How did you become interested in congenital hand surgery?
In general, at what age do you start operating on a child with a congenital hand abnormality? What considerations do you take into account?
The first condition we’d like to discuss is preaxial polydactyly. This condition is most commonly described using the Wassel classification, which is based on the level of thumb duplication. Briefly, type I is a bifid distal phalanx, type II is a duplicated distal phalanx, type III is a bifid proximal phalanx, type IV is a duplicated proximal phalanx, type V is a bifid metacarpal, type VI is a duplicated metacarpal, and type VII is characterized by triphalangism
– When evaluating a child with thumb duplication, what are you looking for on XR and physical exam to determine the surgical approach?
– Can you describe the general principles you think through when planning surgery?
— How important is it to maintain the UCL?
— How to you reconstruct the RCL?
— Do you often need to perform extensor or flexor tendon transfers?
— What is the role of corrective osteotomies in preventing postoperative angular deformities?
— When would you consider the Bilhaut-Cloquet procedure? The procedure entails resection of the central portions in the duplicated digits and fusion of the retained peripheral portions of the digits to form a single thumb. In cases when one thumb is better developed proximally, while the other thumb is better developed distally, an on-the-top plasty may be used to combine the two portions into one digit.
– When do you begin active ROM post-operatively?
The next thumb difference we’ll cover is thumb hypoplasia, which is described using the Blauth classification. Type I is minor hypoplasia, type II findings include UCL insufficiency, first web space narrowing, and intrinsic thenar muscle atrophy, type III has extrinsic muscle abnormalities. In IIIA, the CMC is stable and in IIIB the CMC is unstable, Type IV is pounce flotant or floating thumb, Type V is aplasia
– One of the major determinants of whether the thumb is reconstructable is whether the CMC joint is stable- is this determination usually made on physical exam, do you use XR or US to help differentiate IIIA from IIIB
– What techniques do you use for UCL reconstruction and opponensplasty for type II and IIIA?
– Are there other considerations besides CMC stability when deciding whether to pursue reconstruction vs pollicization?
– Is there a role for toe to thumb transfers or using a non-vascularized fourth metatarsal?
Syndactyly- classified as simple when only soft-tissue structures are involved in the webbing and as complex when bone or fingernails of adjacent fingers are involved. With complete syndactyly, the entire length of adjacent digits is involved in the webbing; with incomplete syndactyly, the webs do not extend the entire length of the digit.
– In cases of complicated syndactyly just as in Apert syndrome, how do you decide where to start? How do you think through staging the procedures?
– What advice do you have when planning skin incisions?
– How do you try to prevent web creep post-operatively?
What is your favorite congenital hand procedure?
What advice to you have for residents or fellows interested in pediatric hand surgery?