Constriction bands and limb reduction defects in two newborns with fetal ultrasound evidence for vascular disruption

Neuromuscular Dysfunction in Clubfeet Associated With Constriction Band Syndrome

INTRODUCTION

Constriction band syndrome (CBS) is a congenital limb anomaly frequently associated with clubfoot. Clubfeet in CBS patients may be associated with peroneal nerve dysfunction in the involved lower extremity; however, the etiology of this neuromuscular dysfunction is not clear. We sought to characterize the distribution of constriction bands on lower extremities with clubfoot and determine if neuromuscular deficit (NMD), defined here as having absent ankle dorsiflexion, was associated with ipsilateral proximal bands. Our secondary aim was to compare the treatment and outcomes of clubfeet with NMD to those without NMD.

METHODS

We performed a retrospective review of all patients with CBS and clubfoot presenting to our facility between January 1, 1998 and December 31, 2018. Treatment with the Ponseti method, at least 1 year of follow-up at this facility, and a detailed physical exam describing lower extremity neuromuscular function and the presence and location of constriction bands were required for inclusion in the study cohort.

RESULTS

Twenty children with 26 clubfeet were included. Forty-six percent (12/26) of the clubfeet had NMD. Clubfeet with and without NMD had ipsilateral thigh or leg constriction bands at similar rates [42% (5/12) vs. 43% (6/14), P =0.106], and the majority (7/12) of clubfeet with NMD did not have an ipsilateral thigh or leg band. While children with an NMD clubfoot tended toward more casts, relapses, and surgical procedures, these differences did not reach statistical significance. The use of a daytime AFO beyond age four was higher in the NMD clubfeet [58% (7/12) vs. 14% (2/14), P =0.04].

CONCLUSION

Clubfeet with neuromuscular deficits may occur in the absence of proximal ipsilateral constriction bands, suggesting they may be caused by mechanisms other than direct damage from visible constriction bands to underlying nerves. They can also coexist with arthrogrypotic conditions. Clubfeet with an NMD tended toward more casts, relapses, and surgeries than those without NMD, but these differences did not reach statistical significance. These patients often elect long-term use of a daytime AFO.

Terminal transverse limb defects with "nubbins"

BACKGROUND

A terminal transverse limb defect with absence of the forearm and hand or just the hand is an uncommon limb deformity in an otherwise healthy newborn. Most of the affected infants also have tiny digit-like nubbins on the stump of the affected limb, a finding that could represent an attempt at regeneration following vascular obstruction in early limb development.

METHODS

One hundred ninety-four newborn infants with a limb deficiency were identified among 289,365 births in an active malformations surveillance program at Brigham and Women's Hospital in Boston, MA from 1972 to 2012. Twenty-eight infants with terminal transverse limb defects were identified.

RESULTS

Twenty-four had tiny digit-like nubbins (0.5 cm in length) on the stump at one of three levels: the proximal portion of the forearm, the wrist or the forefoot. The examination of the placentas of eight affected infants showed no evidence of amnion rupture. Three of these 28 infants had associate chromosome abnormalities: trisomy 21, chromosome 11q deletion and the deletion of 22q11.2.

CONCLUSION

Terminal transverse limb defects reflect failure of early limb development. Awareness of this phenotype at birth, or when identified by ultrasound screening, can provide more accurate counseling than occurs with the more common misdiagnosis of "amniotic band syndrome."

Single-Stage Resection of Type II Constriction Rings in Limbs on the Basis of Histologic and Magnetic Resonance Imaging Observations: A Retrospective Study of 21 Consecutive Patients

BACKGROUND

The purpose of this study was to determine the feasibility of single-stage resection for type II congenital constriction rings by means of histologic examination of resected specimens and imaging examination of affected extremities, and to evaluate the appearance and function of the extremities after single-stage surgery.

METHODS

The features of the skin on the constriction rings and the subcutaneous tissues were identified through continuous sectioning, hematoxylin and eosin staining, and immunohistologic staining of specimens of type II constriction rings obtained by means of surgery. The relationship between the constriction rings and the deep main blood vessels was evaluated using magnetic resonance imaging. Single-stage resection of the constriction band, reduction of the fascial flap, and triangular flap-plasty were performed for 21 patients. The appearance, lymphedema, and movement of the extremities were compared before and after the operation.

RESULTS

Type II constriction rings in the extremities had normal full-layer skin structures. Collagen was found deposited densely at the base of the grooves, but the normal subcutaneous tissue space remained, and the vital nerves and blood vessels were unaffected. Complete resection of the constriction rings was achieved in all 21 patients, and lymphedema subsided 2 months after the operation. No episode of recurrence was found, and limb function was not affected at 26-month follow-up.

CONCLUSIONS

Type II congenital constriction rings in limbs possess normal subcutaneous tissue spaces. A single-stage operation, which includes complete resection of the rings, fascial flap reduction, and triangular flap-plasty, could achieve a satisfactory appearance and good function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Huge Fetal Sacrococcygeal Teratoma with a Vascular Disruption Sequence

Fetal sacrococcygeal teratomas (SCTs) occur in one to two per 20 000 pregnancies that cause high-output cardiac failure. High-output cardiac failure leads to polyhydramnios, hydrops, intrauterine fetal demise and preterm birth. Vascular disruption defects refer to those involving the interruption or destruction of some part of the fetal vasculature. We present a rare case of huge SCT causing multiple fetal disruption defects like cleft lip and palate and limb anomalies besides hydrops.

[Complex of amniotic deformities, adhesions, mutilations: Endless debate]

Amniotic deformities, adhesions, mutilations (ADAM) complex is a broad heterogeneous spectrum of congenital anomalies. ADAM complex is characterized by constriction rings, amputation of fingers or limbs and the presence of the amniotic band. However, it may also involve craniofacial disruptions, body wall defects and internal organ abnormalities. The aim of this review is to present the results found in regard to ADAM complex from its historical background, clinical manifestations, epidemiology, etc. In particular, our attention was focused on demonstrating the varying etiopathogenesis theories of ADAM complex and their contradictions. The study was conducted using the databases of PubMed, EBSCO host, Ovid, SpringerLink, Scopus, nature.com, JAMA and ScienceDirect with the following keywords for the search: "amniotic band syndrome", "amniotic band sequence", "Streeter dysplasia", "ADAM complex". In this study we used 22 full-text articles. Patients with ADAM complex require a complete pre- and postnatal evaluation to integrate the diagnosis and to decide on timely treatment. It is important for clinicians and surgeons to possess knowledge of this entity. Further research is necessary to establish a nosological basis.

Congenital band syndrome with pseudarthrosis of the radius and ulna and impending vascular compromise: a case report

BACKGROUND

Although amniotic band syndrome is relatively rare, reports of pseudarthrosis in conjunction with amniotic band syndrome are even rarer, as are reports of impending vascular compromise in the neonatal period. Careful serial examinations and timely surgical intervention can successfully avoid the catastrophic event of limb loss. We report on a case of upper extremity amniotic band syndrome with pseudarthrosis of the radius and ulna that was complicated by vascular compromise in a neonate.

METHODS

Chart and radiographic data for this single case were reviewed and reported retrospectively.

RESULTS

A 1-day-old neonate born at 28 3/7 weeks of gestational age was transferred to our institution for increased swelling to the forearm distal to a congenital band associated with an underlying radius and ulna pseudarthrosis. Although the forearm and hand were soft and viable initially, severe edema and swelling occurred after fluid resuscitation, and on the fourth day of life, the patient underwent simple band releases at bedside with 2 longitudinal incisions over the radius and ulna. Circulation was restored, and the pseudarthrosis healed with no further surgical intervention. Successful delayed reconstruction of the band with Z-plasties was performed when the baby was 7 months of age.

CONCLUSIONS

In this case, a relatively simple, straightforward procedure that is familiar to most pediatric orthopaedists salvaged a compromised neonatal limb with amniotic band syndrome and allowed healing of a pseudarthrosis, allowing more complex reconstruction to be performed in a delayed, elective manner. Careful observation is necessary in the neonatal period of the baby with a severe band; a viable, well-perfused, compressible extremity may still be at risk.

