper extremity (70%-100%) and lowest for those affecting the digits alone (4%-19%). Fetuses with limb reduction defects, radial longitudinal deficiency, phocomelia, arthrogryposis, abnormal hand positioning, and cleft hand had a higher likelihood of having an associated anomaly.

CONCLUSIONS

At our tertiary referral center, there was a notable prevalence of upper extremity anomalies; however, the overall sensitivity for detecting them with prenatal ultrasound was low. This was disappointing given the value of prenatal identification of anomalies for parental counseling. Prenatal diagnosis of anomalies affecting the entire upper limb was more reliable than diagnosis of more distal anomalies.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Prenatal diagnosis of musculoskeletal conditions

Ultrasonography is a safe, cost-effective tool used to prenatally detect common musculoskeletal conditions, including clubfoot, skeletal dysplasias, limb-length discrepancies, spinal abnormalities, and hand and other upper extremity deformities. With increased detection of such abnormalities, prenatal parental counseling by orthopaedic surgeons is being requested more frequently. Counseling is important for family education on prognosis and treatment options. A thorough understanding of the common musculoskeletal conditions diagnosed on prenatal ultrasonography, classification of these conditions, and the correlations of these classifications to postnatal severity allows the orthopaedic surgeon to conduct well-informed counseling sessions with families. Accurate information and counseling aids parents in understanding their child's diagnosis, assists clinicians in planning treatment algorithms, and optimizes family preparedness.

The utility of ultrasound for the detection of fetal limb abnormalities--a 20-year single-center experience

Objective

The standard obstetric ultrasound examination includes documentation of arms and legs. The purpose of this study is to review the efficacy of ultrasound for the detection of limb anomalies, the type and incidence of associated malformations and pregnancy outcomes.

Method

All cases of polydactyly (POD), abnormal hand position (AHP), limb reduction defects (LRD) and arthrogryposis (ART) scanned in our Unit between 1990 and 2010 were identified. Cases were categorized as isolated (ISO) or non-isolated (NISO). The accuracy of prenatal diagnosis, type and incidence of associated malformations and aneuploidy and pregnancy outcomes were determined.

Results

Most cases were NISO. The sensitivity of ultrasound was 19.1% for POD, 76.0% for AHP, 76.0% for LRD involving the long bones and 81.3% for ART. Cardiothoracic and facial defects were the most common accompanying malformations. The risk for aneuploidy ranged from 3.6% for POD to 47.2% for AHP. The live birth rate ranged from 85.5% for POD to 24.5% for AHP.

Conclusion

While imaging of the arms and legs allows detection of most cases of AHP, LRD involving the limbs and ART, a probable minimum of 20% to 25% of cases will escape prenatal diagnosis. Identification of these defects should prompt an extended anatomic survey and consideration of invasive testing for aneuploidy. © 2014 The Authors. Prenatal Diagnosis published by John Wiley & Sons Ltd.