Congenital malformations of the hand and forearm

Congenital nail abnormalities

Congenital nail disorders are an uncommon presenting symptom which can be difficult to diagnose and manage. Nail diseases in the pediatric population differ from those in adults in terms of diagnosis, approach and management. In most cases, they do not require treatment and resolve with growth. Physicians need to be able to recognize them, to reassure the parents. The most frequently encountered pathologies associated with nail disorder are syndactyly, acrosyndactyly, symbrachydactyly, macrodactyly, Wassel I thumb duplication, Kirner's deformity and congenital onychodysplasia of the index finger. Treatment usually consists in surgical correction of the deformity. Nail malformation can also be an aspect of a systemic disease. It may provide a clue for screening, and should not be overlooked. Nail conditions can be the first sign of nail-patella syndrome, ectodermal dysplasia, dyskeratosis congenita, epidermolysis bullosa, pachyonychia congenita or lung disease. Medical treatment is therefore discussed on a case-by-case basis.

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.

Unusual Presentation of Familial Unilateral Postaxial Polydactyly With Metacarpal Delta Phalanx: A Report of a Rare Case

The term "delta phalanx" is proposed to characterize an uncommon deformity that typically affects the middle phalanx of a finger. It has the appearance of the Greek capital letter delta, meaning it is shaped like a triangle. Because the faulty epiphysis occurs proximally to distally instead of along its usual horizontal course, the bone has a semilunar shape. Functional impairment or significant finger shortening are indications for surgery. A variety of congenital hand anomalies are linked to the delta phalanx. Few cases of middle delta phalanx in the ulnar polydactyly finger have been documented. This case study investigates an extremely uncommon occurrence of metacarpal delta phalanx in an ulnar polydactyly finger.

An Alternative Treatment Option for Blauth III B Thumb Hypoplasia-Thumb Stabilization with Iliac Crest Bone Graft and Intermetacarpal Arthrodesis

Thumb hypoplasia modified Blauth III B is usually treated by pollicization or, less commonly, by toe transfer. Both procedures always result in the resection of a body part, but with good cosmesis and acceptable function. We describe an intermetacarpal I/II arthrodesis with autologous bone graft augmentation to lengthen and stabilize the loose thumb. Clinical data were collected from nine patients, median age at surgery 3 years 8 months, with more than 7 years of follow-up. The results showed a grip strength on the Jamar dynamometer of approximately 61% of the unoperated hand. The Quick-DASH score was 11. The reconstructed thumb was 0.8 cm thinner and 1.9 cm shorter. Overall satisfaction on the VAS, with an average of 1.5 out of 10, is excellent with a partially usable thumb on a hand with five rays. The described procedure is a reliable treatment option with satisfactory results. In addition, none of the patients lost pincer grip between the second and third digit, but their thumb gained new function. Especially in environments where physical integrity has a high value, thumb construction instead of replacement could be considered.

Evaluation of the ulna lengthening by distraction osteogenesis in congenital radial deficiency

PURPOSE

Publications evaluating the results of the ulna lengthening in congenital radial deficiency are based only on small groups of subjects which yield statistical studies of low scientific value. The aim was to examine the effectiveness of ulna lengthening in radial longitudinal deficiency and determine the number and quality of complications based on one of the most numerous study groups described in the literature.

METHODS

The material consists of a study group with 31 upper limbs of unmatured patients diagnosed with type III and IV radial longitudinal deficiency. The study group was evaluated based on the parameters known from the literature. The difficulties during elongation were classified according to Paley's classification.

RESULTS

The study group contained patients with a mean age of 9 years, and the number of boys and girls was comparable. Ulna length significantly increased after elongation compared to the initial bone length. The patient's age didn't affect the ulna lengthening, and the amount of elongation didn't significantly affect the total stabilization period. However, the total stabilization time increased with increasing patient age. Difficulties affected more than half of the cases.

CONCLUSIONS

Ulna elongation in congenital radial deficiency results in significant lengthening of the ulna, and thus the entire forearm, compared to the initial bone length. This technique has a high percentage of difficulty, so its use should be considered after cautious discussion with the parents and patients.

Surgical Technique and Outcomes of Reconstruction for Blauth Type III Thumb Hypoplasia

BACKGROUND

Historically, amputation and pollicization has been the recommended surgical treatment for Blauth type III hypoplastic thumbs. However, due to aesthetic objections or cultural preferences, some parents seek out alternative surgical options. The present study describes a nontraditional technique that preserves and augments the hypoplastic thumb.