Preventing misdiagnosis in amniotic band sequence: a case report

Amniotic band sequence (ABS) is an uncommon and heterogeneous congenital disorder caused by entrapment of fetal parts by fibrous amniotic bands, causing distinctive structural abnormalities involving limbs, trunk, and craniofacial regions. The incidence ranges between 1/1200 and 1/15,000 live births, but is higher in stillbirths and previable fetuses. The intrinsic theory attributes the constriction band syndrome as an inherent development defect of embryogenesis while the extrinsic theory proposes that an early amnion rupture is responsible for the adherent bands. It is also suggested that amputations and constriction rings might be due to vascular disturbances. Anomalies resulting from amniotic bands are quite variable and sometimes may simulate chromosomal abnormalities. The authors report a case of a 36-week-gestation male neonate who lived for 29 hours after a vaginal delivery with an Apgar score of 8/9/9. The mother was primipara, and the prenatal was uneventful except for two episodes of urinary tract infections. The newborn examination depicted multiple anomalies characterized by exencephaly, bilateral labial cleft with distorted nostrils and palate cleft. There was also facial skin tag band, exophthalmos with hypoplasia of the eyelids. The limbs showed distal amputation of the fingers in both hands and feet, oligodactyly associated with syndactyly in the left foot, ring constriction in the right leg, the presence of right hyperextension, and clubfoot. The upper limbs showed length discrepancies. Karyotype analysis was normal at 46 XY. The authors conclude that the recognition of the malformations secondary to ABS is important in genetic counseling to prevent misdiagnosis between chromosomal and secondary disruption disorders.

Congenital vascular anomalies in amniotic band syndrome of the limbs

INTRODUCTION

Bone abnormalities and nerve compression are sparsely reported features of amniotic band syndrome. No studies of the vascular architecture of limbs affected by this syndrome have been published.

MATERIAL AND METHODS

Patients with amniotic band syndrome affecting the limbs were evaluated in the period between 1997 and 2007. The arterial blood supply was studied using magnetic resonance angiography or computed tomographic angiography. The subjects comprised 8 patients with bilateral and 2 with unilateral limb involvement. The patients' ages ranged from 2 months to 8 years. The male-to-female ratio was 4:6. A total of 20 limbs was investigated, comprising 18 lower limbs and 2 upper limbs. The amniotic bands were divided into superficial or deep.

RESULTS

The patients were divided into 4 groups: group 1, thigh bands; group 2, below-knee amputations; group 3, leg bands; and group 4, upper limb bands. A single patient in group 1 with a deep band had a persistent sciatic artery. In group 2, three limbs demonstrated attenuated segments in the superficial femoral artery and/or abnormalities arising at the popliteal artery division. In group 3 (14 legs), 7 with deep bands showed some anomaly either in the popliteal artery division or its branches or both. In the other 7, and in group 4, all with superficial bands, no vascular abnormalities were seen except in one.

CONCLUSION

Our findings show that amniotic band syndrome is definitely associated with vascular abnormalities and the depth of the band is an important contributory factor.

Maternal nutrient intake and risks for transverse and longitudinal limb deficiencies: data from the National Birth Defects Prevention Study, 1997-2003

BACKGROUND

The association between periconceptional intake of supplements containing folic acid with specific subtypes of limb deficiencies has been inconsistent. The objective was to investigate whether intake of nutrients involved in one-carbon metabolism (folate, vitamin B(6), vitamin B(12), riboflavin, choline, betaine, zinc, and methionine) through diet alone or in combination with a supplement containing folic acid influenced the risk for transverse limb deficiency (TLD) and longitudinal limb deficiency (LLD).

METHODS

We analyzed 1997-2003 data from the National Birth Defects Prevention Study and included 324 case infants with TLD, 158 case infants with LLD, and 4982 nonmalformed control infants. A food frequency questionnaire was used to estimate nutrient intakes. Use of supplements containing folic acid 1 month before through 2 months after conception was recorded.

RESULTS

Use of a supplement containing folic acid was not associated with LLD or TLD. For nonsupplement users, within (1) the lowest quartile of dietary folate intake or vitamin B(6) intake, adjusted odds ratios (aORs) for LLD were, respectively, 3.86 (95% confidence interval [CI]: 1.08-13.78) and 4.36 (95% CI: 0.93-20.48); and (2) the lowest quartile for riboflavin intake, the aOR for TLD was 2.94 (95% CI: 1.04-8.32). For supplement users within the lowest quartile of folate intake or riboflavin intake, the aORs for TLD were, respectively, 1.52 (95% CI: 0.91-2.54) and 1.54 (95% CI: 1.00-2.37).

CONCLUSIONS

TLD and LLD were not associated with supplement use, but TLD was associated with low intakes of riboflavin from diet.

