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:

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.
I also believe in precentralization distraction as a means to make the centralization procedure easier.   And I definitely believe in pollicization (making a thumb).

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.