Characteristics of patients with hypoplastic thumbs

An Alternative Treatment Option for Blauth III B Thumb Hypoplasia-Thumb Stabilization with Iliac Crest Bone Graft and Intermetacarpal Arthrodesis

Thumb hypoplasia modified Blauth III B is usually treated by pollicization or, less commonly, by toe transfer. Both procedures always result in the resection of a body part, but with good cosmesis and acceptable function. We describe an intermetacarpal I/II arthrodesis with autologous bone graft augmentation to lengthen and stabilize the loose thumb. Clinical data were collected from nine patients, median age at surgery 3 years 8 months, with more than 7 years of follow-up. The results showed a grip strength on the Jamar dynamometer of approximately 61% of the unoperated hand. The Quick-DASH score was 11. The reconstructed thumb was 0.8 cm thinner and 1.9 cm shorter. Overall satisfaction on the VAS, with an average of 1.5 out of 10, is excellent with a partially usable thumb on a hand with five rays. The described procedure is a reliable treatment option with satisfactory results. In addition, none of the patients lost pincer grip between the second and third digit, but their thumb gained new function. Especially in environments where physical integrity has a high value, thumb construction instead of replacement could be considered.

Transferencia de Huber para mejorar la oposición del pulgar hipoplásico: resultados de una serie de casos

Introducción. La transferencia del abductor digiti minimi o transferencia de Huber permite restaurar la oposición del pulgar y presenta varias ventajas sobre otras técnicas de transferencias de oposición, ya que reemplaza musculatura intrínseca del pulgar por otro músculo intrínseco de la región hipotenar, lo que mejora el volumen de la eminencia tenar. Este procedimiento es usado preferiblemente en los tipos II y III de hipoplasia de pulgar.Objetivo. Describir los resultados funcionales de la transferencia de Huber en una serie de pacientes con hipoplasia de pulgar.Materiales y métodos. Estudio observacional descriptivo realizado en 11 pacientes con hipoplasia de pulgar operados mediante la técnica Huber y a quienes se les había realizado un seguimiento mínimo de 6 meses. Además, algunos habían sido sometidos a pulgarización debido al tipo de hipoplasia que presentaban.Resultados. La edad promedio de los participantes al momento de la cirugía fue de 35 meses y el tiempo promedio de seguimiento fue de 15.4 meses. El promedio de la función de oposición, según la escala modificada de Kapandji mejoró de 1.63 (intervalo de 1-2) a 3.72 (intervalo 2-4).Conclusión. Se obtuvieron buenos resultados funcionales al emplear esta técnica, logrando una mejora general de la oposición según la escala de Kapandji: en 9 pacientes aumentó a grado 4 y en otro pasó de 1 a 3; solo en 1 caso la mejora no fue significativa (grado 1 a 2) dado que el paciente presentaba rigidez de los dedos asociada a Vacterl. La transferencia de Huber es una técnica que permite obtener buenos resultados funcionales de oposición para el pulgar hipoplásico.

Radial Longitudinal Deficiency: Severity Differences Between U.S. and Japanese Cohorts

PURPOSE

Radial longitudinal deficiency (RLD) presents on a spectrum of severity and associated diagnoses. The literature is limited in describing patient presentation without comparative data between countries. In a study comparing 2 cohorts of patients, 1 in the United States and 1 in Japan, we hypothesized that there would be a similar presentation of forearm deficiency severity, thumb hypoplasia severity, and associated syndromes between the 2 cohorts.

METHODS

Patients with RLD were identified via a comprehensive chart review at 2 pediatric hospital cohorts, 1 in the United States and 1 in Japan, capturing patients presenting over 15 years. We assessed RLD and thumb hypoplasia severity via a modified Bayne and Klug and modified Blauth classifications. The relationship between these 2 diagnoses and the presence of common medical conditions were evaluated and correlated.

RESULTS

A total of 194 Japanese patients with 290 involved extremities were compared with 107 U.S. patients with 174 involved extremities. The U.S. cohort had a significantly more severe RLD, and a higher rate of bilaterality (63% vs 50%, respectively). A total of 131 Japanese patients (68%) and 41 U.S. patients (38%) had associated medical syndromes/associations, most frequently vertebral abnormalities, anal atresia, cardiac abnormalities, tracheoesophageal fistula and/or esophageal atresia, renal agenesis and dysplasia, and limb defects (VACTERL; 46 Japanese, 14 U.S.), Holt-Oram (44 Japanese, 5 U.S.), and thrombocytopenia absent radius syndrome (0 Japanese, 12 U.S.). Correlation analysis showed that increased RLD severity was associated with increased thumb hypoplasia severity in both groups, with 95% of modified Bayne and Klug III, IV, or V patients having severely affected thumbs (type IIIb, IV, or V).

CONCLUSIONS

The U.S. patients had a more severe RLD and a higher rate of bilaterality. Japanese patients had a higher incidence of associated syndromes and radial polydactyly. Both cohorts showed that increased forearm severity was associated with more severe thumb hypoplasia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Differential diagnosis/symptom prevalence study III.

Long-term outcomes after pollicization: a mean 11-year follow-up study

This study evaluates the long-term results of pollicization for a congenitally absent or severely hypoplastic thumb. Twenty-nine patients with 34 pollicizations were divided to two groups: those with simple thumb hypoplasia (22 pollicizations) and those with radial longitudinal dysplasia (12 pollicizations). The patients were followed from 1.3 to 32 years, with a mean follow-up time of 11 years. The patients were examined clinically and radiologically, and they completed a questionnaire concerning satisfaction with appearance, function, and social interaction. The Percival score was also calculated. In both groups, grip and pinch strengths of the operated hands were inferior to the normative age-related values. Radiologically, flattening of the original metacarpal head was found in 20 out of the 34 operated hands. We found better patient satisfaction in the simple hypoplasia group than in the radial longitudinal dysplasia group. The functional outcomes and patients' satisfaction did not correlate with the age of patients at operation. Level of evidence: IV.

Congenital thumb differences- current concepts

Anomalies of the thumb development are not uncommon and may be associated with a number of syndromes also. These anomalies range from total absence to duplication. Reconstructive surgery for the creation of an opposable thumb is the most rewarding aspect of Hand Surgery and also the most challenging. Classification systems have been modified for better description. A number of procedures have been introduced to improve the functionality of the hand in anomalies and age old concepts are undergoing a metamorphosis to further this. A brief description of the common conditions and their treatment are discussed here and highlighted by selected clinical cases.

The Second Toe-to-Hand Transfer for Full-length Thumb Reconstruction in Congenital Thumb's Grade IIIb to V Hypoplasia: MTPJ Arthrodesis Instead of Tendon Rebalansing

Congenital thumb hypoplasia is a rare deformity of the upper extremity. The classification of thumb hypoplasia was created by Blauth in 1967 (types I to V). The base of the first metacarpal bone is absent for hypoplasia types IIIb to V, therefore, toe-to-hand transplantation is not recommended. A stable first carpometacarpal joint has been considered a mandatory factor for a successful toe-to-hand transplantation. The aim of this study is to describe a new technique for thumb reconstruction with the second toe transfer and metatarsophalangeal joint (MTPJ) arthrodesis, which can provide a five-digit hand and restore thumb functionality for thumb hypoplasia IIIb to V. We performed second toe-to-hand transplantation with MTPJ arthrodesis for 3 pediatric patients (mean age, 69 mo) with congenital thumb hypoplasia IIIb (n=2), grade V (n=1). Long-term follow-up evaluated the functions and esthetics of the hands for grade IIIb patients (n=2). We believe the second toe transfer with MTPJ arthrodesis transplantation is a promising method for reconstructing a full-length congenital or traumatic thumb absence for the pediatric population.

Reconstruction of A Type IIIB Hypoplastic Thumb with A Huber Opposition Transfer in A Five-Year-Old Girl: Redefining Surgical Treatment

Thumb hypoplasia, a congenital deficiency of bony and soft tissue of thumb, is often associated with systemic syndromes like Holt-Oram syndrome, and is the second most common thumb anomaly after duplicated thumb. It has traditionally been classified into six categories, which help guide treatment including reconstruction versus pollicization (transfer of the index finger to thumb). Amputation of the thumb and pollicization is the traditional treatment for a IIIB hypoplastic thumb. A five-year-old girl presented with a classic type IIIB hypoplastic thumb in which she has absent motor function, aplasia of the metacarpal, shortened first web space, and an unstable but present carpometacarpal (CMC) joint. Instead of amputation, the thumb was reconstructed by capsulodesis to stabilize the CMC joint, Huber Transfer Opponensplasty and abductor pollicis longus transfer to restore motor function, W-plasty to deepen the first web space, and distraction to lengthen the metacarpal. The patient tolerated the multi-stage reconstruction and bony distraction well. She was followed for one year postoperatively and has demonstrated a functional thumb. This case questions the surgical algorithm for hypoplastic thumbs and suggests a revised classification system for hypoplastic thumbs which would further divide class III based on not only the stability of the CMC joint but the presence or absence of the joint as well. We propose that amputation be reserved for type III hypoplastic thumbs in which the CMC joint is absent, (revised class IIIC) and reconstruction be attempted when the joint is present irrespective of stability (revised classes IIIA and IIIB).

