Thursday, August 16, 2018

Unusual "Extra" Finger

I have posted many times on polydactyly- both on the thumb side and the pinky side- as can be seen HERE.  The following patient demonstrates an unusual presentation of what initial appears to be an extra finger, an ulnar polydactyly.  But, as a quick 'count' confirms, there are only 4 fingers with a thumb.


Ulnar deficiency with apparent polydactyly

Ulnar deficiency with apparent polydactyly, palmar view
The xrays are very helpful in understanding this patient's hand.  There is one thumb and four fingers BUT, there are only 4 metacarpal bones in the hand instead of the normal 5.  This is an ulnar deficiency of the hand as demonstrated by the lack of a fifth metacarpal.  The 4th metacarpal is wider than normal.  I have written about this uncommon form of ulnar deficiency HERE.  This is a scientific article sharing our experience.
Ulnar deficiency affecting the hand.

Occasionally the 4th metacarpal is wide enough to allow a surgery to split it to support both the ring finger and the pinky finger.  In this case, however, I did not feel that the metacarpal was wide enough to consider such a reconstruction.  

In addition, in this patient, the pinky finger was tethering or limiting the more normal ring finger, decreasing its motion and causing deformity.  The patient's family was initially hesitant to excise the pinky finger.  It is always difficult to make this decision despite the deformity.  With time, the limitations caused by the pinky finger to both function and appearance were appreciated and the family requested surgery to remove the finger.  Here are pictures and xrays only 6 weeks after surgery.  Function and appearance are excellent and the patient and family are both very pleased.  The function (motion and alignment) of the ring finger are much improved. 

After surgery for pinky excision in ulnar deficiency.  (The picture is a little hard to interpret because the index finger is bent).


Xray after pinky finger excision in ulnar deficiency.

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

Sunday, August 12, 2018

Function in Radial Deficiency

Radial longitudinal deficiency is both a functional challenge and an appearance issue.  Different surgeons have developed different strategies based on these challenges and the lack of a 'perfect' surgery.  My philosophy is to consider different surgeries, based on the child.  I will consider centralization (typically with a period of external fixator distraction prior to the centralization), a release with bilobed flap, or occasionally a lengthening of the radius.  And, sometimes, even with a deficient radius, surgery on the wrist may not be helpful.  The pollicization procedure is one of my favorites because it is so effective and so helpful.

This is a patient with a severe radial deficiency on the right (treated with external fixator, centralization, and pollicization).   Note the 90 degree deformity of the wrist.  The patient had a milder deficiency on the left (treated with pollicization).  This is an image before surgery on the right.
Severe radial deficiency with the wrist at about 90 degrees from the forearm. Note the short forearm and the lack of a thumb.


Here is an image of both hands after surgery on the left wrist (note how much straighter it is compared to the picture above) and the creation of both thumbs with pollicizations.




This first video gives some indication of the outcome of her pollicizations.  Remember- the pollicization helps in a few major ways including fine pinch (such as beads, in this video) and larger object grasp (second video).  The right hand and wrist were severely affected from birth and while she is doing well after surgery, she still has limitations.  You can see how well her left hand and new left thumb work (after pollicization).  However, on the right, the new thumb is not as strong or effective and she sometimes uses  the ring and small fingers (called prehensile function).  This may further change over time to favor use of the new thumb. 




This next video demonstrates several important findings.  First, the right side is weaker and she clearly, she prefers the left hand (which has only had the pollicization).  The left side in general (and the left thumb in particular) is stronger and more stable.  The right hand is helpful to her as is its pollicized digit BUT, when she really tries to use the right hand and the pollicized digit does not help, she switches to try the ring and small finger for grip (that is reflective of her prehensile grasp which never quite goes away).  


I hope these videos are helpful in understanding outcome with severe radial deficiency.

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

Saturday, July 21, 2018

Trigger Thumb and Fingers

Trigger thumb is one of the more common reasons for kids to present to my office.  While uncommon in the general population, for hand surgeons who treat children, trigger thumb is quite common.  And, thankfully, kids do quite well with this condition.  Some will improve on their own without surgical intervention and others require surgery and do well.   I have other posts on this topic which can be found HERE.  Most trigger thumbs in kids are locked (the thumb is stuck in a position of flexion).

Surgery is quite reliable for trigger thumb.  95% or more are cured with a straightforward, 5- minute surgery.  My personal protocol is a small, 1-cm incision closed with dissolving stitches.  We put numbing medicine in at the time of surgery and most kids never require pain medication.  The most common complication is a superficial infection treated with antibiotics by mouth.  Other complications are incredibly uncommon.

Unfortunately, there can be a less than perfect outcome.  This patient is a 5 year old female who was treated surgically for bilateral trigger thumbs at another hospital.  Unfortunately, her symptoms did not improve.  This video demonstrates that her thumb catches when she tries to bend it.  We performed a revision surgery to correct the residual catching.

