Thursday, October 1, 2015

Finger Bump

There are many reasons for bumps, cysts and masses in the fingers.  I have previous blogged HERE on some of these growths.  There is another common finger bump that should be discussed, the retinacular cyst.  The retinacular cyst is a type of cyst- a fluid filled sac- that grows from the flexor tendon sheath.

Here are a link that explain the general concepts of a ganglion cyst
Hand Society Explanation of Ganglion Cyst

Retinacular cysts can affect patients of any age.  These cysts appear as a pea- sized bump, where the finger meets the hand.  The are really a nuisance and usually cause pain with grasping (such as the steering wheel or a hammer).  Pressure causes discomfort as well.  As noted in the article by Hutchinson and Wang, these can disappear or resolve with time.  But in some patients, the cysts don't go away and do cause pain.  In those patients (a minority), treatment is a reasonable option.  This can include aspiration (sucking fluid out of cyst) or surgical excision.  Aspiration has been proven cost effective but is a challenge in kids.

Article by Wang and Hutchinson.  This article reviews ganglion cysts in the hand in children (7 were retinacular cysts).  Most resolved and typically within a year.

Surgery is simple and safe with a removal of the cyst off of the flexor tendon sheath.  The nerves and arteries are typically safe as the cyst is usually fairly central (in the middle of the finger).  When required, this is a satisfying surgery.

Article by Jebsen and Spencer.  This article reviews the outcomes after surgery for the retinacular cyst and reports very good results.

Retinacular cyst in the typical location at the base of the finger.  See the small cyst deep in the incision.

Charles A. Goldfarb, MD
My Bio at Washington University

Wednesday, September 23, 2015

Syndactyly Treatment: What's Next?

The basic treatment of syndactyly has not changed in many years.  The essential surgical care includes the creation of a web space (the 'commissure') with a flap and zig- zag incisions to the tips of the fingers to allow separation without straight- line scars (which can contract).  There is no doubt that our understanding of syndactyly has improved over the years and there have been many technical advances including variations on the commissural flap and modifications based on the exact type of syndactyly. Reports on reconstructing syndactyly without skin grafts have offered exciting new potential although many congenital hand surgeons continue to use grafts suggesting that results are not universally ideal.    I have written many times on syndactyly- check for those posts HERE.

Recently, Dr Landi reported outcomes using a new concept in the treatment of syndactyly.

This article describes the use of a hyalruonic acid scaffold to fill in the defects instead of skin grafting for syndactyly reconstruction.  The results are very good.  Article link  This material has become available in the United States and I wanted to share a recent case of ours.

This one year old child has bilateral cleft hands and cleft feet. He has a complete, cutaneous (skin only) syndactyly of the ring and small fingers bilaterally.  

Cleft hand with ring/ small finger syndactyly

Cleft hand with ring/ small finger syndactyly, palm view

In an effort to improve function and independence of the two fingers, he was brought to the operating room for bilateral syndactyly reconstruction.  We discussed using skin grafts but elected to proceed with the hyaluronic acid scaffold.  The 'hyalomatrix' works as a hydrophilic gel which allows cellular migration onto its 3D scaffold.    Skin cells can then migrate to allow healing.  

Hyaluronic acid scaffold
Hyaluronic acid scaffold- shiny side later peels off.

Here are a few pictures after the surgery.

Syndactyly reconstruction with hyaluronic acid scaffold, palm view
Syndactyly reconstruction with hyaluronic acid scaffold, dorsal view
It is too soon to know if this material will dramatically change the treatment of syndactyly.  But it does seem to be an important step forward to minimize or eliminate the need for skin grafts (with the accompanying scar).  More to come on this treatment.

Charles A. Goldfarb, MD
My Bio at Washington University

Saturday, September 5, 2015

Amniotic Constriction Band

Amniotic Constriction Band commonly affects the hand and feet.  I have previously posted on the topic on several occasions as can be viewed HERE.  I wanted to share a few recent cases to demonstrate the different types of Amniotic Constriction Band.

This young child has Amniotic Constriction Band affecting one foot and one hand as depicted below.  The toes are characteristically short and there is a syndactyly (joining of the digits) as well.  As classically noted, the syndactyly is fenestrated such that the tip of the digits are joined but there is an opening closer to the foot.  The hand has a great thumb and a reasonable index finger but the finger is tethered to the remnants of the other digits.

