Pediatric Hand Surgery

This book describes and illustrates surgical procedures of proven efficacy in infants and children with congenital hand deformities, hand traumas, hand dysfunctions due to obstetric palsy of brachial plexus. Essential background information is first provided on anatomy, hand development, and patterns of use. Extensive sections are then devoted to the surgical treatment of trauma to different parts of the hand and each of the relevant congenital conditions. Full guidance on treatment choice is provided, with description of the treatment pathways appropriate in different circumstances and explanation of the impact of patients’ young age on the surgical approach. Readers will learn about the complex features that may be masked even by the simplest congenital condition such as syndactyly and about the implications for treatment. In depth information is also provided on the character and vital role of rehabilitation in the pediatric population. Pediatricians, hand surgeons, plastic surgeons, pediatric surgeons, rheumatologists, neurologists, and physiotherapists will all find that the book improves their clinical practice. Preface Contents 1: The Congenital Hand: Psychological Aspects 1.1 Psychological Aspects 1.2 Patients, Hand, and Emotions 1.3 Psychologist’s Intervention: Timing Mode References 2: Babies Hand Imaging and X-ray 2.1 Traumatic Injuries 2.2 Congenital Hand Deformities and Syndromic Malformations with Prevalent Bone Involvement 2.3 Congenital Vascular Malformations and Vascular Tumours 2.4 Tumours, Post-traumatic or Post-surgical Inflammatory and Infectious Diseases Further Reading 3: Hand Defects: An Isolated Anomaly Or a Syndromic Disease? 3.1 Definitions 3.2 Why a Proper Classification of Hand Malformations Is So Important? 3.3 The Clinical-Genetic Diagnostic Process 3.4 Main Syndromic Conditions Associated with Hand Anomalies 3.4.1 Amniotic Band Sequence 3.4.2 Poland Syndrome 3.4.3 Acrocephalosyndactylies 3.4.4 Arthrogryposis Multiplex Congenita 3.4.5 Bardet–Biedl Syndrome 3.4.6 Fanconi Anemia 3.4.7 Holt–Oram Syndrome 3.4.8 VATER/VACTERL Association 3.4.9 Oro-Facio-Digital Syndromes 3.4.10 Cornelia de Lange Syndrome 3.4.11 Rubinstein–Taybi Syndrome 3.4.12 Smith–Lemli–Opitz Syndrome 3.4.13 Greig Syndrome 3.4.14 EEC Syndrome 3.5 Differential Diagnosis According Types of Hand Defect 3.5.1 The New Genetic Tests and Their Use in the Diagnostic Process References 4: Paediatric Trigger Finger 4.1 Trigger Finger References 5: Camptodactyly 5.1 Pathogenesis 5.2 Classification 5.3 Clinical Exam 5.4 Treatment 5.5 Conservative Treatment 5.6 Surgical Technique Further Reading 6: Syndactyly 6.1 Introduction 6.2 Epidemiology 6.3 Classification 6.4 Diagnostic Workup 6.5 Treatment 6.5.1 General Principles 6.5.1.1 Flap Coverage of the Web 6.5.1.2 Skin Grafts and Substitutes 6.5.1.3 Fingertip and Nail Wall Reconstruction 6.5.1.4 Exposure and Separation of Neurovascular Bundles 6.5.1.5 Simultaneous Separation of Multiple Syndactylies 6.5.1.6 Dressings and Dressing Changes 6.5.1.7 Timing of Surgery 6.5.2 Surgical Techniques 6.5.2.1 The First Web Space of the Hand 6.5.2.2 The Second to Fourth Web Spaces of the Hand 6.5.2.3 Syndactyly of the Feet 6.6 Complications References 7: Symbrachydactyly 7.1 Introduction 7.2 Epidemiology 7.3 Etiology 7.4 Classification 7.5 Differential Diagnosis 7.6 Treatment 7.6.1 Nonoperative Treatment 7.6.2 Operative Treatment 7.6.2.1 Nubbins 7.6.2.2 Syndactyly 7.6.2.3 Web Contracture 7.6.2.4 Thumb in the Plane of the Hand 7.6.2.5 Digit Instability 7.6.2.6 Brachydactyly and Absence of Fingers Non-Vascularized Free Toe Phalanx Transfers Distraction Lengthening Microsurgical Toe-to-Hand Transfers References 8: Central Synpolydactyly 8.1 Introduction 8.2 Genetics 8.2.1 Classification 8.2.2 Surgical Considerations 8.3 Authors Preferred Method 8.3.1 Secondary Surgery References 9: Thumb Polydactyly 9.1 Introduction 9.2 Embryology and Genetics 9.3 Patient