The psychological impact of microvascular free toe transfer for children and their parents

Establishing the psychological impact of congenital upper limb differences on parents and families

The aim of this prospective study was to report the psychological experiences of parents caring for children with a congenital upper limb difference and to compare these to population norms. Contributing factors were explored, including access to support and coping strategies. Finally, parents with a congenital upper limb difference themselves were compared to those without. Data recorded included demographics, a validated wellbeing and family impact measure, a unique measure of emotions experienced and exploratory questions. Wellbeing and family impact scores were significantly lower than populations norms. Mothers experienced significantly more negative emotions than fathers. There was no significant different between parents with and without a congenital upper limb difference. Of the parents, 68% felt there should be improved access to psychological support. This demonstrates that parents of children with congenital upper limb differences have unique psychological experiences and needs. They may benefit from specialist psychological support and further research is needed.Level of evidence: III.

Improving Understanding and Outcomes in Congenital Hand Differences

SUMMARY

It is very important for us, the surgeons, to understand the difficulties of parents who have a baby with a congenital hand difference, not only because the parents are the decision makers for the operation but also because they need consolation and care to overcome their distress. The psychological and physical developmental milestones of the child with a congenital hand difference should be considered to achieve a satisfactory surgical outcome from the viewpoint of both the surgeon and the child. Even experts in congenital hand differences may have difficulties in decision-making with regard to certain entities because of the clinical diversity and rarity. Communication among surgeons who are interested in congenital hand differences, through social networking services or other communication tools, is very helpful and effective for the exchange of knowledge and experiences. Although the final decision should be made by the surgeon, many questions and answers from friends and colleagues will lead to better decisions.

A systematic review of the use of psychological assessment tools in congenital upper limb anomaly management

STUDY DESIGN

This study is a systematic review.

INTRODUCTION

Congenital upper limb anomalies (CULAs) are often associated with psychosocial difficulties including negative body image, low self-esteem, and withdrawal from social activities.

PURPOSE OF THE STUDY

The purpose of the study was to identify, describe, and evaluate all published psychosocial assessment tools used in the assessment and management of CULAs, to direct the use of these tools in clinical practice, and to identify areas requiring development.

METHODS

A systematic search of Medline, EMBASE, Pubmed, and PsychInfo databases was performed. In total, 23 studies were included for analysis. Data extracted included study and population characteristics, psychosocial measures utilized, psychosocial outcomes reported, and the reliability and validity of measures.

RESULTS

Seventeen patient-reported measures were identified. The most commonly used tool was a Likert scale (n =7) with satisfaction with appearance and function, the most commonly evaluated outcome (n = 18). Other evaluated domains included quality of life or psychosocial functioning (n = 9), self-image (n = 2), and psychological well-being (n = 5).

DISCUSSION AND CONCLUSIONS

There is no well-established, validated assessment tool in regular use to effectively address psychosocial outcomes for children with CULAs. Although the majority of children born with a CULA appear to adjust well, this is by no means the case for all children. There is a need for routine psychosocial evaluation preoperatively and postoperatively with long-term follow-up data to help direct patient-orientated management. A clear understanding of these, and how to measure them, is needed to help for a patient-centred, multidisciplinary, evidence-driven approach to CULA management.

Appearance of congenital hand anomalies

Background and objective:

Impact of appearance of congenital hand anomalies has not previously been reported. The purpose of this study was to describe the common perception about how different congenitally malformed hands look.

Methods:

We developed a questionnaire in a game format to evaluate the appearance of different hands. Altogether 1450 (954 females) 4- to 84-year-old residents (296 children) of two European and one Asian (n = 102) country were asked to rate the appearance of different looking hands on a five-point pictorial Likert-type scale. Standardized photographs of the dorsal aspect of 17 different congenitally malformed non-operated hands and a normal hand were presented to respondents. Significance of age, gender, nationality, and profession of the respondents was assessed.

Results:

The respondents’ ranking order of the hands was nearly consistent. The normal hand (mean = 4.43, standard deviation = 0.85, Md = 5) and clinodactyly (mean = 4.37, standard deviation = 0.86, Md = 5) were perceived to have the best appearance. Symbrachydactyly (mean = 1.42, standard deviation = 0.68, Md = 1) and radial club hand (mean = 1.40, standard deviation = 0.68, Md = 1) received the lowest scores. Adults rated the appearance of hands higher than children regarding 14 hands, females higher than men regarding 15 hands, and Europeans higher than Asians in 4 hands (p < 0.05, respectively). Europeans rated four-finger hand (mean = 3.21, standard deviation = 1.18, Md = 3) better looking than six-finger hand (mean = 2.92, standard deviation = 1.18, Md = 3, p < 0.005), whereas Asians gave higher scores to six-finger hand (mean = 2.66, standard deviation = 1.26, Md = 3) compared to four-finger hand (mean = 2.51, standard deviation = 1.14, Md = 2). Medical doctors and nurses gave higher scores compared to the other profession groups, school children, and high school students in five hands (p < 0.05).

Conclusions:

A normal hand is perceived distinctly better looking than most congenitally different hands. Different malformations’ appearance was ranked very coherently in the same order despite of participants’ age, gender, nationality, or profession. Asians seem to prefer an additional digit to a four-finger hand.

Congenital Hand Differences

Congenital hand differences are frequently encountered by pediatric plastic surgeons. These anomalies may cause significant emotional and functional challenges for children. Pediatric plastic surgery nurses should have a basic understanding of common congenital hand differences and related treatment options to facilitate patient education and postoperative care. This article discusses clinical findings and management of 4 of the most common hand anomalies: syndactyly, polydactyly, thumb hypoplasia, and cleft hand. The goals of surgical treatment are to maximize hand function and aesthetics with minimal adverse outcomes.

Parental Assessment of Status of Congenital Upper Limb Differences: Analysis of the Pediatric Outcomes Data Collection Instrument

PURPOSE

To determine the range of the Pediatric Outcomes Collection Instrument (PODCI) scores for children with a wide variety of congenital upper limb differences and to examine the scoring effect of the patient's surgical history, family history, severity of involvement, and syndromic associations.

METHODS

We reviewed the PODCI scores for 109 patients, aged 2-18 years, treated for nontraumatic upper extremity conditions. Charts were reviewed for sex, age, extent of limb involvement, laterality, family history, surgical history, and syndrome association. All patients were classified based on the Oberg, Manske, Tonkin classification with general categories of malformation, deformation, or dysplasia.

RESULTS

Of 109 patients, 80 (73%) had a malformation, 12 (11%) had a deformation, and 17 (16%) had a dysplasia. The cohort as a whole had a happiness PODCI score that was similar to the normal population, yet a lower (worse) PODCI score for upper extremity and global function. Patients with a dysplasia had a higher upper extremity function scores than those with malformations or deformations, but they had similar happiness and global function scores. Complete upper limb involvement and lower extremity involvement statistically lowered the PODCI score within our study cohort, whereas a positive family history and syndromic association increased PODCI scores.

CONCLUSIONS

This study showed that there was a similar level of perceived happiness between children/adolescents with congenital upper extremity conditions compared with the normal pediatric population based on PODCI scores. In contrast, the perceived upper extremity and global function was significantly decreased in patients with congenital differences compared with normal individuals. This investigation also revealed that the extent of upper extremity involvement, lower extremity involvement, family history, and syndromic association may affect PODCI scores as independent variables and should be taken into consideration in studies of upper extremity congenital anomalies.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Do Patient- and Parent-reported Outcomes Measures for Children With Congenital Hand Differences Capture WHO-ICF Domains?

BACKGROUND

Patient- and parent-reported outcome measures (PROMs) are increasingly used to evaluate the effectiveness of surgery for congenital hand differences (CHDs). Knowledge of an existing outcome measure's ability to assess self-reported health, including psychosocial aspects, can inform the future development and application of PROMs for CHD. However, the extent to which measures used among children with CHD align with common, accepted metrics of self-reported disability remains unexplored.

QUESTIONS/PURPOSES

We reviewed studies that used PROMs to evaluate surgery for CHD to determine (1) the number of World Health Organization-International Classification of Functioning, Disability and Health (WHO-ICF) domains covered by existing PROMs; (2) the proportion of studies that used PROMs specifically validated among children with CHD; and (3) the proportion of PROMs that targets patients and/or parents.

METHODS

We performed a comprehensive review of the literature through a bibliographic search of MEDLINE®, PubMed, and EMBASE from January 1966 to December 2014 to identify articles related to patient outcomes and surgery for CHD. We evaluated the 42 studies that used PROMs to identify the number and type of WHO-ICF domains captured by existing PROMs for CHD and the proportion of studies that use PROMs validated for use among children with CHD. The most common instruments used to measure patient- and parent-reported outcomes after reconstruction for CHD included the Prosthetic Upper Extremity Functional Index (PUFI), Disabilities of the Arm, Shoulder, and Hand questionnaire, Childhood Experience Questionnaire, and Pediatric Quality of Life Inventory.

RESULTS

Current PROMs that have been used for CHD covered a mean of 1.3 WHO-ICF domains (SD ± 1.3). Only the Child Behavior Checklist and the Piers-Harris Children's Self-Concept Scale captured all ICF domains (body functions and structures, activity, participation, and environmental factors). The PUFI, the only PROM validated specifically for children with congenital longitudinal and transverse deficiency, was used in only four of 42 studies. Only 13 of the 42 studies assessed patient-reported outcomes, whereas five assessed both patient- and parent-reported outcomes.

CONCLUSIONS

The PROMs used to assess patients after CHD surgery do not evaluate all WHO-ICF domains (ie, body structure, body function, environmental factors, and activity and participation) and generally are not validated for children with CHD. Given the psychological and sociological aspects of CHD illness, a PROM that encompasses all components of the biopsychosocial model of illness and validated in children with CHD is desirable.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Indications for microsurgical reconstruction of congenital hand anomalies by toe-to-hand transfers

BACKGROUND

The indications for microsurgical toe-to-hand transfers in congenital hand surgery have not been defined as clearly as for posttraumatic reconstruction of thumb and finger amputations. The purpose of this study was to develop simple guidelines for referral of children with congenital absent digits for consideration of microsurgical reconstruction with toe-to-hand transfers, based on the morphological or radiographic anatomy of the hand anomaly, not on embryological classifications.

METHODS

From a consecutive series of 204 children referred with congenital absence of the thumb and fingers, 100 toe-to-hand transfers were performed. The indications for microsurgical reconstruction of these children were analyzed retrospectively.

RESULTS

Forty-one thumbs were reconstructed in 38 children-15 children with an absent thumb distal to the metacarpal base but with four relatively normal fingers; 12 children with an absent thumb and only one or two digits remaining on the ulnar side of the hand; and 11 children with complete absence of all five digits. Twenty-nine second toes and 12 great toes were transferred to reconstruct congenital absent thumbs. Fifty-nine fingers in 52 children were reconstructed mostly with single second toe transfers-41 children with a thumb but absence of all four fingers and 11 children with absence of all five digits.

CONCLUSIONS

The morphological or radiographic anatomy of a child's hand with congenital absent digits is a more logical indication for microsurgical reconstruction than any embryological classification. The three most common indications for toe transfers for reconstruction of congenital absent thumbs are (1) absent thumb distal to the carpometacarpal joint with four relatively normal fingers, (2) absent thumb with only one or two fingers remaining on the ulnar border of the hand, and (3) complete absence of the thumb and all four fingers. The two indications for toe transfers for reconstruction of congenital absent fingers are (1) absence of all four fingers but with a normal thumb remaining and (2) complete absence of all five digits.

Children with surgically corrected hand deformities and upper limb deficiencies: self-concept and psychological well-being

We studied self-concept and psychological well-being in children with hand deformities and upper limb deficiencies. Ninety-two children, 53 boys, 39 girls, aged 9-11 years were included. The children were divided into two subgroups - one with milder (less visible) deformities and one with severe (more complex and visible) finger-hand-arm deformities. Of the 92 children, 79 had received reconstructive surgery, and 13 had been treated with prostheses. The Piers-Harris Children's Self-Concept Scale (PHCSCS) was used to measure self-esteem and well-being. Overall PHCSCS scores showed that the whole hand deformity group had 'good' self-concept with mean scores in excess of 60 points, equal to a comparison group of healthy children. Within the hand deformity group, those with mild deformities had lower scores than those with severe deformities. This result was also found in the group of boys but not in the girls. The children with severe deformities had even higher scores than the comparison group regarding the subscale 'Intellectual and School Status'. The children with milder deformities had lower scores than the comparison group regarding the subscale 'Popularity'.

Reconstruction of congenital differences of the hand

SUMMARY

Congenital differences of the upper limb occur in approximately 0.16 to 0.18 percent of live births. These patients provide a unique challenge for the reconstructive hand surgeon. The correct and timely diagnosis of hand and upper limb congenital differences will lead to appropriate care and rehabilitation. The International Federation of Societies for Surgery of the Hand has classified congenital upper limb differences based on abnormalities of embryogenesis: failure of formation of parts, failure of differentiation of parts, duplication, overgrowth, undergrowth, constriction ring syndrome, and general skeletal abnormalities. This classification scheme is used as a basis for discussion of the most common upper limb anomalies. Both surgical and nonsurgical treatments are discussed, as is appropriate timing of intervention.

