Sunday, December 18, 2011

More thoughts on Pollicization

More thoughts on Pollicization

The decision to proceed with pollicization is not easy.  It is most straightforward when the thumb is completely absent and is most difficult when the child has any thumb, as families very reasonably would like to keep and improve the small thumb rather than excise it and pollicize the index finger.  However, the majority of congenital hand surgeons (especially in the United States) believe that a pollicized index finger will look and function better than a reconstructed small (hypoplastic) thumb.   Importantly, this is not to say that all small thumbs should be excised- in reality most can be reconstructed and stabilized but need to have a stable base (CMC joint).

This case demonstrates a Type 3b hypoplastic thumb with an unstable CMC joint.  Therefore, we did not feel that reconstruction made sense and we recommended pollicization.

Small, hypoplastic thumb, without function, prior to pollicization

This pictures were taken one week after pollicization.  The bruising and discoloration typically improves over the next 2 weeks.
Pollicization, the creation of a new thumb

Another picture of pollicization.  Note the new web space.
The bruising disappears within a couple of weeks after surgery.



Sunday, December 11, 2011

Radial Polydactyly



An extra thumb has been labeled many different ways: ‘radial polydactyly, thumb polydactyly, split thumb, and duplicated thumb’.  My preferred name is radial polydactyly as it tells you exactly the issue.  The term ‘duplicated thumb’ is not ideal as the thumbs are both smaller than normal but ‘split thumb’ is not perfect either because the thumbs are usually more than 50% of the size of the opposite thumb.

Radial polydactyly is typically both a functional problem and an appearance issue.  Surgery is recommended.  However, surgery is not simply removing the extra thumb- it is a reconstructive procedure that can range from a moderately complex procedure to a very complex procedure.  There is no ideal time for surgery but typically surgeons choose to operate between 1 and 2 years of age.  Sometimes the thumbs are merged to make the best, combined thumb and sometimes the bigger, more mobile thumb is reconstructed to make it stable and straight.  Surgery can involve soft tissues only but often also involves bone surgery.  A second procedure is required in some patients as they get older.

In this case, an older child had the smaller, outer thumb removed with a stabilization and reconstruction of the larger thumb.  



Before Surgery







After Surgery



Friday, December 9, 2011


Symbrachydactyly

Taking the word literally, “sym” means joined (like “syn”), “brachy” means short and “dactyly” means finger= short, joined fingers.  However, symbrachydactyly comes in many different forms.  In fact, some forms of symbrachydactyly don’t have developed fingers at all.  We can classify symbrachydactyly in 4 basic types- these are helpful for discussion.

 - Short finger type- fingers generally well formed but short, likely webbed.
2     - Cleft hand type- absence of central digits.  Nubbins may be in cleft.
3     - Monodactyly- Fingers are absent and only the thumb is present (and may not be normal).  Finger     nubbins may be present.
4     -  Peromelia- Finger and thumb are absent and only the wrist bones are present.  Finger nubbins may be present.

    In addition, symbrachydactyly can end in the forearm with amputation; finger nubbins may be present at amputation site.



This child has a cleft hand type of symbrachydactyly.  He was in clinic for evaluation of the index finger after stabilization.  Pinch has been improved by our surgery to stabilize the index finger DIP joint (near the nail).


Here is an example of the short finger type of symbrachydactyly.