Saturday, November 24, 2018

Severe Radial Deficiency, Before and After

I have posted numerous times on radial longitudinal deficiency.  The birth anomaly is common in my practice and I have been fortunate to meet many great kids and families with radial deficiency.  A few posts can be seen HERE.

Early in my career, as influenced by my training, most patients with radial deficiency were treated with a centralization procedure.  This procedure can be effective in straightening the deviated wrist but comes with a risk of the complication of shortening of an already shortened forearm (due to pressure on the growth plate of the ulna bone).  Due to this concern, there is now less consensus in treatment and, at least in our practice, each child is considered individually and may be treated with a number of techniques including: observation, centralization, centralization with precentralization distraction, release with bilobed flap, and fusion.  These decisions are affected by severity of the radial deficiency, the function of the fingers, the presence of a thumb, whether both arms are affected, amongst other factors.

I wanted to share somewhat early results in patient with severe radial deficiency, affected bilaterally.  She had limited use of her hands due to positioning and we elected to proceed with distraction and then centralization.  We used a ringed fixator (vs a uniplanar fixator) as the ringer fixator has so much more 'power' to correct and to do so in multiple planes.  Then we centralized the wrist.  The next step will be to create a thumb.  Finally, we will address the other side.

Radial deficiency on the right.  Note the absent radius and marked curvature of the ulna together with the deviated wrist.

Radial deficiency on the left.  Note the absent radius and marked curvature of the ulna together with the deviated wrist.

Clinical pictures of radial deficiency, severe.  Note the absent thumbs on both sides and markedly deviated wrist.

The patient was treated with an external fixator as depicted here.
External fixator in place during distraction before centralization

After centralization, radial deficiency wrist with temporary pin in place.  Note the straight forearm/ wrist.
After centralization, radial deficiency wrist with temporary pin in place. If you look at the middle aspect of the ulna, there is evidence of healing bone where we cut and realigned the ulna.

The patient is now several months after centralization.  Note the difference between the two sides.
The right side with radial deficiency is untreated, the left has undergone centralization.

The right side with radial deficiency is untreated, the left has undergone centralization.

There is much left to offer this child and her family but we are all pleased with the initial step.  Radial deficiency remains a tough challenge but there are good options to improve function and appearance.

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








Tuesday, November 20, 2018

Thumb Web Space in Amniotic Band

Amniotic Constriction Band is a common condition which affects each child differently.  It can lead to syndactyly (joining of fingers), amputations, or deep bands which limit function.  It often affects more than one extremity (ie, hands and feet) making efforts to maximize function really important.  I have posted many times on amniotic band- those posts can be found HERE. 

The thumb web space (also know as thumb- index web space or first web space) is vital for function.  A wide, deep space allows large object grasp.  For example, we often hold a soda can in the first web space whereas we cannot hold it between the fingers. 

Normal large object grasp

If we do not have a nice thumb web space, we often need to use two hands to grab larger objects.  The web space is also limited if the fingers are short- this makes the web space more shallow.


In patients with a tight first web space, surgery often makes sense to maximize the depth and width of this space.  This improves function in a very clear way- making it a very satisfying surgery for patient, family, and surgeon! This can happen in various conditions of the child's hand including arthrogryposis, cerebral palsy, hand burns, small thumbs, and amniotic constriction band.  There are various ways to address this surgically but the basic idea is to deepen the space and thus widen the gap between the thumb and index finger.  This usually requires a flap of skin to be rotated and sometimes a skin graft.

These pictures are of a child with amniotic constriction band.  Note the shortened fingers and narrow first web space.

Amniotic constriction band with tight first web space and short digits

Amniotic constriction band with tight first web space and short digits



After discussions with the family on the option of surgery to deepen the web, the patient was taken to the operating room for rotation flap from the top of the hand to deepen the space.  It has been dramatically helpful even at 3 months after surgery.  He is using the hand more and can more easily grab objects.  Note the flap and large space.

Amniotic constriction band with tight first web space with flap deepening.


Amniotic constriction band with tight first web space with flap deepening.


This patient will be closely watched over the next few years.  The other option we have to increase function is to lengthen the thumb and potentially the index finger.  This serves to deepen the web also.  I have previously written about lengthening HERE.

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