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IC 58: Anyone can do Congenital Hand

Surgery! - A High Yield Refresher Course

of the Most Common Diagnoses

Moderator(s): R. Chris Chadderdon, MD

Faculty: Julie Woodside, MD, Aaron Daluiski, MD, Randip R. Bindra, FRCS, MCh Orth

Session Handouts

Saturday, September 07, 2019

74TH ANNUAL MEETING OF THE ASSH

SEPTEMBER 5 – 7, 2019

LAS VEGAS, NV

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: meetings@assh.org

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SyndactylyPatientconsiderationsandsurgicaltechnique

JulieWoodside,MDOrthoCarolina

ASSH2019

Syndactyly

•  Why?–  Failureofapoptosisinterdigitalskin

•  (6th–8thwkgestation)–  Constrictionbands

•  WhichDigits– Middle-ring(50%)–  Ring-small(30%)–  Index-middle(15%)–  1stweb-leastcommon(5%)**

•  Increasedinsyndromicsyndactyly

Syndactyly•  Types– CompletevsIncomplete– SimplevsComplex– Complicated

•  Syndromicvspuresyndactyly

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Family/Patients

•  10%familial– Autosomaldominant

•  Complexsyndactyly– MorecommonwithAperts,DownSyndrome,polydactyly

Poland’sSyndrome

•  Sporadic•  Absentpectoralis

•  Syndactyly

•  Brachydactyly

•  Hypoplasticarm

Woodside,JulieC.,andTerryR.Light.“Symbrachydactyly—Diagnosis,Function,andTreatment.”TheJournalofHandSurgery,vol.41,no.1,2016,pp.135–143.,doi:10.1016/j.jhsa.2015.06.114.

Apert’sAcrocephalosyndactyly

•  Bilateralcomplex,completesyndactyly•  Multi-digitalbonymass•  Oftensinglecommonnail

•  Stronglydominantgene

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Constrictionband

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Constrictionband

Examination

•  Prenatal,postnatal,familialhistory•  Besidesthehand,thecranium,face,torso,andlowerextremitiesàforanomalies

•  Numberofdigitspresent•  Levelofwebinvolvement•  Lengthofthefinger•  Appearanceofthefingernails•  Bonyanatomy

Syndactyly

•  Whyshouldweseparate– Abduction/Adductionofthefingers– Grip– Dexterity

•  Surgicalconsiderations– Hypoplasticdigits,willnotdowellontheirown–  Jointstiffness,contracture– Stageproceduresasneeded

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SurgicalPrinciples

•  Fascialbands– Causetethering– Especiallylongerdigit

•  Digitdeformities– Flexion/rotation– Usuallydeformityremainsafterseparation

Syndactyly

•  When– Lengthdiscrepancy•  Borderdigitsearlier

–  Afewmonths,withinthefirstyear

•  Thumb–  Earliertoallowprehension–  Avoidrotational/flexioncontractureofindex

– Otherwisewaituntil18months•  Decreasedwebcreep

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Techniques

•  GeneralAnesthesia•  PediatricTourniquet•  LoupeMagnification•  Consider– Whichfingersfirst– WhereamItakingskingraftoramIusinggraftlessorskinsubstitutetechniques

– Flapdesign

Grafts

•  Autograft– Fullthickness•  Groin,Abdomen,Antecubital

– Characteristics•  Hairless,colormatch

•  SkinSubstitute– HyaluronicAcidScaffold

•  Graftless

FlapDesign

•  Commissure***– Dorsalskin-thinner/mobilization,recreatesdorsal-palmarslope

– Flapbasedatlevelofmetacarpalheadsà2/3lengthoftheproximalphalanx,width>7mmtopreventwebcreep

•  Digitflaps– Midlineofonetomidlineoftheother– Palmaroppositeofdorsalflaps

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SurgicalTechnique•  Inflatetourniquet•  Raiseflaps

–  Dorsalwebfirst-preserveveinsandparatenon–  De-fat

•  Improvesappearance,decreaseflattension–  Workdistaltoproximal

•  IDdigitalnerveandartery–  Easierfromdorsalside–  Nerve-ifdistalbifurcationcansplitmoreproximal–  Artery-distalbifurcation?

•  Isonefingerhavingmoresurgery•  Smallerartery•  Microvesselclampandreleasetourniquet

SurgicalTechnique•  Sutureflaps–  Smallabsorbablesuture

•  5-0chromic–  Suturewebfirstthenflaps–  Incisetraversebandsandnatatoryligamentstoallowforcommissureplacement

•  Templateforgrafts– Hairless,goodskinmatcharea

•  RaiseFTSGanddefat•  Suturewithtension–  Cancutdrainageholetopreventhematoma

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Dressings

•  Nonstick•  Compressionongrafts– Soakedcottonballs

•  Hardtogetoff(kidsaremagic)– Abovetheelbowcastorplaster

•  Remove2-4weeks•  Startbathingandeitheruseband-aidsorwebsplints

PostoperativeCare

•  Rarelytherapy•  Scarmassage•  VitaminEorsiliconeforscars

Graftless-NietalJHS2015

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References•  Eaton,CharlesJames,andGrahamDuncanLister.“Syndactyly.”

HandClinics,vol.6,no.4,Nov.1990,pp.555–575.•  Kozin,ScottH.“Syndactyly.”JournaloftheAmericanSocietyfor

SurgeryoftheHand,vol.1,no.1,2001,pp.1–13.,doi:10.1053/jssh.2001.21778.

•  Marumo,Eiji,etal.“AnOperationForSyndactyly,AndItsResults.”PlasticandReconstructiveSurgery,vol.58,no.5,1976,pp.561–567.,doi:10.1097/00006534-197611000-00005.

•  Ni,Feng,etal.“TheUseofanHourglassDorsalAdvancementFlapWithoutSkinGraftforCongenitalSyndactyly.”TheJournalofHandSurgery,vol.40,no.9,2015,doi:10.1016/j.jhsa.2015.04.031.

•  Wang,Sisheng,etal.“DorsalHexagonLocalFlapWithoutSkinGraftforWebReconstructionofCongenitalSyndactyly.”TheJournalofHandSurgery,2019,doi:10.1016/j.jhsa.2019.03.009.

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Pediatric Trigger Finger, Clasped thumb, and mild Thumb Hypoplasia – how to

treat, and when to consider referring

Randy Bindra, MD FRACS

Gold Coast, Australia

Pediatric trigger finger

• 2% of all upper extremity anomalies

• Different from adults- presents in locked position

• 10 times more common in thumb

• 4.4/10,000 live births

• Acquired condition, rare at birth and usually presents at 2 years of age

Pathoanatomy

• Nodule in FPL- Nodule of Notta

• Anatomical variation in FDS chiasma

Exam:

• Normal sized thumb, normal flexion/extension creases

• Contracture at IP not MP joint

• Nodule at A1 pulley in thumb and A1/A3 pulley in trigger fingers

Treatment:

• Spontaneous recovery 30% age <6 months, 12% if > 30 months

• Observe for 6 months

• Surgical release- best results if surgery <30 months age

• Thumb: Release A1 pulley

• Finger: Release A1, A3 pulley and excise 1 slip of FDS

Complications:

• Infection

• Digital nerve injury- radial digital nerve

• Residual IP contracture is rare and usually mild

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Clasped thumb

• Progressive flexion and adduction thumb deformity presenting with heterogenous congenital abnormalities

• Deficient extensor mechanism

• Variable presentation

Classification:

• Type I: Flexible type - thumb can be passively extended with no other abnormality.

• Type II: thumb cannot be passively abducted or extended, skin contracture, collateral ligament or thenar muscle abnormalities

• Type III: occurs together with arthrogryposis.

Treatment

• Type I: Passive stretching by parents/therapist until old enough for splinting

• Splint to correct wrist and thumb simultaneously

• Forearm-based orthotic with MCP and IP joints in neutral and CMC in abduction

• Full-time wear for 3-6 months and night only for 3 months

• Can regain active MP extension

• Best outcome in 2 years old child, but improvement up to age 5 Surgery

• if no improvement with splinting

• Goal- to bring thumb out of the way

• Correct first web contracture- 4 flap z plasty or Index flap

• MP passively correctable: Tendon transfer to extend MP= EIP / FDS/ Brachioradialis

• MP cannot be passively corrected- chondrodesis

GOALS OF THUMB RECONSTRUCTION

• Stable, opposable post- directed 90 degrees from palm and out of palm

• Correct first web contracture

• Mobile and stable CMC

• Stable MP

• Active abduction

Mild thumb hypoplasia

• Part of radial deficiency even with normal forearm

• Exclude associated anomalies: VACTERL association, thrombocytopenia-absent radius (TAR) syndrome, Holt-Oram syndrome, CHARGE syndrome, and Fanconi anemia (FA)

• Mild hypoplasia is not obvious and usually detected late

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Clinical assessment:

• Careful physical examination and x-rays

• Assess: Length, girth, motion, and stability

• The normal thumb length: just proximal to PIP joint of the index finger.

• X-ray length: 70 % of the length of index finger proximal phalanx

• The thumb girth and nail width are 133 % and 105 % of index finger

• Document overall thumb motion, CMC motion, MP and IP motion and stability of each of these joints

• Present and absent intrinsic and extrinsic muscles Classification- guides treatment - Blauth Type I hypoplasia

• minor generalized hypoplasia, usually affecting the thenar muscles

• treat only if functional deficit

• Tendon transfer to augment opposition Type II

• absence of thenar muscles innervated by the recurrent branch

• of the median nerve (abductor pollicis brevis, opponens pollicis, and superficial head of the flexor pollicis brevis)

• ulnar innervated deep head of the flexor pollicis brevis is usually present and provides MCP joint flexion

• Unstable MP joint with global laxity or UCL laxity alone

• Tight first web space Type III

• Same as Type II + extrinsic muscle and tendon deficiencies

• hypoplasia of the extrinsic extensors (extensor pollicis longus and extensor pollicis brevis) or flexors (flexor pollicis longus)

• Subdivided into IIIA and IIIB

• IIIA: stable CMC joint- reconstruction

• IIIB: Unstable CMC joint- ablation and pollicization

• Radiographs are unreliable because trapezium ossifies age 6

• Metacarpal base tapers to a point rather than having the typical metaphyseal flare

• MR can be helpful to evaluate the integrity of the cartilaginous metacarpal base and the trapezium

• Repeat examinations often required to detect a thumb unworthy of reconstruction

• If the child completely bypasses thumb, the index-long web space widens, then thumb reconstruction is contraindicated, and index pollicization preferred.

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Surgery:

• Webspace deepening- 4 flap Z plasty

• Augment weak intrinsics: FDS transfer/EIp transfer or Huber opponensplasty

• Unstable MP: Global: chondrodesis, UCL- use remainder of FDS transfer to create UCL

REFERENCES

Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from stockholm, sweden. J Hand Surg Am. 2010;35(11):1742–1754. Ghani HA, El-Naggar A, Hegazy M, et al. Characteristics of patients with congenital clasped thumb: a prospective study of 40 patients with the results of treatment. J Child Orthop. 2007;1:313–322. Goldfarb CA, Gee AO, Heinze LK, Manske PR. Normative values for thumb length, girth, and width in the pediatric population. J Hand Surg Am. 2005;30:1004–8. Lin SC, Huang TH, Hsu HY, Lin CJ, & Chiu HY et al. A simple splinting method for correction of supple congenital clasped thumbs in infants. J Hand Surg. (Britishand European Volume). 1999;24(5):612–4. Manske PR, McCarroll HR, J.-R. Reconstruction of the congenitally deficient thumb. Hand Clin. 1 992 Feb; 8(1): 177-96. Medina J, Lorea P, Marcos A, et al. Flexion deformities of the thumb: clasped thumb and trigger thumb. Chir Main. 2008;27: 35–39. TsuyuguchiY, Masada K, Kawabata H, Kawaii H, Onon K,et al. Congenital clasp Thumb: A review of forty-three cases. J Hand Surg. 1985;10(5), 613–618. Kozin SH, Ezaki M. Flexor digitorum superficialis opponensplasty with ulnar collateral ligament reconstruction for thumb deficiency. Tech Hand Up Extrem Surg.2010b;14(1):46–50.

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