The position of symbrachydactyly in the classification of congenital hand anomalies

Characterization of Hand Anomalies Associated With Möbius Syndrome

PURPOSE

To investigate the distinguishing morphological characteristics of the upper extremities in children with Möbius syndrome.

METHODS

Twenty-seven involved extremities in 14 patients with a diagnosis of Möbius syndrome were identified at 2 institutions. Medical records, radiographs, and clinical photographs were evaluated. Congenital hand differences were classified according to the Oberg, Manske, and Tonkin classification, and hands with symbrachydactyly were classified by the Blauth and Gekeler classification. The presence of other congenital anomalies was catalogued.

RESULTS

There was bilateral involvement in 93% of patients with congenital hand anomalies. Twelve patients demonstrated congenital hand anomalies and 2 patients had been diagnosed with arthrogryposis. Among the 12 patients with congenital hand anomalies, 21 hands were classifiable as symbrachydactyly by the Oberg, Manske, and Tonkin classification and could be categorized by the Blauth and Gekeler classification. Short finger type was the most common subtype of symbrachydactyly, present in 13 hands. Eleven of these 13 patients (85%) were primarily affected on the radial side of the hand. Proximal arm involvement was identified in 2 patients with symbrachydactyly, both of whom had Poland syndrome and an absent pectoralis major.

CONCLUSIONS

Symbrachydactyly in Möbius syndrome differs from the typical presentation of symbrachydactyly. Characteristically, there is a bilateral presentation with a strong predilection for radially based brachydactyly. These described characteristics may help the hand surgeon appropriately assess patients, especially those with radial-sided symbrachydactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Description of Congenital Hand Anomalies: A Personal View

A series of four congenital hand cases exhibiting central clefting are presented. The cases are morphologically similar and exhibit characteristics of both symbrachydactyly and central longitudinal deficiency. The cases demonstrate difficulties in classification by either the IFSSH classification system or the JSSH modification of it. An alternative descriptive approach to classification is suggested.

Phenotypic manifestation of congenital transverse amputation of autopod in Pakistani subjects

Terminal transverse deficiency of forearm is a very rare limb malformation. Most of the cases have traumatic etiology and congenital presentation is less common. A series of six individuals with transverse deficiency through the hands is presented in this communication. The cases were congenital, morphologically similar and showed loss of four fingers, most often postaxial. The affected arm was reduced in size compared to the contralateral limb and there was distortion of palmer creases. All cases were sporadic and non-syndromic in nature. The characteristics of these cases were concordant with the symbrachydactyly type III or monodactylous type, when classified according to the scheme proposed by Blauth and Gekeler (1973). The malformation resulted in permanent quality-of-life impairment in these subjects and warrant prosthetic management. Detailed physical and phenotypic features of the patients have been presented.

Epidemiology of congenital upper limb anomalies in Stockholm, Sweden, 1997 to 2007: application of the Oberg, Manske, and Tonkin classification

PURPOSE

To investigate the epidemiology of congenital upper limb anomalies (CULA) based on the newly proposed Oberg, Manske, and Tonkin (OMT) classification, to compare this classification with the International Federation of Societies for Surgery of the Hand (IFSSH) classification, and to provide incidence rates of the different CULA.

METHODS

In this study, the same 562 individuals with a CULA who were analyzed in a previous epidemiologic study based on the IFSSH classification were reclassified according to the OMT classification. All children identified with CULA and born in Stockholm County between January 1, 1997 and December 31, 2007 were included in the study. During the period there were 261,914 live births in Stockholm County, and the population of Stockholm County was 1,949,516 inhabitants at the end of the period. From medical records and available radiographs, all cases were analyzed regarding type of CULA, sex, affected side, associated nonhand anomalies, and occurrence among relatives. Individuals with right and left side anomalies belonging to different OMT subgroups were counted as 2 anomalies; thus, the material consisted of 577 CULA in 562 children.

RESULTS

It was possible to organize all CULA into the OMT classification. The largest main category was malformations (429 cases), followed by deformations (124 cases), dysplasias (10 cases), and syndromes (14 cases). We present the relation between the IFSSH and OMT classifications, elucidate difficulties within the OMT classification, and propose additions to the classification.

CONCLUSIONS

This study confirms that the OMT classification is useful and accurate, but also points out difficulties. With further refinements, we regard the OMT classification as a needed and appropriate replacement for the IFSSH classification.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

A new documentation system for congenital absent digits

BACKGROUND

Congenital absent digits continue to be described by many confusing terms and are currently classified in categories I, V, and VI of the International Federation of Societies for Surgery of the Hand classification and seven subclassification systems. Very few classification systems provide any logical basis for surgical reconstruction. The purpose of this study was to develop a simple alphanumerical documentation system to reproducibly describe the morphological or radiographic appearance of congenital absent digits and facilitate communication of these childrens' hand anomalies from one hand surgeon to another.

