Saturday, July 28, 2012

Symbrachydactyly Web Deepening

Web space deepening is a straightforward surgical technique to provide a deeper space between fingers.  There are several variations of the technique of web space deepening, typically based on the number of skin flaps that are utilized.  These techniques include 2- flap, 4- flap, 5- flap and other variants; precision is required for all.  A variety of congenital anomalies may be surgically addressed with a web space deepening, including a small thumb (hypoplastic thumb) and certain types of syndactyly.

Symbrachydactyly (short, webbed fingers) may present in a variety of different ways.  I have provided some basic information about symbrachydactyly in a previous blog, http://congenitalhand.wustl.edu/search/label/Symbrachydactyly , and one treatment technique- lengthening- in another blog, http://congenitalhand.wustl.edu/2012/06/finger-lengthening.html .

What follows is a description of how a web space deepening can be helpful in symbrachydactyly.  In the first case, the short finger type, function is very limited.  Surgery will not restore normal or even near normal function but our goals should be limited.  Because the opposite hand is almost always normal, the goals for surgery on the affected hand in symbrachydactyly are limited.  If we can even slightly improve function, we can make the hand a better helper hand.  We can help the hand hold bigger objects.  In this case, we used a dorsal flap to resurface the web space between the thumb and the index finger.
Symbrachydactyly, short finger type, after surgery to deepen web space between thumb and index finger.

The second case is more unusual.  This is an example of the cleft type of symbrachydactyly.  This condition is different from a true cleft hand (central deficiency) which is discussed in previous postings:   http://congenitalhand.wustl.edu/2012/05/cleft-hand-surgery.html  and
http://congenitalhand.wustl.edu/2012/01/central-deficiency.html .  In this case, the patient and family complained about his inability to grasp large objects between the thumb and other digits.  After a discussion of the options, the family wanted to deepen the cleft.  While this might make the hand difference more apparent to others (i.e., make it more of a cosmetic issue), both the family and me felt that the functional improvement was worth this risk.
Symbrachydactyly, cleft type before surgery.

Symbrachydactyly, cleft type, after surgery from palm side

Symbrachydactyly, cleft type, after surgery from top of hand


Other treatment techniques for symbrachydactyly must be considered on a patient-by- patient basis.

Sunday, July 8, 2012

Recurrent Radial Longitudinal Deficiency

The best treatment for the forearm/ wrist deformity in Radial Longitudinal Deficiency remains uncertain as I have previously outlined in a previous blog posting http://congenitalhand.wustl.edu/2012/05/form-and-function-in-radial-deficiency.html .  The problem is that the anatomical deficiencies in Radial Longitudinal Deficiency limit our ability to sufficiently correct the underlying deformity.  There is a lack of muscles to extend (bend back) the wrist and a lack of bony support for the thumb side of the wrist and forearm.  The most common surgery to address this issue is a centralization (or radialization) procedure.  The idea is that the tight structures on the thumb side (Radial) of the wrist are released, the ECU tendon is advanced (tightened) to help balance the wrist, and the wrist and hand are placed on the end of the ulna (i.e., centralized).  We like the concept of the surgery as it lengthens the forearm, improves appearance and likely helps function overall.  Obviously, however, if there is severe recurrence, we need to reconsider it.

For some kids with Radial Longitudinal Deficiency, the surgery succeeds in balancing the wrist and the alignment is maintained but for others, the deformity recurs.  And by deformity, typically we mean both radial deviation (wrist and hand angle towards thumb) and flexion (bending down) of the wrist.  There have been many different techniques utilized to try to prevent recurrence of deformity.  These attempts include using a toe (with joint) including its blood supply to provide thumb sided support to the wrist.  This broadens the platform for the wrist and may help prevent recurrence.  However, this procedure is technically complicated and requires the sacrifice a toe without certain improvement in the long term.

