An alternative method to reconstruct grade-3 hypoplastic thumb by hemi-metacarpal transfer

We designed a new method using hemi-longitudinal second metacarpal bone to reconstruct grade-3 hypoplastic thumbs. Seven patients were treated in two stages. In the first stage, the second metacarpal was split longitudinally and transferred to reconstruct the first metacarpal. In the second stage, opponensplasty was performed by transferring the FDS tendon. Bone union was achieved in all cases. All patients could oppose to their middle finger at least. They managed to do daily activities such as writing, eating, using smartphones and so on. This is a useful procedure to preserve a 5-digit hand with good function in treating grade-3 hypoplastic thumbs, with no harm to the foot and no need for vascular anastomosis. LEVEL OF EVIDENCE: IV.

Intraoperative Observation of the Proper Digital Nerves in Wassel-Flatt Type Ⅳ Radial Polydactyly

PURPOSE

The aim of the study was to present the intraoperative findings of the relevant digital nerves of the duplicated thumbs in an excision and reconstruction procedure for the Wassel-Flatt type Ⅳ radial polydactyly.

METHODS

The study was conducted on patients with Wassel-Flatt type IV radial polydactyly who underwent excision and reconstruction between 2018 and 2021 at our institution. The ulnar digital nerve of the radial thumb and the radial digital nerve of the ulnar thumb were identified and traced intraoperatively. The level of the bifurcation of the nerves and abnormal findings were documented.

RESULTS

A total of 123 hands in 119 patients were included in this study. In 114 hands, the bifurcation of the nerves was located within 1 cm of the metacarpophalangeal flexion crease. The radial digital nerve to the ulnar thumb was abnormally compressed in deep fascial tissue in 7 of these 114 hands. In 5 hands, the level of bifurcation was more than 1 cm proximal to the crease. No radial digital nerve to the ulnar thumb was identified in the remaining 4 hands.

CONCLUSIONS

Although rare, abnormal nerve compression of the digital nerve may exist in duplicated thumbs of Wassel-Flatt type IV radial polydactyly.

CLINICAL RELEVANCE

In an excision and reconstruction procedure, we suggest that the bifurcation of the nerves should be identified before the nerve to the radial thumb is excised to avoid injuring the nerve to the main ulnar thumb.

Performance Outcomes and Return to Sport Following Metacarpal Fractures in Major League Baseball Players

BACKGROUND

Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers.

METHODS

Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed.

RESULTS

Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) (P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort.

CONCLUSIONS

Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.

Postoperative Immobilization of Scaphoid Fractures: A Comprehensive Review of the Literature

The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. Reports of successful management with brief postoperative immobilization suggest that earlier restoration of function may be achieved by limiting the duration of immobilization. However, the risk of nonunion and its associated complications suggest that a more conservative approach with extended immobilization could optimize fracture healing. This paper presents a thorough review of the relevant literature and summarizes the myriad postoperative immobilization protocols and their reported outcomes. Postoperative immobilization protocols and reported outcomes for displaced, comminuted, and proximal pole fractures are discussed separately. The literature is reviewed following different operative techniques, including open reduction internal fixation and percutaneous screw fixation. Vigilant postoperative care of scaphoid fractures managed surgically is warranted to monitor for signs of nonunion while attempting to regain motion and strength to the injured wrist.

A Customised paediatric thumb web splint for management of adduction contracture of thumb

The thumb web has a unique anatomy, the integrity of which is vital to both form and function of the hand. Thumb web space adduction contractures are a common consequence of hand burns and are a progressive disabling deformity and prevention or early intervention is advisable. This case describes the use of a customised removable web splint in children with scarring and gradual contracture of the first web space causing pain with movement and significant restriction in the hand function to maintain the thumb web expansion. This inexpensive and effective appliance can be safely applied to an injured hand, maintain web space following surgical release and allows movement at the first carpometacarpal joint and hence obtains a good functional outcome.

Volar Plating of Scaphoid Fractures: A Retrospective Case Series

BACKGROUND

The purpose of this study was to evaluate the rate of union of scaphoid fractures managed with volar plating and assess postoperative complications.

METHODS

Retrospective consecutive case series of 28 patients with scaphoid fractures, 9 acute and 19 chronic nonunions, undergoing surgical fixation with volar scaphoid plating by a single surgeon between 2013 and 2019. Patients were followed up for a minimum of 3 months with scaphoid bony union being confirmed on radiograph or computed tomography. Postoperative complications and need for plate removal were recorded.

