Saturday, June 20, 2015

Finger Masses

I see a number of kids with growths on the fingers.  These growth vary tremendously in size and expectations but these are technically tumors. The good news is that almost all of these finger masses are benign- meaning that they don't spread to other parts of the body.  They are still concerning to the family.  It is, therefore, key to have a good sense of what each mass might be so that can better understand the best treatment.

One such growth is infantile digital fibromatosis.  This is a benign growth- typically a bump on the finger or fingers.  It does not hurt.  Often, infantile digital fibromas are small as depicted in this picture from Medscape:

However, these growths can also be much bigger and concerning.  Here is one dramatic example of an infantile digital fibroma.

Infantile Digital Fibroma

Infantile Digital Fibroma

Here are a couple of links with more pictures of infantile digital fibroma:

The key step in evaluation of these bumps is be evaluated by a physician or surgeon with experience.  If the correct diagnosis of infantile digital fibroma is made, observation is recommended because surgery can lead to the bumps coming back bigger (recurrence).  In the case above, there was a biopsy done to make a diagnosis and the bumps did come back even bigger.  Surgery for infantile digital fibromatosis is not curative and is, therefore, typically avoided.  I must admit, however, that this is difficult to accept for the family AND for the surgeon.  Everyone wants this to be cured but unfortunately, there is no easy answer.  The good news is that over time with observation alone, many of patients with infantile digital fibromatosis will find that the lesions spontaneously get smaller or disappear.

Failla, et al nicely summarized the condition at this LINK.

Charles A. Goldfarb, MD
My Bio at Washington University

Sunday, May 31, 2015

Exciting Times!!

The opening of a new hospital or major facility is unusual in our modern healthcare system.  It requires a great deal of planning, coordination, and plans for growth.  That is why it is so incredibly uncommon and exciting that TWO new pediatric facilities are opening right now in St. Louis.  TWO, both in the first week of June, 2015!

Saint Louis Childrens Hospital is opening a large outpatient facility about 15 miles west of the main St Louis Childrens Hospital.  It is called the CSCC- Childrens Specialty Care Clinic.  It is beautifully done, outside and inside, is 3 stories high and is 140, 000 square feet in size.  It will be the home to specialty clinics (thus, the name) including orthopedics and hand surgery as well as 3 operating rooms.  There will also be some pediatrician offices housed in the building.  We are excited because it will make the St Louis Childrens Hospital team of doctors more accessible for more people.

View from highway of St Louis Childrens Specialty Care Clinic (CSCC).

A recent picture of mine of a the St Louis Childrens Specialty Care Clinic (CSCC) from the west side.

The new St Louis Shriners Hospital is opening Monday June 1st, 2015.  Originally, in 1924, the Shriners opened in St Louis on the Washington University Medical School campus.  40 years later, we moved to Frontenac and now we are moving back to the Medical School Campus.  The practice of medicine has changed a great deal and the needs of the new hospital are different.  The 90,000 square foot, 3 story hospital has far fewer inpatient beds, more space for research, and lots of great space for taking care of patients.
New St Louis Shriners Hospital

New St Louis Shriners Hospital

Entry of the new St Louis Shriners Hospital

While both facilities are beautiful, what really matters is that we now have even better space for our patients- St Louis Childrens Hospital, St Louis Specialty Care Clinic (CSCC) and St Louis Shriners Hospital.  I am lucky to have the chance to work in all 3 facilities and look forward starting this week!

Charles A. Goldfarb, MD
My Bio at Washington University

Saturday, May 30, 2015

Stiff Fingers

Symphalangism is one type of finger stiffness;  I previously written about it here.  I wanted to share a few more thoughts.  In addition to the classification noted in my other post, I often think of symphalangism in terms of whether or not the fingers are short.  Whether the fingers are short or not, symphalangism is quite rare.

Flatt and Wood reported on symphalangism and divided it into 3 types (a long time ago- 1975, in the journal Hand)
- Symphalangism with normal length fingers (i.e. True Symphalangism)
- Symphalangism with short fingers (symbrachydactyly)
- Symphalangism with another syndrome like Aperts

The clinical examination is notable for the lack of motion of one or more of the interphalangeal joints- typically the proximal interphalangeal joint.  It can be one finger or it can be many fingers. Importantly, the normal creases of the fingers are not there in symphalangism.

The arrow is pointing to the top of the PIP joint of the pointer (index) finger.  Note the normal creases which demonstrate that the finger has been moving.
Kids with symphalagism lack the normal joint development and therefore lack motion and therefore lack the creases.  Here is one child with symphalangism affecting both hands.
Symphalangism.  This is the child attempting to make a full fist.  The PIP joints do not flex (bend) much.

The other hand in Symphalangism.  This is the child attempting to make a full fist.  The PIP joints do not flex (bend) much.
Also note the lack of creases on the tops of the fingers.
Careful review of the x- rays show that the PIP joints have not developed in symphalangism.

Lateral view (side view) of the hand and fingers.  The PIP joints have not developed in symphalangism.  The arrow marks the PIP joint of the long finger (middle finger).
Charles A. Goldfarb, MD
My Bio at Washington University

Sunday, May 24, 2015

World Congenital Forum

Once every three years, an international group comes together for approximately 3 days to discuss all things relevant to the care of children born with musculoskeletal differences.  In 2012, it was here in the United States, Dallas Texas to be specific.  In 2015, the 10th World Symposium on Congenital Malformations of the Hand and Upper Limb was held in Rotterdam, The Netherlands.  It also included a precourse on cerebral palsy.  There were more than 45 invited speakers, 50 free paper presentations, 70 posters, and much, much conversation about malformations, treatments, and research.  We were hosted by Christianne van Nieuwenhoven and Steven Hovius, plastic surgeons with a wonderful congenital program at Erasmus University in Rotterdam.  And WOW! it was quite a meeting.

Our hosts.  We had a delightful small group tour on Saturday.  This picture is in front of a statue of Erasmus.

I had the opportunity to present some of our work and enjoyed the back and forth regarding this information from the widely experienced audience:
1) Data from our study of the prevalence of congenital differences based on the New York State Congenital Malformation Registry.
2) Syndactyly
3) Central Synpolydactyly (poster presentation)

As always, there was a great deal of information shared and I learned much from my colleagues from all over the world.

This is my registration badge- I wanted to share the awesome logo.
I could also show you many sites from the beautiful city of Rotterdam, but the bridge is it most notable piece of architecture (at least to me).
Rotterdam's Erasmus Bridge

Thank you again to our hosts, Steven and Christianne.

Charles A. Goldfarb, MD
My Bio at Washington University

Friday, April 24, 2015

Triphalangeal Thumb

The normal thumb has two bones- 2 "phalanges"- which makes it different from the three bones of the fingers.  Occasionally, we see a thumb with 3 bones- 3 "phalanges"- and we call it a triphalangeal thumb.  I have previously blogged about different aspects of the triphalangeal thumb5- finger hand and another on the Five finger hand.  Also, sometimes, the triphalangeal thumb is part of radial polydactyly when there is one triphalangeal thumb and one more typical thumb with two phalanges.

I wanted to share a case in which there was a single triphalangeal thumb.  This case is somewhat typical in that the extra bone is a really small, triangular shaped bone.  This bone causes a deviation of the thumb and that is usually the reason that the family seeks help. Surgery, as shown below, is reliable in straightening the thumb but does not always restore full motion.

Triphalangeal thumb, crooked due to the extra triangular shaped bone.

Another view of the Triphalangeal thumb, crooked due to the extra triangular shaped bone.

X-ray of the triphalangeal thumb.  There is a really small triangular bone between the main 2 thumb bones.

Another view of the X-ray of the triphalangeal thumb.  There is a really small triangular bone between the main 2 thumb bones.

This extra bone causes the thumb to be crooked and can also limit motion.  For both reasons, the patient may be taken to the operating room to remove the extra bone and tighten the joint.  A pin is placed to allow the soft tissues to heal.

This is the extra bone after removal.

Triphalangeal thumb after removal of the extra bone.  The thumb is straight once again.

Charles A. Goldfarb, MD
My Bio at Washington University

Monday, April 20, 2015

Underdeveloped Thumbs

Underdeveloped Thumbs 

It is always interesting to me when I see an older child with underdeveloped thumbs, aka hypoplastic thumbs.   Most of the time, children with small thumbs are identified early in life as small thumbs are typically part of a larger issue, radial longitudinal deficiency (RLD).  However, when isolated, underdeveloped thumbs can be easy to “miss” early in life and may only be noticed when children face increased demands on their thumbs in school or sports.

There are 3 parts to the underdeveloped thumb.
1) The thumb looks different due to a lack of the muscles at the base of the thumb, the thenar muscles.  While this may be clear to someone with training, this deficiency in muscles may not always be easy to appreciate.
2) The thumb MCP joint (connecting the thumb to the hand) is unstable.  This may be the most important part of the underdeveloped thumb from a functional standpoint.  The reason this is important is the lack of joint stability affects pinch strength and, eventually, this can cause functional limitations.    Basically, a weak pinch is not ideal and can absolutely limit what a child or adult can accomplish.
3) The web between the thumb and index finger may be shallow in the underdeveloped thumb.  While not always a problem, when this web is really shallow, it can limit the size of the object that the child can grab (such as a ball or soda can).

As mentioned above, the three signs are usually identified early as part of the bigger problem of RLD.  But sometimes, the thumb is an “isolated” problem.  We see that when one arm has severe RLD and the other seems normal.  But with close examination, the thumb on this "normal" side is really underdeveloped.  Or, as noted above, the child comes to clinic at age 10 or so complaining of different appearing thumbs that lack strength.  That is the case for this child.

Underdeveloped or hypoplastic thumbs.  Not the lack of muscle at the base of the thumb.

The underdeveloped thumb looks slightly different here but no obvious findings.

The underdeveloped thumb does not have good stability as shown in this stress picture.
X-rays of an underdeveloped thumb.  While not obvious, there is a clear difference in the thumb development compared to normal.

And why do we like to make this diagnosis?  Well, the underdeveloped thumb is a part of the spectrum of RLD.  So, even if the underdeveloped thumb is isolated, the patient still has RLD.  And, as I have blogged about Here, this carries risks for other abnormalities such as VACTRL, TAR syndrome, Holt- Oram Syndrome, and others.  If the child is properly identified, these other issues can be properly assessed.

In addition, if we identify the underdeveloped thumb, we can treat it to maximize function.  I have previously written about this Here, although that post discusses pollicization (not appropriate here) and reconstruction of the joint and the muscles (what we would consider for this patient).

Charles A. Goldfarb, MD
My Bio at Washington University

Friday, April 10, 2015

Unusual Clinodactyly

I have written previously on clinodactyly with several posts.  Clinodactyly, the curved finger, is typically not a functional problem.  But, a more severe deformity is more likely to be a problem with activities and patients often complain of trouble with things like keyboarding and musical instruments.  Clinodactyly of the small finger is most common location and it almost always causes a deviation of the pinky towards the ring finger.  It is rare to see any other deformity.

This 17 year old patient has clinodactyly but with the very uncommon deviation away from the ring finger.  It does not cause pain but it does cause trouble with activities.

Notice the curved small fingers- clinodactyly- but with deviation away from the hand.

Close up view of small finger clinodactyly.

Finger flexion is good (almost always the case) in this patient with clinodactyly.
Clinodactyly.  Not the abnormal shape of the middle bone causing deviation.
Clinodactyly.  Not the abnormal shape of the middle bone causing deviation.

Thanks for reading.

Charles A. Goldfarb, MD
My Bio at Washington University