Thursday, December 26, 2013

Social Media

The last 6 weeks have been a little hectic and I have not been as timely as I would like with my posts. My goal is 1- post/ week and while that may not seem too difficult, it can be a challenge.  I will add a few new posts in the next week or so and will work as hard as possible in the new year to stay on track.

This brief post is to let the regular readers out there know that I am going to try to be better about linking my posts to social media venues including Twitter, Google+, and Facebook.  While I realize that some of you follow me on Blogger and some just check in from time to time, Twitter, Google +, and Facebook will offer another way to keep track of posts.

You can find me by name at Google +  and on Twitter- @congenitalhand

You can also find my updates on Facebook- Birth Abnormalities of the Hand and Arm.


Also, the best email address for questions (if you wish to avoid a general post) is congenitalhand@wudosis.wustl.edu


Thank you and Happy New Year!

Charles A. Goldfarb, MD

Friday, December 13, 2013

Symbrachydactyly, now what?

I have posted on symbrachydactyly several times in the past.  http://congenitalhand.wustl.edu/search/label/Symbrachydactyly

There are, by different symbrachydactyly classifications, 7 types:

  1. short finger
  2. cleft type (thumb and small finger present)
  3. peromelic (nubbins)
  4. monodactyly (only the thumb present)
  5. wrist bones present (but nothing more distal)
  6. wrist bones absent (ie, arm ends at the end of the forearm)
  7. transforearm (amputation at mid forearm level)
Nubbins, one of the classic findings in symbrachydactyly, can be present with any of these except the short finger type.  All can be associated with Polands syndrome (partial breast muscle absence with or without breast abnormality and chest wall abnormality) but the short finger variety is most commonly associated.  A recent manuscript offered a classification for Poland syndrome and confirmed that the most common finding in the hand was either no anomaly or 5 fingers but limited motion/ length.  http://www.ncbi.nlm.nih.gov/pubmed/22955538

One of my patients has a severe cleft type (almost a monodactyly type) of symbrachydactyly.  This is the original x- ray appearance.
Symbrachydactyly xray, severe cleft ype.


We treated him years ago with lengthening of the 5th metacarpal to allow functional pinch.  For several years he did well but now is limited by an inability to bring the thumb to the small finger ray.  Please note that we did not correct the thumb (despite the triangular shaped bone) because the deformity was helpful.
Symbrachydactyly after lengthening.  Note the longer 5th metacarpal.

Symbrachydactyly after lengthening.

Symbrachydactyly on right, normal hand on left.

We have discussed options with family including a surgery on the the 5th metacarpal (the lengthened bone) to angle it towards the thumb.  However, we have all agreed to attempt to treat this without another surgery at this point.  We will create a "post" to lengthen the small finger further (occupational therapy and prosthetics) to assess whether this helps functionally.  If it does (stay tuned for pictures), a formal prosthetic can be constructed.


Sunday, November 17, 2013

5- finger hand, follow- up



I have previously posted on the topic of the 5- finger hand.   This previous post summarized many of the key issues with this diagnosis.  http://congenitalhand.wustl.edu/2013/03/the-5-finger-hand.html

Here is the preoperative picture of one such child with a 5- finger hand.  Note the small extra thumb and the digits all aligned in the same plane.

5 finger hand with an extra thumb as well.  Note how difficult it is to sort out on which side the thumb resides.



There are 2 main problems with this situation: 1) The "thumb" is too long which can make pinching awkward and 2) the patient does not have a wide first web space which would allow the child to grasp large objects (soda can, etc).




Additionally, the child has to depend on a scissor- like pinch (side to side) rather than placing the "pulps" of the digits together to pinch.




We corrected this child's hand by:
1) removing small extra thumb
2) "pollicizing" the index finger.  See previous posts:
http://congenitalhand.wustl.edu/2011/10/pollicization-creating-new-thumb.html
http://congenitalhand.wustl.edu/2011/12/more-thoughts-on-pollicization-decision.html
http://congenitalhand.wustl.edu/2013/09/more-thoughts-on-pollicization.html
3) Shortening the new thumb.


5 finger hand after reconstruction including pollicization


In this case, there was a strong family history of the condition and the family is very pleased both with appearance and function.  The hand functions quite well with daily activities.