Amniotic band syndrome with persistent sciatic artery: a case report

Amniotic band syndrome (ABS) has an incidence of 1/15,000. Deformities vary from rare but bizarre craniofacial defects or truncal defects to the commoner limb defects. The pathogenesis of ABS remains controversial. The following is a case of a 3-month-old infant with amniotic band syndrome with the typical limb reduction defects, a constriction band on the thigh associated with a persistent sciatic artery and bifurcation of the femur and the duplication of the knee and tibia on the contra lateral side. The anatomy of the persistent sciatic artery is demonstrated in magnetic resonance angiography and digital subtraction angiography. The vascular anomaly was unilateral. The patient underwent surgical correction of the constriction band by excision and multiple Z plasty. This case is the first description of the coexistence of ABS and persistent sciatic artery. Persistent sciatic artery has angiographic incidence of 0.05%. Is this purely a coincidence? Or perhaps their coexistence may serve to further the understanding of the mechanism of ABS.

Obstetric US: watch the fetal hands

Hand anomalies are difficult to diagnose and are often overlooked during prenatal ultrasonography (US). The spectrum of malformations varies from subtle finger deformities to the complete amputation of limbs. Malformations of the hand can be classified, according to the predominant anomaly, among the following categories: alignment abnormalities (clenched hand, camptodactyly, clinodactyly, hypokinesia, clubhand, phocomelia), thumb anomalies, abnormal size (macrodactyly, trident hand), abnormal echogenicity (abnormal calcifications), abnormal number (polydactyly, syndactyly, ectrodactyly), and constriction band sequence. A fetal hand anomaly has important diagnostic and prognostic implications as well as functional consequences. Malformation may be isolated but often is associated with a syndrome or karyotype anomaly. Classification and characterization of the anomaly help to narrow the differential diagnosis: Some malformations (clenched hand, hitchhiker thumb) are highly suggestive of a specific diagnosis. The detection of a fetal hand malformation warrants a complete work-up, including complete fetal and cardiac US examinations, as well as genetic counseling to determine whether familial inquiry and karyotype analysis are necessary.

A case of prenatal diagnosis of fetal hydantoin syndrome by ultrasound

Fetal hydantoin syndrome (FHS) is a set of disruptions occasionally present in fetuses exposed in utero to phenytoin or other anticonvulsants. Administration of phenytoin in early pregnancy may impair proper psychomotor performance expected for children's development. Several combined phenotypic markers delineate the syndrome, but the presence of single clinical signs is more common. There is controversy about the etiology of FHS. Associated disruptions may be related to a deficiency in a detoxifying enzyme (epoxide hydrolase), vascular problems, and/or factors not yet known. Genetic causes are believed to influence susceptibility to the drug. This text reports an unusual pattern of malformations detected in an ultrasound scan (gastroschisis, sacral meningomyelocele, and absence of the right lower limb) and in the anatomopathological study (left-side gastroschisis, sacral meningomyelocele, scoliosis, left clubfoot, absence of the right lower limb, and pectus carinatum) of a fetus whose mother took phenytoin. These defects may have been provoked by exposure to the drug during embryogenesis. In view of similar malformations observed in cases of prenatal exposure to cocaine, a recognized vasoconstrictor, it is suggested that vascular disruptions of hemodynamic origin constituted the event leading to some of the anomalies caused in the developing embryo. A complication of the chorionic villus sampling procedure, used for cytogenetic analysis, is another possibility.

Limb reduction defects in endothelial nitric oxide synthase-deficient mice

Nitric oxide synthases are a family of enzymes capable of converting L-arginine to L-citrulline with the subsequent release of nitric oxide (NO). NO has been shown to have multiple biologic effects depending on the isoform responsible for its production and its tissue of origin. Murine endothelial nitric oxide synthase (eNOS) is encoded by Nos3, located on mouse chromosome 5. NO produced from this isoform causes vascular smooth muscle relaxation. Other investigators have shown that the administration of nonspecific inhibitors of nitric oxide synthases to pregnant rats induces limb reduction defects. However, mice deficient in Nos3 have not previously been noted to show such abnormalities. To explore the importance of eNOS during development, we produced mice deficient in eNOS using embryonic stem cell technology. Limb reduction defects were seen in approximately 10% of the null animals. We also observed increased neonatal loss of homozygous deficient pups. One functional copy of Nos3 eliminates the risk of limb defects observed in our mouse strain. These findings have implications for understanding genetic predisposition to sporadic limb reduction defects in humans.

