Saturday, October 26, 2019

Hand Camp 2019- St. Louis Shriners Hospital

I realize that I post about Hand Camp nearly every year.  Our St. Louis Shriners Hand Camp is really something special.  But I do so for good reason- it is just so impactful for kids, families, staff, and me!  Being outside the hospital setting allows a different kind of conversation and allows a different perspective for everyone.  Kids and families being with other kids and families with similar challenges is simply something that the hospital environment cannot reproduce.  Plus the activities at Hand Camp as shown below are fun, build confidence in the kids, and provide a similar sense of confidence for parents.  The parents come to really understand that their child truly will not have limits.  The group sessions allow honest conversation amongst parents and allows parents to ask our teen counselors questions- who better to provide a honest perspective than a teen or young adult who is living with similar challenges?

There a handful of Hand Camps throughout the US, some bigger than others but most with similar philosophies.  Most of these are hospital based and typically free for participants and families (ours certainly is).  Some are run through organizations:

Camp No Limits

Hands to Love

Nubability

Here are a few pictures and videos to inspire us!

Hand Camp nature hut with guinea pig.

Shriners Hand Camp team.

Hand Camp.  Dream Team.



Shriners Hand Camp climbing wall

Inspirational video of the climbing wall.




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

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Sunday, October 20, 2019

Nerve Injury after Trauma

The blog is mostly about kids born with differences in the arms (and occasionally legs).  However, my practice also includes kids with sports injuries and other traumas.  I will occasionally post interesting findings on these topics as well.  This is a child with a nerve that is not working correctly after an elbow fracture.  Specifically, this child sustained a fracture of the humerus (supracondylar humerus fracture) as shown here.



This patient was treated with a closed reduction (bones put back in place without making a skin incision) and pins were placed to keep the bones stable as healing started. 

Supracondylar humerus fracture after fixation


It is important to understand the patient's physical examination prior to surgery- this patient had a median nerve palsy.  That is, the median nerve was stretched and not functioning perfectly.  There were signs of the muscles/ tendons not working and signs the feeling in the fingers was not normal. 

This is not expected to improve during surgery and typically the nerve recovers over months after the surgery.  We typically watch and wait as the nerve recovers. 

This patient is now 8 weeks after surgery.  The bone is healed.  Elbow motion is almost normal.  BUT, the median nerve is not working perfectly- specifically, the FPL and FDP to index fingers are not strong as she demonstrates in this amazing video.




Also, this picture helps with an understanding of the change in feeling- see the skin changes on the index finger.  The other helpful finding on examination is the lack of sweat on the index finger- without the nerve working well, the finger is dry.

Skin changes with median nerve palsy

To be clear- this patient has a median nerve palsy (bruising).  This injury affect muscle and feeling.  Sometimes, there can be a AIN (anterior interosseous nerve) palsy which only affects the muscles (specifically, the FPL, the FDP to index and middle, and the pronator quadratus).  Patients with an AIN palsy have normal feeling.  Or, if the whole median nerve is affected, there are changes to the muscle and to the nerve that affect feeling. Anatomically, the AIN is part of the median nerve at the elbow and then, typically around 5 cam past the joint, the median nerve branches the AIN as a separate nerve.  The AIN is susceptible to injury because it sits in the back of the nerve, closest to the bone and, in this case, closest to the fracture.

At this point, we will watch and expect the nerve to get better over the next few months.  Very rarely, the nerve will not perfectly recover and further assessment with nerve studies can be helpful to understand the nerve's recovery.



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

Please CLICK HERE to support our research.  
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Saturday, October 12, 2019

Activity Specific Prosthetics

This is a brief post on activity- specific prosthetics.  There has been much controversy on the timing and appropriate use of prosthetics in kids.  I have previously blogged about this several times as can be seen HERE.  I really appreciate activity specific prosthetics.  The child is engaged in the process based on a demonstrated interest and the specially designed and fitted prosthetic makes a difference.  This idea, compared to the 'old- fashioned' idea that every kid is fitted with a general prosthetic at 6 months of age, just makes so much more sense!

This is a great example of a really helpful tennis specific prosthetic.  It allows an ability to more easily play tennis including serving.
Activity specific prosthetic.  This one is designed for tennis to allow serving.  

Here are a few other activity specific prosthetics.  I took these pictures in the lab and the prosthetic is not typical (harness included) but demonstrate the point- easily changeable prosthetics that have a specific function.  These are durable, functional, and appreciated by kids and families.



Voluntary closing prosthetic.  

Activity specific prosthetic.  Associated with harness (not typical).  This one can be used for weight lifting, etc.

Activity specific prosthetic.  This one is designed for riding a bicycle.  

Activity specific prosthetic.  This one is designed for... yes- lacrosse. 

Activity specific prosthetic.  This one is designed for volleyball. 

Activity specific prosthetic.  This one is designed for volleyball (other view)

I will close by saying- search the internet.  There is a great deal of information and pictures out there on what is possible.  Many companies will work with you for sports and activities.


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

Please CLICK HERE to support our research.  
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Sunday, September 29, 2019

Untreated Adult Hypoplastic (Small) Thumb

On occasion, an adult comes to my clinic for evaluation of one issue and a previously unrecognized issue is identified.  This type of presentation can come in different varieties and, due to my particular practice type, often we find a birth anomaly that has not been recognized or treated.  This patient is one very interesting example.  She has a left hypoplastic thumb.  There is an appearance difference and a functional difference yet it has not caused major problems for her.  Her right thumb and hand are dominant and the left hand and thumb are used for assist (as we all function).  Her thumb is weaker and more lax and has decreased motion.  But none of these problems were completely troubling to her and she certainly is not interested in treatment at this point. 

From the hand surgeon perspective, she has a classic small thumb on the right (technically a hypoplastic thumb- Type IIIA).  It is thin (and seems long but that is really only because it is thin).  She has small muscles at the base of the thumb (thenar muscles), a decreased web space (between the index and thumb), laxity at her MCP joint, and decreased thumb motion.  In other words, she checks all the boxes for a classic hypoplastic thumb.

These videos demonstrate many of these classic findings for hypoplastic thumb and hopefully are helpful to better demonstrate the limitations of her left thumb.  While I see many children with this condition, it is a little bit more tricky to capture the presentation on video!








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

Please CLICK HERE to support our research.  
Designate my name.  Thank you!

Sunday, September 22, 2019

Distal arthrogryposis, before and after

Distal arthrogryposis is very different from AMC or other forms of arthrogryposis.  By definition, distal arthrogryposis includes joint tightness (contractures) in the hands and feet.  Here is an excellent Link from NIH.  I have also previous posted on distal arthrogryposis, those links can be found HERE.

I wanted to share some early results on a 5 year old patient with distal arthrogryposis.  This patient had surgery 3 months ago on his right hand and is planned for surgery on the left.  There were two goals with surgery- free the tight thumb while placing it in a better position for function AND releasing the tight middle finger (camptodactyly).  This patient is helpful as an example because the surgically treated right hand previously looked almost exactly like the left hand looks today. 
Distal arthrogryposis, right hand, after surgery.  Note the position of the thumb and middle finger.

Distal arthrogryposis, left hand, before surgery.  Note the tight thumb and middle finger.

These two videos emphasize the same points on distal arthrogryposis of the right hand after surgery and the left hand before surgery.  I apologize for my video skills (trying to multitask) but the improved positioning on the right is striking while recognizing that the hand still has limitations.




The family is very pleased and have noticed functional improvements already. Surgery included
1) Flap to deepen thumb- index web space with release of contracture
2) Stabilization of thumb MCP joint
3) Release of tight PIP joint of middle finger
4) Flap to release tight PIP joint

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

Please CLICK HERE to support our research.  
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Thursday, September 19, 2019

Fixators for Lengthening. Fun?