METHODS

Patient charts were retrospectively reviewed to identify patients with Blauth type III hypoplastic thumbs who underwent thumb reconstruction at our institution from 2008 to 2018. The reconstruction procedure involved toe phalanx transfer, staged tendon transfers, and lengthening as needed. Motion was assessed categorically as ability to flex, extend, or oppose the thumb. Functionality was assessed as ability to pinch and grasp with the surgical hand. Patient- or parent-reported improvement in thumb function was also recorded.

RESULTS

Of the 13 patients, 100% could flex, extend, and oppose the thumb to some degree. Eleven patients (85%) had functional one-handed grasp, and 9 (69%) had a functional pinch. Eleven patients (85%) reported no functional limitations of the operative hand. Thirteen patients (100%) reported improvement in hand function after surgery as compared to pre-operatively. There were 2 minor complications (15%), both of which resolved after intervention. No patients experienced donor-site morbidity.

CONCLUSIONS

Reconstruction of Blauth III thumbs is a nontraditional technique that allows for digit retention by salvaging the hypoplastic thumb. In the present study, the majority of patients had functional thumbs and all reported postoperative improvement. Overall, our results suggest that reconstruction is a viable surgical option for Blauth III hypoplastic thumbs.

Nonvascularized Iliac Crest Bone Graft for Reconstruction of the First Metacarpal in Type IIIB Thumb Hypoplasia: A Radiographic Follow-Up Study

PURPOSE

To present a radiographic follow-up study of the use of a nonvascularized iliac crest bone graft as a treatment for modified Blauth type IIIB thumb hypoplasia.

METHODS

From January 2015 to December 2019, nonvascularized iliac crest bone grafts were used to reconstruct the first metacarpal in 23 cases with type IIIB thumbs. The average follow-up duration was 1.9 years (range 1.0-3.9 years). We evaluated the patients' serial x-rays and measured the width and length changes of the reconstructed first metacarpals.

RESULTS

Survival of the graft, judged radiographically, was achieved in 20 cases (20/23, 87%), with an average reduction of 33% in the width of the graft. Shortening of the graft (average 2.3 mm, range 0.1-5.6 mm) was noted in 11 of the 20 cases, and an increase in the length of the graft (average 4.2 mm, range 0.7-8.6 mm) was observed in the other 9. Bone graft failure (3/23, 13%) occurred in 3 cases because of significant bone resorption.

CONCLUSIONS

For type IIIB thumb hypoplasia, a nonvascularized iliac crest bone graft was a feasible method to reconstruct the first metacarpal, with a 13% risk of graft failure, 33% average reduction in graft width, and 55% reduction in graft length. However, in cultures that value the preservation of a 5-digit hand, this technique may provide an alternative to excision with index pollicization.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Triphalangeal thump, thumb duplication, and syndactyly: The first case report in the literature

RATIONALE

Triphalangeal thumb (TPT) is a rare congenital malformation where the thumb has three phalanges instead of two. Syndactyly is a condition in which children are born with fused or webbed fingers. The combination of TPT, Syndactyly, and thumb duplication is extremely rare, especially when these deformities are combined in one hand.

PATIENT CONCERNS

Hand abnormalities and polydactyl have been reported in a 1-year-old boy.

DIAGNOSIS

A clinical examination reveals two thumb duplications, finger fusion (Syndactyly), and a thumb with three phalanges (TPT). The diagnosis was based on clinical findings and an X-ray image of the hand.

INTERVENTIONS

The Z-plasty method was used to remove the adhesion between the thumb and forefinger, as well as the removal of the medial and distal phalanx of the thumb's medial tip.

OUTCOMES

The patient was followed for 2 months and found him in good health. To authors' knowledge, we described an unusual case from Syria, considered the first in medical history.

LESSONS LEARNED

General and plastic surgeons should be aware about this unusual mix of the three abnormalities. The family history must also be carefully investigated to explore the occurrence of hereditary illnesses.

Double Vascularized Fibula Proximal Growth Plate Transplantation: Novel Technique for the Radial Longitudinal Deficiency (RLD) Grade IV Reconstruction

Radial absence or severe hypoplasia in radial longitudinal deficiency (RLD) is most commonly treated through stabilization of the carpus on the ulna (centralization or radialization) with or without preliminary distraction. Alternative methods include bone transfer to replace the absent or deficient radius using the proximal fibula, vascularized or nonvascularized, and more recently the transfer of a vascularized second metatarsophalangeal joint. There is paucity of articles suggesting vascularized fibula growth plate transfer for RLD grade III where proximal part of radius can be found and none about double fibular growth plate transplantation. We developed new technique a bilateral growth plate transplantation for the pediatric patient with unilateral RLD stage IV (Bayne and Klug). Totally 2 patients were operated using new technique. No vascular problems occurred and no peroneal nerve damage were observed at the follow-ups. Annual growth was determined on x-rays at the 1 and 2-year follow-ups measuring 0.75 to 0.9 cm with open growth plates. The x-rays also show no changes that can harm the long-term growth potential in the forearm, demonstrating this technique's capacity to achieve better results for forearm length and functionality in comparison to the Vilkki procedure or radialization operation and there is no need to sacrifice second toe. Thumb reconstruction can be done at age 3 or 4 years using pollicization or toe-to hand transplantation techniques. The patients and parents are satisfied with functional and esthetic outcomes. We believe the double fibular growth plate transplantation is a promising method to use to reconstruct unilateral RLD grade IV.

A detailed analysis of long-term outcomes following reconstruction for congenital thumb hypoplasia

This retrospective study analyses long-term outcomes of reconstruction for congenital thumb hypoplasia Grades 2 and 3 A. In 22 thumbs (mean follow-up 9 years), instability of the metacarpophalangeal joint was found in 20 thumbs regardless of the method of reconstruction, double breasting of local tissue with or without adductor pollicis advancement or use of a slip of flexor digitorum superficialis to supplement local tissue. There was a trend towards a greater global strength, higher Kapandji score and better subjective function score when the abductor digiti minimi was used as an opposition transfer as compared with the flexor digitorum superficialis. Results for motion and subjective parameters were consistent with comparable studies though these comparisons are compromised by different methods of classification and assessment. Consistent application of an expanded Blauth grading system and a formal hypoplastic thumb score will improve the ability to compare pre- and postoperative status, different techniques and results from different centres.Level of evidence: IV.

Combined clinic and home-based therapeutic approach for the treatment of bilateral radial deficiency for a young child with Holt-Oram syndrome: A case report

BACKGROUND

Holt-Oram syndrome (HOS) is a rare, genetic condition characterized by the combination of congenital heart defect and hypoplasia in one or both upper extremities. Children with HOS commonly present with varied joint and limb involvement including radial longitudinal deficiency impacting hand function. Evidence-based guidelines regarding orthotic wear and therapeutic techniques are lacking.

PURPOSE

The aim of this case report was to present the results of a long-term occupational therapy program for a patient with HOS pre and postpollicization.

STUDY DESIGN

Case report.

METHODS

A 4-month-old patient with bilateral radial longitudinal deficiencies began outpatient occupational therapy for custom orthosis fabrication and treatment which included long term clinic and home-based intervention. Techniques included passive range of motion, orthosis wear, therapeutic taping, and modified constraint induced movement therapy. Longitudinal assessment of musculoskeletal alignment and functional hand use was performed using goniometry for passive and active range of motion, the Assisting Hand Assessment (AHA), and The Thumb Grasp and Pinch Assessment (T-GAP).

RESULTS

Improvement in passive and active range of motion was achieved as well as improved activity level function as measured by the AHA and T-GAP postpollicization and intervention.

CONCLUSIONS

A combined clinic and home-based therapeutic approach can be effective for children with HOS to improve alignment and function pre and postpollicization to further enhance hand function. Comprehensive, long-term assessment is necessary to fully evaluate and communicate improvement.

Restoration of Five Digit Hand in Type III B & C Thumb Hypoplasia-A Game Changer in Surgical Management

Background  Hypoplasia of thumb is the second common congenital difference of the thumb, next only to duplication. It may occur as an isolated hand difference or as a part of radial longitudinal deficiency. In approximately 60% of these children, the radius shows hypoplasia. The incidence of thumb hypoplasia is one in 100,000 live births. In 50% of these children, the other hand will also have similar deficiency, although variable in severity. Hypoplasia of thumb has been classified into five major categories, according to the increasing severity of hypoplasia. Type III hypoplasia of thumb is characterized by skeletal hypoplasia involving the first metacarpal and carpometacarpal joint, absent intrinsic muscles and rudimentary extrinsic muscles. It was further subclassified into types A, B & C. Type III B, described by Manske and McCarroll, involves extensive deficiency of extrinsic and intrinsic musculature with aplasia of the metacarpal base. Type III C, described by Buck-Gramcko, has hypoplastic metacarpal head.

Methods  It is widely believed that reconstruction of Type III B & C hypoplastic thumb will not be functionally useful, and they are often included in the indications for pollicization in thumb hypoplasia. In India, we frequently come across parents, who are not willing to remove the hypoplastic digit. This forced us to find out a way to reconstruct the hypoplastic thumb into a functionally useful digit. We describe our surgical technique of reconstruction of hypoplastic thumbs and our experience in utilization of the technique in five children with Type III B & C hypoplasia of thumb. Carpometacarpal joint of thumb was reconstructed and stabilized with a toe phalangeal transfer in the first stage and an opponensplasty was done in the second stage to improve movement.

Results  In all the five operated children, our surgical technique yielded a stable thumb which was functional. The donor site morbidity was acceptable. The parents were satisfied with the appearance and functional improvement.

Conclusion  Surgical reconstruction of hypoplastic thumbs of Type III B & C is possible, and conversion of these poorly developed remnants into a useful digit by our surgical technique is a gamechanger in the management of thumb hypoplasia.

A Comparative Analysis of 150 Thumb Polydactyly Cases from the CoULD Registry Using the Wassel-Flatt, Rotterdam, and Chung Classifications

PURPOSE

Three commonly used classifications for thumb polydactyly are the Wassel-Flatt, Rotterdam, and Chung. The ideal classification system would have high validity and reliability and be descriptive of the thumb anomaly. The purposes of this investigation were to (1) compare the inter- and intrarater reliability of these 3 classifications when applied to a large sample of patients enrolled in the Congenital Upper Limb Differences (CoULD) Registry and (2) determine the prevalence of radial polydactyly types when using the various classifications in a North American population.

METHODS

Inter- and intrarater reliability were determined using 150 cases of radial polydactyly presented in a Web-based format to 7 raters in 3 rounds, a preliminary training round and 2 observation rounds. Raters classified each case according to the Wassel-Flatt, Rotterdam, and Chung classifications. Inter- and intrarater reliability were evaluated with the intraclass correlation coefficient (ICC) calculated using 2-way random measures with perfect agreement.

RESULTS

For Wassel-Flatt, both the interrater (ICC, 0.93) and the intrarater reliability (ICC, 0.91) were excellent. The Rotterdam classification had excellent reliability for both interrater reliability (ICC, 0.98) and intrarater reliability (ICC, 0.94), when considering type alone. Interrater analysis of the additional subtypes demonstrated a wide range of reliabilities. The Chung classification had good interrater (ICC, 0.88) and intrarater reliability (ICC, 0.77). Within the Wassel-Flatt classification, the most frequent unclassifiable thumb was a type IV hypoplastic thumb as classified by the Rotterdam classification.

CONCLUSIONS

The Wassel-Flatt and Rotterdam classifications for radial polydactyly have excellent inter- and intrarater reliability. Despite its simplicity, the Chung classification was less reliable in comparison. The Chung and Rotterdam classification systems capture the hypoplastic subtypes that are unclassifiable in the Wassel-Flatt system. Addition of the hypoplastic subtype to the Wassel-Flatt classification (eg, Wassel-Flatt type IVh) would maintain the highest reliability and classify over 90% of thumbs deemed unclassifiable in the Wassel-Flatt system.

CLINICAL RELEVANCE

The Wassel-Flatt and Rotterdam classifications have excellent inter-and intrarater reliability for the hand surgeon treating thumb polydactyly. Addition of a hypoplastic subtype to the Wassel-Flatt (Type 4h) allows classification of most previously unclassifiable thumbs.

Triphalangeal thumb: clinical features and treatment

Triphalangeal thumb is a rare congenital anomaly in which the thumb has three phalanges. Clinical presentation of triphalangeal thumb can vary considerably and can be present in both hands or unilateral. The thumb can be long with a finger-like appearance. The presence of clinodactyly depends on the shape of the extra phalanx varying from wedge-shaped to rectangular. Various joints, ligaments, muscles, and tendons of the first ray can be hypoplastic or absent, with varying degrees of stiffness or instability. The aim of surgical treatment is to reconstruct or correct the anatomic anomalies to obtain greater function and a more acceptable appearance. In our series, operations varied from removal of the delta phalanx with ligament reconstruction to multiple osteotomies and rebalancing of soft tissues. Results in these often complex cases can be rewarding if the surgeon has sufficient knowledge of the underlying anatomic differences. This review summarizes our current concepts of presentation and management of the triphalangeal thumb.

