Friday, August 15, 2014

Scarring after Syndactyly


Syndactyly, or the fusion of digits, is a condition present at birth and is related to the failure of the fingers to separate in utero.  I have previously blogged about this condition, as seen here.  There are different surgical techniques to correct syndactyly and generally good results are obtained, no matter the technique.  

Scarring is one concern with any surgery for syndactyly.  There are several problems with scarring. First, if scar bands form, the finger may contract and motion may be limited.  This can cause a functional problem, most commonly, a limitation in finger straightening.  One way to lower this risk is zig- zag incisions.  Another problem with scarring is what we call creep.  Creep is the slow process of the skin "growing" towards the fingers- causing a loss of the deep webspace.  One way to think of this is that the syndactyly is regrowing.  The literature is not clear on the percentage of children with syndactyly that develop creep after surgery, but it is likely less than 1 in 5 patients.  The 3rd issue regarding scarring after syndactyly surgery is the appearance.  We hope and strive for a complete correction of syndactyly without prominent scars and usually we can accomplish that goal.  However, thick scars and dark skin grafts are a problem that no one likes to see.  We try to avoid skin grafts to avoid the appearance below but sometimes grafts are necessary.  We have found better results with skin grafts taken from the front of the elbow compared to the groin.

Most children with syndactyly reconstruction do wonderfully.  Surgery can create new webspaces between the fingers that look very similar to the other webspaces/ fingers.   It is, therefore, a surgery that we enjoy.  However, the risks of scarring, as noted above are concerning and we work to minimize the risk of those problems.  The surgical techniques and surgeon experience both can help lower the odds of problems with scarring.


Scarring after syndactyly surgery.  Note the prominence in the space between the thumb and index finger.

Scar bands limiting finger extension after syndactyly surgery.  Note also the darkened skin grafts.  
Another view of scarring after syndactyly surgery.  See the lack of finger extension from scars.
The following patient has symbrachydactyly (short, webbed fingers) and has had surgery for the syndactyly.  While he and his family remain pleased, there was creep between the index and ring fingers.


Patient after surgery for symbrachydactyly.  Doing very well but scars are notable.

Limitation noted with creep affecting the space between the index and long fingers after symbrachydactyly surgery.


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



Sunday, August 3, 2014

More on 3D Printing

I have shared my thoughts on 3D printing with several previous posts

In addition, I have recently been working with a reporter from veja.com- the largest magazine in South America about 3D printing and medical applications.  I look forward to this article- the more press, the better for the progress of this new technology. 

Finally, and the real reason behind this post, here is a very interesting link to a webmd article.

Happy reading/ watching.

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

Friday, August 1, 2014

Form versus Function. Can we have both?

Orthopaedic surgery is the branch of medicine that focuses on movement and function.  In orthopaedics, we work with bones, joints, muscles, and tendons, as well as nerves and vessels.   Hand surgery is a subspecialty of orthopaedics (and also a subspecialty of both plastic surgery and general surgery) that addresses all of the same issues but focuses on the upper extremity, especially the intricate anatomy of the hand.  In this age of specialization and subspecialization (and what we call super- subspecialization), there is also congenital hand surgery, the field that focuses on children born with differences in the anatomy of the hand and upper extremity.

As an orthopaedic surgeon, my first priority is always function.  I seek to help children born with hand differences to be as functional as possible.  Typically (but not always) that is working to "normalize" the hand and upper extremity anatomy. However, the needs of each child are different and depend on many factors including that status of the affected hand, the status of the other hand (i.e., whether it is affected or not), and the specific limitations of the child.  While each child is considered independently, children born with differences in anatomy do have patterns of presentation so that we see similar birth anomalies repeated over time (this is why experience is important in your surgeon).  These patterns helps us understand how to best help the child.

Typically, we think of plastic surgery as the field that is concerned with appearance.  But appearance is an important concern for all physicians taking care of children born with hand anomalies. Not only do we want to help the child function better, but we also have the chance to help the child interact with the world differently.  If we can improve hand appearance, we can ease the social stigma of the birth anomaly.   Rarely can we make the hand look "normal", but small changes can pay big dividends.  We never perform surgery to improve appearance if it will hurt function but if we can improve both with surgery, we best meet our goals for the patient.

A couple of definitions.  Cosmetic surgery (the act of improving the appearance of normal anatomy) differs from aesthetic surgery (the act of normalizing abnormal anatomy).  In congenital hand surgery, we improve the aesthetics of the birth anomaly by working to make the birth anomaly of the hand more like an unaffected hand.

There are many examples of how form AND function can be improved in congenital hand surgery. One excellent example of a condition improved with surgery (both appearance and function) is cleft hand as depicted here.

Wednesday, July 16, 2014

Best Scientific Publication on Birth Anomalies of the Upper Extremity

I have been fortunate to learn from a number of wonderful hand surgeons over my career.  One of the most impactful was Paul Manske, a hand surgeon and, more specifically, a congenital hand surgeon.  He spent the majority of his career here at Washington University School of Medicine.  I am not alone in this sentiment of appreciation and 4 of us have established an an annual award recognizing the "best" or most impactful publication in the field of upper extremity congenital/ pediatric anomalies.  Ann Van Heest, Michelle James, Relton McCarroll and I review the literature in our field to determine the winner of the award each year.  