Friday, November 8, 2013

Challenges with Cleft Hand Reconstruction

When surgery is required for cleft hand, the goal is to create a maximally functional hand that is as "normal" appearing as possible.  While each child with cleft hand is different, usually we can create a hand that works well and looks good.  However, certain challenges exist after surgery related to hand anatomy.  A cleft hand is not only missing bone, it is also missing muscle (called intrinsic muscle), tendon, and the ligaments may be weak as well.  We believe that there are 3 primary functional limitations after reconstruction for cleft hand (these same limitations are likely present without surgery).

#1  The space between the thumb and index finger is called the first web space.  It is vital for grabbing large objects and for hand use overall.  We all tend to use this space to hold objects like soda cans.  If the space is small, it becomes impossible to hold such objects with then hand.  The other hand or both hands are then required.  Cleft hand almost always has a small web space between the index and long fingers.  Therefore, part of surgery is to reconstruct this space.  I have written about this issue already.
http://congenitalhand.wustl.edu/2013/05/cleft-hand-long-term-follow-up.html  and
http://congenitalhand.wustl.edu/2012/05/cleft-hand-surgery.html

#2  The ring finger may be affected with cleft hand as it can be difficult to straighten the finger fully.  The intrinsic muscles (those muscles in the palm that normally help to straighten the fingers) may be absent next to the cleft and, therefore, the ring finger may not get the normal muscle that it should.  Without this intrinsic muscle, straightening the finger may be a challenge at the PIP joint (first knuckle in finger).  There is no easy solution to this problem but fortunately, most kids function just fine even if the finger does not straighten fully.

Right cleft hand.  Not that the ring finger does not straighten fully.  The thumb- index web space has been reconstructed as has the ring- small finger space.
Palmar view of cleft hand after reconstruction.


Fist in cleft hand after reconstruction.  Function is excellent.


#3  The final function issue in cleft hand is the stability of the knuckles.  The MCP joint connects the fingers to the hand.  Normally, this joint allows you to bend and straighten the fingers but not a great deal of side to side motion.  If the ligaments that normally stabilize the MCP joint are not strong in cleft hand, the joints may move too much- so- called joint laxity.  This laxity or instability is most common in the index and ring fingers.  Often it does not cause a functional problem but sometimes it will and we use surgery to stabilize the joint.  This can be tricky because we also need to protect the normal structures including the growth plates.  Here is an example of a patient after cleft hand reconstruction.  He is doing great, family is very happy and they do not want additional surgery now.  However, we spent some time discussing the index finger.  He might benefit from re- aligning the index finger (i.e., cutting and straightening the metacarpal bone) and stabilizing the joint.  The thumb, ring, and small finger look great. The thumb- index web space also looks great.  The finger alignment is the primary issue.
Cleft hand- left side- after reconstruction.  Gentle stress provides good alignment.

Left cleft hand after reconstruction.  Note deviated index finger but rest of hand looks great.
Palmar view of cleft hand after reconstruction.







Friday, October 25, 2013

Trigger Thumb, Video

Most children with trigger thumb have a thumb stuck in a position of flexion.   It does not hurt but the thumb will not straighten.  While most kids function just fine, some activities may be difficult.  I have covered the basic in a previous post: http://congenitalhand.wustl.edu/2013/08/trigger-thumb-trigger-finger.html

In these cases of a locked trigger thumb, we typically, eventually perform surgery to release the trigger thumb.  It is a surgery that works, has very low risks (i.e., low complication rate), and happy parents and patients.

Less commonly, kids may have a thumb (or finger) that actually pops.  This is more like the adult type of trigger digit.  In this case, sometimes it hurts and sometimes it does not.  This video shows an example of a child who could make her thumb pop.  It was essentially stuck in a flexed position but she could, with a notable effort, straighten the thumb.  Clearly not painful (but mom reported that sometimes it would be uncomfortable).  This shows the mechanical nature of this problem- that is the tendon can't move through the tendon sheath and must be pulled through (with a pop).  Check it out.


Saturday, October 12, 2013

Hand Society 2013

Last week was the annual meeting of the American Society for Surgery of the Hand in San Francisco.  As usual, it was a great meeting with an amazing collection of speakers giving paper presentations and courses on a variety of topics.  There were two presentations of congenital research from our institution (along with a number of other presentations from our institution) and both were fantastic.