An additional technique to minimize recurrence in Radial Longitudinal Deficiency is to use an external fixator prior to centralization.  This stretches the soft tissues and makes the centralization more straightforward and balanced and seems to prevent recurrence.  We have discussed this previously at http://congenitalhand.wustl.edu/2012/05/fixator-for-radial-longitudinal.html .

Ultimately, in those kids that do have severe recurrence after centralization, a fusion of the wrist can be a very effective procedure.  Usually this procedure has to be delayed until at least age 12 when there is enough bone for the fusion.  While the procedure sounds scary, it has many positives (by improving the position) and very few negatives (related to a loss of some motion- motion which is limited anyway).  We like this procedure very much in certain kids.

Here are some clinical pictures showing recurrent deformity in an 8 year old with radial longitudinal deficiency.

Radial Longitudinal Deficiency which has recurred.

Close up of recurrent Radial Longitudinal Deficiency.  Note the marked radial deviation of at least 70 degrees.

Radial Longitudinal Deficiency with recurrence with flexion of the wrist.

Radial Longitudinal Deficiency, recurrent.  Note that the index finger has not been pollicized as there is very poor motion of the index finger.

More information is always available through our website at http://ortho.wustl.edu/content/Patient-Care/3220/SERVICES/Hand-Wrist/Congenital-Hand-Disorders.aspx

Tuesday, July 3, 2012

Clinodactyly


Clinodactyly is a curvature of a finger (or thumb).  The bend is in relation to the next finger rather than towards the palm or towards the top of hand.  This is not to be confused with camptodactyly as we discussed in a previous post, http://congenitalhand.wustl.edu/2012/03/camptodactyly.html .  Additional information, as always, is available from our website, http://ortho.wustl.edu/content/Patient-Care/3220/SERVICES/Hand-Wrist/Congenital-Hand-Disorders.aspx
Small finger clinodactyly with bending of the small finger towards the ring finger


Clinodactyly most commonly affects the small finger and causes a bending towards the ring finger through the middle phalanx.  However, clinodactyly can occur in any finger and often affects the thumb in children affected by syndromes (Downs syndrome, Aperts syndrome).  A complete listing of associated syndromes is beyond the scope of this review but more can be found at http://www.ncbi.nlm.nih.gov/omim

Unusual clinodactyly of the index finger.
The middle phalanx is typically the site of an abnormal growth plate.  The growth plate is usually only at the base of the finger bone but in this situation, there may be a growth plate around one side of the bone- a "bracketed epiphysis."  This actually causes abnormal growth with one side growing more slowly, thus causing the curvature of the finger.  This typically worsens with age.
Clinodactyly xray with abnormal growth plate of middle phalanx, a "bracketed epiphysis."  This leads to abnormal growth and worsening of the abnormality with time.
In most cases, clinodactyly is not severe and is most often an appearance issue rather than a function problem.  However, when severe or if particular activities are limited, surgery can be considered.  In young children, I prefer a simple procedure which divides the abnormal growth plate, thus correcting the tether from the bracketed epiphysis.  This procedure does not provide immediate correction but allows gradual correction with growth.  It is performed in younger kids, ideally less than age 5.  This concept is not new and an early description of this technique was provided by Caouette-Laberge, http://www.jhandsurg.org/article/S0363-5023(02)00014-X/abstract .

It is more common that clinodactyly becomes noticed or problematic in older children, past the age where this simple procedure is effective.  In those children, the bone can be cut and realigned (an osteotomy) with good results.  There are a number of different techniques with all providing similar good outcomes.  One issue after this surgery is stiffness affecting the last joint in the finger (the DIP joint).  This improves over time.  We reviewed these two basic procedures in the following article:
http://journals.lww.com/techhandsurg/Abstract/2010/03000/Surgical_Correction_of_Clinodactyly__Two.12.aspx

Here are a few clinical photographs of patients before and after surgery.   Patients and families are typically quite happy with the results of surgery.

Clinodactyly after correction on the left hand small finger and before correction on the right.


A different patient with clinodactyly correction on the one pinky but not yet on the other.