A Case of a 5-Year-Old Boy with a Blauth Type IIIB Hypoplastic Thumb Reconstructed with a Nonvascularized, Hemilongitudinal Metatarsal Transfer

The treatment methods used for Blauth type IIIB hypoplastic thumbs are controversial. We performed a nonvascularized, hemilongitudinal metatarsal bone transfer on a 5-year-old boy with a type IIIB hypoplastic thumb. Despite the child's age, the growth of the thumb was confirmed and the thumb had stabilized. Moreover, growth disorder of the donor toe was not observed. This method is relatively easy to perform. And donor toe deformation can be prevented, because of the preservation of more than half of the metatarsal bone. In our case, the patient was 5 years of age; nevertheless, the epiphyseal line was opened and the grafted metatarsal bone grew. This method is useful in terms of its simplicity and prevention of postoperative complications.

Long-Term Outcomes of Huber Opposition Transfer for Augmenting Hypoplastic Thumb Function

PURPOSE

This study was conducted to report the functional outcomes of the Huber opposition transfer (abductor digiti minimi muscle) in types II and IIIA hypoplastic thumbs.

METHODS

Patients who had undergone a Huber opposition transfer with at least 5 years of follow-up were included in this study. There were 21 thumbs included; 12 returned for a detailed evaluation and 9 were included with a medical record review. Outcome measures included range of motion and pinch strength; Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected on those who could return. There were 15 type II and 6 type IIIA thumbs.

RESULTS

Range of motion was significantly less than normal for both the interphalangeal and the metacarpophalangeal joints. For the returning cohort, key and tripod pinch were 44% and 65% of normal. The median Kapandji score was 9 (range, 6-10). The PODCI scores were high for global, upper extremity function, happiness, and pain. The PROMIS scores were similar to normal, except for parent reports of physical function. For all included patients, there was a revision surgery rate of 22%, primarily related to persistent instability.

CONCLUSIONS

At a minimum 5-year follow-up, the Huber opposition transfer for types II and IIIA thumbs was shown to provide good subjective outcomes, despite limited range of motion and strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Role of Genetic Factors in the Pathogenesis of Radial Deficiencies in Humans

Radial deficiencies (RDs), defined as under/abnormal development or absence of any of the structures of the forearm, radial carpal bones and thumb, occur with a live birth incidence ranging from 1 out of 30,000 to 1 out 6,000 newborns and represent about one third/one fourth of all the congenital upper limb anomalies. About half of radial disorders have a mendelian cause and pattern of inheritance, whereas the remaining half appears sporadic with no known gene involved. In sporadic forms certain anomalies, such as thumb or radial hypoplasia, may occur either alone or in association with systemic conditions, like vertebral abnormalities or renal defects. All the cases with a mendelian inheritance are syndromic forms, which include cardiac defects (in Holt-Oram syndrome), bone marrow failure (in Fanconi anemia), platelet deficiency (in thrombocytopenia-absent-radius syndrome), ocular motility impairment (in Okihiro syndrome). The genetics of radial deficiencies is complex, characterized by genetic heterogeneity and high inter- and intra-familial clinical variability: this review will analyze the etiopathogenesis and the genotype/phenotype correlations of the main radial deficiency disorders in humans.

Holt-Oram Syndrome Associated with Aortic Atresia: A Rare Association

Holt-Oram syndrome (HOS) is a rare autosomal dominant disorder that causes abnormalities of the upper limbs and heart. It is seen in 1:1, 00, 000 live births. It is linked to a single-gene TBX5 “protein-producing” mutation with gene map locus 12q24. Most commonly it is characterized by the cardiac septation defects and pre-axial radial ray abnormalities. We are reporting a case of HOS with aortic atresia which is a rare association.

Defining Features of the Upper Extremity in Holt-Oram Syndrome

PURPOSE

To investigate the distinguishing morphological characteristics of children with radial longitudinal deficiency (RLD) in Holt-Oram syndrome (HOS).

METHODS

One hundred fourteen involved extremities in 62 patients with a diagnosis of HOS were identified at 3 institutions. Medical records and radiographs were evaluated. Radial longitudinal deficiency and thumb hypoplasia were classified according to the modified Bayne and Klug classification and Blauth classifications, respectively, when possible. Other unusual or distinguishing characteristics were catalogued.

RESULTS

There was bilateral involvement in 84% of patients. The forearm was involved in 81% of the extremities and a shortened distal radius (Bayne and Klug type I RLD) was the most commonly identified forearm anomaly (40%). Radioulnar synostosis was present in 15% of the extremities, all in the proximal forearms with reduced radial heads. Thumb aplasia (Blauth type V hypoplastic thumb) was the most common type of classifiable thumb abnormality and occurred in 35% of involved thumbs. Twenty-seven percent of abnormal thumbs affected were not classifiable according to the Blauth classification, and 19% of involved thumbs (hypoplastic or absent) had first-web syndactyly.