External fixators are devices that rest outside of the skin.  They can be used to stabilize broken bones (although not used very often for this purpose today) or to correct a short or angled extremity/ bone.  We use fixators to lengthen small bones such as the thumb to allow pinch or to grow the forearm to assure that the two bones of the forearm are nearly the same length.  The forearm is interesting because if the bones are not the same length, the wrist can deviate and/ or the elbow can dislocate or shift out of position.  Neither of these are good.  So, if we can avoid those problems by lengthening the short bone, it can be a real help.  I have previously blogged about fixators of different varities HERE.

There are three common reasons why we lengthen a forearm bone
1) Multiple hereditary exostosis (MHE).  In this case, the ulna is often short and the radius is at risk for dislocating at the elbow.  See my other posts on this topic HERE.

2) Radial longitudinal deficiency (RLD).  In this case, the radius is short and, if there is a radius present, it can be lengthening to balance the wrist.  See other posts HERE.

3) A trauma or injury which affects the growth plate of the radius.  This may be a fracture near the growth plate of the distal radius which affects growth and leads to a long ulna.  Or, an infection of the growth plate can have the same effect. 

This patient had multiple infections around the time of birth.  The infection affected her thumb and index finger and has led to a short radius.  We have elected to lengthen her radius with a fixator to achieve balance and hopefully avoid future problems.  Here are x-rays showing the short radius bone.

Short radius related to infection affecting the growth plate

At the time of surgery, we applied a fixator to lengthen the bone.
External fixator to lengthen the radius.  The cut in the one (osteotomy) is visible- this is where we will lengthen the bone
over time.
The idea is that with slow stretching of the bone, the bone will grow.  Typically we 'turn
the dial' on the fixator 2-4 times each day.  This lengthens the bone from 1/2 of a millimeter to a full millimeter each day.  We do this slowly to allow the body to make enough bone so that after we lengthen (and then give the bone time to get stronger), we can remove the fixator and the bone will be strong!  The fixator is on the arm different times for each patient depending on how much length is needed and how much bone is created.

This young lady shows that the fixator is no big deal!  She has had her fixator about 2 weeks and is doing really, really well with it.  Super cute and, surprisingly, a little shy here.



Thanks to mom for allowing her daughter to share her experience!  What an amazing kid and amazing family.  I have had the pleasure of knowing this family since shortly after birth and I am so happy to have had this chance to get to know them and watch her grow!

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

Please CLICK HERE to support our research.  
Designate my name.  Thank you!

Sunday, August 18, 2019

Forearm Synostosis

The forearm typically has two bones, a radius and an ulna.  The benefit of having two bones is that it allows the radius to rotate around the ulna.  This means we can position the hand palm up and down.  This is functionally helpful but not functionally mandatory as there are many ways to make up for limited or absent forearm rotation.

One of the most common conditions that affects forearm rotation is a joining of the two bones- a radioulnar synostosis.  Developmentally, the bones just don't ever completely separate.  So the condition is present at birth but may not be picked up on until later.  If the forearm bones are stuck with the palm all the way down or up and if both right and left sides are both involved, it is more likely to be obviously at a young age.  However, if only one side is affected and if the forearm is fused in neutral (i.e., hand clapping position), the condition may not be diagnosed until 7-9 years of age or even later.

Here are a few older posts on the topic:
Radioulnar synostosis Post 1
Radioulnar synostosis Post 2

Here is a great kid explaining his radioulnar synostosis.  It affects only his left side.  There is NO pain.  His function is great but not perfect as you can hear him describe.  We are going to watch him for now.  If problems develop over time, there may be treatment but, as I explained to this family, we are unable to restore motion of the forearm.  He will no limitations with activities.




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

Please CLICK HERE to support our research.  
Designate my name.  Thank you!