Sunday, November 20, 2016

Clasped Thumb Follow Up

I have posted several times on clasped thumb, a rare condition in which the muscles that straighten the thumb are slow to develop and the thumb rests across the thumb.  It must be differentiated from several other diagnoses included trigger thumb and spastic thumb (in which the tight muscles pull the thumb down).  Here are links to the other two posts: Post 1 and Post 2.

In, this post, I wanted to briefly share the early results after surgical treatment for clasped thumb.  Surgery is usually not required.  In most cases, support in the form of a soft splint or hard splint allow the thumb muscles time to develop.  However, for the rare child, those muscles don't develop and we perform a tendon transfer- where we move a muscle/ tendon from one position to the thumb to improve the strength of extension.  Good results are expected and, at early follow- up, here at 3 months, good results have been obtained.  Remember, it is not easy to capture pictures of a very active 2 year old but I believe we can see the results!

Patient doing well after clasped thumb surgery

Excellent thumb straightening 3 months after clasped thumb surgery.

Charles A. Goldfarb, MD
My Bio at Washington University

Saturday, November 19, 2016

Patient Pollicization Testimonial

Gracie is an 11- year old who had a pollicization 3 months ago for her hypoplastic (small) thumb. Compared to the typical patient treated with a pollicization, Gracie is unusual because she was much older at the time of her surgery.  Gracie's age at the time of surgery does bring a few challenges mainly because she has been using her four finger hand with her 'small' thumb for her entire 11 years. However, she came to realize the challenges of life without a highly functional thumb- her thumb did not function .  The thumb is key for large object grasp such as grasping a soda can which is impossible with the fingers for most of us.  Additionally, the thumb allows fine pinch- also very difficult with the fingers.  Gracie and her family elected to proceed with the surgery.  Below find pictures before and immediately after surgery.

Hypoplastic thumb before surgery
Hypoplastic thumb before surgery

New thumb immediately after surgery
New thumb immediately after surgery

New thumb immediately after surgery

I recently saw Gracie in the office 3- months after her surgery.  She is an impressive and dynamic 11 year old and agreed to share her thoughts on video.  She is very excited about the results of the surgery.  Her thumb is working great and will continue to get better.  I wanted to capture Gracie on video as her words may help parents considering this surgery for their child.

I hope these pictures and, more importantly, this video are both helpful for families considering the pollicization procedure!

Charles A. Goldfarb, MD
My Bio at Washington University

Surgery Ecosystem

There are many factors for families to consider as they choose a surgeon and a hospital.  There is no perfect path to making these choices but some factors that I believe are important include:

1) Surgeon.  I have previously blogged about choosing-your-childs-surgeon  and this is a key factor for consideration.   I believe that the surgeon must be committed to the care of kids' upper extremities, be involved in the community of doctors who care for these types of patients, and be committed to advancing the field.  I believe surgeons who only occasionally treat kids are not ideally suited to take care of your child with a birth difference of the upper extremity.

2) Hospital.  Utilizing a children's hospital that takes care of kids 100% of the time is an important criteria, as everything the hospital offers is specifically for children.  The anesthesia is more routine, the nurses more familiar, the whole process easier.  This does not mean that you can't get good care in a hospital that treats all aged patients, it just means that if you have a choice, pick a hospital that has specific expertise in pediatric and adolescent patients.

3) Therapy.  We tend to focus on surgery as the most important step in treatment.  And it often is critical, but in many conditions, therapy can be effective instead of surgery and therapy is almost always utilized after surgery.  Therapy matters and therapist experience matters.  You want a team taking care of your child that has experience in your child's specific condition. Splints, exercises, and wound/scar care all effect outcome.

4) Communication.  I strongly believe that when a physician takes care of kids, they should provide increased access for families.  While this can mean the opportunity for thorough office visits, it also means availability to communicate via phone or email.  I understand that decisions about surgery can be challenging for families, and having all questions answered and feeling comfortable help to make the decision easier.  While not every doctor will share his/ her email or cell phone, many will.  Consider this in your decision.

5) Research.  While taking care of the patient is and should be the primary 'job' of any doctor or surgeon, research is another consideration.  Some doctors focus on patient care, but others take care of patients AND teach and conduct research.  Research has the potential to change our understanding of birth differences, change our treatments, and improve outcomes.  Research is ultimately the way we can positively affect all kids born with upper extremity differences.  I feel this is a critically important goal.  It is important for families to understand that research can be done in a way that does affect their child's care in any way as most research is simply observational (we watch and understand how certain treatments affect outcome).  Participating in research offers the hope of a future with increased knowledge of best practices for kids with birth differences of the upper extremity.

There are many factors for families to consider as they pick a team to care for their child.  I hope my brief discussion of a few of these factors is helpful.

Charles A. Goldfarb, MD
My Bio at Washington University