Amniotic Constriction Band of the foot

Amniotic Constriction Band of the hand

Amniotic Constriction Band of the hand, view of the palm

Here is another case of Amniotic Constriction Band demonstrating a slightly different appearance. First, here is the hand prior to surgery.  The thumb is somewhat short, the index finger short and the first webspace (between the thumb and index finger) is tight.  The index finger is bulbous as may be seen in this condition.
Amniotic Constriction Band of the hand, view of the palm.  The pinky is normal but the other digits are short.

Amniotic Constriction Band of the hand.  Note the abnormal index finger with bulbous index finger.

Amniotic Constriction Band of the hand, view of abnormal index finger

Tight first web space with 2 bands of contracture.  Amniotic Constriction Band.
The decision for surgery is based primarily on function but also should consider appearance.  Mom and family were concerned about the length of the thumb and the appearance of the hand.  Certainly, I agreed with the concerns about the thumb because the short thumb and tight webspace limit large object grasp.  And, the bulbous nature of the index finger also limits both function and appearance.  We therefore offered reconstructive surgery.  The webspace was limited in two planes and therefore we used a more complex flap than typical.
Flap raised to reconstruct the first webspace in Amniotic Constriction Band
Flap raised to reconstruct the first webspace in Amniotic Constriction Band. The flap has been laid across the tight web.
Reconstructed hand with deeper webspace and contoured index finger Amniotic Constriction Band

Reconstructed hand with deeper webspace and contoured index finger Amniotic Constriction Band.  The pinky finger is held by the instrument.
Reconstructed hand in Amniotic Constriction Band

Charles A. Goldfarb, MD
My Bio at Washington University

Wednesday, August 19, 2015

3D Progress

I have posted several times previously on our work with 3D Printed Prosthetics, the posts are compiled here.  Sydney is one of our patients who has been a big part of this process.  She recently received the latest prosthetic version, a 3D Printed, Myoelectric device and fabricated for about $110. Today, there was a great deal of press on Sydney and her new 'arm'.  Here are a few of the links:

KSDK link


Fox2 Link

In addition, Sydney and I talked just after she got the new prosthetic.  She wasn't yet a pro at using the hand but still lots of interesting things to say.  Check it out

Charles A. Goldfarb, MD
My Bio at Washington University

Tuesday, August 18, 2015

More on Amniotic Constriction Band

I recently posted on a young child with Amniotic Constriction Band Here.  I wanted to update that post with additional information.  Prior to coming to me, the patient had been treated in an urgent way by Dr Erin Greer who performed a z- plasty and release of the tight band.  This surgery was done to help the thumb survive as it looked concerning due to the tight band.  Needless to say, this surgery was successful and the thumb looks really good and clearly will survive.

Here are new pictures (not previously posted) just after birth with a thumb with Amniotic Constriction Band that is at risk.  See the tight band and the swollen thumb past the band.

Amniotic Constriction Band with tight band.

Amniotic Constriction Band with tight band.

Amniotic Constriction Band with tight band.

Here are some pictures soon after the procedure- notice how improved the thumb looks already.
Amniotic Constriction Band after band release

Amniotic Constriction Band after band release
Finally, here is one picture when the patient came to see me.  Look how much improved the thumb is with the additional time.  There is still evidence of the band but this is a thumb that will do well long term and really help with function!

Amniotic Constriction Band with tight band after release.

Charles A. Goldfarb, MD
My Bio at Washington University

Sunday, August 16, 2015

Amniotic Constriction Band and the Hand

Amniotic Constriction Band is a common problem in our clinics.  Kids can have a diagnosis of amniotic constriction band and yet their hands can all look very different from one another as there are simply so many different presentations.  I have previously written about this topic here but I wanted to share a few more thoughts.

We typically think of 3 things when we make a diagnosis of amniotic constriction band.  Kids may have 1, 2, or 3 of these issues- that is what makes the diagnosis so different from one child to the next.  First, they can have constriction rings or indentations in the skin.  These can be mild or can go really deep.  If deep enough, the blood supply to the finger (or for that matter the whole arm if the ring is higher up in the arm) can be affected and can theoretically not survive.  These rings can be in the arms, hands, or legs.  