METHODS

Dorsal and palmar photographs and PA radiographs of 235 hands in 204 children born with congenital absent digits over a 15-year period were analyzed to determine which digital rays were missing and their level of absence. Each hand can be described by three letters, R (radial), C (central), and U (ulnar), as well as numbers 1-5. The first letter and number designate which rays are missing and the second and third letters and numbers designate which rays remain present.

RESULTS

There are 15 morphological phenotypes of congenital absent digits. The three most common phenotypes are U4R1 (a thumb but absence of all four fingers), R1U4 (absent thumb), and R5 (aplastic hand).

CONCLUSIONS

This new documentation system allows hand surgeons to describe the simple morphological or radiographic appearance of congenital absent digits; incorporates all the previous subclassification systems that have attempted to describe congenital absent digits in radial, central, and ulnar deficiencies, symbrachydactyly, and congenital constriction ring syndrome; and has subsequently allowed the development of an algorithm which predicts whether conventional or microsurgical reconstruction is indicated for each specific phenotype.

TOE-TO-HAND TRANSFER IN SYMBRACHYDACTYLY

Symbrachydactyly, or central atypical cleft, is classified as a failure of formation. For the adactylous or monodactylous forms, free toe transfer is the treatment of choice. We present 18 free toe transfers in 13 patients for symbrachydactyly. Despite abnormal anatomy, the functional building blocks have always been available and transfer technically possible. The result has been improved function and high levels of parental satisfaction.

Congenital differences of the upper extremity: classification and treatment principles

For hand surgeons, the treatment of children with congenital differences of the upper extremity is challenging because of the diverse spectrum of conditions encountered, but the task is also rewarding because it provides surgeons with the opportunity to impact a child's growth and development. An ideal classification of congenital differences of the upper extremity would reflect the full spectrum of morphologic abnormalities and encompass etiology, a guide to treatment, and provide prognoses. In this report, I review current classification systems and discuss their contradictions and limitations. In addition, I present a modified classification system and provide treatment principles. As our understanding of the etiology of congenital differences of the upper extremity increases and as experience of treating difficult cases accumulates, even an ideal classification system and optimal treatment strategies will undoubtedly continue to evolve.

Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from stockholm, sweden

PURPOSE

There are few true epidemiological studies of congenital anomalies of the upper limb (CULA) on total populations in the literature, and most incidence studies are hospital based. The purposes of this study were to describe the epidemiology and classify all CULA in a region of Sweden during an 11-year period.

METHODS

Between 1997 and 2007, there were 261,914 live births in the Stockholm region. A total of 562 children born during this period were found to have CULA. From medical records and available radiographs, all cases were analyzed regarding the type of congenital anomaly, gender, laterality, occurrence among relatives, associated non-hand anomalies, and syndromes. All 585 main anomalies were classified according to the International Federation of Societies for Surgery of the Hand classification. Individuals with right- and left-side main anomalies belonging to different categories were counted as having 2 anomalies.

RESULTS

The recorded incidence of CULA was 21.5 per 10,000 live births. Of the 562 children, 304 were boys. The anomalies affected the right side only in 169 children, the left side only in 186, and both sides in 207. Non-hand anomalies were recorded in 129 children, most commonly in the lower limbs. In 99 children, there was a known occurrence among relatives. Failure of differentiation was the most common category (276 of 585) followed by duplication (155 of 585), failure of formation (103 of 585), undergrowth (18 of 585), generalized abnormalities and syndromes (14 of 585), overgrowth (10 of 585), and constriction ring syndrome (9 of 585).

CONCLUSIONS

The incidence of CULA in our region was similar to the only previously comparable total population study from Western Australia. The minor differences in incidences between the categories according to the International Federation of Surgical Societies of the Hand may be due to variations in classification strategy. The results of the present study can be used as a reference of CULA in a total population.

Congenital hand differences: embryology and classification

Congenital hand differences affect approximately 1 in 500 persons and present unique diagnostic and classification challenges. The embryology of the hand and upper extremity is discussed, including the molecular basis for patterning of the upper limb. The Swanson/International Federation of Societies for Surgery of the Hand classification system is described, along with a discussion of the difficulties in classifying congenital hand differences based on morphology or etiology.

An assessment of the relationship between congenital transverse deficiency of the forearm and symbrachydactyly

PURPOSE

A relationship between symbrachydactyly and transverse deficiency has been suggested but has not been critically investigated or established by scientific studies. The purpose of this investigation was to evaluate a large group of patients with transverse deficiency of the forearm for clinical and radiologic features typically seen in patients with symbrachydactyly.

METHODS

A retrospective review of the medical records of 291 patients with a diagnosis of upper-extremity transverse deficiency at the level of the forearm was performed. Patient charts, photographs, and radiographs were evaluated for manifestations of symbrachydactyly; specifically, we clinically assessed for the presence of nubbins and skin invaginations and radiologically assessed for hypoplasia of the proximal radius and ulna.

RESULTS

Two hundred seven patients had soft tissue nubbins at the end of their amputation stumps including 38 with the additional finding of skin invagination at the distal end. Another 36 extremities had a skin invagination alone. Twenty-nine of the extremities without nubbins or skin invaginations had hypoplasia of the proximal radius and ulna. Thus, 272 of the 291 extremities with transverse deficiency had manifestations of symbrachydactyly.

CONCLUSIONS

The majority of patients with the diagnosis of transverse deficiency have soft tissue nubbins, skin invaginations, or hypoplasia of the proximal radius and ulna at the end of their amputation stumps. These clinical and radiologic features support the concept that transverse deficiency through the forearm represents a proximal continuum of symbrachydactyly.

Reconstruction of the first web space in symbrachydactyly using the reverse radial forearm flap

PURPOSE

To present a new approach for the reconstruction of severe first web contractures using a distally based reverse radial forearm flap in symbrachydactyly patients.

METHODS

This study included 6 hands in 5 patients. Subjective evaluation included appearance, parent satisfaction (and patient satisfaction when appropriate), and ability to perform daily activities such as thumb-index grasp and pinch at follow-up evaluations. We measured the angle between the first and second rays using a goniometer at maximum radial abduction, and pinch and grasp strengths were evaluated as an objective assessment.

RESULTS

The average follow-up period was 2 years. All parents and patients were happy with the aesthetic appearance. They were completely satisfied in their daily living activities. The average first web angle measurement was 56 degrees . An average of 39 degrees of improvement of web measurement was achieved. For the unilateral 4 patients, the average pinch strength measurement was 80% of the normal contralateral hand and the grip strength was 75% of the normal contralateral hand.

CONCLUSIONS

The reverse radial forearm flap was found to be a safe and simple method in the reconstruction of severe first web contractures in symbrachydactyly patients. This method provided good coverage of appropriate thickness and skin quality, and supple soft tissue that filled the first web space.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The middle phalanx in Poland syndrome

The classic deformity of Poland syndrome consists of the combination of unilateral aplasia of the sternocostal head of the pectoralis major muscle and an ipsilateral hypoplastic hand with simple syndactyly and short fingers. The current study specifically investigates the abnormalities of the middle phalanx in a series of 15 patients with Poland syndrome. The degree of hand hypoplasia and finger brachydactyly was classified into 3 grades: mild (n = 2), moderate (n = 10), and severe (n = 3). The middle phalanges of all fingers in all patients showed abnormalities. The degree of deficiency in the middle phalanx (from mild hypoplasia to aplasia) correlated with the degree of brachydactyly, which in turn correlated with the degree of hand hypoplasia. Several other radiologic features of the hypoplastic middle phalanges were documented, such as the central nidus, the rounded or truncated appearance, and the cone-shaped epiphyses. The embryology of limb development was reviewed and it was proposed that abnormalities of the middle phalanx in Poland syndrome occur as a result of a mild ischemic insult during stage 19 of the embryonic life, leading to an arrest or lack of chondrification of the mesenchymal mass of the phalanx.

Bone lengthening for congenital differences of the hands and digits in children

PURPOSE

We investigated the growth of bones after lengthening to evaluate the effectiveness and usefulness of bone lengthening in congenital hand deficiencies.

METHODS

Bone lengthening was performed to treat congenital hand deficiencies including hypoplastic thumb, hypoplasia of the small finger, cleft hand, metacarpal synostosis, brachymetacarpia, symbrachydactyly, and amniotic band syndrome. A total of 15 patients (1-13 years old) underwent lengthening of 23 bones. The average of distraction was 10 mm. The mean follow-up period was 59 months. The length of the bones at follow-up evaluation was measured and then compared with the length of the bones immediately after lengthening. The bone growth after lengthening, the percentage of growth after lengthening, and the growth rate were compared among diagnostic groups.