Surgical techniques for reconstruction of the hypoplastic thumb

The reconstruction of a congenital hypoplastic thumb usually involves release of a tight first web space, metacarpophalangeal joint stabilization, reconstruction of intrinsic muscle function, and extrinsic tendon reconstruction, as appropriate. Numerous surgical options and combinations are available, but the approaches vary among surgeons who work in the field of congenital hand surgery and the empirical evidence that allows for evaluation of the results of techniques is scarce. Both the pre-operative assessment and intra-operative findings of all thumb elements - bone, joints, and soft tissues - should be considered in the surgical decision-making and eventually define the methods of reconstruction. This article summarizes the different reconstructive options.

Ulna Growth Patterns After Soft Tissue Release With Bilobed Flap in Radial Longitudinal Deficiency

BACKGROUND

Centralization is commonly utilized for treating the severely deviated wrist in radial longitudinal deficiency (RLD). Individuals with RLD have congenital shortening of the ulna and previous studies have shown that traditional centralization, in particular with notching of the carpus, results in additional ulnar growth retardation. At our institution, we use a technique of soft tissue release with bilobed flap. We examined if this technique preserves the growth potential of the distal ulna, therefore, avoiding an additionally shortened forearm.

METHODS

We retrospectively reviewed serial radiographs of 16 patients with 18 wrists who had at least 3 years of follow-up after a soft tissue release with bilobed flap. Radiographic lengths were measured using the method described by Heikel. Percentage of normal growth was calculated using normative data published by Maresh. Comparisons were made with preoperative, postoperative, and final follow-up studies.

RESULTS

The average length of follow-up was 9.2 years (range, 3 to 16.3 y) with an average age of 11.6 years (range, 5.2 to 17.5 y). The average age at the time of surgery was 27 months (range, 14 to 48 mo). A minimum of 3 radiographic studies were available for each subject. The average ulna length preoperatively was 63.9% of age-matched normal length (51.4% to 75.3%). The average ulna length at final follow-up was 61.9% of age-matched normal length (48.5% to 70.3%). The difference was not statistically significant. In addition, there were no distal ulnar physeal arrests.

CONCLUSIONS

Soft tissue release with bilobed flap does not affect ulna growth like traditional centralization procedures can. This procedure has previously been shown to retain motion and have similar recurrence rates to formal centralizations. Therefore, we advocate that it be considered more widely for use in patients with RLD and significant wrist deviation to maximize growth and improve hand position. Soft tissue release with bilobed flap can be safely used on young children and preserve ulnar growth.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Long-Term Outcomes of Huber Opposition Transfer for Augmenting Hypoplastic Thumb Function

PURPOSE

This study was conducted to report the functional outcomes of the Huber opposition transfer (abductor digiti minimi muscle) in types II and IIIA hypoplastic thumbs.

METHODS

Patients who had undergone a Huber opposition transfer with at least 5 years of follow-up were included in this study. There were 21 thumbs included; 12 returned for a detailed evaluation and 9 were included with a medical record review. Outcome measures included range of motion and pinch strength; Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected on those who could return. There were 15 type II and 6 type IIIA thumbs.

RESULTS

Range of motion was significantly less than normal for both the interphalangeal and the metacarpophalangeal joints. For the returning cohort, key and tripod pinch were 44% and 65% of normal. The median Kapandji score was 9 (range, 6-10). The PODCI scores were high for global, upper extremity function, happiness, and pain. The PROMIS scores were similar to normal, except for parent reports of physical function. For all included patients, there was a revision surgery rate of 22%, primarily related to persistent instability.

CONCLUSIONS

At a minimum 5-year follow-up, the Huber opposition transfer for types II and IIIA thumbs was shown to provide good subjective outcomes, despite limited range of motion and strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Tendon Transfers for the Hypoplastic Thumb

Thumb hypoplasia is a component of radial longitudinal deficiency. The severity of hypoplasia can range from a slightly smaller thumb to a complete absence. Types II and IIIA hypoplastic thumbs are candidates for reconstruction to improve function, stability, and strength. There are 2 commonly used tendon transfers that can augment thumb opposition strength: the Huber abductor digiti minimi muscle transfer and the flexor digitorum superficialis opposition transfer. Both transfers use ulnar-sided structures to augment the thenar musculature. The Huber opposition transfer increases thenar bulk, but does not provide additional tissue for metacarpophalangeal stability.

Flexor Digitorum Superficialis Opposition Transfer for Augmenting Function in Types II and IIIA Thumb Hypoplasia

PURPOSE

To report the functional outcomes associated with the flexor digitorum superficialis (FDS) opposition transfer for types II and IIIA thumb hypoplasia and determine if there is any noteworthy difference in the outcome dependent on the pulley used.

METHODS

We included patients who underwent a ring FDS opposition transfer and had at least 2 years follow-up. The study group consisted of 36 patients with 40 treated thumbs. All patients underwent follow-up examination and standardized testing. Outcome functional measures were recorded using the Pediatric Outcomes Data Collection Instrument (PODCI). There were 9 type II and 31 type IIIA hypoplastic thumbs. All patients underwent a ring FDS opposition transfer and a 4-flap z-plasty for first web space deepening. The pulley for opposition was flexor carpi ulnaris in 19 and the transverse carpal ligament in 21. Thirty-six thumbs had ulnar collateral ligament reconstructions, with 5 of the 36 undergoing combined ulnar collateral ligament/radial collateral ligament stabilizations. Average follow-up was 7.6 years (range, 2-16 years).

RESULTS

Average postoperative Kapandji score was 8 (range, 4-10). Grip, lateral pinch, and tripod pinch strengths averaged 46%, 49%, and 48% of age- and sex-matched normal controls, respectively. There was no significant difference between surgical pulleys used. The Pediatric Outcomes Data Collection Instrument global was 91 (range, 53-100), and PODCI happiness was 87 (range, 15-100).

CONCLUSIONS

We found the ring FDS opposition transfer to be an effective method for providing opposition for both type II and IIIA thumb hypoplasia. At follow-up, excellent opposition function and PODCI scores were noted, with no difference related to the type of pulley used. Type II thumbs had significantly greater grip and pinch strengths when compared with type IIIA thumbs.

Congenital Clasped Thumb That Is Forgetten a Syndrome in Clinical Practice: A Case Report

Congenital clasped thumb is a progressive flexion and adduction deformity presenting with heterogeneous congenital anomalies. Although the disease is rare, diagnosis is usually delayed due to natural location of thumb within the palm in first 3 months of life. A 4-year-old girl with congenital clasped thumb deformity due to absence of extensor pollicis brevis tendon whose treatment consisted of extensor indicis proprius (EIP) transfer and z-plasty reconstruction to first web space. The patient was so happy with both cosmetic appearance and functional status. There was not any limitation at interphalangeal or metacarpophalangeal (MCP) joints of the thumb and the result was. Stability of MCP joint was full and power for grasping any object was much better than the original status. In cases of isolated clasped thumb deformity associated with absence of tendon whose treatment attempts with splinting and physical treatment have failed, EIP tendon transfer and reconstruction of contracture in first web space with z-plasty is an easy and successful method to obtain functional improvement.

Soft tissue release and bilobed flap for severe radial longitudinal deficiency

PURPOSE

To report the hand position, range of motion, functional results, and radiographic outcomes associated with treating radial longitudinal deficiency with release of constricting or deforming soft tissue and resurfacing of the radial skin deficiency with a bilobed flap.

METHODS

We recalled and reviewed patients with at least a 3-year follow-up who had undergone soft-tissue release and coverage with a bilobed flap. The study group consisted of 16 patients and 18 wrists. All patients underwent follow-up examination and radiographs. Outcome measures using Pediatric Outcomes Data Collection Instrument (PODCI), Disabilities of the Arm, Shoulder, and Hand (DASH), and visual analogue scale (VAS) scores were recorded.

RESULTS

At a mean of 9.2 years follow-up, the average final resting wrist radial deviation angle was 64° compared with 88° preoperatively. The average active wrist flexion-extension arc was 73°. Average DASH score was 27 (range, 5-54). PODCI global was 88 (range, 75-97), PODCI happiness was 86 (range, 70-100), and VAS overall satisfaction (range, 0-10) was 1.2 (range, 0-8). At final follow-up, no physeal growth arrests were noted on radiographs, and no patients to date have required ulnocarpal arthrodesis.

CONCLUSIONS

Soft-tissue release and coverage with a bilobed flap should be considered in the treatment algorithm for patients with radial longitudinal deficiency. Outcome measures show that these patients maintain useful active motion, and along with their parents, are satisfied with both the appearance and function. Some recurrence of radial deviation was noted, which was similar to results previously reported following centralization/radialization procedures, although with a lower inherent risk of both physeal injury to the ulna and stiffness. In addition, potential future procedures are not compromised by this surgical approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The 2014 ABJS Nicolas Andry Award: The puzzle of the thumb: mobility, stability, and demands in opposition

BACKGROUND

The paradoxical demands of stability and mobility reflect the purpose and function of the human thumb. Its functional importance is underscored when a thumb is congenitally absent, injured, or afflicted with degenerative arthritis. Prevailing literature and teaching implicate the unique shape of the thumb carpometacarpal (CMC) joint, as well as its ligament support, applied forces, and repetitive motion, as culprits causing osteoarthritis (OA). Sex, ethnicity, and occupation may predispose individuals to OA.

QUESTIONS/PURPOSES

What evidence links ligament structure, forces, and motion to progressive CMC disease? Specifically: (1) Do unique attributes of the bony and ligamentous anatomy contribute to OA? (2) Can discrete joint load patterns be established that contribute to OA? And (3) can thumb motion that characterizes OA be measured at the fine and gross level?

METHODS

We addressed the morphology, load, and movement of the human thumb, emphasizing the CMC joint in normal and arthritic states. We present comparative anatomy, gross dissections, microscopic analysis, multimodal imaging, and live-subject kinematic studies to support or challenge the current understanding of the thumb CMC joint and its predisposition to disease.

RESULTS

The current evidence suggests structural differences and loading characteristics predispose the thumb CMC to joint degeneration, especially related to volar or central wear. The patterns of degeneration, however, are not consistently identified, suggesting influences beyond inherent anatomy, repetitive load, and abnormal motion.

CONCLUSIONS

Additional studies to define patterns of normal use and wear will provide data to better characterize CMC OA and opportunities for tailored treatment, including prevention, delay of progression, and joint arthroplasty.

On the classification of congenital thumb hypoplasia

In 1937, Müller introduced the concept of a teratological sequence of thumb hypoplasia with increasing severity from mild deficiency, through severe deficiency, to thumb absence. Blauth subsequently detailed five specific grades. In 1992, Manske and McCarroll altered Blauth's classification such that Grade 3 was sub-divided into Grades 3A and 3B, according to a presence or absence of the proximal metacarpal. Buck-Gramcko added a Grade 3C in which there was only a remnant metacarpal head. This article investigates their publications and those of others to identify 'who said what' and clarify the definitions of grades of thumb hypoplasia. A modification of Blauth's classification is proposed, which retains the integrity of the concept of Müller and the skeletal and soft tissue grading of Blauth, but which also incorporates the disparate anomalies that may present in Grades 2 and 3 hypoplastic thumbs.

Management of congenital radial longitudinal deficiency: controversies and current concepts

SUMMARY

Radial longitudinal deficiency is a spectrum of upper extremity dysplasia and hypoplasia affecting the proximal arm and the radial aspect of the forearm, wrist, and hand. Often, the hand surgeon is the first to evaluate a patient with radial longitudinal deficiency and thus must be aware of its common associated syndromes. Specific evaluation, including clinical examination and laboratory testing, is necessary. At this time, there are many surgical approaches that can be used for treatment of radial longitudinal deficiency. The procedures should be specifically tailored to the patient and family to improve overall function and clinical outcome.

Recurrence of radial bowing after soft tissue distraction and subsequent radialization for radial longitudinal deficiency

PURPOSE

Centralization and radialization are the most widely reported surgical treatments for Bayne and Klug Type III and IV radial longitudinal deficiency. Prior soft tissue distraction has been introduced to improve reducibility of the deformity without skeletal resection. Satisfying long-term effects have been reported with centralization but are still unclear with radialization.

METHODS

This is a retrospective study of 8 consecutive children with Bayne and Klug Type III or IV radial longitudinal deficiency treated with preliminary soft tissue distraction followed by radialization between 2003 and 2008. All children underwent the same surgical protocol. End points of the study were clinical appearance, the hand-forearm angle, and mean angular correction at last follow-up.