Claire Manske (an orthopaedic resident) presented the results  (at 6+ years) of children treated with fixator distraction prior to centralization for radial deficiency.  Results were good but recurrence of the radial angulation was more notable than expected.  This is something we will continue to monitor moving forward as we feel the technique of using the fixator is still valuable (maintains wrist motion and makes centralization procedure easier).  We are in the process of publishing these results.

Alex Aleem (also an orthopaedic resident) presented on cleft hand treatment, specifically the results of patients treated with a transverse bone (i.e., a bone lying 90 degrees to the expected position).
Cleft hand with transverse bone.
Again, Alex did a wonderful job and the paper is in the process of being published.  The results were overall very good.

Additionally, I was able to participate in a couple of sessions specifically on children.  First, Michael Tonkin from Sydney Australia and I led a precourse (4 hours course prior to official start of meeting) with 150+ attendees and a wonderful faculty discussing cerebral palsy, brachial plexus, and arthrogryposis as well as other birth anomalies of the upper extremity.  Great course.

I also presented at 2 other courses on kids- the first on the complications of common pediatric and congenital procedures.  Complications are fortunately uncommon in procedures on children (whether trauma cases or birth anomaly cases or other types of cases) but are extremely educational.  Sharing such experiences helps everyone learn and, hopefully, avoid complications (when avoidable).  

The other course was on the pediatric and adolescent athlete.  I may post in the future on these athletes but for now, suffice it to say that injuries are increasing in this population due to year- round play and higher expectations that come with specialization in a single sport at a younger age.  I feel strongly that kids should play multiple sports for years (at least well into high school).  Anyway, the course discussed common injuries at the elbow, forearm and wrist, and hand.  Interesting topics and discussion.

Friday, October 11, 2013

Severe Radial Longitudinal Deficiency

As with most medical conditions, different children will be affected at different severities.  These differences can be notable such that two kids labeled with the same congenital difference may look completely different.  While this obviously matters to the family, it also matters to the physicians because once we sort out a diagnosis (sometimes easy, sometimes not), we then have to give the best treatment recommendations.  Most of us have a preferred treatment based on a particular diagnosis.  For example, a believe in the concept of centralization for radial longitudinal deficiency.    http://congenitalhand.wustl.edu/2011/07/radial-longitudinal-deficiency.html
I also believe in precentralization distraction as a means to make the centralization procedure easier.  http://congenitalhand.wustl.edu/2012/05/fixator-for-radial-longitudinal.html   And I definitely believe in pollicization (making a thumb).  http://congenitalhand.wustl.edu/2013/09/more-thoughts-on-pollicization.html

However, there is no "one size fits all" solution for children with radial longitudinal deficiency.  Some mildly affected kids may need therapy only or a tendon transfer only to balance the wrist.  The thumbs may be reconstructed rather than treated with pollicization.  And centralization is not always the right choice.  For example, in kids with poor elbow motion (fortunately, this is rare in radial deficiency), centralizing the wrist can take the hand away from the mouth if the elbow doesn't move- bad idea.

I think this video is an amazing example of a child who makes us think about our normal treatment plans for radial longitudinal deficiency and what might be best for this particular child.   Watch the child function.  The wrists are markedly radially deviated but his hands are working straight ahead.  This is because the ring and small fingers are the digits that work best for him (amazing dexterity).  The thumb does not work at all and the index and long finger are limited.  When considering these facts, the typical treatment of centralization of the wrist and then pollicization of the index finger into a position of a thumb might not make sense.  This is because
1) Centralization takes the vital ring and small fingers out of the best position and makes them lie further away from where they are needed (i.e., more ulnar).
2) Pollicization outcomes depend on the quality of the index finger.  In this case, the index finger is not great and therefore when pollicized, it will not make a great thumb.

Therefore treatment for this child has to be carefully considered.  There are options but the best ones might be different from the typical "protocol."

Thank you to mom for allowing us to post this video.