The psychological and social impact of disfigurement to the hand in children and adolescents

Hand disfigurement creates potential problems for the developing child. Parental adjustment to the hand is of prime importance in the child's ability to accept and integrate the disfigurement. Self-consciousness follows a developmental path because of internal and external factors in the child's development. This paper presents a research study carried out in order to examine the decision-making process in toe-to-hand transfers. 34 families were assessed of whom 27 decided to proceed with surgery following the decision-making process. Factors which influenced that decision included the way the surgeon communicated information. Those who decided against surgery tended to have more positive beliefs about the role of the disfigured hand in the child's psychological development. The process of decision-making allowed families and the older children to engage in a therapeutic approach.

Toe-to-hand transfers for congenital anomalies of the hand

Reconstruction of congenital differences of the hand presents a surgical challenge. Microsurgical toe-to-hand transfer is becoming an accepted treatment for these difficult problems. These transfers can provide functionally useful and cosmetically acceptable digits in children with congenital absence of the thumb, fingers, or both. Currently, the success rate is routinely greater than 95%.

Outcome Analysis, Including Patient and Parental Satisfaction, Regarding Nonvascularized Free Toe Phalanx Transfer in Congenital Hand Deformities

The therapy for congenital hand malformations, especially in symbrachydactyly and constriction ring syndromes, is challenging. Between 1975 and 1995, 20 children with congenital hand deformities underwent reconstruction by 56 nonvascularized free toe phalanx transfers. The average age at initial surgery was 4.8 (range, 0.5 to 22) years. Retrospectively, the children were examined after an average of 3.5 (range, 1.5 to 17.6) years for function of the hand, transplanted phalanx growth, assessment for the epiphyseal plate, and assessment for psychologic performance with their parents. Donor-site morbidity was determined according to measured growth deficit, observing the child's gait, and toe function. In the younger patients (up to 1.5 years), the grafts were well tolerated and showed good growth and only few resorptions. In the age group from 1.5 to 4 years, the grafts showed no growth. In the age group older than 4 years, the grafts were mostly resorbed. The clinical reexamination revealed in most cases only passive motion in the joints, but the function of the hand was improved, with only few problems of the donor site. Most patients and their parents reported a positive effect of the phalanx transfer.

Restoration of functional prehension after radial hemihand amputation in a three-year-old child: rationale for and long-term result after great toe transfer

Partial hand amputations are rare injuries among children, causing significant functional impairment. Reports on thumb reconstruction in children and adults are used to develop a reconstruction plan for restoring prehension. While either first or second toe transplantation may be indicated to restore prehension in adults with thumb loss, near universal reluctance to use the great toe in children centers around concern regarding the subsequent function and appearance of the foot. This report details the reconstruction of functional prehension after radial hemihand amputation in a 3-year-old child. Great toe transplantation was used and resulted in neither objective nor subjective donor site morbidity. The rationale for use of the great toe in this child and long-term functional outcome are described.

[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.

Psychological aspects of toe to hand transfer in children. Comparison of views of children and their parents

Thirty-seven children with congenital (n = 32) or post-traumatic (n = 5) hand anomalies underwent unilateral or bilateral toe transfers. All had undergone preoperative counselling. After rehabilitation and more than 1 year after surgery, the children and their parents were reviewed by a clinical psychologist to assess the psychosocial outcome of the surgery. A high level of satisfaction was reported with regard to the surgery, in terms of function, cosmesis, donor site, psychosocial wellbeing and the reactions of others. This was true regardless of the gender of the child. However, there was a tendency for the children to be more positive in their responses than their parents.

Late toe-to-hand transfer for the reconstruction of congenital defects of the long fingers

Toe-to-hand transfer is a well established procedure and is one of the best ways of reconstructing the missing fingers or parts of fingers. In congenital deformities of fingers and hands such as absence of digits, second toe transfer may create the grip function and is superior to all other procedures. We present three cases of four second toe transfer to reconstruct long finger defects after congenital malformations of the long fingers. The aim of this paper is to discuss some aspects of the procedure and to evaluate achieved results. All our four patients were operated on when they were over 10 years of age.