RESULTS

Overall union rate of 96% with all 19 chronic nonunions demonstrating radiological union and 1 of 9 acute fractures not uniting and requiring revision surgery. The only postoperative complication identified was symptomatic plate impingement which necessitated plate removal in 57% of cases.

CONCLUSIONS

This case series demonstrates volar plating of scaphoid fractures can be used as an alternative technique to achieve union.

Prevalence of Hand Malformations in Patients With Moebius Syndrome and Their Management

BACKGROUND

Moebius syndrome is a disorder characterized by facial and abducens nerve paralysis. Patients can present a wide range of upper extremity malformations. Literature focused on orthopedic manifestations of Moebius syndrome shows variability in the prevalence and clinical presentation of upper extremity anomalies. The aim of this work is to evaluate the prevalence of upper extremity malformations in patients with Moebius syndrome, clarify its various clinical presentations, and present treatment strategies for their management.

METHODS

This is a retrospective, cross-sectional study including patients with Moebius syndrome and upper extremity malformations between 2012 and 2019. Data include demographic characteristics, Moebius syndrome subtype, type of malformation, affected extremity, and surgical procedures underwent. Quantitative data were recorded as mean (standard deviation [SD]), and qualitative data were expressed in terms of totals and percentages. Statistical association between Moebius syndrome subtype and development of upper extremity anomalies was evaluated using binary logistic regression.

RESULTS

Twenty-five out of 153 patients (16.3%) presented upper extremity malformations (48% male). Mean age of presentation was 9.08 ± 9.43 years. Sixty-eight percent of the malformations were unilateral. The most common presentations included Poland syndrome and simple syndactyly with 8 cases each (32%), followed by 5 cases of brachysyndactyly (20%), 3 cases of amniotic band syndrome (12%), and 1 case of cleft hand (4%). No statistical association was found between Moebius syndrome subtype and odds ratio for development of upper extremity anomalies. Thirteen patients (52%) underwent reconstructive procedures.

CONCLUSION

Poland syndrome and syndactyly are the most common anomalies in patients with Moebius syndrome. Patients may present with a wide range of hand malformations, each patient should be carefully evaluated in order to determine whether surgical treatment is needed and to optimize rehabilitation protocols.

First dorsal interosseous muscle transfer to restore opposition of the new thumb after index pollicization: anatomical description of an original technique and case report

Index pollicization in severe thumb hypoplasia or aplasia in children or for the reconstruction of a mutilated thumb in adults is a rare and technically demanding procedure. Weakness of the new thumb is routinely reported after index pollicization. An inappropriate position of the first dorsal interosseous muscle (FDIM) can partly explain this strength deficit. Here, we report an original anatomical study on FDIM transfer for reanimation of the new thumb's opposition function and its clinical application. An anatomical study was carried out on three upper limbs from fresh, non-embalmed adult cadavers. We demonstrated the feasibility of an FDIM transfer pedicled on the proper FDIM artery and the deep branch of the ulnar nerve. The proximal FDIM insertions were sutured to the lateral border of the flexor retinaculum to recreate the superficial thenar musculature. This procedure was performed on a 52-year-old man who was referred to us with swelling on his hand. We discovered a myxoid inflammatory fibroblastic sarcoma of the thumb that required proximal thumb amputation while preserving the base of the first metacarpal. To our knowledge, this is the first description of FDIM pedicled flap transfer during an index pollicization procedure among an adult population. However, in severe thumb hypoplasia or aplasia cases, this procedure is limited by the size and anatomical variations of the neurovascular structures among a population affected by radial longitudinal deficiency.

Open-wedge osteotomy for thumb radial angulation in Apert syndrome using a bone-graft substitute

A short thumb with radial angulation causes loss of hand function in patients with Apert syndrome. Although past reports have described various procedures for the correction of the thumb, there has been no consensus on the best procedure. This study aimed to assess the clinical and radiographic results of a surgical technique for the correction of a thumb radial angulation deformity: open-wedge osteotomy using a bone-graft substitute. Ten patients (18 thumbs) who underwent open-wedge osteotomy on the proximal phalange using a bone-graft substitute were evaluated retrospectively. The open-wedge osteotomies had been performed at the center of the proximal phalanx. Thumb radial angles and thumb lengths were measured on radiographs, and the clinical results were investigated, including bone union and complications. The median patient age at the time of surgery was 5.8 years, and the average follow-up period was 6.7 years. The average thumb radial angle was 57.3° preoperatively, 6.5° immediately postoperatively, and 19.8° at the most recent follow-up. The average thumb length was 12.1 mm preoperatively, 18.1 mm immediately postoperatively, and 22.3 mm at the most recent follow-up, indicating an extension effect of more than 50% immediately postoperatively. In all cases, the artificial bone had been absorbed and developed into autologous bone, and there were no complications such as infection and skin necrosis. These findings suggest that open-wedge osteotomy with an artificial bone substitute is simple and effective for treating radial-angulation deformities in patients with Apert syndrome. Level of evidence: Level IV - retrospective case series.

Improving Metacarpophalangeal Joint Instability by Joint Implantation in Parallel From a Supernumerary Thumb in Severely Hypoplastic Duplicated Thumbs

ABSTRACT

Here, we present 2 cases of a severely hypoplastic duplicated thumb classified as Wassel types 5 and 6 and discuss whole-joint implantation from a supernumerary thumb as an alternative to stabilize the hypoplastic metacarpophalangeal (MCP) joint. The aim of the surgical treatment of thumb polydactyly is to reconstruct a functional and aesthetically pleasing thumb. Hypoplasia of joint components and abnormal tendon alignment lead to unpleasing results with angular deformity of the reconstructed thumb. In 2 cases, the MCP joint of the dominant digit was hypoplastic and unstable in all directions. The main problem was underdevelopment of the affected MCP joint, and it was reasonable to attempt to stabilize the unstable joint by adding another redundant joint in parallel. Whole-joint implantation with a flap on a vascular pedicle is useful to repair both joint instability and soft tissue hypoplasia, as in case 1. The vascularized joint can maintain balanced growth potential. However, nonvascularized interphalangeal (IP) joint implantation is a simple solution for repairing MCP joint instability, as in case 2. These joints have no tendon insertions, so we believe they are acting as a splint supporting the hypoplastic joint for a long period. The transfer of composite tissues from the foot has been reported for reconstruction of finger and thumb hypoplasia. Duplicated thumb operation is usually recommended at 1 year old. Similarly, nonvascularized joint implantation in parallel may be a promising choice to overcome MCP joint instability and to maintain range of motion in hypoplastic cases with a duplicated thumb.In conclusion, joint implantation in parallel from a supernumerary thumb could prevent angular deformity and is an alternative to overcome MCP joint instability in cases of a severely hypoplastic duplicated thumb without any donor morbidity.

Vascularized Toe Joint Transfer for Hypoplastic Thumb Type IV

Vascularized toe joint transfer can be an alternative treatment for children who have hypoplastic thumb with unstable carpometacarpal joint and refuse thumb ablation with index pollicization. This procedure can reconstruct a 5-digit hand with stable thumb for opposition. As the viable epiphyseal plate is included in this transfer, the potential for future growth can be expected from this type of reconstruction. This article describes details of the surgical procedures. The outcomes of this reconstruction are shown in a 7-year-old girl who presented with hypoplastic thumb type IV. Initially, her thumb was unstable, nonmobile, and had no function. The skin pedicle of this thumb had a diameter of about 3 mm. Preoperative radiography showed floating thumb without first metacarpal bone. The vascularized metatarsophalangeal joint from the opposite second toe was used for her hypoplastic thumb reconstruction. During the procedure, the flail thumb was preserved. The intraoperative bone gap that was needed for reconstruction was 3.5 cm. The artery was anastomosed with common digital artery from the third web space. Two dorsal veins were joined with the subcutaneous vein at the dorsum of the hand. Total operative time was 6 hours. At the 9-month follow-up, this girl achieved a 5-digit hand with stable thumb that had opposition to the tip of her little finger. She can use this hand to perform all activities of daily living without any pain. Both patient and parents were very satisfied with the functional and cosmetic appearance.

Hand Deformities in the Paintings of Giacomo Ceruti (1698-1767), Nicknamed 'il Pitocchetto' for his Depictions of the Poor

Giacomo Ceruti was a renowned painter in northern Italy during the middle third of the 18th century, although he is not well-known today. He produced pictures in several different genres but his reputation after his death was based primarily on his portrayal of beggars and poor working people; hence, his posthumous nickname, il Pitocchetto, the little beggar. Of medico-artistic interest is the realism with which he depicted the hands of his impoverished subjects, a quality that enables them to be examined for signs of pathology or trauma. The present article displays some representative examples of hand deformities in Ceruti's paintings, thus extending into the 18th century the authors' previous research on medical aspects of art works from the 15th to the 17th century.

[Application of anterograde fascial flap of digital artery in Wassel -D thumb duplication reconstruction]

Objective

To explore the effectiveness of anterograde fascial flap of digital artery in reconstruction of Wassel Ⅳ-D thumb duplication.

Methods

Twelve cases of Wassel Ⅳ-D thumb duplication were treated with anterograde fascial flap of digital artery between June 2014 and March 2017. There were 7 boys and 5 girls with an age of 9-32 months (mean, 13.3 months). Eight cases were on the left side and 4 cases on the right side. The main bunion bed width was 70%-85% of the healthy side (mean, 75.3%). The degree of fullness was 50%-75% of the healthy side (mean, 62.4%). The anterograde fascial flap with one proper digital artery was used to fill the nail fold on the radial side of the finger and increase the circumference of the finger. At last follow-up, the ratio of abdominal circumference of deformed finger to contralateral finger was measured at the base of nail. The appearance and function of all reconstructed thumbs were evaluated with Japanese Society for Surgery of the Hand (JSSH) scoring.

Results

All the operations were successfully completed without early complications such as infection and skin necrosis. All children were followed up 7-27 months (mean, 14.3 months). At last follow-up, there was no recurrence of deformity in the digital body and no obvious change of scar contracture in the surgical wound. Pulp and nail fold symmetry was improved in all cases. The ratio of abdominal circumference of deformed finger to contralateral finger was 93%-96% (mean, 94.7%). The JSSH score was 15-20 (mean, 17.9); the results were excellent in 8 cases, good in 2 cases, and fair in 2 cases.

Conclusion

The anterograde fascial flap of digital artery is a safe and effective approach to restore symmetry for esthetic improvement in treatment of Wassel Ⅳ-D thumb duplication.

Rubinstein-Taybi Syndrome in a 19-years old boy

INTRODUCTION

Rubinstein-Taybi syndrome is a rare genetic multisystem disorder comprising motor organ dysfunction, craniofacial dysmorphism and psychomotor retardation, frequently with the abnormalities of the thyroid gland.

OBJECTIVE

Presentation of a case of a 19-year-old patient with Rubinstein-Taybi syndrome in whom serum TSH, fT3 and fT4 levels were assessed.

CASE

Craniofacial abnormalities including: microcephaly, underdeveloped maxilla, micrognathia, high arched palate, malocclusion, down-slanting palpebral fissures, thick eyelashes and full eyebrows. Clinodactyly, broad thumbs and toes were observed in the musculoskeletal system. The patient presented with moderate mental retardation, short stature and obesity. Furthermore, I° thoracolumbar scoliosis, elbow joint deformation resulting from the radial head dislocation and limitation of the right hip motion as a consequence of Perthes disease were found. Genetic testing revealed a mutation affecting the CREBBP gene located on the short arm of chromosome 16. The measured serum TSH level was 1.510 μlU/ml (normal range 0.27-4.20), fT3 5.1 pmol/l (normal range 4.1-6.7), fT4 15.5 pmol/l (normal range 13.1-21.3). The patient is subjected to long-term rehabilitation.

CONCLUSIONS

The obtained results of laboratory tests of serum TSH, fT3 and fT4 levels point to a lack of thyroid gland dysfunction in the patient with Rubinstein-Taybi syndrome. Rehabilitation treatment of patients with RTS is necessary to improve the patient's mobility.

Handedness may be related to variations in palmar arterial arches in humans

INTRODUCTION

The superficial and deep palmar arterial arches are the main sources of blood supply to all structures in the human hand, and variations in these arterial arches are quite common. Although several studies have reported diameters and variations of these arches, to the authors' knowledge, no study has correlated such changes to handedness in adults. It is likely that dominance may play a role in arterial variations, such as those seen in the diameter or number of arteries formed in the palmar arches, much like in other areas of the human body. This cadaver study was conducted to determine any such association.

METHODS

42 formalin-fixed hands were dissected to expose the superficial and deep palmar arches. These arches were then thoroughly examined for any variations between the dominant and non-dominant hands. All cadavers were noted to be right-handed as per hospital records.

RESULTS

19 complete superficial arterial arches (right hand 14; left hand 5) were found in the 42 hands dissected.

CONCLUSION

Most complete superficial palmar arches were found in the dominant hand of the cadavers studied, and therefore, handedness may have a role to play in determining palmar arterial arch variations in humans. Due to dominance or handedness, some arteries may likely persist into adulthood while others may become obliterated, thus leading to variations. Dissection of foetal hands may help to shed more light on the persistence or obliteration of various arteries after birth. Knowledge of such variations may prove helpful for surgeons during hand surgeries.

Legg-Perthes disease-like joint involvement and diagnosis delay in Scheie syndrome: a case report

Mucopolysaccharidosis (MPS) type I is an inherited disease caused by the absence or malfunctioning of lysosomal enzymes. Three subtypes, based on severity of symptoms, were described, and Scheie syndrome (also called MPS I S) is the mildest form. Although there may be some typical extra-articular manifestations, musculoskeletal involvement may be the only presenting sign in the absence of other symptoms in the patients with less severe forms. The patients with MPS I S, especially in attenuated phenotypes, may be sometimes difficult to recognize for physicians not familiar with the disease. With this case presentation, it is aimed to draw attention to this disease, which could be delayed for the correct diagnosis. An increased awareness of the disease may contribute to more accurate diagnosis, and patients may benefit from early intervention.

Total absence of the alpha2(I) chain of collagen type I causes a rare form of Ehlers-Danlos syndrome with hypermobility and propensity to cardiac valvular problems

BACKGROUND

Heterozygous mutations in the COL1A1 or COL1A2 gene encoding the alpha1 and alpha2 chain of type I collagen generally cause either osteogenesis imperfecta or the arthrochalasis form of Ehlers-Danlos syndrome (EDS). Homozygous or compound heterozygous COL1A2 mutations resulting in complete deficiency of the proalpha2(I) collagen chains are extremely rare and have been reported in only a few patients, albeit with variable phenotypic outcome.

METHODS

The clinical features of the proband, a 6 year old boy, were recorded. Analysis of proalpha and alpha-collagen chains was performed by SDS-polyacrylamide gel electrophoresis using the Laemmli buffer system. Single stranded conformation polymorphism analysis of the proband's DNA was also carried out.

RESULTS

In this report we show that complete lack of proalpha2(I) collagen chains can present as a phenotype reminiscent of mild hypermobility EDS during childhood.

CONCLUSIONS

Biochemical analysis of collagens extracted from skin fibroblasts is a powerful tool to detect the subset of patients with complete absence of proalpha2(I) collagen chains, and in these patients, careful cardiac follow up with ultrasonography is highly recommended because of the risk for cardiac valvular problems in adulthood.

[Anesthetic management of a patient with Freeman-Sheldon syndrome]

We describe a case of Freeman-Sheldon syndrome that presented some problems for anesthetic management. A 2-yr-old girl required orthopedic surgery for the bilateral lower extremities. Anesthesia was induced via a mask with oxygen (2 l.min-1), nitrous oxide (4 l.min-1) and sevoflurane (approximately 5%). Tracheal intubation by direct laryngoscopy was successfully achieved. Combined caudal epidural block was, however, avoided because spina bifida occulta was suspected. Spina bifida occulta was revealed postoperatively by X-ray. For anesthetic management of a patient with Freeman-Sheldon syndrome, the spine should be evaluated preoperatively when performing epidural/spinal anesthesia.

Triphalangeal thumb in a Bantu family

1 . Three cases of triphalangeal thumb are described in three generations of a Bantu family. In the youngest member both thumbs were affected; in his mother and grandfather only one thumb was abnormal.

2. The literature is reviewed and the etiology of the anomaly is discussed.

3. Attention is drawn to the hereditary tendency of this condition.

Ossicular abnormality in Larsen's syndrome: a case report

Larsen's syndrome consists of a skeletal dysplasia with multiple joint abnormalities and a characteristic facies. No reports of this syndrome have documented hearing loss due to ossicular joint abnormalities. A 6-year-old girl is presented with the characteristic abnormalities of Larsen's syndrome, a normal otoscopic examination, and significant bilateral conductive hearing loss. Exploratory tympanotomy demonstrated an incudostapedial joint abnormality, as well as a fixed stapes footplate. The possibility of ossicular joint abnormalities, in addition to the other joint abnormalities associated with this syndrome, must be considered.