Thursday, September 26, 2013

Congenital Radial Head Dislocation

Congenital radial head dislocation is an unusual congenital anomaly of the elbow.  It is undoubtably present at birth but is rarely discovered until children get a bit older.  This is mainly because the limitations of radial head dislocation are not life- altering for most (including the motion limitations).  X- rays are usually the best way to discover a joint dislocation but may not be diagnostic in a young child.  Much of the elbow is cartilage in a young patient and the cartilaginous elbow is difficult to understand because cartilage is not visible on x- ray.  

So, congenital radial head dislocation often presents as children the reach an age of increased activities-   typically 4-8 years of age but often even older.  They usually complain of a lack of motion- specifically limited rotation of the forearm.  Rarely, elbow flexion or extension limitations may be noted.  Pain is rare in the younger patients but pain can be a problem in the teenager with a marked deformity .  When the dislocated radial head is bumped- it hurts.

Some basics.  First, children with congenital radial head dislocation have it for both elbows.  Second, it can be associated with syndromes- including nail- patella syndrome: http://ghr.nlm.nih.gov/condition/nail-patella-syndrome.  Others may include Klinefelters and Cornelia de Lange. Third, most dislocations are posterior or posterior- lateral but some may be anterior or truly lateral.  

One of the biggest issues with the diagnosis of congenital radial head dislocation is separating it from trauma causing a radial head dislocation.  It can be confusing.  There may be several tricks to separate the two. First, if both sides are involved, it is a birth (congenital) problem.  And second, the x- rays can help.  Typically the capitellum is rounded and the radial head is concave and round.  If these shapes are not present-  the radial head and capitellum have not developed normally because it is a problem present since birth (i.e., not a trauma).  Third, most radial head dislocations in kids are accompanied by an ulna fracture (Monteggia injury)- make sure ulna is ok!  And fourth, radial head dislocation may be a part of proximal radioulnar synostosis.  This is a different issue altogether.

In most cases, we do not surgically treat congenital radial head dislocations.  If discovered in a young child, there have been thoughts about putting it back in place but most believe this will not succeed.  In older kids, attempts to put radial head back in place are even less likely to succeed because the anatomy is altered.  So, given that most kids have few if any complaints- we do not recommend surgery.  However, in older kids, typically teenagers, pain can be an issue.  If the pain is a real issue, surgical excision of the radial head can be considered.  It should ideally be delayed until the growth plates are closed.  I have been very happy with our results with this operation but there are a couple of issues for families to consider.  First, the radius can move slightly proximally (away from wrist).  If it does, the ulna becomes prominent at the wrist and can be painful.  This can, in a small percentage of patients, require another surgery.  Second, we worry about the stability of the elbow and possibility of development of arthritis.  And third, excision of the radial head may improve elbow motion (best for rotation) but obviously does not make it normal.  We have published our results in this area with good outcomes: http://www.ncbi.nlm.nih.gov/pubmed/23123151

Here are a few pictures of recent radial head excision in a teen with elbow pain.

AP x-ray of elbow with congenital radial head dislocation demonstrating deformity of radial head.  This teenager had pain.

Congenital radial head dislocation.  Not the head of the radius is out of place and misshapen.
The shape and appearance of the excised radial head.  The head should be round and completely covered in shiny, white cartilage.  This radial head in a 15 year old is arthritic and misshapen.  The separate piece of cartilage is also a problem- a loose body.

We take an x-ray of the wrist to understand the relationship of the radius and ulna before we remove the radial head.  This helps us understand issues later that might develop.



Friday, September 13, 2013

Short Fingers- Brachydactyly

I have written several times about symbrachydactyly- that is short, webbed fingers.  This common condition is distinctive in appearance (although there are multiple different types).   I have actually written 10 posts that relate to symbrachydactyly.  http://congenitalhand.wustl.edu/search/label/Symbrachydactyly

Brachydactyly, or short fingers, is a different condition as there are the normal 5 digits with shortening of either the phalanges or metacarpals or both.  The different classifications are helpful as there are so many types and the classifications help keep some sort of organization.  Most commonly cited are those by Bell and Temtamy and McKusick (Temtamy SA, McKusick VA. The Genetics of Hand Malformations. New York: Alan R Liss, INC; 1978).  There are a number of good educational sites on the topic of brachydactyly.  One such site is the OJRD- Orphanet Journal of Rare Disease which provides information through the NIH http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441618/#B1
and another great site is through OMIM- the Online Mendelian Inheritance in Man which categorizes each individual type.  http://www.ncbi.nlm.nih.gov/omim/?term=brachydactyly

I will not repeat all the detailed information available through these amazing sites.  A few key points, however, are worth repeating.  First, brachydactyly can be isolated or can be part of a larger syndrome.  This means that for most people, the short fingers are the only issue- there are not other conditions to worry about.  Second, it is most commonly passed in an autosomal dominant fashion (50% chance of passing it on to your children).  So, in most cases, a parent will have brachydactyly which obviously helps in understanding the abnormality.  And last, many of the genes associated with brachydactyly have been identified.  We actually know where the problem is in the human genome but, as of now, we can't do anything about it. Eventually, we may be able to "fix" the problem, but the science is simply not there yet.

Brachydactyly is typically a condition that affects the appearance of the hand more than the functional ability of the hand.  The type of brachydactyly obviously matters as some types will cause finger deviation, some an isolated shortness of the digits and some a combination.  The finger deviation is a type of clinodactyly as I have previously discussed. http://congenitalhand.wustl.edu/search?q=clinodactyly

Surgery is not usually required but can be helpful for marked deviation or, rarely, for marked shortening of the digits.  Surgery is usually an osteotomy (cutting of the bone).

This is an example of brachydactyly type E.  This patient had no pain, excellent motion (as shown), and was not overly concerned about the appearance of her hand.



Brachydactyly- both hands affected but the right hand is more noticeable.
Note the knuckle asymmetry in brachydactyly.
Brachydactyly with different length metacarpals.
The most notable finding in this patient with brachydactyly is the short 5th metacarpal. The 4th metacarpal is also short.
The right hand in the same patient with brachydactyly shows a very short 3rd and 5th metacarpal along with a short 4th metacarpal.



Sunday, September 1, 2013

Even More Thoughts on Pollicization

Pollicization is the surgical procedure in which the index finger (typically) is used to create a thumb.  It is most commonly performed for children born without a thumb or with a markedly small, unstable thumb but can also be performed in post- trauma situations in the adult.  The importance of a good thumb can not be overstated: first, it allows large object grasp (grabbing a soda can).  While one may be able to grab a soda can between the index and long finger, it is difficult as most of us do not have a big enough space to accomplish that goal.  The second reason that the thumb is so important is small object fine manipulation.  It is true that  one can manipulate beads or blocks between the index and long finger BUT, when you do so, you are using the sides of these two fingers which is a challenge.  It is much easier when one uses the pulpy part of the finger/ thumb to accomplish this goal.

So when the thumb is not suitable, the pollicization procedure is a great option because it really helps function.  There is an added benefit that it also really helps appearance as well.  A hand with a thumb (or pollicized digit) and 3 fingers looks almost normal and is almost never noticed as being abnormal.  However, a four fingered hand without a thumb is always noticed.

So, in case you can't tell, I (and others who share my passion for congenital hand surgery) really feel strongly that the pollicization procedure is a great operation for the right child (and family).  The risks are relatively low for such a procedure and the results are really predictable and good.  However, it is also an operation that is slightly different based on the surgeon.  Dr Manske, my former mentor and partner and a father of this field of surgery, published a "cookbook" of how to actually perform the procedure.  The 10- step process really does break it down nicely into straightforward steps.  http://www.ncbi.nlm.nih.gov/pubmed/1572922

But, the pollicization procedure, as much as any procedure I know in orthopaedic surgery, is really affected by the surgeon and the small decisions that the surgeon makes during the surgery.  We have written on some of the factors that affect the appearance outcome of pollicization http://www.ncbi.nlm.nih.gov/pubmed/17826558.

Some factors are out of the control of the surgeon and these factors include mobility (the most important factor affecting the outcome of the pollicization procedure is the quality/ mobility of the index finger), girth or size, nail width, among others.  However the surgeon can control some really important features including length, position of the web space, angulation (sometimes), mobility (to some degree), and perhaps most importantly, rotation.  None of these are easily controlled and, I believe, the decision- making comes with years of experience and lots of procedures performed.  It is why I believe that the best way to learn the entire field of congenital hand surgery is with a mentorship model- meaning that I feel that to be high quality congenital hand surgeon, one needs to learn from another very experienced congenital hand surgeon over time).  After all of my training (college, 4 years of medical school, 5 years of residency in orthopaedic surgery, and 1 year of fellowship in hand surgery), I had the pleasure/ honor of learning for another 10 years with Dr. Manske.  While I was certainly well- enough trained to perform the procedure immediately after I finished those years of training, I feel the extra years helped me immensely and helped to make me a better surgeon today.

My advice to parents considering this procedure is to understand the surgeon's training and the number of pollicization procedures that the surgeon performs each year.  He or she should be willing to share that information and if the topic is uncomfortable for discussion, to me, that is not ok.  Ask to see pictures of previous cases, talk to other patients, etc.

Here is a child after bilateral wrist procedures and pollicizations (1+ year out from last pollicization).  The left side, to me, looks wonderful and functions beautifully.  The right side works really well also but was more of a challenge as there was limited motion before surgery and so we made some decisions to help function at a slight cost of appearance.  The right side is rotation differently compared to the left and is a bit longer.  These are trade offs.  Mom and child are both very happy and he uses BOTH thumbs wonderfully.

Bilateral pollicization.  Left side is a bit more natural appearing due to decisions to maximize function on right.

Left side pollicization.

Left side pollicization demonstrating pinch.

Right side pollicization.  Thumb is slightly longer than usual to make up for decreased motion.

Left sided small block pinch after pollicization.


Left sided large block grasp after pollicization.

Friday, August 23, 2013

Trigger Thumb/ Trigger Finger


Trigger digits are common in the adult population.  It can be called different things including stenosing tenosynovitis but we really do not understand who gets it and why they get it.  The only population that seems to get trigger fingers more than everyone else are diabetics.  Adults with trigger finger (and it really can be all the fingers and/ or the thumb) have pain at the location where the fingers meet the palm and sometimes can feel a catching when they bend the finger.  It is classically worse in the morning and gets better over the course of the day.  We know it is caused by the tendon rubbing at the anatomical entrance to the canal- the A1 pulley.  Again, we just don't know why.  Treatment is straightforward.  Splints and braces don't work in most cases and treatment is either a steroid injection or a surgery.  Steroid injections work about 60% of the time but we don't repeat the injection over and over.  Surgery is very effective and has only rare complications (but it is surgery so we try to avoid).

There are multiple websites which detail trigger finger diagnosis and treatment.  The AAOS (American Academy of Orthopaedic Surgeons) is a great site and the following link is as good as any.
http://orthoinfo.aaos.org/topic.cfm?topic=a00024

Trigger digits in kids are very different and again, we don't know why.  A couple of thoughts.

1) Most importantly, it is almost always a trigger thumb.  Trigger fingers are rare in kids but trigger thumbs are "common," at least in my world.
2) The term congenital (meaning present at birth) is often used in describing trigger digits/ thumbs in kids.  This is not accurate.  There are several (at least 3) studies which look at a large number of newborns and trigger thumbs just don't exist.  The appear later.  So the best term is pediatric trigger thumb.
3) Kids almost always present with the thumb in a bent or flexed position at the distal joint- the IP joint. Typically it is stuck in that position.  Occasionally, kids can straighten the thumb but usually it is just stuck.
4) It doesn't hurt.  Because it is stuck, there is no pain.
5) Function is usually pretty good but we worry about function over time- in school with writing and scissorts, etc.

For those who see kids with trigger thumbs or fingers, the diagnosis is clear.  The thumb is stuck in a bent position and sometimes there is swelling at the base of the thumb (MCP joint).  We call this a "Notta's node" and it is where the tendon gets stuck in the sheath.  We don't need x-rays or MRIs.

Treatment for trigger thumbs or fingers.
There are 3 options for treatment.
1)  Ignore it as it might get better.  This is not unreasonable given that it doesn't hurt but in our experience, rarely does this go away on its own.  But, a 6- month trial of watchful waiting is certainly a reasonable plan.  This is the recommendation from Korea with a good study supporting that it will help.  Dr Baek is an extremely well respected surgeon who has written on many topics in kids hand surgeries.    In his study, 4 years after the first visit, about 60% of kids had resolved and another 20% were improved.  http://www.ncbi.nlm.nih.gov/pubmed/18451388  These are impressive numbers but obviously require some patience from the patient, family, and surgeon.
2) Stretch and splint.  There is little data to support splinting of the thumb but there is actually good data to support considering a splint and/ or stretching for trigger finger.  http://www.ncbi.nlm.nih.gov/pubmed/22624785
3) Surgery.  Surgery works for pediatric trigger thumb.  It is a small surgery, it is outpatient and takes less than 10 minutes.  Patients have little pain after and most heal uneventfully with a cure.  Complications are rare and include a risk of infection (likely around 1/200) and scarring.  It does require a general anesthetic but again, minimal risks.  Trigger finger surgery may be more complicated as it can require a more extensive operation compared to trigger thumb.  It is just less predictable.  Still effective and reliable.
The decision of when to go to surgery is not easy.  It depends on the family perspective, the time that the trigger finger has been present, and the surgeon's beliefs.  For me, a conversation between the family and myself helps to bring all the issues out and guide the decision.  In the USA, we tend to be more aggressive than our Asian counterparts about the decision of when to go to surgery.

This is a case of a pediatric trigger finger.  Again, much less common than trigger thumbs.  This case had a swelling or "Notta's node" at the A1 pulley which limited extension.  At surgery, the A1 pulley was released and the finger extended.  Additional surgical dissection was not required and the patient's condition resolved.

Pediatric trigger finger which is more rare than trigger thumb.  Not the flexed position of the finger.    It could not be straightened.
I am trying to straighten the finger but it is blocked in this pediatric trigger finger.

Bilateral trigger thumb.  Photos courtesy of my partner, Dr Wall.

Trigger thumb.  We are trying to straighten the thumb but it is locked.  Photo courtesy of Dr Wall.



Saturday, August 17, 2013

Mild Camptodactyly

Camptodactyly comes in different types based on age and severity.  I have written several times about camptodactyly including http://congenitalhand.wustl.edu/2012/03/camptodactyly.html

While there are different ways to consider camptodactyly, there are three basic types: infantile, adolescent, and camptodactyly associated with a syndrome (i.e., athrogryposis, etc.).  For most patients, camptodactyly affects the small fingers on both sides but may be different on each side.  Syndromic kids may have any finger affected.  When, for example, the long finger is affected, it tends to be more of a problem compared to the small finger and get in the way of grasp.  Upton and others have done a nice job breaking down these 3 types with the results of treatment.  http://www.ncbi.nlm.nih.gov/pubmed/7814601

I certainly see all three types of camptodactyly patients and each has its challenges.  Pain is rare but with a worsening deformity (i.e., worsening position of flexion), functional issues increase.  This includes difficulties with playing musical instruments, typing on the computer, sports, among others. Different patients are bothered at different levels of contracture.  We, as surgeons and doctors, try to define the point at which camptodactyly becomes a problem but the reality is that we can assign numbers like 30 degrees or 45 degrees or others but, again, it is really about the patient.

The good news about camptodactyly is that many patients will respond to therapy including stretching and splinting.  This depends, again, on the patient, but also on the degree of camptodactyly because once it is too severe, splinting and therapy become less effective.  Therapy and splinting may be a challenge in really young patients but is easier in adolescents (who really want their finger to get better).  Stretching during the day, specialized dynamic splints during the waking hours, and static splints at night all have a role.  Progress is typical.

Here is a recent patient with what I would consider mild camptodactyly.  He was excited to try therapy and I expect that he will improve.  I plan to post soon on the surgical options.

Bilateral small finger camptodactyly.  Note that the bottom hand, the right hand, is worse and was more of a problem.

Left small finger x-ray of camptodactyly.  Attempted full straightening.  The joint is well formed.

The more severely affected side in camptodactyly.  The joint is not quite normally formed but is generally satisfactory.





Tuesday, August 13, 2013

Partial Syndactyly

I have written several times on syndactyly, most recently about an unusual case of thumb- index syndactyly http://congenitalhand.wustl.edu/2013/08/thumb-index-syndactyly.html

I have also mentioned (but not discussed in great detail) partial syndactyly.  Partial syndactyly means that the fingers are joined together by a skin bridge without bony connection.  The skin bridge does NOT travel all the way to the fingertip (thus, partial).  Many times the skin bridge is short, only to the first knuckle (the PIP joint).  Partial syndactyly may or may not cause functional problems.  Often the partial syndactyly involves the long finger and the ring finger (also most common site for complete syndactyly- which is a joining of the skin to the fingertip).  Syndactyly between the long and ring finger can limit spread of the fingers and limits the ability to wear a ring (perhaps a wedding ring, one day). Partial syndactyly of the index and long finger can tether the index finger and affect pinch activities- patients/ families do complain about this aspect.  And, as always, there is the appearance issue which really does matter to patients and to families.

When I meet a patient/ family with a partial syndactyly, we discuss the nature of the syndactyly and I learn how it affects the child.  For some, the partial syndactyly is simply not a big deal and no intervention is recommended.  For others, the syndactyly limits function.  In those patients with functional limitations, surgery is discussed.  Surgery in those patients who simply want the syndactyly treated for appearance reasons is rare but does happen (in my mind, this discussion includes those who want to be able to wear a ring).  I frankly discuss the difficulties of surgery, the healing process, the risks, etc.  Some will chose surgery.

Surgical protocol.
Surgery is outpatient meaning you can go home that night.  I use a big, bulky but soft dressing for most patients but occasionally for the younger child will use an above elbow cast.  I typically leave the dressing on for about 3 weeks.  I use dissolving sutures so nothing to remove.  Depending on the appearance of the wound, sometimes we use a dry dressing and sometime we use an odoform support at night (and splint at night).  Scar massage is instituted when the sutures start to dissolve.

Partial syndactyly between the index and long fingers.  Not severe but functionally limiting.

Partial syndactyly view from palm


After syndactyly reconstruction with dorsal commissural flap.

Another case demonstrating the box flap technique.  This 3 flap technique is effective in covering the partial syndactyly is some patients.
Box flap design for recurrent syndactyly reconstruction. 
Corrected syndactyly with box flap

Box flap reconstruction with flaps in place.
Partial syndactyly of the long and ring fingers.  The first case is corrected by a dorsal first metacarpal artery flap.  See the diagram of the flap.
Partial syndactyly between long and ring fingers
Partial syndactyly flap reconstruction (without skin grafts)
 Other long and ring finger partial syndactyly.

Partial syndactyly past the PIP joint.  This is a longer than typical partial syndactyly.

Partial syndactyly from palm

Additional syndactyly 
Additional partial syndactyly




Tuesday, August 6, 2013

Thumb Index Syndactyly

I have posted a number of times about syndactyly.  The two basic posts include:
http://congenitalhand.wustl.edu/2011/06/syndactyly.html and http://congenitalhand.wustl.edu/2011/07/frequently-asked-questions-about.html

The long and ring finger are most commonly involved in syndactyly whereas the thumb and index finger are uncommonly conjoined.  There are several important points to consider regarding thumb and index finger syndactyly:

1) The syndactyly between the thumb and index finger is functionally the most significant type of syndactyly as it limits pinch and large object grasp.  Without a wide, soft webspace between the thumb and index finger, function of the hand is difficult and will be frustrating to the child.

2) It is also notable as it should be correctly at a younger age to de- tether the index finger as otherwise, the index finger can deviate towards the shorter thumb with growth.  While long finger and ringer syndactyly may be corrected at any age (preferences vary, but we often aim to correct at 18 months), we correct the thumb and index finger syndactyly closer to 6 months of age, if not before.

3) Finally, thumb index syndactyly is a more difficult correction as the typical techniques are not applicable.  We like to use a dorsal flap to cover the web space to create a soft, function webspace.


Thumb and index finger syndactyly.  Note the large space between the index finger and the long finger (which is joined to the ring finger and is contracted).

Another view of both syndactylies- thumb/ index on the left and long/ ring finger in the center.



Here I isolate the thumb and index finger syndactyly.
This is an unusual correction of syndactyly as mentioned above.  In this case we borrowed skin between the index and longer finger and bring it over towards the new space between the thumb and index finger (with the zig- zag separation).