Pediatric Trigger Thumb


Trigger finger is much less common compared to trigger thumb.  It can be helped with therapy and splinting but occasionally surgery is required.  This video shows the finger catching with bending.  While treating a trigger thumb in a child or adult requires a similar surgery, trigger finger surgery can be quite different.  A pediatric trigger finger surgery can be more complex and requires a step-wise approach to care.
Pediatric Trigger Finger Video demonstrating catching.




Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

Sunday, July 15, 2018

Extra Thumb Reconstruction

I have posted a number of times on radial polydactyly- aka split thumb, extra thumb, etc- HERE.  This is a common birth anomaly and the decision for surgery is usually straightforward.  Sometimes surgery is also straightforward while other times the reconstruction can be quite challenging.  And, about one out of three patients with radial polydactyly will need a second surgery at some point down the road.

I wanted to briefly share images of one patient who recently came back for repeat assessment after reconstruction for a somewhat complex radial polydactyly reconstruction.  Here is one picture before surgery in the clinic.  Note that the inner thumb is larger, clearly the dominant thumb.

Radial polydactyly

Here are other pictures before surgery from top and bottom.
Radial polydactyly from the palm view.

Radial polydactyly from top view

In surgery, we removed the outer, smaller thumb and realigned the remaining thumb with a cutting of the bone.  We also created a new ligament to support the thumb.  The metal pin is left in place for about 6 weeks with a cast.

The thumb after reconstruction for radial polydactyly.

Another view after reconstruction for radial polydactyly

Here is the patient/ thumb about 6 months after surgery.  He has fully incorporated the thumb into daily use. The thumb is stable and has reasonable motion.  Importantly, despite a very successful surgery for radial polydactyly, when we compare the thumbs, the smaller size of the new thumb is clear.  That is why some of us prefer the term 'split thumb' which emphasizes that even after surgery, the thumb will be smaller.  However, the thumbs will typically look great and unless directly compared as in the pictures, this size difference does not affect function and does not dramatically affect appearance.
Smaller thumb after radial polydactyly reconstruction.

Thumb after reconstruction for radial polydactyly

I typically follow patients for a few years after surgery to assure no early problems develop and, of course, welcome families to come back anytime if issues are noted.  Overall, reconstruction for radial polydactyly is usually a very successful surgery providing a highly functional thumb which works well and looks near normal.

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu



Saturday, June 16, 2018

Families, Choices, and Untreated Triphalangeal Thumbs

One of the benefits to my taking care of kids with birth anomalies of the upper extremity is the opportunity to really come to know the patient and the family, often over many years.  This is magnified when more than one child is affected.  This is one of the best things about my practice (and one of the limitations of the other parts of my practice)- that is treating a patient and family over years.  I really enjoy watching kids grow, learning about their development, and understanding how their birth anomaly does or does not affect their lives.

Another interesting opportunity is talking to and understanding the experience of an affected parent.  This is critically important because the experience of the affected parent influences their goals and hopes for their child.  It also usually moderates their concerns.  What I mean by this is that most parents who are also affected understand that their child is likely to be highly functional and also likely to be well adjusted

Kids with birth anomalies never cease to amaze us and it takes time for 'new' or unaffected parents to realize just how well their child will do and how many expectations will be exceeded.  Affected parents simply better understand their child's status and have appropriate expectations for the future.  

One particular family has become particularly special to me as I have come to know the whole family and done so over many years.   Mom and the kids have triphalangeal thumbs together with an extra thumb.  Mom's triphalangeal thumbs were untreated (although the extra thumbs were removed when she was a child) and she understands the diagnosis and its implications very well.  We have performed surgery on her kids due, at least in part, to mom's understanding of how surgery would be helpful.

A few features to take note of.  
1) The thumbs are long.  This is due to the extra bone in each of the thumbs (triphalangeal- 3 phalanges instead of the normal thumb with 2 phalangers).  
2) The thumbs appear thin, almost like a finger.  
3) The thumbs do not rest in the normal position.  The thumbs are more in the plane of the fingers- some might call this a 5 fingered hand rather than a hand with 4 fingers and a thumb.

Adult with triphalangeal thumbs.

Adult with triphalangeal thumbs, palm side

Adult with triphalangeal thumbs, thumb flexion.  Note the length.

Adult with triphalangeal thumbs. Note that the thumbs are in the plane of the fingers.

Adult with triphalangeal thumbs, right
Adult with triphalangeal thumb, left























Nonetheless, the patient has very good function.  There are a few challenges with fine motor skills and pinch.  This video shows thumb motion and gives a sense of function.






A few relevant blog posts:

The bottom line is that patients with a triphalangeal thumb function well with or without surgery.  However, surgery does offer improved function and appearance as confirmed by this family and the choices they have made.