CONCLUSIONS

The upper extremity in HOS differs from the typical presentation of RLD. The forearm is more often involved and may demonstrate radioulnar synostosis. The thumb is frequently unclassifiable by the Blauth classification and has first-web syndactyly. The presence of radioulnar synostosis and syndactyly of the radial 2 digits in RLD should prompt the hand surgeon to obtain a cardiac evaluation and consider genetic testing for HOS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Study of three non-syndromic cases of congenital thumb aplasia in captive rhesus monkeys

Although congenital thumb absence has been reported frequently in humans, their occurrence in macaques is rare. We observed three cases of spontaneous thumb defects in captive female rhesus monkeys. One animal exhibited bilateral absence and two other presented unilateral thumb absence, all with metacarpal integrity. This report presents the clinical, radiological, and genealogical details as well as possible etiologies in an attempt to draw a parallel with humans and other primate species.

Congenital hypoplasia of first digital ray of hands as an isolated presentation in four subjects

Congenital hypoplasia of thumb is rare malformation which is less likely to appear as an isolated entity. Four independent subjects exhibiting various grades of underdeveloped first digital ray were recruited. The affected autopods had narrow palms, medial or valgus inclinations of index fingers and thenar weakness, while the postaxial digits were least affected. According to the classification of hypoplastic thumb by Blauth and Schneider-Sickert (1981), the phenotypes were concordant with types 3 and 4. In one of the subjects there was contralateral preaxial polydactyly. All cases were sporadic and nonsyndromic and parental consanguinity was witnessed in two individuals. Recurrent appearance of similar phenotypes may suggest genetic etiologies which should be elucidated with the help of high-throughput genetic methods.

Atypical Carpal Tunnel Syndrome in a Holt Oram Patient: A Case Report and Literature Review

We present a case report of a patient diagnosed with Holt-Oram syndrome (HOS) presenting with clinical and electrophysiologically confirmed carpal tunnel syndrome. Pre-operative Magnetic resonance imaging revealed an abnormal course of the median nerve; as such an atypical incision and approach were carried out to decompress the nerve to excellent post operative clinical effect. To our knowledge this is the first description of abnormal nervous course in a patient with HOS leading to peripheral entrapment. A literature surrounding the important aspects of HOS to the orthopaedic surgeon is presented concomitantly.

On the classification of congenital thumb hypoplasia

In 1937, Müller introduced the concept of a teratological sequence of thumb hypoplasia with increasing severity from mild deficiency, through severe deficiency, to thumb absence. Blauth subsequently detailed five specific grades. In 1992, Manske and McCarroll altered Blauth's classification such that Grade 3 was sub-divided into Grades 3A and 3B, according to a presence or absence of the proximal metacarpal. Buck-Gramcko added a Grade 3C in which there was only a remnant metacarpal head. This article investigates their publications and those of others to identify 'who said what' and clarify the definitions of grades of thumb hypoplasia. A modification of Blauth's classification is proposed, which retains the integrity of the concept of Müller and the skeletal and soft tissue grading of Blauth, but which also incorporates the disparate anomalies that may present in Grades 2 and 3 hypoplastic thumbs.

Study of non-syndromic thumb aplasia in six independent cases

OBJECTIVES

To report on six independent and isolated cases demonstrating thumb aplasia as an essentially limb-specific phenotype.

METHODS

The subjects were ascertained during 2011-2013 from six different geographic regions of Pakistan, and underwent detailed clinical and phenotypic examination.

RESULTS

The affected arms of patients had complete absence of first digital rays, medial inclinations of second and fifth fingers, narrowing of palms, missing carpals, and shortening of zeugopod. All the subjects were presented with isolated and sporadic limb deficiencies, and five had no family history of limb or any other malformation. Parental consanguinity was denied in majority of the cases. We present detailed phenotypic manifestation of thumb apalsia in these subjects.

CONCLUSION

Thumb aplasia markedly impairs the normal function of affected hand. Surgical procedures like pollicisation of the index finger should be employed to improve the quality of life of these subjects. There is so far no specific genetic factor known for isolated thumb aplasia, compromising an accurate genetic counseling. Collection of patients with similar phenotypic presentations could be useful in further molecular genetic investigations.

The added value of measuring thumb and finger strength when comparing strength measurements in hypoplastic thumb patients

BACKGROUND

When interventions to the hand are aimed at improving function of specific fingers or the thumb, the RIHM (Rotterdam Intrinsic Hand Myometer) is a validated tool and offers more detailed information to assess strength of the involved joints besides grip and pinch measurements.

METHODS

In this study, strength was measured in 65 thumbs in 40 patients diagnosed with thumb hypoplasia. These 65 thumbs were classified according to Blauth. Longitudinal radial deficiencies were also classified. The strength measurements comprised of grip, tip, tripod and key pinch. Furthermore palmar abduction and opposition of the thumb as well as abduction of the index and little finger were measured with the RIHM.

