Symbrachydactyly

The Hand Accumulation aNd Dexterity FUnctional Limits-Shriners (HANDFULS): A New Clinically Feasible Measure of Hand Volume and In-Hand Manipulation for Children

IMPORTANCE

Having a problem-specific hand function test that can be administered easily with children is important for consistency in measuring and monitoring outcomes.

OBJECTIVE

To introduce basic testing procedures for Hand Accumulation aNd Dexterity FUnctional Limits-Shriner (HANDFULS), a clinically feasible hand outcome measure for two common hand problems, in-hand manipulation and palmar workspace volume; examine its face validity and test-retest reliability; and provide reference values for children and adolescents with typically developed, noninjured hands as a foundation for further study.

DESIGN

Prospective cohort study.

SETTING

Pediatric hospital and surrounding community.

PARTICIPANTS

Children and adolescents, ages 2 to 20 yr, with typically developed, noninjured hands.

INTERVENTION

A newly developed hand function test called HANDFULS.

OUTCOMES

HANDFULS measured palmar workspace volume, represented by the number of marbles children and adolescents could comfortably fit in their hand, and in-hand manipulation, represented by seconds per marble needed to collect the marbles in the hand.

RESULTS

Results for the primary outcomes palmar workspace volume and the HANDFULS scores were reported by age group. For every year increase in age, HANDFULS score decreased by 0.02 s per marble (p < .001). The test showed moderately high test-retest reliability (intraclass correlation coefficient = .84) and was typically administered in less than 5 min with supplies costing about $30.

CONCLUSIONS AND RELEVANCE

This study proposes a hand outcome measure that addresses a gap in the literature and clinical practice in the measurement of hand function. Plain-Language Summary: The Hand Accumulation aNd Dexterity FUnctional Limits-Shriners (HANDFULS) offers a new, clinically feasible outcome tool for measuring in-hand manipulation (the number of seconds per marble a child or adolescent needs to collect marbles in one hand). HANDFULS simultaneously considers palmar workspace volume (the number of marbles a child or adolescent can comfortably fit in one hand) as a foundation for future testing with various patient populations to provide meaningful and relevant information about hand function.

Engineered phalangeal grafts for children with symbrachydactyly: A proof of concept

Tissue engineering approaches hold great promise in the field of regenerative medicine, especially in the context of pediatric applications, where ideal grafts need to restore the function of the targeted tissue and consider growth. In the present study, we aimed to develop a protocol to engineer autologous phalangeal grafts of relevant size for children suffering from symbrachydactyly. This condition results in hands with short fingers and missing bones. A previously-described, developmentally-inspired strategy based on endochondral ossification (ECO)-the main pathway leading to bone and bone marrow development-and adipose derived-stromal cells (ASCs) as the source of chondroprogenitor was used. First, we demonstrated that pediatric ASCs associated with collagen sponges can generate hypertrophic cartilage tissues (HCTs) in vitro that remodel into bone tissue in vivo via ECO. Second, we developed and optimized an in vitro protocol to generate HCTs in the shape of small phalangeal bones (108-390 mm3) using freshly isolated adult cells from the stromal vascular fraction (SVF) of adipose tissue, associated with two commercially available large collagen scaffolds (Zimmer Plug® and Optimaix 3D®). We showed that after 12 weeks of in vivo implantation in an immunocompromised mouse model such upscaled grafts remodeled into bone organs (including bone marrow tissues) retaining the defined shape and size. Finally, we replicated similar outcome (albeit with a slight reduction in cartilage and bone formation) by using minimally expanded pediatric ASCs (3 × 106 cells per grafts) in the same in vitro and in vivo settings, thereby validating the compatibility of our pediatric phalanx engineering strategy with a clinically relevant scenario. Taken together, these results represent a proof of concept of an autologous approach to generate osteogenic phalangeal grafts of pertinent clinical size, using ASCs in children born with symbrachydactyly, despite a limited amount of tissue available from pediatric patients.