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu








Sunday, June 10, 2018

Three thumbs

Radial polydactyly (duplicated thumb) is an uncommon condition in the general population- I have blogged about kids with extra thumbs a number of times.  Those posts can be found HERE.  Extra thumbs come in a wide variety of patterns, some of which are captured in the Flatt Classification (previously called the Wassel Classification) as shown in the this picture from orthobullets.com.
Flatt Classification for radial polydactyly from orthobullets.com


Yet, this classification does not capture the extra thumbs in all kids with radial polydactyly.  Many simply do not fit this pattern.  As a result, the Rotterdam (in the Netherlands) group added a more complex classification system which is much more comprehensive.  The publication abstract can be found HERE.  It includes more specific patterns for triphalangeal thumbs (longer thumbs, more like a finger), triplicate thumbs (three thumbs, rather than the more common 2 thumbs), as well as adjustments for stiffness, deviation, and small size). 

This is one example of a triplicate thumb.  These are uncommon (even compared to the uncommon radial polydactyly). 
Triplicate thumb

Triplicate thumb, another view

Final view of triplicate thumb

And here are a few x- rays which show the complexity.  This is a complex arrangement of bones and joints.
Triplicate thumb xrays

Additional xrays for triplicate thumb

The principles for treating the triplicate thumb are to create a stable, well aligned thumb.  The thumb's main role is to serve as a post and if stable and well- aligned, it can do just that.  Ideally, we would love to have motion at the joints but motion is not mandatory for a great thumb.  So, in reconstructing these three thumbs- the goal is to create the best single thumb.  This requires excision of some parts, straightening of some bones, stabilizing joints (with new ligaments), and careful treatment of the skin and soft tissues (cosmetic surgery).

Here are images at about 3 months after surgery for the triplicate thumb. The child is starting to use his new thumb and will, over time, use it more and more.  The thumb is stable.  It is reasonably straight although not perfect.  And he does have some motion.  It may be that he will benefit from additional surgery down the road.  If so, we try to perform that second surgery before kindergarden.  Such surgery is needed in approximately 1/3 typical radial polydactyly patients but in notably more triplicate thumb patients like this one.

Top view of thumb after reconstruction for triplicate thumb

Palm view after triplicate thumb reconstruction



Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

Sunday, April 15, 2018

Mission Trip

I wanted to share the experience of my first Mission Trip.  I went with the World Pediatric Project (WPP), a wonderful organization with which I have a long relationship.  I have cared for many of their patients in the US but have not traveled with them (or any other organization).  Their website, which can be accessed HERE, tells the organization's story.  Two teams traveled together, our upper extremity team (see pictures) and the lower extremity team. 
WPP Mission Trip to St. Vincent.  Our two teams at Milton Cato Memorial Hospital

The Upper Extremity Team with Tina, Valerie, and Brinkley in front and Dave and I in the back.

Dr Gordon, my Washington University partner at St Louis Childrens Hospital and St Louis Shriners Hospital, has led many teams to Mission Trips including a number to St Vincents.  He led this trip and the Lower Extremity Team. 

This map highlights the Southern Caribbean islands.

While many of the pictured islands are tourist destinations, access to medical care, especially complex orthopedic care, can be limited.  The WPP has a number of people in the Southern Caribbean on various islands to help increase awareness and facilitate the care of kids with challenging orthopedic issues.

For several months prior to the trip, I reviewed emails, images and videos of potential patients with two goals.  First, we want to have a reasonable understanding of whether we can help kids in advance and second, we want to understand what supplies may be helpful.  We brought most of the supplies that we would need and, thankfully, planning was successful in this regard.  I should also note that this trip was not just about surgery.  Valerie, an outstanding hand therapist, was a key part of the team treating kids that did not need surgery and providing splints to surgical and nonsurgical patients.

The two team saw more than 120 patients on Sunday and then operated the rest of the week.  The Upper Extremity Team saw 40 children on Sunday and performed 18 total surgeries on Monday, Tuesday, and Wednesday.  We treated children with cerebral palsy, arthrogryposis, birth anomalies, and brachial plexus palsy.  Each day was really busy but the local team (nurses, coordinators, hospital staff, etc) and our team worked so well together.

Clinic day on Sunday.  The waiting room was in the Courtyard of the Hospital.  We were able to evaluate 120+ children.

The Upper Extremity surgery team.

Part of our two surgery teams with one visiting surgeon from a nearby island.

The WPP local team who are one key to success.  Lucianne and Jackie are pictured here with Brinkley and myself.
Here are a few of the patients that we had a chance to evaluate and treat.
Sprengels Deformity

A growth arrest of the distal ulna

Birth brachial plexus palsy

This was a really great experience for all of us.  It was a privilege to take this trip and bring our experience to an area in which there is a need.  I would like to express my gratitude to the WPP and to the American Society for Surgery of the Hand and the Touching Hands Project (THP) which provided financial and other support for this trip!

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu