Sunday, December 14, 2014

Extra Digits- What Happens After Treatment

Postaxial polydactyly is the medical term for an extra digit on the pinky side of the hand.  It is far and away the most common location for an extra digit.  It is much more commonly seen in African Americans compared to whites (the reverse is true with radial polydactyly- thumb side).  There is a definite inheritance pattern (typically autosomal dominant).  I have previously written about this on several occasions- read here. 

I find it interesting that most children with an extra finger next to the pinky are not treated by a hand surgeon.  The extra digits are routinely "tied- off" in the newborn nursery.  Rarely these children may be treated in the pediatrician's office or at an orthopedic surgeon's office.  And most of these kids do really well, although small signs of the extra digit remain years later.  However, this treatment is best for the small extra digit and not the fully formed digit which requires a more formal surgery.

There is a huge variety in how the extra finger may appear- from quite small to normally sized.  The position and development of the extra digit is also variable as noted in this excellent article in the medical literature.
This child has a fully formed extra digit next to his pinky.

Smaller (and a bit swollen) extra finger.

Another type of extra digit, this time coming off the small finger closer to the nail.

So, no matter whether the extra digits is "tied- off" in the newborn nursery, clipped in the clinic or treated with formal surgery, most patients do great. 
 
Subtle hint of where the extra digit was removed.




However problems do develop.

1) One potential problem with an extra digit procedure is the need for a later surgery, a formal surgery to address the scar or pain.  In a recent article on using clips in the clinic (see here), 7% of kids needed a scar revision surgery.  Here is an example of a child treated in the nursery with an uncomfortable residual "nubbin."
Painful, small nubbin after treatment of polydactyly.
2) When the extra finger is clipped or tied, the blood supply to the digit is cut off and the extra digit enlarges, turns black and eventually falls off.  However, the timing of this process is unclear and the extra digit can stay on for week.  There is also a risk of infection.  These factors affect family satisfaction with this type of procedure and it certainly makes education of the family very important.


Necrotic extra digit after being tied off.

Another necrotic small finger polydactyly after being tied off.
3) Even formal surgery is not perfect for polydactyly.  The goal with formal surgery is to remove the finger and address the nerves, arteries, and tendons to allow a satisfactory appearance and function. And it is usually successful.  There are few problems reported.  Here is one recent example of a patient I treated with a revision excision.  His first surgery had been elsewhere and the surgeon had left behind some bone and the nerve stump had become painful as well.
After incomplete extra finger excision.  The patient needed a revision surgery.


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



21 comments:

  1. Has anyone (or should I say any parent) ever wanted to keep the extra fully formed digit? Especially if it is not aesthetically offensive (such as the 1st photo)?
    I think it would be neat to have a normal looking extra digit, although it would be annoying having to buy custom made gloves!

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  2. Kelly,
    Thank you for the question. That has indeed happened in my practice (not often). But, as I recall, both patient came back early in their teenage years to request the surgery to remove the digit.

    This brings up an important question- when can a child make such a decision for himself/ herself (as some families wan this to be a decision for the child). And the answer, is likely older than we think. Teenage years most likely. So while I respect the wishes of all my parents, I do make sure they understand that if they want their child to make the decision on this (or anything, really), it will need to be in many years. For that reason, I discourage the 'waiting' whenever possible.

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  3. What if the normal pinky next to the extra digit doesn't have a nail and is shorter? Can the surgeons transfer the nail from the extra digit to the real one?

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    1. Hello,
      In this situation, both fingers are abnormal- making for a more complex situation. This is very unusual and I would certainly recommend seeing an experienced hand surgeon who regularly addresses this type of issue. We do not routinely transfer nails.

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  4. My nephew has an extra digit coming off his pinky. He has endured years of ridicule from classmates and is almost 15 now. He wants to have the finger removed but is scared of his functionality after the procedure. He is a very skilled drummer and dabbles with piano and guitar as well so losing function in his hand is a big deal. The pinky is sharing a joint with the extra finger and they move together. Do you any experience with this? Any advice would be helpful and much appreciated. Thanks in advance.

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    Replies
    1. Hello,
      I do have experience treating teenagers with extra digits. Typically, the family decided to wait and let the child decide. It does take time for a child to make this decision (your nephew is about the required age in my opinion), and it is an adjustment for a teenager (it is not for a young child when these are typically treated).
      While I cannot comment specifically about your nephew because so much depends on his specific situation, rest assured that I would expect him to do great and not lose function with this surgery. The key is to see a surgeon with experience! Good luck.

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  5. What type of infection would happen if a string is tied around the extra digit near the pinky

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  6. When a suture is tied around the extra finger, it swells and then 'dies' without blood supply. It then falls off but can take 4-6 days and sometimes longer. Infections are rare although the digit goes through somewhat ugly phases in which it swells and changes color. I hope this helps.

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    1. Hi, can this fall off happen without the finger being tied? My baby has one and it is seemingly changing color at the base and seems to be causing some pain.

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    2. Hello. It is difficult to answer your question but if there is limited blood supply to the small finger, it could 'auto- amputate'. While pain would be unusual, I would absolutely see a congenital (pediatric) hand surgeon. Good luck.

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  7. hello Charles we had the string tied around my sons extra digit it was mostly skin however today it started leaking a bit this is normal right?

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    1. Thank you for the question. I assume that this procedure was done by a medical professional who has experience with placing and tensioning the string. One of the challenges is knowing what is normal after this has been done- swelling, change in color are both common. I am not sure what "leaking" means but could be concerning and it probably makes sense to be seen by whomever placed the suture/ ligation. Good luck.

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  8. Hi Charles if a baby is born with extra digits with bone on both hands and toes does it make the sugery and recovery more complicated.and how long does it usually take to heal?

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  9. Larger extra digits may be more challenging to treat compared to simple 'nubbins' but there are many factors. The type of extra digit and the surgery required are the key factors for complexity of surgery and time to healing. Good luck.

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  10. Hello, I was born with an extra digit (no bones or anything just skin) and my mom had it tied off in the hospital while I was born. However, it has formed into a "nubbin" or "neuroma" aka. a bump has formed into my pinky finger where it was tied off. How can I get this surgically removed? Or what procedure should I undergo and who should I contact (what kind of doctor). Please help me, I am 19 now and I always wanted this fully removed but I did not know how to proceed

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    1. Thank you for this question. This is an important issue and one that is common. Sometimes the 'nubbin' is painless and sometimes there can be pain from the nerve. Either way, a relatively straightforward surgery can help. A hand surgeon can help, ideally one with experience with birth differences- someone who treats this type of issue commonly. Feel free to contact me offline by email if helpful.

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  11. My daughter's was like photo #2. I wanted to keep hers but she got hair tangled around one and it started to die so i had them removed when she was about 6months old. She's now 12 and said that sometimes it hurts where her scar is. The doctors used a scalpel to remove hers not tie it. Why is she experiencing pain? My 2 brothers had the same both are adults now and said theirs hurt sometimes as well.

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    1. Thankfully this is uncommon, but does happen. Typically, this is a neuroma- an inflammed nerve ending. When the digit was removed, the nerve to the digit was also cut. Sometimes it can be painful later. Surgery to remove the neuroma is well tolerated and with a relatively quick recovery. Obviously, if only a nuisance, she should ignore. But, if more problematic, there are solutions.

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  12. My 3yr old had hers tied. And now she has a small nubbin. I Wonder if it will get bigger as she grows. She doesn't complain of pain yet

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  13. Hello,

    I would hope that there will never be pain. The nubbin may get likely get slightly bigger but not dramatically so. Hopefully no additional treatment will be necessary.

    Good luck.

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