Prenatal exposure to disulfiram implicated in the cause of malformations in discordant monozygotic twins

Female monozygotic (MZ) twins were discordant for congenital structural anomalies: Twin A had a reduction defect of the right forearm; Twin B had a cleft palate. Both infants were small for gestational age. Specific prenatal exposures were identified at different times in the first trimester of pregnancy: crack cocaine, marijuana, disulfiram, heavy ethanol exposure, and cigarettes. The mother's hospitalization in a drug abuse program and incarceration allowed for identification of exposure timing. The cleft palate could have been related to either disulfiram or alcohol exposure; the limb abnormality most likely corresponded to the timing of disulfiram exposure. Discordance of anomalies in these twins may reflect differences in developmental timing, differences in susceptibility to one or more teratogens, or random events occurring within very complex developmental programs, with the thresholds for malformation affected by one or multiple teratogenic compounds.

Atypical aortic coarctation and innominate artery stenosis associated with clubfoot and lower leg ischemia in an infant

We report findings in a male infant born with talipes equinovarus and ischemic necrosis of the left lower leg and foot associated with atypical coarctation of the ascending aorta and stenosis and hypoplasia of the proximal innominate artery. We hypothesize that a vasculopathy of unknown etiology occurred in utero that resulted in ascending aortic arch coarctation and innominate artery stenosis. The presence of a thrombus in the coarcted segment suggests that one or more emboli could have been responsible for vascular compromise and subsequent clubfoot deformity and lower leg ischemia. Alternatively, a vasculopathy similar to that hypothesized as occurring in the aorta might also have occurred in the left anterior tibial artery, causing structural deformity and soft tissue ischemia of the left lower leg and foot. We believe that this is the first report of this association of findings.

Congenital abnormalities associated with limb deficiency defects: a population study based on cases from the Hungarian Congenital Malformation Registry (1975-1984)

Limb deficiency defects (LD) occurring among 1,575,904 births in Hungary during 1975-1984 were reviewed. The overall birth prevalence of LD was 1 in 1,816. This paper discusses the nature and distribution of the limb and other defects in the 275 (32%) children who had structural malformations in other systems. Two main forms of classification were used: morphologic and causal. Additional malformations were most commonly seen in infants with amelia, rudimentary limb (RL), radial/tibial (RT), intercalary or central axis (CA) LD and rarely in those with terminal transverse (TT) or ulnar/fibular (UF) defects. Upper limbs (81%) were involved significantly more often than lower limbs (42%) and there were more right-sided defects (83% vs. 71%) due to an excess of right arm involvement especially with radial ray and split hand anomalies. Single limb involvement was relatively common with amelia (88%), UF (82%), RT (50%), and TT (50%) defects. With other LD, multimelic involvement was more characteristic. This was usually symmetric with intercalary and RL defects but asymmetric with CA anomalies and digital deficiencies (DD). From a causal perspective, 17% of cases had genetic disorders, 52% had recognized associations, anomalies, sequences, environmental causes or patterns of unknown origin, and 31% had unknown patterns of malformations. The commonest entities were amnion disruption sequence (16% of cases) and VACTERL association (8%). Both of these disorders showed unusual temporal distribution. As anticipated, patterns of malformations differed with the type of LD. Amelia and digital amputations were often seen with body wall defects, atypical anencephaly or encephalocele, and cleft lip reflecting amnion disruption. Rudimentary limb was seen with anencephaly, omphalocele, renal agenesis, aberrant genitalia, and imperforate anus, reflecting defects of blastogenesis including the cloacal exstrophy and caudal regression sequences and Schisis association. Radial/tibial defects were associated with different patterns depending on whether the limb defects were unilateral or bilateral. Unilateral defects occurred with anomalies suggesting VACTERL association or the facio-auriculo-vertebral anomaly, while bilateral defects occurred more often in genetic or potentially genetic disorders including VACTERL with hydrocephalus. Central axis defects showed three main patterns of association: one reflecting the ectrodactyly-ectodermal dysplasia-clefting syndrome; one with tongue anomalies representing a variant of oro-mandibular-limb (Hanhart) anomaly, and the last with hydronephrosis indicating a group of "acro-renal" syndromes. Strong associations with other anomalies were not seen in the groups with TT, UF, or intercalary defects.

Structural anomalies resulting from vascular disruption

A diverse yet distinctive group of disorders and structural anomalies result from vascular disruption of embryonic and fetal blood vessels. The extent of damage, timing in gestation, and the mechanism of vascular disruption all determine the nature of the resultant structural anomalies. The developing human remains susceptible throughout pregnancy to teratogenic agents and events that alter uterine, placental, and embryonic or fetal circulation.