RESULTS

The mean preoperative hand-forearm angle was 61° (26°-91°). The average duration of distraction was 1.9 month (1-3 mo). The initial postoperative angle averaged 12° (-14°-40°). There were 3 postoperative complications: 2 cases of pin loosening and 1 case of fracture of the base of the small finger metacarpal. Mean follow-up duration was 2.6 years (1-4 y). At last follow-up, 7 of the 8 patients had visible recurrence of the deformity, the hand-forearm angle had deteriorated to 44° (20°-69°), and the mean angular correction was 18° (-43°-59°).

CONCLUSIONS

Preoperative distraction allows a gradual realignment of the hand on the forearm without skeletal resection, but the recurrence rate after radialization is high. Tendon transfers and soft tissue tensioning were unable to maintain hand-forearm alignment following soft tissue distraction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Thumb strength in all types of triphalangeal thumb

Strength is regarded as normal in patients with an opposable triphalangeal thumb. Our clinical impression is, however, that intrinsic musculature is probably affected in all forms of triphalangeal thumb. Therefore, we established the strength of 38 thumbs in patients with a triphalangeal thumb. Patients were excluded if the intrinsic musculature was enhanced or if osteotomies of the first metacarpal were performed. On average, strength of all thumb functions was significantly diminished, up to 63% for opposition strength. Strength of the power grip was on average 70%. As shown in this study, strength of the musculature of the thumb is affected in all types of triphalangeal thumb. Although strength of the thumb is diminished, in the investigated group it is apparently sufficient in daily life, as these individuals did not seek surgical enhancement. However, reconstructive procedures that enhance intrinsic musculature must be considered in all types of triphalangeal thumb.

[Blauth classification of thumb hypoplasia: thought and proposition of modification]

Using the conclusions of the previous article concerning the therapeutic indications for handling hypoplastic thumb, we suggest an amendment to the current Blauth classification. This alteration is based on the management of this congenital anomaly, whereas the Blauth classification describes the morphological characteristics of the malformation. It appears for us more usable in practice by its easiness to be memorized.

[The Adams-Oliver syndrome. A case report]

The authors report a case of Adams-Oliver syndrome in an 11 months child. This child was referred to our unit at the age of six months with right hand brachydactyly and alopecia on the vertex. We decided not to treat hand malformations, given the lack of functional impact. Alopecia of the vertex was corrected by tissue expansion of the scalp, with a satisfactory cosmetic result at five months.

Radial longitudinal deficiency

Radial longitudinal deficiency encompasses a spectrum of upper limb dysplasias and hypoplasias. The bony abnormalities of the thumb and radius are the most pronounced, but deficiencies of the accompanying muscles, nerves, vessels, and joints also greatly influence the ultimate upper extremity function. The striking clinical presentation of the involved upper limb is often more obvious than the potentially life-threatening associated systemic conditions. All children presenting with radial longitudinal deficiency, regardless of severity, require a renal ultrasound, echocardiogram, and complete blood count to evaluate the potential for associated systemic conditions; these include Fanconi's anemia, the Holt-Oram syndrome, and the VATER (vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal agenesis) syndrome or VACTERL (vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal agenesis, and limb defects) association. The overall health of the child, as well as the severity of the osseous and soft-tissue deformities of the affected limb, guides the long-term treatment plans.

The hypoplastic thumb

Thumb hypoplasia is part of a spectrum of radial longitudinal deficiencies involving the upper limb. Systemic involvement of other organ systems is not uncommon, thus requiring a team approach to management. Because of the variety of anatomic abnormalities associated with thumb hypoplasia, clinical and intraoperative evaluation of the thumb must be precise. Effective management of thumb hypoplasia requires an understanding of the embryology, epidemiology, classification, presentation, and management options. Management, which is primarily determined by the grade of thumb hypoplasia, may include nonsurgical techniques, reconstruction, pollicization, and, recently, microsurgical procedures.

The developing limb and the control of the number of digits

Congenital malformations of the limbs are among the most frequent congenital anomalies found in humans, and they preferentially affect the distal part--the hand or foot. The presence of extra digits, a condition called polydactyly, is the most common limb deformity of the human hand and is the consequence of disturbances in the normal program of limb development. However, despite the extensive use of the developing limb as a classical developmental model, the cellular and genetic mechanisms that control the number and identity of the digits are not completely understood. The aim of this review is to introduce the reader to the current state of knowledge in limb development and to provide the necessary background for an understanding of how deviations from the normal developmental program may lead to polydactyly.