Upper-extremity phocomelia reexamined: a longitudinal dysplasia

Microsurgical reconstruction of congenital upper extremity deformities of malformations

We present two rare microsurgical reconstructions. A case with phocomelia was treated with lengthening of soft tissues following vascularized fibula grafting with epiphysis, and a case with cleft hand was reconstructed with spare-part toe transfer.

Current concepts in the management Radial Longitudinal Deficiency

Radial longitudinal deficiency represents a spectrum of musculoskeletal hypoplasia and dysplasia affecting the upper limb involving mainly the radial aspect of the forearm, wrist, and hand and not infrequently the proximal arm. 2/3rd of the patients with this condition suffer from an associated medical or musculoskeletal disorder and 1/3rd of them show features of a well-known syndrome with systemic manifestations. Hence it is mandatory to do a detailed clinical, radiological and laboratory evaluation which should also include genetic counselling and assessment. Its management has evolved greatly since the beginning of last century. The vast variations developed for the treatment only reflects on the persisting controversy on the ideal treatment which still eludes the medical fraternity. Current treatment options for wrist deformities include radialization or centralization with or without distraction which unfortunately has often shown poor outcomes with high rates of recurrence and poor growth of ulna leading some workers to suggest alternative techniques, which include microsurgical reconstruction using the proximal fibula and the second toe. The management of the associated hypoplastic thumb has been encouraging with recent improvements in classifications and increased options for milder deformities. The article reviews the management options available for this common condition with respect to the recent developments in literature.

Dorsal and Ventral Dimelia in the Same Hand in A Patient with Severe Ulnar Ray Deficiency: A Case Report

Dorsal dimelia (the appearance of dorsal hand structures on the palmar aspect of the hand) and ventral dimelia (the appearance of ventral hand structures on the dorsal aspect of the hand) are rare congenital anomalies of the hand. None of the previously reported cases had combined dorsal and ventral dimelia in the same patient. Here, we report a case of severe ulnar ray deficiency. The hand had two digits: the radial digit had a palmar nail (dorsal dimelia) and the ulnar digit had absence of the normal dorsal nail along with the appearance of an ectopic pulp on the dorsal aspect of the digit (ventral dimelia). Ulnar ray deficiency is an error of sonic hedgehog (SHH) responsible for antero-posterior patterning of the limb in-utero. Ventral and dorsal dimelia are errors of dorso-ventral patterning of the hand. The complex interactions of SHH with the dorso-ventral axis of development may explain the concurrent dimelia in our patient.

Role of Genetic Factors in the Pathogenesis of Radial Deficiencies in Humans

Radial deficiencies (RDs), defined as under/abnormal development or absence of any of the structures of the forearm, radial carpal bones and thumb, occur with a live birth incidence ranging from 1 out of 30,000 to 1 out 6,000 newborns and represent about one third/one fourth of all the congenital upper limb anomalies. About half of radial disorders have a mendelian cause and pattern of inheritance, whereas the remaining half appears sporadic with no known gene involved. In sporadic forms certain anomalies, such as thumb or radial hypoplasia, may occur either alone or in association with systemic conditions, like vertebral abnormalities or renal defects. All the cases with a mendelian inheritance are syndromic forms, which include cardiac defects (in Holt-Oram syndrome), bone marrow failure (in Fanconi anemia), platelet deficiency (in thrombocytopenia-absent-radius syndrome), ocular motility impairment (in Okihiro syndrome). The genetics of radial deficiencies is complex, characterized by genetic heterogeneity and high inter- and intra-familial clinical variability: this review will analyze the etiopathogenesis and the genotype/phenotype correlations of the main radial deficiency disorders in humans.

Defining Features of the Upper Extremity in Holt-Oram Syndrome

PURPOSE

To investigate the distinguishing morphological characteristics of children with radial longitudinal deficiency (RLD) in Holt-Oram syndrome (HOS).

METHODS

One hundred fourteen involved extremities in 62 patients with a diagnosis of HOS were identified at 3 institutions. Medical records and radiographs were evaluated. Radial longitudinal deficiency and thumb hypoplasia were classified according to the modified Bayne and Klug classification and Blauth classifications, respectively, when possible. Other unusual or distinguishing characteristics were catalogued.

RESULTS

There was bilateral involvement in 84% of patients. The forearm was involved in 81% of the extremities and a shortened distal radius (Bayne and Klug type I RLD) was the most commonly identified forearm anomaly (40%). Radioulnar synostosis was present in 15% of the extremities, all in the proximal forearms with reduced radial heads. Thumb aplasia (Blauth type V hypoplastic thumb) was the most common type of classifiable thumb abnormality and occurred in 35% of involved thumbs. Twenty-seven percent of abnormal thumbs affected were not classifiable according to the Blauth classification, and 19% of involved thumbs (hypoplastic or absent) had first-web syndactyly.

CONCLUSIONS

The upper extremity in HOS differs from the typical presentation of RLD. The forearm is more often involved and may demonstrate radioulnar synostosis. The thumb is frequently unclassifiable by the Blauth classification and has first-web syndactyly. The presence of radioulnar synostosis and syndactyly of the radial 2 digits in RLD should prompt the hand surgeon to obtain a cardiac evaluation and consider genetic testing for HOS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

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.

Single-stage management of a neglected radial club hand deformity in an adult

Radial club hand is an intercalary congenital deformity involving the forearm, wrist and hand. A congenital absence of radius (partial or complete) and ulnar bowing are classical radiographic abnormalities seen in this condition. This deformity is usually treated surgically in infants and young children but the management of this problem in an adult is complex and challenging. We present a neglected case of an adult with severe and rigid deformity that was successfully treated by one-stage correction involving ulnar osteotomy and wrist arthrodesis, simultaneously.

The effect of soft tissue distraction on deformity recurrence after centralization for radial longitudinal deficiency

PURPOSE

To assess recurrence and complications in children with radial longitudinal deficiency treated with or without external fixator soft tissue distraction prior to centralization.

METHODS

Thirteen upper extremities treated with centralization alone were compared with 13 treated with ring fixator distraction followed by centralization. Resting wrist position between the 2 groups was compared before surgery, approximately 2 years after surgery (midterm), and at final follow-up, which was at a mean of 10 years for the centralization-alone group and 6 years for the distraction group. Radiographs were reviewed for hand-forearm angle, hand-forearm position, volar carpal subluxation, ulnar length, and physeal integrity.

RESULTS

The clinical resting wrist position was improved significantly after surgery and at final follow-up in both groups, but recurrence was worse at final follow-up in the distraction group patients. Radiographically, in the centralization alone group, the hand-forearm angle improved from 53° before surgery to 13° at midterm but worsened to 27° at final follow-up. In the distraction group, the hand-forearm angle improved from 53° before surgery to 21° at midterm but worsened to 36° at final follow-up. The hand-forearm position improved between preoperative and final assessment in both groups, but at final follow-up, the centralization-alone group had a significantly better position. Volar subluxation was 4 mm improved in the centralization alone group and 2 mm worse in the distraction group at final follow-up.

CONCLUSIONS

Centralization, with or without distraction with an external fixator, resulted in improved alignment of the wrist. Distraction facilitated centralization, but it did not prevent deformity recurrence and was associated with a worse final radial deviation and volar subluxation position compared with wrists treated with centralization alone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Forearm post-traumatic deformities: classification and treatment

INTRODUCTION

There is no classification for acquired forearm deformities. A clinical-radiographic study was conducted to classify these deformities and evaluate the results.

MATERIALS AND METHODS

Thirteen patients with forearm deformities following traumas or their treatment were included (11 men and two women, from 2000 to 2010). Mean age was 31 years (range 10-75 years). Initial treatment was conservative in five patients and surgical in eight patients. One segment was affected in seven patients (the radius in four patients, the ulna in three), and both segments were affected in six patients. Location assessment: 2 projections X-rays, including wrist and elbow. Deformity location: proximal, diaphisary, distal, defined with the abbreviation, in distal sense, R1, R2, R3 for the radius, and U1, U2, U3 for the ulna. Primary and secondary deformities were distinguished: secondary deformities occurred later in a different location than the primary one. Six patients were treated with plate and screws. An external fixator was used in six patients. One patient was treated with bone resection. Iliac crest bone graft was used in 10 patients, and vascularised fibula graft in one patient.

RESULTS

The primary deformity affecting the radial diaphysis (R2) determined a secondary deformity in four patients: in the distal ulna (U3) with ulnocarpal dislocation in three patients and in the distal radius (R3) in one patient. Results of osteosynthesis treatment were excellent in one patient, satisfactory in four and unsatisfactory in one. External fixation was excellent in one patient and satisfactory in five. Bone resection was satisfactory in one patient.

DISCUSSION

Surgical treatments with osteosynthesis are the major cause of acquired forearm deformities in adults. Location and aetiology of the deformities are essential for the surgical indication and the result. It is important to restore the length of the deformed segment, realigning the anatomical axis. X-rays enable clinicians to distinguish between primary and secondary forearm deformities.

CONCLUSION

Characteristics and locations of post-traumatic deformities were identified. The major location is diaphisary and distal, the elbow is rarely affected. The functional consequence is a limitation in the range of motion of the hand. The best results are achieved with short-term treatment.

Epidemiology of congenital upper limb anomalies in Stockholm, Sweden, 1997 to 2007: application of the Oberg, Manske, and Tonkin classification

PURPOSE

To investigate the epidemiology of congenital upper limb anomalies (CULA) based on the newly proposed Oberg, Manske, and Tonkin (OMT) classification, to compare this classification with the International Federation of Societies for Surgery of the Hand (IFSSH) classification, and to provide incidence rates of the different CULA.

METHODS

In this study, the same 562 individuals with a CULA who were analyzed in a previous epidemiologic study based on the IFSSH classification were reclassified according to the OMT classification. All children identified with CULA and born in Stockholm County between January 1, 1997 and December 31, 2007 were included in the study. During the period there were 261,914 live births in Stockholm County, and the population of Stockholm County was 1,949,516 inhabitants at the end of the period. From medical records and available radiographs, all cases were analyzed regarding type of CULA, sex, affected side, associated nonhand anomalies, and occurrence among relatives. Individuals with right and left side anomalies belonging to different OMT subgroups were counted as 2 anomalies; thus, the material consisted of 577 CULA in 562 children.

RESULTS

It was possible to organize all CULA into the OMT classification. The largest main category was malformations (429 cases), followed by deformations (124 cases), dysplasias (10 cases), and syndromes (14 cases). We present the relation between the IFSSH and OMT classifications, elucidate difficulties within the OMT classification, and propose additions to the classification.

CONCLUSIONS

This study confirms that the OMT classification is useful and accurate, but also points out difficulties. With further refinements, we regard the OMT classification as a needed and appropriate replacement for the IFSSH classification.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Disruption of the radial/ulnar axis:congenital longitudinal deficiencies

Radial, ulnar, and central deficiencies represent a spectrum of abnormalities in the development of the upper limb. Radial longitudinal deficiency is often associated with abnormalities in other organ systems, such as cardiac and renal, and so requires a comprehensive medical evaluation. On the other hand, ulnar longitudinal deficiency tends to be associated only with other musculoskeletal abnormalities. In all of these conditions, there is a high incidence of ipsilateral thumb abnormalities. Given the importance of the thumb in overall hand function, abnormalities of the thumb often guide treatment for these conditions. Surgical treatment of the wrist and forearm in radial longitudinal deficiency is controversial, as will be outlined in this review.

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.

Phocomelia: a worldwide descriptive epidemiologic study in a large series of cases from the International Clearinghouse for Birth Defects Surveillance and Research, and overview of the literature

Epidemiologic data on phocomelia are scarce. This study presents an epidemiologic analysis of the largest series of phocomelia cases known to date. Data were provided by 19 birth defect surveillance programs, all members of the International Clearinghouse for Birth Defects Surveillance and Research. Depending on the program, data corresponded to a period from 1968 through 2006. A total of 22,740,933 live births, stillbirths and, for some programs, elective terminations of pregnancy for fetal anomaly (ETOPFA) were monitored. After a detailed review of clinical data, only true phocomelia cases were included. Descriptive data are presented and additional analyses compared isolated cases with those with multiple congenital anomalies (MCA), excluding syndromes. We also briefly compared congenital anomalies associated with nonsyndromic phocomelia with those presented with amelia, another rare severe congenital limb defect. A total of 141 phocomelia cases registered gave an overall total prevalence of 0.62 per 100,000 births (95% confidence interval: 0.52-0.73). Three programs (Australia Victoria, South America ECLAMC, Italy North East) had significantly different prevalence estimates. Most cases (53.2%) had isolated phocomelia, while 9.9% had syndromes. Most nonsyndromic cases were monomelic (55.9%), with an excess of left (64.9%) and upper limb (64.9%) involvement. Most nonsyndromic cases (66.9%) were live births; most isolated cases (57.9%) weighed more than 2,499 g; most MCA (60.7%) weighed less than 2,500 g, and were more likely stillbirths (30.8%) or ETOPFA (15.4%) than isolated cases. The most common associated defects were musculoskeletal, cardiac, and intestinal. Epidemiological differences between phocomelia and amelia highlighted possible differences in their causes.

Developmental biology and classification of congenital anomalies of the hand and upper extremity

Recent investigations into the mechanism of limb development have clarified the roles of several molecules, their pathways, and interactions. Characterization of the molecular pathways that orchestrate limb development has provided insight into the etiology of many limb malformations. In this review, we describe how the insights from developmental biology are related to clinically relevant anomalies and the current classification schemes used to define, categorize, and communicate patterns of upper limb malformations. We advocate an updated classification scheme for upper limb anomalies that incorporates our current molecular perspective of limb development and the pathogenetic basis for malformations using dysmorphology terminology. We anticipate that this scheme will improve the utility of a classification as a basis for diagnosis, treatment, and research.

A child with longitudinal cleavage of the upper extremity: treatment and etiology considerations

We report a 4-year-old boy with a normal right upper extremity and 2 left upper extremities. These extremities included one with radial components including the radius and rudimentary thumb ray extended from the humerus in the more superior extremity, and another with the ulna and ulnar hand elements attached more inferiorly to the thorax. The patient had normal shoulder motion but no other function in the more superior extremity; the inferior extremity had active flexion and extension of the 2 fingers. We excised the nonfunctioning radius and thumb and performed an "on-top-plasty" by mobilizing the inferior extremity on its neurovascular pedicle and fusing the ulna to the distal aspect of the humerus of the superior extremity. This unusual clinical presentation may represent a proximal manifestation of central longitudinal deficiency with early limb bud cleavage affecting the apical ectodermal ridge and underlying mesoderm.

Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from stockholm, sweden

PURPOSE

There are few true epidemiological studies of congenital anomalies of the upper limb (CULA) on total populations in the literature, and most incidence studies are hospital based. The purposes of this study were to describe the epidemiology and classify all CULA in a region of Sweden during an 11-year period.

METHODS

Between 1997 and 2007, there were 261,914 live births in the Stockholm region. A total of 562 children born during this period were found to have CULA. From medical records and available radiographs, all cases were analyzed regarding the type of congenital anomaly, gender, laterality, occurrence among relatives, associated non-hand anomalies, and syndromes. All 585 main anomalies were classified according to the International Federation of Societies for Surgery of the Hand classification. Individuals with right- and left-side main anomalies belonging to different categories were counted as having 2 anomalies.

RESULTS

The recorded incidence of CULA was 21.5 per 10,000 live births. Of the 562 children, 304 were boys. The anomalies affected the right side only in 169 children, the left side only in 186, and both sides in 207. Non-hand anomalies were recorded in 129 children, most commonly in the lower limbs. In 99 children, there was a known occurrence among relatives. Failure of differentiation was the most common category (276 of 585) followed by duplication (155 of 585), failure of formation (103 of 585), undergrowth (18 of 585), generalized abnormalities and syndromes (14 of 585), overgrowth (10 of 585), and constriction ring syndrome (9 of 585).

CONCLUSIONS

The incidence of CULA in our region was similar to the only previously comparable total population study from Western Australia. The minor differences in incidences between the categories according to the International Federation of Surgical Societies of the Hand may be due to variations in classification strategy. The results of the present study can be used as a reference of CULA in a total population.

Congenital cleft scapula with type V ulnar longitudinal deficiency: case report

A rare case of malformation of the scapula, a cleft scapula, has been encountered. This case is associated with type V ulnar longitudinal deficiency of the ipsilateral upper limb. The scapular malformation has been treated with fusion of the 2 parts, with good aesthetic and functional outcome. In this report, the clinical, radiological, and surgical findings, as well as the surgical technique, are described. Four cases of similar malformation have been reported in the literature, and they were described as complete scapular duplication. According to the current findings and reinterpretation of the previous reports, this malformation is better called cleft scapula rather than scapular duplication.

Congenital longitudinal deficiency

Radial and ulnar longitudinal deficiencies are the 2 most common types of congenital longitudinal deficiencies of the arm, with radial deficiency being 3 to 4 times more common. They are a spectrum of abnormalities, ranging from mild deficiency of the digits to complete loss of one-half the forearm, wrist, and fingers. Radial longitudinal deficiency is associated with a number of medical syndromes that require a comprehensive medical evaluation, while ulnar longitudinal deficiency (ULD) is associated with other musculoskeletal anomalies. Both conditions have a high incidence of ipsilateral thumb abnormalities. Wrist and forearm procedures, such as soft tissue distraction and centralization, are more often required in radial longitudinal deficiencies than in ULD. Elbow involvement can occur in both conditions but is more frequent and often more severe in ULD.

Combined congenital radial and ulnar longitudinal deficiencies: report of 2 cases

Variation in longitudinal deficiencies is likely related to the timing and duration of an insult during early limb development. In experimental models, teratogenic insults induce ulnar deficiencies earlier in gestation than radial deficiencies. In this report, we describe the rare combination of right radial and left ulnar deficiencies in 2 cases. Interestingly, 1 case had a history of 2 separate and apparently distinct episodes of bleeding during early gestation, whereas the other demonstrated associated hematoma formation early in development. These cases also demonstrate the susceptibility for ulnar defects on the left and radial defects on the right. The authors discuss the relationship of prenatal insults on limb development and the mechanisms underlying longitudinal deficiencies.

Congenital hand surgery: what's new and what's coming

Congenital hand surgery has advanced during the last 10 years with surgical technique improvements, the incorporation of new technologies, and an enhanced understanding of the basic pathology of upper extremity anomalies. This article reviews the literature with a survey of 70 articles from seven leading journals published in the last 12 years. The author concludes that the next decade should be even more exciting with the incorporation of an improved understanding of tissue engineering and molecular genetics into classification and treatment algorithms. Understanding the genetic pathways of normal, and therefore abnormal, development should allow improved classification schemes and intervention to prevent, modify, or remedy these birth abnormalities.

Congenital failure of formation of the upper limb

This article provides an overview of the various classification systems for radial longitudinal, central longitudinal, and ulnar longitudinal deficiencies. It looks specifically at radius deficiency, hypoplastic thumb, index finger pollicization, narrowed thumb web, forearm-elbow deformities, and hand abnormalities. Various surgical approaches to these conditions and their results are explored. The authors conclude that longitudinal failure of formation deformities comprises a substantial portion of the anomalies of the upper limb. Although much of the past and current congenital hand literature has been devoted to these conditions, they continue to be a reconstructive challenge to hand surgeons involved in their care.

Preimplantation genetic diagnosis for severe albright hereditary osteodystrophy

CONTEXT

Preimplantation genetic diagnosis (PGD) enables the selection of embryos without mutations for implantation and has not been described to our knowledge for mutations in GNAS. Phocomelia in a patient with Albright hereditary osteodystrophy (AHO) has also not been previously described.

OBJECTIVE

The aim of this study was to identify a GNAS mutation in a patient with a severe form of AHO and pseudohypoparathyroidism type 1a with phocomelia and to perform PGD on embryos derived by in vitro fertilization to deliver an unaffected infant.

DESIGN

A proband and his family are described clinically, the GNAS gene was sequenced to identify a novel mutation in the proband, and PGD was performed on embryos.

SETTING

The setting was in a tertiary-care hospital.

PATIENTS

The patients were from a single family in which the proband has a severe form of AHO.

INTERVENTIONS

Interventions were PGD and in vitro fertilization.

MAIN OUTCOME MEASURES

The main outcome measures were the clinical phenotypes and GNAS gene sequences of the proband, embryos, and family members.

RESULTS

After PGD, three genotypically normal embryos were transferred back to the mother. Pregnancy ensued, and a healthy male infant was delivered at 36.5 wk gestation. The GNAS genes in the baby were confirmed as wild-type, and the infant is free of any signs of AHO.

CONCLUSIONS

We describe herein a proband with AHO and severe skeletal deformities (including phocomelia) related to a novel GNAS mutation and the delivery of a male infant with homozygous normal GNAS genotype after PGD.

Clinical manifestations of type IV ulna longitudinal dysplasia

PURPOSE

Ulna longitudinal dysplasia is an uncommon congenital anomaly that demonstrates a wide variety of clinical manifestations. The clinical manifestations and function of patients with Bayne type IV ulna longitudinal dysplasia have not been well characterized. The purpose of this study was to report the clinical features of type IV ulna longitudinal dysplasia and the extent to which this affects a patient's ability to perform activities of daily living.

METHODS

The medical records of children diagnosed with ulna longitudinal dysplasia in our institution between 1960 and 2004 were reviewed. The children found to have ulna longitudinal dysplasia with radiohumeral synostosis (Bayne type IV ulna dysplasia) were studied. The laterality of the deformity, associated musculoskeletal and nonmusculoskeletal anomalies, and treatments were recorded. Patients were interviewed regarding their ability to perform activities of daily living.

RESULTS

One hundred twenty-five patients with 146 affected limbs were identified with ulna dysplasia. Seventeen limbs in 14 patients (12% of affected limbs) demonstrated radiohumeral synostosis (RHS). Three of 14 patients with RHS had bilateral involvement. The elbows were fixed in 20 degrees to 90 degrees of flexion. No elbows were positioned in full extension. Eleven of the 17 involved limbs with RHS had digital anomalies. Nine of the 17 limbs had surgical reconstruction. The majority of these procedures were performed on the hand.

CONCLUSIONS

The elbow, forearm, wrist, and hand clinical findings associated with type IV ulna longitudinal dysplasia are variable. Surgical treatment usually focuses on correction of hand abnormalities. Many patients function satisfactorily and are able to perform daily activities without surgical intervention.

Objective features and aesthetic outcome of pollicized digits compared with normal thumbs

PURPOSE

To evaluate the objective features and subjective aesthetic outcome of pollicized digits compared with normal thumbs.

METHODS

Thirty-one pollicized digits in 26 patients were evaluated at an average 41 months after surgery. The length, girth, and nail width were measured and compared with previously reported data for normal thumbs. A surgeon, therapist, and caregiver completed Visual Analog Scales (VAS) to subjectively assess the aesthetic outcome; they also provided the principal reasons for their assessment of the altered appearance compared with normal thumbs. All data were statistically analyzed.

RESULTS

The average length of the pollicized digit relative to the long finger proximal phalanx was 90% (+/-26%), compared with an age-matched normal average of 71%. The girth of the pollicized digit relative to the long finger was 92% (+/-8%), compared with an age-matched normal thumb average of 132%. The nail width of the pollicized digit relative to the nail width of the long finger was 96% (+/-9%), compared with an age-matched normal thumb average of 104%. The VAS scores averaged 7.3 for the caregiver, 6 for the therapist, and 6.4 for the surgeon. The most frequently cited (altered) features were narrow girth, angulation, and excess length of the pollicized digit.

CONCLUSIONS

Pollicized digits are longer and have reduced girth and nail width compared with age-matched normal thumbs. The most significantly abnormal features are decreased girth, excess length, and angulation.

Thumb function and appearance in thrombocytopenia: absent radius syndrome

PURPOSE

To evaluate thumb function and appearance in patients with thrombocytopenia absent radius (TAR) syndrome.

METHODS

The size and shape of the 14 thumbs in 7 patients with TAR syndrome were quantified and compared with age-matched normals. Function was assessed using a series of standardized tasks.

RESULTS

The thumb length averaged 73% relative to the length of the index finger proximal phalanx (normal, 70%) and 36% relative to the length of the entire index finger (normal, 32%). The thumb/index nail width and girth ratios measured 138% and 101%, respectively (normal, 133% and 105%, respectively). The relative thumb/index thumbnail width-to-girth ratio was 1.36, which was significantly greater than the normal average of 1.27, suggesting the TAR thumbs are relatively wide and flat compared with normal thumbs. The thumb interphalangeal joint was held in a neutral posture and did not show active motion in any patient; the metacarpophalangeal joint was held in a position of flexion and had an average of 32 degrees of extension lag. Patients had difficulty with all activities tested, especially grasping large objects.

CONCLUSIONS

The thumb in TAR syndrome patients is of relatively normal size and shape; however, the thumb is held in a position of metacarpophalangeal flexion in most patients and function is impaired.

Radial longitudinal deficiency: the incidence of associated medical and musculoskeletal conditions

PURPOSE

Radial longitudinal deficiency (RLD) is associated with certain syndromes and medical and musculoskeletal conditions. The purpose of this investigation was to evaluate the incidence of these conditions with RLD.

METHODS

A comprehensive chart review identified patients with RLD and a complete medical record. These charts were evaluated for the presence of associated medical and musculoskeletal conditions and biographic information on gestation, delivery, and family history.

RESULTS

A total of 164 patients with 245 affected extremities were identified; 138 patients had radius abnormalities and 26 patients had isolated thumb hypoplasia. Twenty-five patients had thrombocytopenia absent radius syndrome; 22 patients had vertebral, anal, cardiac, tracheoesophageal, renal, and limb abnormalities association; 7 patients had Holt-Oram syndrome; and 1 patient had Fanconi anemia. There were 32 patients with cardiac abnormalities and 60 patients with spinal or lower-extremity musculoskeletal abnormalities. The percentage of patients with associated abnormalities increased with an increasing severity of RLD. One hundred two of the 138 patients with types I through V RLD had associated medical or musculoskeletal abnormalities. In contrast, only 9 of 26 patients with an isolated thumb hypoplasia (type 0 RLD) had associated abnormalities.

CONCLUSIONS

The high incidence of associated medical and musculoskeletal abnormalities in patients with RLD emphasizes the importance of a complete assessment including a complete musculoskeletal examination, cardiac auscultation, complete blood count, echocardiogram, renal ultrasound, and spinal radiographs. Although approximately one third of patients in this investigation had a syndrome commonly associated with RLD, most patients with RLD types I through V had an additional medical or musculoskeletal anomaly. Patients with type 0 RLD were less likely to have comorbidities.