FINDINGS

For all longitudinal radial deficiency patients, grip and pinch strength as well as palmar abduction and thumb opposition were significantly lower than reference values (P<0.001). However, strength in the index finger abduction and the little finger abduction was maintained or decreased to a lesser extent according to the degree of longitudinal radial deficiency. All strength values decreased with increasing Blauth-type. Blauth-type II hands (n=15) with flexor digitorum superficialis 4 opposition transfer including stabilization of the metacarpophalangeal joint showed a trend toward a higher opposition strength without reaching statistical significance (P=0.094),however compared to non-operated Blauth-type II hands (n=6) they showed a lower grip strength (P=0.019).

INTERPRETATION

The RIHM is comparable in accuracy to other strength dynamometers. Using the RIHM, we were able to illustrate strength patterns on finger-specific level, showing added value when evaluating outcome in patients with hand related problems.

Management of congenital radial longitudinal deficiency: controversies and current concepts

SUMMARY

Radial longitudinal deficiency is a spectrum of upper extremity dysplasia and hypoplasia affecting the proximal arm and the radial aspect of the forearm, wrist, and hand. Often, the hand surgeon is the first to evaluate a patient with radial longitudinal deficiency and thus must be aware of its common associated syndromes. Specific evaluation, including clinical examination and laboratory testing, is necessary. At this time, there are many surgical approaches that can be used for treatment of radial longitudinal deficiency. The procedures should be specifically tailored to the patient and family to improve overall function and clinical outcome.

[Unilateral congenital absence of the carpal scaphoid associated with dysplasia of the capitate. Presentation of a case]

We report on a case of aplasia or unilateral congenital absence of the carpal scaphoid associated with dysplasia of the capitate. Congenital absence of the carpal scaphoid is a rare but well-documented condition. As far as we know, the present case is the seventh one reported in the medical literature. Imaging studies (X-ray and MRI) confirmed the absence of the carpal scaphoid associated with a dysplasia of the capitate and malformation of the radial styloid process. Congenital absence of the scaphoid when other congenital abnormalities (such as hypoplasia or aplasia of either forearm bones or thenar eminence, malformations of the skeletal elements of the thumb, absence of sesamoid bones or abnormal development of the forearm bones) do not exist is probably the main feature of the present case report.

Characteristics and associated anomalies in radial ray deficiencies in Finland--a population-based study

Upper-limb defects with deficiencies of the radial ray have varying etiologies, with a low proportion of true Mendelian disorders. We carried out a population-based study to elucidate the birth prevalence and clinical spectrum of radial ray deficiencies in Finland. We identified all births with radial ray deficiency reported to the Finnish Register of Congenital Malformations in 1993-2005. Altogether 138 cases were identified (123 live births), with a birth prevalence of 1.83 per 10,000 births and a live birth prevalence of 1.64 per 10,000 live births. The proportion of infant deaths was as high as 35%. The majority of the cases were associated with known syndromes or multiple anomalies; only 13% were true isolated radial ray deficiencies. The most common syndrome was trisomy 18, and the most common in multiple anomalies was VACTERL association. In 8.7% of cases an association between radial ray deficiency and heart anomaly was observed. The high proportion of cases with associated major anomalies indicates that radial ray deficiency can be regarded isolated only after thorough assessment of the various organ systems in an affected infant.

Holt-oram syndrome associated with double outlet right ventricle: A rare association

Holt-Oram syndrome is a rare inherited disorder that causes abnormalities of the hands, arms, and the heart. Most commonly, there are defects in the carpal bones of the wrist and in the bones of the thumb along with cardiac defects such as atrial or ventricular septal defects. We report a case of Holt-Oram syndrome with a rare association of double outlet right ventricle.

Blauth II thumb hypoplasia: a management algorithm for the unstable metacarpophalangeal joint

Blauth Type II thumb hypoplasia is defined by first web space narrowing, deficiency of thenar musculature, and instability of the metacarpophalangeal joint (MCPJ). This instability can be uni-axial (type IIA) or multi-axial (type IIB). The aim of this study was to assess the results of treating type II thumb hypoplasia using an algorithm based on the type of instability present. Cases of uni-axial MCPJ laxity (type IIA) underwent stabilization as part of a flexor digitorum superficialis opposition transfer. Type IIB cases with multi-axial instability were treated with an MCPJ chondrodesis and an abductor digit minimi transfer for opposition. First web space release was achieved using a z-plasty approach in all patients. An analysis was carried out of all cases of type II thumb hypoplasia treated by the senior author within the setting of a tertiary referral children's hospital over a 9 year period. Using our management algorithm, equivalent functional results were seen in each subgroup in terms of first web space release, MCPJ stabilization, and opposition.

Incidence of Fanconi anemia in children with congenital thumb anomalies referred for diepoxybutane testing

PURPOSE

Fanconi anemia (FA) is a rare genetic disorder of DNA repair that with near uniformity leads to bone marrow failure and resulting morbidity and mortality. Approximately 50% of FA patients are born with anomalies of the thumb or thumb and radius, and it has been recommended that all patients born with thumb anomalies undergo testing. However, the risk of FA in this population is unknown. We determined the incidence of FA in children with congenital thumb anomalies referred for FA testing and characterized those who tested positive.

METHODS

We queried our database for patients who presented with congenital thumb anomalies and who underwent diepoxybutane (DEB) testing for FA between 1999 and 2008 at Children's Hospital Boston and the Dana-Farber Cancer Institute.

RESULTS

During this time period, 543 congenital thumb anomaly patients (235 with thumb hypoplasia) presented to our institution. A total of 81 patients with thumb abnormalities underwent DEB testing. Six patients (7% of those tested; 1% of the total; 3% of thumb hypoplasia patients) had a positive DEB test consistent with the diagnosis of FA; all had other non-upper-extremity anomalies associated with FA. Of 6 FA patients, 5 had bilateral involvement; all had some degree of thumb hypoplasia (3 also had radial dysplasia). Mean age at testing was 2.6 years (SD 4.3). Most of the patients tested had multiple physical anomalies (n = 66). The anomaly distribution was: thumb hypoplasia and radial dysplasia (n = 29), thumb hypoplasia (n = 26), radial polydactyly (n = 12), radial polydactyly and radial dysplasia (n = 1), and proximally placed thumb and radial dysplasia (n = 1). Twelve patients had other thumb anomalies.

CONCLUSIONS

Although the incidence of FA in patients with thumb anomalies may be low, patients with thumb hypoplasia and other physical findings associated with FA, specifically café au lait spots and short stature, appear to have an increased risk of FA. Because hand surgeons see these patients early in life, they have the opportunity to refer these patients for FA testing to initiate early education, family genetic counseling, and treatment if warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Treatment of common congenital hand conditions

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Recognize the clinical features associated with five common congenital hand conditions. 2. Describe the indications and appropriate timing for various surgical procedures used to treat congenital hand anomalies. 3. Identify the pearls and pitfalls of these surgical treatments to avoid complications. 4. Understand the expected postoperative outcomes associated with these surgical procedures.

SUMMARY

This article provides an introduction to congenital hand differences by focusing on practical surgical strategies for treating five commonly encountered conditions, including syndactyly, constriction ring syndrome, duplicated thumb, hypoplastic thumb, and trigger thumb. The accompanying videos demonstrate common and reliable surgical techniques for syndactyly release, duplicated thumb reconstruction, and pollicization for hypoplastic thumb.

Abductor digit minimi opponensplasty: technique, modifications, and measurement of opposition

The abductor digiti minimi is one of several muscles described as transfers for restoration of thumb opposition, a critically important function. This operation, also known as the Huber opponensplasty, is most commonly used for reconstruction of opposition in children with type 2 or 3a thumb deficiency, when it is often combined with Z-plasty of the thumb-index web space and metacarpophalangeal ulnar collateral ligament reconstruction. In our experience this operation reliably improves thumb opposition for children with this thumb deficiency.

Reconstruction of the hypoplastic thumb

Thumb hypoplasia is characterized by diminished thumb size, metacarpal adduction, metacarpophalangeal joint instability, thenar muscle hypoplasia or aplasia, extrinsic tendon dysplasia, and in the most severe cases, carpometacarpal joint instability or thumb aplasia. Severe thumb hypoplasia and aplasia are best treated by thumb ablation and pollicization of the index finger. Less severe thumb hypoplasia can be reconstructed by a combination of soft tissue release, first web space local flap coverage, metacarpophalangeal joint collateral ligament and capsule reconstruction, extrinsic tendon tenolysis, and muscle or tendon transfers.

Thumb hypoplasia

Hypoplasia of the thumb refers to a spectrum of clinical abnormalities ranging from a slightly small digit to complete absence (or aplasia) of the thumb unit. As a component of radial dysplasia, thumb hypoplasia can be either an isolated entity or seen in conjunction with other elements of radial longitudinal deficiency. Treatment of this condition initially involves identifying and addressing co-morbid anomalies in other body systems. The severity of thumb hypoplasia is then graded so that appropriate treatment methods can be instituted. The goal of treatment is ultimately to provide the child with a stable and functional thumb unit.

Congenital thumb deformities and associated syndromes

Upper limb defects occur in approximately 3.4 per 10,000 live births. Major thumb defects represent 16% of these upper limb defects (Tay SC, Moran SL, Shin AY, et al. The hypoplastic thumb. J Am Acad Orthop Surg 2006;14:354-366). Embryologically, hand development begins by the fifth week. This occurs simultaneously with the growth and development of the cardiovascular, neurologic, and hematopoietic systems. Therefore, congenital anomalies seen in the hands of infants may indicate significant anomalies in these other systems, requiring a comprehensive physical evaluation. Although the cause of 40% to 50% of congenital hand anomalies is unknown (Gallant GG, Bora FW. Congenital deformities of the upper extremity. J Am Acad Orthop Surg 1996;4:163-171), several others have traced this to specific genetic mutations. Others are due to a variety of teratogenic effects (Sadler TW. Langman's Medical Embryology. 10th ed. Philadelphia: Lippincott Williams &Wilkins, Chapter 9, 2006:125-142). For the clinician, this paper has been organized to identify possible corresponding syndromes that may accompany specific thumb deformities.

Congenital failure of formation of the upper limb

This article provides an overview of the various classification systems for radial longitudinal, central longitudinal, and ulnar longitudinal deficiencies. It looks specifically at radius deficiency, hypoplastic thumb, index finger pollicization, narrowed thumb web, forearm-elbow deformities, and hand abnormalities. Various surgical approaches to these conditions and their results are explored. The authors conclude that longitudinal failure of formation deformities comprises a substantial portion of the anomalies of the upper limb. Although much of the past and current congenital hand literature has been devoted to these conditions, they continue to be a reconstructive challenge to hand surgeons involved in their care.

Reconstruction of the type IIIA hypoplastic thumb

The management of the hypoplastic thumb depends on the degree of bony malformation, soft tissue anomaly, and deficiencies. Type IIIA thumbs have thumb-index web-space narrowing, hypoplasia of the thenar musculature, metacarpophalangeal joint instability, and extrinsic tendon abnormalities. They also have a hypoplastic metacarpal with a stable carpometacarpal joint, differentiating them from type IIIB thumbs which have an unstable carpometacarpal joint due to partial metacarpal aplasia. Whereas type IIIB thumbs are best treated with ablation and index pollicization, type IIIA thumbs are amenable to reconstruction. Many techniques have been described for correction of the variety of deformities found in theses thumbs. The purpose of this article is to present our preferred technique for comprehensive reconstruction of type IIIA thumbs.

Intercarpal degenerative arthritis in adulthood as a late consequence of unilateral congenital aplasia of the scaphoid: a case report

We report a case of unilateral congenital aplasia of the carpal scaphoid bone discovered in adulthood, which probably caused a severe painful intercarpal degenerative arthritis. This case was not associated with hypoplasia or aplasia of thenar and forearm muscles, abnormality of the skeleton of the thumb ray, absence of the sesamoid bones, hypoplasia of the forearm bones, as in cases reported in the literature; the only additional anatomic abnormality was a mild hypoplasia of the radial styloid. A surgical treatment (4-bone arthrodesis) has been performed to treat the advanced carpal collapse and the arthritis.

Radial longitudinal deficiency

Radial longitudinal deficiency encompasses a spectrum of upper limb dysplasias and hypoplasias. The bony abnormalities of the thumb and radius are the most pronounced, but deficiencies of the accompanying muscles, nerves, vessels, and joints also greatly influence the ultimate upper extremity function. The striking clinical presentation of the involved upper limb is often more obvious than the potentially life-threatening associated systemic conditions. All children presenting with radial longitudinal deficiency, regardless of severity, require a renal ultrasound, echocardiogram, and complete blood count to evaluate the potential for associated systemic conditions; these include Fanconi's anemia, the Holt-Oram syndrome, and the VATER (vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal agenesis) syndrome or VACTERL (vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal agenesis, and limb defects) association. The overall health of the child, as well as the severity of the osseous and soft-tissue deformities of the affected limb, guides the long-term treatment plans.

Radial longitudinal deficiency: the incidence of associated medical and musculoskeletal conditions

PURPOSE

Radial longitudinal deficiency (RLD) is associated with certain syndromes and medical and musculoskeletal conditions. The purpose of this investigation was to evaluate the incidence of these conditions with RLD.

METHODS

A comprehensive chart review identified patients with RLD and a complete medical record. These charts were evaluated for the presence of associated medical and musculoskeletal conditions and biographic information on gestation, delivery, and family history.

RESULTS

A total of 164 patients with 245 affected extremities were identified; 138 patients had radius abnormalities and 26 patients had isolated thumb hypoplasia. Twenty-five patients had thrombocytopenia absent radius syndrome; 22 patients had vertebral, anal, cardiac, tracheoesophageal, renal, and limb abnormalities association; 7 patients had Holt-Oram syndrome; and 1 patient had Fanconi anemia. There were 32 patients with cardiac abnormalities and 60 patients with spinal or lower-extremity musculoskeletal abnormalities. The percentage of patients with associated abnormalities increased with an increasing severity of RLD. One hundred two of the 138 patients with types I through V RLD had associated medical or musculoskeletal abnormalities. In contrast, only 9 of 26 patients with an isolated thumb hypoplasia (type 0 RLD) had associated abnormalities.

CONCLUSIONS

The high incidence of associated medical and musculoskeletal abnormalities in patients with RLD emphasizes the importance of a complete assessment including a complete musculoskeletal examination, cardiac auscultation, complete blood count, echocardiogram, renal ultrasound, and spinal radiographs. Although approximately one third of patients in this investigation had a syndrome commonly associated with RLD, most patients with RLD types I through V had an additional medical or musculoskeletal anomaly. Patients with type 0 RLD were less likely to have comorbidities.

The hypoplastic thumb

Thumb hypoplasia is part of a spectrum of radial longitudinal deficiencies involving the upper limb. Systemic involvement of other organ systems is not uncommon, thus requiring a team approach to management. Because of the variety of anatomic abnormalities associated with thumb hypoplasia, clinical and intraoperative evaluation of the thumb must be precise. Effective management of thumb hypoplasia requires an understanding of the embryology, epidemiology, classification, presentation, and management options. Management, which is primarily determined by the grade of thumb hypoplasia, may include nonsurgical techniques, reconstruction, pollicization, and, recently, microsurgical procedures.

[Thumb hypoplasia]

All the components of the thumb can be involved in congenital hypoplasia. Blauth's classification continues to be helpful for description of the degree of hypoplasia leading to different options of surgical reconstruction. Surgical strategy includes first web deepening, MP ligamentoplasty, thenar augmentation using tendon transfer and correction of associated abnormalities involving the extensor and flexor tendons. For grade IIIB and grade IV, recommended option for reconstruction is index finger pollicisation.

The association of radial deficiency with thumb hypoplasia

BACKGROUND

Congenital longitudinal deficiencies of the radius and thumb are known to be associated with one another; however, the details of their relationship are unknown. The purpose of this study was to determine whether increased severity of radial deficiencies is associated with increased severity of thumb deficiencies and to review the relationship between radial deficiency and reconstructibility of a hypoplastic thumb.

METHODS

Radiographs and charts of 227 affected upper extremities of 139 patients with radial longitudinal deficiency were reviewed. The associated thumb deficiency was classified according to a modification of the Blauth and Schneider-Sickert scheme and the radial deficiency was classified according to a modification of the Bayne and Klug criteria for 191 extremities of 119 patients.

RESULTS

The severity of the thumb deficiency was directly proportional to the severity of the radial deficiency (p < 0.0001). Half of the extremities had either a thumb deficiency or thumb and carpal deficiencies without radial deficiency. Two-thirds (sixty-three) of the ninety-five limbs with a normal radius had a thumb that could be surgically reconstructed. Seventy-one (91%) of seventy-eight extremities with a thumb amenable to surgical reconstruction had a radius that did not require surgical reconstruction. All extremities with a radial and/or carpal deficiency had a thumb deficiency. Forty-eight (94%) of fifty-one extremities with complete absence of the radius had a thumb that was not reconstructible.

CONCLUSIONS

This study supports the growing body of evidence that the components of radial longitudinal deficiency represent a progressive spectrum of upper extremity abnormalities, and a distal progression of severity, with distal structures likely to be more involved than proximal structures.

Abductor digiti minimi musculocutaneous island flap as an opposition transfer: a case report

We described the use of an abductor digiti minimi musculocutaneous (ADM) island flap as an opposition transfer. This procedure is easy and safe, and provides more of a bulge in the thenar area than the Huber transfer. This procedure can be used in the treatment of Blauth grade 2 and 3A hypoplastic thumb.

The spectrum of radial longitudinal deficiency: a modified classification

The records of 119 patients with 196 extremities with radial longitudinal deficiency seen between 1923 and 1996 were reviewed. We propose a global classification system that includes the spectrum of pathology affecting the radial side of the extremity, including deficiency of the radius, carpal abnormalities, and hypoplastic thumbs. Radial deficiency could be classified for 181 extremities of 104 patients using this classification system. Type N has a normal length radius and a normal carpus with thumb hypoplasia, type O has a normal length radius and radial side carpal abnormalities, type 1 has more than 2 mm shortening of the radius, type 2 has a hypoplastic radius, type 3 has a partial radius with absence of the distal physis, and type 4 has complete absence of the radius. All patients had thumb hypoplasia. Eighty-two percent of extremities with thumb hypoplasia but no deficiency of the radius that were available for carpal bone classification had carpal anomalies, including absence, hypoplasia, and coalitions. All the extremities with type 1 radial deficiency had carpal anomalies. Carpal abnormalities could not be determined for types 2, 3, and 4 deficiency because most had a prior centralization. Proximal radioulnar synostosis or congenital dislocation of the radial head was seen in 44% of extremities with type 1 radial deficiency. This classification includes carpal anomalies and thereby links isolated thumb hypoplasia and deficiency of the radius into one system.

Advanced carpal collapse associated with congenital hypoplastic thumb

We present the long term sequelae of two patients with congenital hypoplastic thumbs. Neither had surgical correction in childhood, but maintained adequate function in their hands. However, both have developed progressive carpal collapse in adulthood, leading to painful wrists.