 In 2011, the winner was Ann Nachemson's group for "Children with surgically corrected hand deformities and upper limb deficiencies: self concept and psychological well- being.  JHS 2011; 36E: 795- 801.  This manuscript provides insight into how children with deficiencies of varying severity identify with their anomalies.  The more severe group had a self concept score similar to a group of healthy children.  Children with milder deformities were found to have lower (worse) scores than those children with more severe deformities.  Nachemson Study
 
 In 2012, the winner was PP Kotwal, et al for "Comparison of surgical treatment and nonoperative management for radial longitudinal deficiency.  JHS Eur 2012; 37(2) 161-9.  This study evaluated two groups of children treated for radial deficiency and found superior outcomes in those treated with centralization (or radialization).  This study is important as it was the first to scientifically demonstrate the positive effect of centralization. Kotwal Study
 

Finally, we recently notified the authors Clement and Porter that "Forearm Deformity in Patients with Hereditary Multiple Exostoses: Factors Associated with Range of Motion and Radial Head Dislocation" in the Journal of Bone and Joint Surgery was the 2013 winner.  In a large group of patients, this study showed that distal radius exostoses were most common.  Additionally it confirmed that a shortened ulna was related to decreased forearm motion and radial head dislocations.  It suggested, therefore, that surgery should be considered in such patients. Clement Study

Tuesday, July 8, 2014

Type 2 Radial Longitudinal Deficiency

Bayne and Klug wrote what is now a classic scientific article on radial longitudinal deficiency in 1987 Classic Article.  This article described 4 types of radial longitudinal deficiency:

Type 1- Short distal radius
Type 2- Radius in miniature (short proximal and distal)
Type 3- Absent distal radius
Type 4- Absent entire radius

More recently, we added a Type 5- which is a Type 4 deficiency + an absence of the proximal humerus- Type 5 article and a James, McCarroll and Manske added the Type 0 and N Modified Classification.

Perhaps the least common type of radial longitudinal deficiency is the Type 2- Radius in Miniature. Because it is uncommon, treatment is not clearcut.  Here is one example of such a case.


Type 2 Radial Longitudinal Deficiency.  Note the very short radius bone.

In this patient, we lengthened the radius in an attempt to better balance the wrist on the forearm bones. Unfortunately, we did not obtain as much length as we hoped but the length we did obtain stood the test of time over the next 12+ years.  The wrist is balanced and the pollicization is doing well.

2 years after lengthening surgery for Type 2 Radial Longitudinal Deficiency

4 years after lengthening surgery for Type 2 Radial Longitudinal Deficiency

12 years after lengthening surgery for Type 2 Radial Longitudinal Deficiency.

Here are clinical pictures of the patient at 12 years after surgery for Type 2 Radial Longitudinal Deficiency.  There are several interesting features. First, the ulna has a big bow which makes it look like the elbow does not straighten fully (it does). Second, the wrist has remained relatively balanced- we will continue to follow him and with growth there may be a need to lengthen the bone a second time.  This time, we would plan an external fixator lengthening- this option was not possible due to the young age at the time of the first surgery.  There is also a pollicization which has helped function.  
Type 2 Radial Longitudinal Deficiency. 12 years after surgery.  Note relatively balanced wrist and pollicization.

Type 2 Radial Longitudinal Deficiency.  Elbow straight (it doesn't look straight as the ulna bone is curved (bowed).

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

Wednesday, July 2, 2014

Popular Press News Stories

I have attached a few links that I believe you might like to see.  These are stories relating to birth anomalies of the hand and upper extremities.  These stories were in the popular press.

World Cup Soccer  Interesting link which is also thought provoking.  Thanks to Terry Light.

Phantom Limb Pain  Link regarding birth anomalies and the brain.  Fascinating.

Robotic Prostheses  Technology advancement for prosthetics

More on Prosthetics  Summary of our 3D prosthetic work at Washington University.

Happy Reading.

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

Sunday, June 29, 2014

Cerebral Palsy, Thumb Deformity

Cerebral palsy (CP) is defined as a permanent limitation in physical function which does not change or get worse over time.  Most commonly, it is a disorder with spastic muscles and limitations in motion but kids can present in a variety of different ways.  I have not previously blogged on this topic and will start with the case as an example as it is an good example of the difficulty with cerebral palsy and the potential benefit of surgery in certain situations.  I will break this down further in a series of posts on cerebral palsy in general as well as other posts on specific joint issues.  More to come!

Today, I would like to share a case of an older adolescent with cerebral palsy involving all four limbs. Previously, due to a severe wrist flexion position, he had been treated with a wrist fusion.  That surgery had helped him overall but left his thumb in difficult position.    He has a very weak pinch with the thumb and also difficulty trying to hold bigger objects due to the position of the thumb.  Muscle overfiring and tightness, as commonly seen in cerebral palsy, combine to make this thumb position difficult.
Cerebral palsy thumb with marked deformity.

Attempted pinch in cerebral palsy thumb. 

Holding a spoon with cerebral palsy thumb deformity.

The thumb abnormal positioning has been classified by Dr House from Minnesota.  He practiced at Gillette Children's Hospital and was a great educator on cerebral palsy.  The classic article from 1981 House article described 4 types of possible thumb deformity, the explanation behind these deformities of the thumb, and treatment options.  This thumb is a type 3 cerebral palsy thumb most noted by the severe adduction contracture of the thumb metacarpal (thumb positioned next to index finger) and the notable hyperextension of the MCP joint.  Treatment considerations are somewhat different in this patient based on age but the reasoning behind the positioning of the thumb is well explained from this article on cerebral palsy thumb from more than 30 years ago.

Due to the challenges of the thumb position, we elected to proceed with a stabilization of the CMC joint- the carpometacarpal joint at the base of the thumb.  We were able to align the joint after muscle lengthenings and joint release.  We held this position with temporary pins.  Next, we fused (or made stiff) the MCP joint- the joint where the thumb meets the hand.  The pins are also temporary (6 weeks) but the joint will be stiff forever although in a very functional position.  
Improved thumb position in cerebral palsy after surgery.

Improved thumb position in cerebral palsy after surgery.

Improved thumb position in cerebral palsy after surgery.
Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu