Monday, January 1, 2018

Macrodactyly, Syndactyly, and Keloid

Macrodactyly is very rare, even at centers such as ours that evaluate and treat many kids with birth anomalies of the upper extremity.  Macrodactyly is a difficult condition to research as there is so much variability in presentation- fingers may be dramatically large, moderately large, or only slightly larger than the expected finger size.   Treatment varies depending on the age of the child and the severity of the macrodactyly.  This manuscript nicely summarizes treatment strategies.

Excellent review on macrodactyly treatment

Keloid is the prominent thickening of scar after trauma or a surgical incision.  It is more often seen in dark skinned patients and is common on the torso.  If a patient demonstrates keloid formation at the site of one scar/ surgery, the patient is more likely to demonstrate keloid formation at the next surgery site.  Treatment of macrodactyly carries a risk of keloid formation.  Syndactyly reconstruction in patients with enlarged digits likewise carries a risk of keloid formation.  The medication Methotrexate has been suggested as a means to treat keloid formation, typically at the time of a revision surgery.  Two manuscripts have reviewed this issue and the use of methotrexate:

Here are two examples of keloid formation after treatment of syndactyly patients.  In the first, there was a clear, dramatic macrodactyly of the middle finger with syndactyly to an unaffected ring finger.  The family requested reconstruction of the syndactyly.  Scarring is prominent.

Macrodactyly and syndactyly

Thickened scars on both fingers after syndactyly reconstruction and debulking of macrodactyly.

Thickened scars on both fingers after syndactyly reconstruction and debulking of macrodactyly.

In the second case, the digit enlargement is much more subtle.  But there is likely a degree of digit enlargement associated with prominent scarring after syndactyly reconstruction.

Syndactyly preoperative.
Prominent scarring after syndactyly reconstruction

A more detailed view of scarring after syndactyly reconstruction.
Revision treatment of both of these patients is an option.  At the time of revision surgery, methotrexate would be considered and a lengthy discussion with the family will be important regarding the risks and benefits of this medication.

Charles A. Goldfarb, MD
My Bio at Washington University

Travel and News

Happy 2018!  I hope it is a great one for you and your family.

Well, I already have one resolution for 2018- blog more consistently.  I am not meeting my goals and hope to do better in this new year.

A few things to share.

I had a wonderful trip to Japan as guest speaker for the Japanese Pediatric Orthopedic Society.  I spent 3 days in Tokyo at the meeting and exploring the city.  My hosts, pictured below, were wonderful and I thoroughly enjoyed the exchange of knowledge and culture.  I had the privilege of speaking on arthrogryposis.  I shared our philosophies for the care of the arthrogrypotic child including our assessment and treatment strategies.

My host and the President of the JPOA, Dr Takayama and his amazing wife.
Catching up with old friends, Hide and Emiko, who I see almost each year at our study group, CHASG.

An absolutely amazing dinner hosted by Professor Takayama!  Many courses of delicious food and even better conversation.  

There have been a few news stories that caught my eye in the later half of 2017.  Today, a major college football bowl day, is a good time to share one such story.  Troy Fumagalli is a talented tight end for the University of Wisconsin.  He is likely to be drafted as a high pick in the upcoming NFL Draft and he is reported to have "great hands".  He is also an amniotic constriction band patient who is missing the index finger on his left hand!  His early life story will sounds familiar to many of you.  His confidence and determination should inspire all of us.
Fumagalli link
Second Fumagalli link

One of the reasons that I love what I do is the interactions I have with amazing children with birth differences of the upper extremity and their families.  Their positivity and hope sends a strong message for me every day.

I am very much looking forward to the new year.  As with each preceding year, it will bring many opportunities to make a positive impact.  Exciting travels await as well!  Stay tuned!

Charles A. Goldfarb, MD
My Bio at Washington University