Monday, October 13, 2014

Ulnar Deficiency and Syndactyly

Ulnar deficiency (or ulnar longitudinal deficiency) is much less common that radial deficiency, possibly only 1 case of ulnar deficiency per 10 of radial deficiency.  And it is much different in the problems that it may cause.  The forearm abnormality can include a deficient or absent ulna and flexor muscles BUT, it is much better tolerated than radial deficiency.  There is less deformity and more wrist stability.  And the shoulder can help compensate more easily for the deformity.

The hand abnormality in ulnar deficiency can include missing digits (so- called ectrodactyly) and syndactyly (abnormal joining of the fingers).  I have previously blogged about ulnar deficiency- multiple examples are seen on this page.  Also, I have written on multiple occasions about syndactyly here.

The following case demonstrates many important points in the understanding and treatment of ulnar deficiency and syndactyly.

Ulnar deficiency and syndactyly

Palmar view of ulnar deficiency and syndactyly

This child has a relatively normal forearm (slightly short ulna only) without deviation of the wrist.  He has great wrist motion along with good elbow motion and forearm rotation.   He has a great thumb, a full thumb web space, and  two really good fingers.  However, the fingers are joined together (syndactyly).  To further promote hand function with independence of the fingers, the family and I elected to separate the fingers.

What follows are clinical pictures of the planned skin incisions for syndactyly reconstruction and the separate digits.
Syndactyly flaps from top of hand

Syndactyly flaps from palm side.

The flaps are elevated and sutured into place.  We use absorbable sutures so nothing has to be removed and place a bulky dressing for 3 weeks.
Syndactyly reconstruction from top of hand.

Syndactyly reconstruction from palm view.

We performed this surgery as we believe it will take a really good hand in a child with ulnar deficiency and syndactyly and make it functionally better.

Charles A. Goldfarb, MD
My Bio at Washington University

Sunday, September 28, 2014

St Louis Shriners Hospital Does Great Things for Kids

I am very fortunate to work at the St Louis Shriners Hospital.  The first Shriners Hospital opened in 1922 in Shreveport, Louisiana and more soon followed to care for children with polio.  The St Louis Shriners Hospital opened in 1924 on the main campus of Barnes Hospital and moved to the current location on Lindbergh in 1963.  Now, 90 years after opening the original facility, the hospital is about to move back to the Barnes Hospital campus with a beautiful new facility.  We care for children with orthopedic challenges of all varieties including those with birth anomalies, trauma, scoliosis, and many other conditions.

After 90 years in St Louis, the Hospital and its staff continue to do amazing things for kids.  Here is a great video highlighting one such special patient who I know well.

Hope for Jude Video

Another amazing program which our team hosts each year is Hand Camp.  I have previously blogged about hand camp Hand Camp 2013 and Hand Camp 2012 but this camp has been an anticipated part of our year since 2008.  Each year dedicated therapists, nurses, and staff meet at Camp Lakewood in Pitosi Missouri for a weekend of fun, education, and enlightenment.  The junior counselors at Hand Camp share their experiences and guide the kids (and families) all weekend.  It is definitely one of my favorite times of the year; I am able to interact with families outside the hospital and watch them learn and share with other kids and families struggling with similar issues.

Amazingly educational, grounding, and fun.  Here are a couple of pictures from Hand Camp 2014!
The amazing junior counselors at Hand Camp 2014.  
Kids and Counselors at Hand Camp 2014

Two campers just before Hand Camp 2014
Hand Camp 2014.  

Friday, September 5, 2014

Patient TV Interview Regarding 3D Printed Prosthesis

Check out this great interview with a wonderful patient/ family regarding our 3D printed prosthesis. 
Go Sydney!

Interview with Sydney and family

Charles A. Goldfarb, MD
My Bio at Washington University

Tuesday, August 26, 2014

Central Polysyndactyly

Polydactyly means that more than the normal 5 digits.  Typically patients have either an extra thumb or an extra pinky.
A patient with radial polydactyly (extra thumb).
Syndactyly is the abnormal joining of the fingers.  It is most common between the middle digits but can affect any of the fingers.
Syndactyly of the fingers.
While these conditions are uncommon, each is one of the most common birth (i.e., congenital) anomalies of the upper extremity.  And both typically do well with surgery.  I have previously posted several times on both syndactyly and polydactyly.

Central synpolydactyly is, in contradistinction, very uncommon.  In this condition, there is both syndactyly of the central digits and an extra digit in the middle of the other fingers.   It comes in variety of different formats- I have shown a few of these different types below.

Central synpolydactyly is, however, a very difficult problem to treat.  Even with successful excision of the extra digit and separation of the digits, the outcome is still a challenge.  Specifically, even after a "successful" surgery, finger motion is often limited and there may be finger deformity.  Yet, surgery makes sense because it does improve both function and appearance.
Left hand, central polysyndactyly.

Right hand, central polysyndactyly.

Right and left hands, central polysyndactyly.  Note the differences between the right and left sides.  There is a "bizarre" collection of bones rather than the typical straight fingers.

Happy reading.

Charles A. Goldfarb, MD
My Bio at Washington University

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

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 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

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.