The next issue is amputation, or loss of an arm or more commonly a finger or part of a finger.  We think this is related to a deep, tight ring while the baby is still in the womb.  Rarely, a newborn can have a tight ring and we worry that the finger might not live unless we do surgery to save it (and that is what happened in this child's thumb- early surgery may have saved the thumb).

The final issue is amniotic constriction band is joining of the fingers together- the so- called syndactyly.  This is different from other types of syndactyly as we believe it is related to scarring after an amputation of a finger.  It can be two fingers or the whole hand.  This can be difficult to treat but early treatment can lead to really satisfying results and a great hand.

Here is a case for consideration showing all 3 types of problems in amniotic constriction band.

First is the left hand.  Note the constriction in the index finger.  This can be addressed with surgery which will decrease the band and allow more normal growth. The second picture has a side view showing another view of the band.  The rest of this hand looks pretty good.  The middle finger (or long finger) has been amputated and is about the length of the index finger.  Amputation of the long finger is most common.

Amniotic constriction band with a tight band of the index finger.

Amniotic constriction band with a tight band of the index finger, a side view.

The right hand is more complicated in this case of amniotic constriction band.  The thumb had urgent surgery after birth for a tight band and looks very good now.  There is also a reasonably well formed pinky.  The ring finger has a tight band that will be released.  But the other digits are joined together from scarring and are short due to amputations.  Early surgery may help create better, more functional fingers and hand.
Amniotic constriction band with a thumb band previously released.

Amniotic constriction band with a tight ring finger band, amputations of other digits.
Amniotic constriction band with several amputations.

Amniotic constriction band with a tight band of the ring finger.

Charles A. Goldfarb, MD
My Bio at Washington University

Hand Surgery in Children

The timing and appropriateness of surgery of the hand and arm in children with  birth anomalies are difficult topics.  The problem for parents and doctors is that we don't truly know how well any particular child will adopt to his limitations and how much those limitations will affect his/ her life.  We all hope for kids with excellent function and 'normal' appearance and, therefore, families seek doctors and surgery to make their kid's hands 'normal'.  As a surgeon with experience, I see it as my job to share reasonable expectations about surgery (as well as risks and recovery).

As kids get older, they can participate in decision- making.  But the reality is that families often want 7 year old or 10 year old kids to really make the touch decisions about whether to have surgery and that is not likely to be helpful.  We want such kids to have a stake in the decision but they are not usually able to truly really make such difficult decisions.  Understanding the future is tough and having reasonable expectations about surgery (pain, recovery, etc) is really challenging.  In the case below of a 17 year old, his feelings and his life experience with his condition are vital to an appropriate decision for surgery (in this case family was interested and he was absolutely not).

These are issues that we face every day in clinic and every family approaches such decisions differently.  It is my job to help each family, in its different way, make the best decision.  Not easy (and sometimes talking through this is more challenging than the surgery itself).

Distal arthrogryposis is, in my practice, less common that amyoplasia or the more extensive disease. Because the disease is focused on the hands alone, patients tend to function at a higher level and have an easier time with activities in general.  I have posted twice on this topic, here and here.  Surgery is often considered as it can improve hand position and sometimes finger and thumb motion.  But such decisions are not easy for most families.

I recently met a 17 year old male who reminded me that function can be very good even with some deformity and some limitations in motion.  He was absolutely not interested in surgery as he felt he could perform all activities without too much difficulty.  He did admit to using two hands for activities that others would accomplish with only one hand.  He also stated that some tasks might take him a bit longer to complete compared to other kids.  But he was not interested in surgery.

Here are some pictures of his hand (both sides looked the same) to frame the discussion.  The fingers do not straighten fully, especially the ring and small fingers with camptodactyly.  The fingers do however make a great fist (which is not always the case in other types of arthrogryposis) and with some strength.  Finally, the thumb web space is only marginal, not great, which limits his ability to grab larger things.
Distal arthrogryposis with attempted finger straightening

Distal arthrogryposis with attempted finger straightening from palm view

Distal arthrogryposis with a full fist demonstrated

Obviously, we did not perform surgery on this happy 17 year old with imperfect hands.  His parents were somewhat interested in learning more about the options which included therapy to help straighten the fingers (vs surgery to release the tightness on the palm side) and possibly surgery to help the thumb web space.  But could do everything he wanted to do and was okay with accomplishing certain goals differently than his peers.

Charles A. Goldfarb, MD
My Bio at Washington University