Saturday, December 31, 2016

Surgery for Macrodactyly

Macrodactyly is an uncommon birth condition of the upper extremity.  I have posted several previous times on macrodactyly:

Macrodactyly Post
Macrodactyly Post 2

Macrodactyly means 'large finger' and sometimes is referred to as local gigantism.  My other posts have discussed different facts about the diagnosis including why this may happen but here I would like to discuss three potential surgeries for macrodactyly.

1. Local control of size and growth.  It is not uncommon that this surgery is performed multiple times on a young child.  The idea is to debulk the finger (primarily by removing extra fat and skin) but also potentially closing growth plate early.  The appeal of this surgery is that it is straightforward and seemingly less of a major step.  But there is a real negative- the potential for the need to repeat this surgery multiple times on a growing child.  This is an important consideration which must be considered.

2.  Ray resection.  If there is one large digit in macrodactyly, excision of that digit may be the best option.  This might make sense for a few reasons including the fact that the digit likely does not function well (often stiff) and is a cosmetic concern.  It is typically the middle finger that is large although the thumb and index finger may be involved.  But, when the middle finger is the one that is primarily involved, the functional and appearance concerns can be made notably better with this surgery.  The surgeon must consider whether to:
- only excise the middle finger (often called the ray resection which means removal of the finger and the appropriate metacarpal bone of the hand)
- excise the middle finger and move the index finger into its position.  The benefit of this surgery is that it makes a more normal appearing hand and removes the gap between the index and ring fingers.

Here is a recent surgical case in an adult who had grown frustrated with his large middle finger which did not help him functionally.  
Macrodactyly primarily involving middle finger.

Macrodactyly primarily involving middle finger.
Macrodactyly after ray resection with a nice appearance outcome.
Macrodactyly after ray resection and carpal tunnel release

3. Carpal tunnel release.  Macrodactyly is often associated with an enlarged median nerve and enlarged nerves to the fingers (digital nerves).  In both kids and adults with macrodactyly, this can lead to carpal tunnel syndrome including pain, numbness, and tingling.  A relatively straightforward carpal tunnel release surgery can relieve these symptoms.

Here is another recent macrodactyly case in which the patient was not concerned about the appearance of the hand and felt that function was satisfactory.  The thumb and index finger were most affected.  We therefore only performed a carpal tunnel release for the symptoms of pain and tingling.

Macrodactyly involving the thumb and index finger primarily.

Macrodactyly involving the thumb and index finger primarily.

Charles A. Goldfarb, MD
My Bio at Washington University
My Publication List

Saturday, December 3, 2016

Simple Surgery for Symbrachydactyly

I have posted on several times on symbrachydactyly, with one post HERE.  Each child with symbrachydactyly, and really any birth difference of the upper extremity, is unique. No matter their bony and soft tissue deficit, their family situation and functional needs must also be considered.  So even if two kids look similar, I believe that musculoskeletal appearance is only part of the story- many other issues are considered.

This child has symbrachydactyly with a single digit (monodactyly type).  The thumb tip is flexed and he cannot straighten it.  His other extremity is normal.  Overall, he functions well.  The question that we discussed with the family is whether anything could be done to further improve his function.  Note the small palm which is typical in symbrachydactyly.

Symbrachydactyly with a single digit.

Symbrachydactyly with a single digit- side view.

Symbrachydactyly with a single digit- palm view.

Our team had discussions with the family and observed his function with activities.  Given that the thumb would not extend, together we all decided to position the thumb in extension with a stiffening of the joint (like a fusion but given the bony immaturity, technically not a fusion).  This more extended position should help with activities and will allow the patient to better use the hand for function.

Symbrachydactyly post surgery top view.

Symbrachydactyly post surgery- side view.

The pins will be in place for about one month and then he will use a splint temporary.  We look forward to this straightforward surgery improving function.

Charles A. Goldfarb, MD
My Bio at Washington University
My Publication List