RESULTS

In the cases involving older patients the bone length changed little and the growth plates of these patients closed naturally soon after lengthening. In contrast, in the cases in which the patients were younger than 7 years old the lengthened bones grew continuously. The amount of bone growth was different for each disease in the younger patients. In patients with amniotic band syndrome the lengthened bones grew at the same rate as the bones in the hand. Other diagnoses such as symbrachydactyly had a different growth pattern in the hand.

CONCLUSIONS

We conclude that bone lengthening is a reliable method for the correction of congenital differences of the hand. The indications for this procedure must be determined while considering the relationship between the specific disease and subsequent bone growth.

Recording congenital differences of the upper limb

Consistent classification of congenital differences of the upper limb is of paramount importance for the study of the pathogenesis. To overcome the inconsistencies of present classifications, a non-classifying recording method has been developed. This method records individual aberrations, including bone and soft-tissue defects. Between 1996 and 1998, a prospective study was performed to validate the method. Two hundred and thirty-one patients with upper limb differences were assessed, and all individual aberrations were recorded. These data can be transferred to any classification. It is concluded that the presented method will allow consistent grouping of patients without losing details about simple and complex differences.

Congenital anomalies: a 25-year overview

Expansion of the discipline of hand surgery and heightened interest in congenital problems have resulted in major advances in the treatment of congenital hand anomalies over the past 25 years. Increased experience with congenital anomalies of the hand has expanded the hand surgeon's knowledge of patterns and relationships between different anomalies resulting in new methods of classification and more logical approaches to treatment. The principles of treatment of the more common anomalies, such as syndactyly, established by prior generations of hand surgeons have been refined in details of technique. New technologies, such as distraction lengthening and free vascularized transfers, have allowed the surgeon to treat new problems and old problems in new ways. In spite of our successes, much remains to challenge hand surgeons in this new millennium, especially in the construction of joints and the expanding field of fetal surgery.

[Classification and treatment of symbrachydactyly. A series of 117 cases]

In the present study, a modification has been proposed of the Blauth and Gekeler classification, aimed at a more accurate definition of appropriate surgical treatment. An analysis was made of a series of 120 cases of symbrachydactyly (117 patients); however, surgery was only performed in 86 cases (51 toe transfers in 49 patients; mean age at surgery 12 months). Type I included the separation of short and sometimes stiff fingers; type II, the 'pseudo-cleft', could be subdivided into three groups. Type IIA included those hands with more than two long and frequently hypoplastic digits, regarding which a decision had to be made between removal of rudimentary fingers or their stabilization. In type IIB, hand function was good and surgery was rarely needed. Type III (monodactylous) could also be subdivided into two categories, i.e., normal thumb in type IIIA and hypoplasia in IIIB. Finally, in type IVA, toe transfer surgery was performed on condition that wrist mobility was sufficient to compensate for the insufficient mobility of the artificial thumb on the anterior aspect of the radius. In all cases, a weak but useful pincer movement was obtained, with poor cosmetic results. In the case of toe transfers, surgery was advocated before the age of one year; and although mobility was disappointing (35 degrees active motion), good growth and excellent discrimination (5 mm on average) was observed. Symbrachydactyly is a fairly frequent congenital malformation; its diverse clinical features require a precise classification to better determine adequate treatment management.

Classification of congenital anomalies of the upper limb

Six hundred and ninety-four patients with 993 anomalies of the upper limbs were classified according to the classification of Swanson et al. (1983). The data from these patients were compared with previous studies, and similar discrepancies were found. One explanation for these discrepancies is a lack of uniformity in the classification of Swanson et al., which may be caused by out-dated knowledge of the pathogenesis of congenital limb anomalies. Therefore, it seems necessary to describe the anomalies instead of the diagnoses. A descriptive method is being validated in our outpatient department that records all anomalies of the upper limb.

Toe to hand transfer in children. Part 1: technical aspects

Between 1988 and 1994 40 children (age range 9 months-14 years) with either congenital (85%) or acquired hand deformities underwent reconstruction by microvascular autotransplantation of one or more toes. Fourteen underwent a single toe transfer whilst 26 had two second toes transferred to one hand. In 14 of these cases both second toes were transferred at one operation. Whether one or two toes were transferred, the children spent on average 9 days in hospital. None of the transfers failed but 75% of the children underwent staged additional surgery to improve appearance and function. Thirty-seven of the 40 children attended with their parents for follow-up examination by an independent surgeon, a physiotherapist and a clinical psychologist in order to evaluate the results and consequences of surgery. This paper presents the technical considerations for this surgery and examines the influence of the transfer on growth.