Correction of symbrachydactyly: a systematic review of surgical options

Symbrachydactyly is a rare congenital malformation of the hand characterized by short or even absent fingers with or without syndactyly, mostly unilaterally present. The hand condition can vary from a small hand to only nubbins on the distal forearm. This study aims to systematically review the surgical management options for symbrachydactyly and compare functional and aesthetic outcomes.The review was performed according to the PRISMA guidelines. Literature was systematically assessed searching the Cochrane Library, PubMed, Embase, and PROSPERO databases up to January 1, 2023. Studies were identified using synonyms for 'symbrachydactyly' and 'treatment'. Inclusion criteria were the report of outcomes after surgical treatment of symbrachydactyly in humans. Studies were excluded if they were written in another language than English, German, or French. Case reports, letters to the editor, studies on animals, cadaveric, in vitro studies, biomechanical reports, surgical technique description, and papers discussing traumatic or oncologic cases were excluded.Twenty-four studies published were included with 539 patients (1037 digit corrections). Only one study included and compared two surgical techniques. The quality of the included studies was assessed using the Modified Coleman Methodology Score and ranged from 25 to 47. The range of motion was the main reported outcome and demonstrated modest results in all surgical techniques. The report on aesthetics of the hand was limited in non-vascularized transfers to 2/8 studies and in vascularized transfers to 5/8 studies, both reporting satisfactory results. On average, there was a foot donor site complication rate of 22% in non-vascularized transfers, compared to 2% in vascularized transfers. The hand-related complication rate of 54% was much higher in the vascularized group than in the non-vascularized transfer with 16%.No uniform strategy to surgically improve symbrachydactyly exists. All discussed techniques show limited functional improvement with considerable complication rates, with the vascularized transfer showing relative high hand-related complications and the non-vascularized transfer showing relative high foot-related complications.There were no high-quality studies, and due to a lack of comparing studies, the data could only be analysed qualitatively. Systematic assessment of studies showed insufficient evidence to determine superiority of any procedure to treat symbrachydactyly due to inadequate study designs and comparative studies. This systematic review was registered at the National Institute for Health Research PROSPERO International Prospective Register of Systematic Reviews number: CRD42020153590 and received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.Level of evidenceI.Systematic review registrationPROSPERO CRD42020153590.

Type 3A Symbrachydactyly in a Newborn Female: A Case Report

Symbrachydactyly is a complex and rare congenital hand deformity characterized by missing or underdeveloped fingers and rudimentary digit nubbins. This case report focuses on a newborn female with type 3A symbrachydactyly, highlighting the unique clinical presentation, diagnostic assessment, and initial management approach. The rarity of this condition underscores the need for sharing cases to enhance understanding and treatment strategies. Various classification systems exist, contributing to the challenge of accurately categorizing symbrachydactyly. Surgical interventions play a crucial role in restoring hand function and appearance, with treatment choices tailored to individual evaluation and goals. Early surgical intervention is often necessary to improve outcomes, and nonvascularized toe phalangeal transfers have shown promising results. Further research is required to uncover the underlying cause and pathogenesis of symbrachydactyly, enabling more targeted and effective treatment approaches. This case report contributes to the existing knowledge and management of this uncommon congenital anomaly, emphasizing the importance of sharing and studying such cases for improved patient care.

Cutis Calcinosis of the Hand in 2 Patients With Symbrachydactyly

Cutis calcinosis of the hand in the setting of symbrachydactyly is presented in 2 unique patients. Both lesions were treated based on the standard of care protocols with resection of the calcified mass and hand reconstruction, as appropriate. The patients healed uneventfully without recurrence of the calcification at a the 1-year follow-up. The association between symbrachydactyly and calcinosis cutis is discussed along with a hypothesis on the pathophysiologic mechanism that could potentially explain this unusual occurrence and why it might be more common than previously identified.

Hypothesis: Symbrachydactyly

The term symbrachydactyly has been used for the phenotype of two or three short fingers or toes, hypoplasia of the middle and distal phalanges and variable syndactyly of the affected digits. Some clinicians have extended this diagnosis to include other phenotypes, specifically cleft hand, terminal transverse limb defects, hypoplasia of the thumb and fifth finger with nubbins for fingers 2, 3, and 4 and the hand deformity of the Poland anomaly. A malformations surveillance program can identify enough affected infants to characterize a phenotype. In the Active Malformations Surveillance Program in Boston (1972-2012) among 289,365 births, all infants and fetuses with structural abnormalities were identified from reading the examination findings by the pediatricians and pathologists and the results of diagnostic tests. Liveborn and stillborn infants were included, as well as fetuses from elective terminations because of anomalies identified in prenatal testing. We present the findings in 14 infants, all liveborn, who had symbrachydactyly of one or both hands (n = 12) or feet (n = 2). We suggest restricting the term symbrachydactyly to this single phenotype to improve counseling and to focus future research on identifying the cause(s).

Nonvascularized Free Toe Phalangeal Transfers in Congenital Hand Differences: Radiological, Functional, and Patient/Parent-Reported Outcomes

PURPOSE

To evaluate radiologically, functionally and by patient-reported outcome measures, nonvascularized free toe phalangeal transfer (NVFTT) in the reconstruction of congenital short fingers with redundant soft tissue.

METHODS

Nineteen children who underwent NVFTT in 40 digits were studied. Of these, 13 patients with a mean follow-up of 5.2 years were assessed radiologically for epiphyseal patency, growth, growth rate, and length comparison with the contralateral toe. Eight children were available for an in-person follow-up. In these patients, we measured the pinch strength and range of motion. The Pediatric Outcomes Data Collection Instrument; the upper extremity, depression, anxiety, pain interference, and peer relationships domains of the Patient-Reported Outcomes Measurement Information Systems; and the aesthetic component of the Michigan Hand Questionnaire were used for the assessment of psychosocial impact.

RESULTS

An open epiphysis was found in 24 of 31 grafts. Among these, 20 of 21 grafts were in 9 children younger than 18 months and 4 of 10 grafts were in children older than 18 months at the time of operation. The mean growth was 3.4 mm. The mean growth rate was 1.3 mm/y. Length was 71.8% of the contralateral phalanx. The key pinch strength was 1.3 kg (2.6 kg on the normal side). The mean range of motion at the metacarpophalangeal joint was -4° to 65° flexion. Two proximal interphalangeal joints were stiff and 2 had range of motion of 0° to 30°. Children evaluated with Pediatric Outcomes Data Collection Instrument had high mean scores in all domains. The Patient-Reported Outcomes Measurement Information Systems scores were low for the upper-extremity domain. On the aesthetic component of the Michigan Hand Questionnaire, children gave higher scores than parents. Donor toes, though short, did not cause a functional disability.

CONCLUSIONS

NVFTT reliably provides length, stability, and movement in short fingers with redundant soft tissue. In addition to good radiological and clinical outcomes, the patient-reported outcome measures support performing NVFTT in children. Surgery before 18 months, extraperiosteal harvests of grafts, and avoidance of tight skin closures are important.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Free Non-vascularized Toe Phalangeal Transfers in Symbrachydactyly: Outcome Analysis

Introduction Free nonvascularized toe phalangeal transfer is an established surgical option for the reconstruction of hypoplastic digits. The purpose of the present study was to evaluate our experience with this procedure and to assess bone growth and digit function as well foot morbidity.

Material and Methods We retrospectively evaluated the clinical records for all children with symbrachydactyly submitted to free nonvascularized toe phalangeal transfer between 2002 and 2017. A total of 8 patients were included. We summoned the patients to an appointment to clinically assess the range of motion, the stability, and the alignment of the neo-joint. We radiographically measured the final length and the expected percentage of growth of the transferred phalanx. We also evaluated the foot for comorbidities.

Results The mean age at the time of the first surgery was 19 months (range: 8–42 months). A total of 20 phalanges were harvested: 16 total proximal phalanges, 2 middle phalanges, 1 subtotal proximal phalanx, and 1 accessory thumb phalanx. The distal part of one proximal phalanx was trimmed because the skin pocket was too tight. Two patients underwent a secondary procedure to release the syndactyly. One transfer required revision surgery due to distal tip necrosis and exposition of the transferred phalanx. In the present series, the overall clinical and radiographic outcomes were compatible to those reported in other studies.

Discussion The main limitation of the nonvascularized toe phalanx transfer is the preexisting soft tissue envelope of the finger and the limited growth potential of the transferred bone.

Conclusion Irrespective of the amount of growth achieved in the transferred phalanx, the actual transfer and growth attained should not be viewed as the end result, but rather as a means of providing a stable and functional joint.

Improving prenatal detection of congenital hand defects through collaborative goal-directed antenatal care: a case report on symbrachydactyly

BACKGROUND

Prenatal ultrasonography for the detection of fetal structural anomaly is an important component of antenatal care. During the assessment, proximal limb deformities are readily diagnosed. Distal limb, especially digit, abnormalities, however, may be difficult to detect, particularly if the ultrasonography is performed in the third trimester, and the deformity is unilateral and isolated.

CASE

A 24-year-old primigravida booked for antenatal care with a general practitioner had threatened miscarriage at 12 weeks of gestation, and at 34 weeks was referred to an obstetrician for further care and delivery. The growth ultrasonographic examination was normal but at 40 weeks of gestation she developed antepartum haemorrhage of unknown origin. She had a caesarean delivery and a female baby with "rudimentary" left fingers ("isolated symbrachydactyly") was delivered. The parents were counselled and they declined further assessment of the baby by a hand surgeon and a clinical geneticist. At 3 years of age, the baby had normal development and "is using her hand even without fingers," according to the mother.

CONCLUSION

Collaborative goal-directed antenatal care that involves different categories of healthcare professionals, but particularly a certified sonologist who performs fetal anomaly ultrasonography, is essential for the detection of congenital hand defects. Adequate counselling is essential for the satisfaction of the baby's family.

Atypical cleft hand with complex syndactyly: An unusual form of hand oligodactyly

Hand oligodactyly refers to a developmental defect which results in the presence of less than 5 digits on a hand. It presents as a component of 4 main categories of congenital upper limb malformations. Herein, we present a 50-year-old man with an unusual form of hand oligodactyly which is characterized by atypical cleft hand accompanied by complex syndactyly between the thumb and the index finger. Accurate characterization of hand oligodacticity can sometimes be challenging due to unusual phenotypic appearances accompanying the abnormality. Radiological evaluation is of great importance for correct identification and classification of such complex hand anomalies, and the treatment should be highly individualized in these patients.

Characterization of Hand Anomalies Associated With Möbius Syndrome

PURPOSE

To investigate the distinguishing morphological characteristics of the upper extremities in children with Möbius syndrome.

METHODS

Twenty-seven involved extremities in 14 patients with a diagnosis of Möbius syndrome were identified at 2 institutions. Medical records, radiographs, and clinical photographs were evaluated. Congenital hand differences were classified according to the Oberg, Manske, and Tonkin classification, and hands with symbrachydactyly were classified by the Blauth and Gekeler classification. The presence of other congenital anomalies was catalogued.

RESULTS

There was bilateral involvement in 93% of patients with congenital hand anomalies. Twelve patients demonstrated congenital hand anomalies and 2 patients had been diagnosed with arthrogryposis. Among the 12 patients with congenital hand anomalies, 21 hands were classifiable as symbrachydactyly by the Oberg, Manske, and Tonkin classification and could be categorized by the Blauth and Gekeler classification. Short finger type was the most common subtype of symbrachydactyly, present in 13 hands. Eleven of these 13 patients (85%) were primarily affected on the radial side of the hand. Proximal arm involvement was identified in 2 patients with symbrachydactyly, both of whom had Poland syndrome and an absent pectoralis major.

CONCLUSIONS

Symbrachydactyly in Möbius syndrome differs from the typical presentation of symbrachydactyly. Characteristically, there is a bilateral presentation with a strong predilection for radially based brachydactyly. These described characteristics may help the hand surgeon appropriately assess patients, especially those with radial-sided symbrachydactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.