Presentation 9.4 Classification 9.5 Physical Examination 9.5.1 Patient Selection 9.5.2 Treatment/Surgical Technique 9.6 Operative Treatment 9.6.1 Radial Polydactyly at the MCPJ (Type IV) 9.6.2 Postoperative Care 9.6.3 Outcomes, Prognosis and Complications References 10: Ulnar Polydactyly 10.1 Introduction 10.2 Evaluation 10.3 Treatment References 11: Cleft Hand or Split Hand Foot Malformation 11.1 Definition 11.2 Incidence 11.3 Clinical Presentation 11.3.1 Distinction Between True and False Median Clefts 11.4 Inheritance 11.5 Genetic Classification 11.5.1 Embryological Hypothesis 11.6 The Cleft Hand in the Classifications of the Congenital Hand Anomalies 11.7 Classification of Clinical Forms of SHFM 11.8 Principle of Treatment 11.8.1 Tendon Anomalies 11.9 Surgical Procedures 11.9.1 Simple Forms 11.9.2 Complex Forms 11.9.3 Severe Types 11.9.4 Central Clefts of the Feet 11.10 Conclusions References 12: Brachydactyly Types D and E 12.1 Introduction 12.2 Background 12.3 Epidemiology and Classification 12.4 Etiology 12.5 Clinical Presentation and Indications 12.6 Surgery Technique (Author’s Preferred Method) 12.6.1 Brachydactyly Type E 12.6.2 Brachydactyly Type D 12.7 Treatment Results 12.8 Conclusion References 13: Surgical Management of the Blauth 1 to 3A Thumb Hypoplasia 13.1 Introduction 13.2 Definitions 13.3 Flexus Adductus Thumb 13.4 Thumb Hypoplasia 13.5 Incidence 13.6 The First Consultation 13.7 Physical Examination 13.8 Palpation 13.9 General Examination 13.10 Imaging and Para-Clinical Explorations 13.10.1 X-Rays of the Hand 13.10.2 Other Imaging 13.10.3 Essential Para-Clinical Explorations 13.10.4 Genetic Counselling 13.11 Treatment 13.11.1 Conservative Treatment 13.11.1.1 Manipulations 13.11.1.2 Splints 13.11.2 Surgical Treatment 13.11.2.1 Techniques Release of the First Web Exploration and Rerouting of Extrinsic Tendons Opposition Transfers Extension Transfer Stabilization of the MP Joint 13.11.2.2 Indications Type 1 Type 2 Type 3 References 14: Thumb Hypoplasia: Genesia, Pollicization 14.1 Epidemiology 14.2 Associated Conditions 14.3 Classification 14.4 Indications 14.5 Techniques 14.6 Complications and Outcomes References 15: Radial Longitudinal Deficiency: Classification and Surgical Technique 15.1 Radial Longitudinal Deficiency and Syndromes 15.2 Presentation 15.3 Function 15.4 Classification 15.5 Treatment 15.6 Surgical Algorithm 15.6.1 Type N–0 15.6.2 Type I–II 15.6.3 Type III–V 15.7 Distraction of the Soft Tissues at Wrist Level 15.8 Wrist Stabilisation 15.9 Pollicisation 15.10 Ulnar Bone Distraction in RLD 15.11 Outcomes in RLD Treatment 15.11.1 Function, Participation and Activity 15.11.2 Surgical Versus Non-surgical Treatment 15.11.3 Pollicisation in RLD Patients 15.11.4 Residual Ulnar Growth and Distraction Osteogenesis 15.12 Conclusion References 16: Progressive Bone Distraction Lengthening in the Treatment of Congenital Malformations of the Upper Limb 16.1 Historical Perspective 16.2 Indications 16.3 Operative Technique 16.4 Technical Variations 16.5 Technical Problems According to the Applications of PBDL 16.6 Complications 16.7 Conclusions References 17: Radial Club Hand: Microvascular Reconstruction 17.1 Introduction 17.1.1 General Principles before Operative Treatment 17.1.2 Hand Quality 17.1.3 Indications and Prerequisites for Microvascular Reconstruction 17.2 Distraction 17.2.1 General Principles and Choice of Distractor 17.2.2 Pin Positioning 17.2.3 Distractor Alignment 17.2.4 Advancement of Distraction 17.2.5 How Much to Distract or Where is the Goal of Distraction? 17.3 Operative Treatment. Microvascular Wrist Reconstruction 17.3.1 Goal of Operation 17.3.2 Anesthesia 17.3.3 Foot Dissection and Raising the MTP II-Joint Graft Flap 17.3.4 Final Preparation of MTP-II Graft 17.3.5 Wrist Recipient Site Preparation 17.3.6 Reconstruction of the Radial Half of the Wrist with MTP-II-Joint Graft 17.4 Postoperative Treatment 17.4.1 Early Postoperative Care 17.4.2 Distractor Removal 17.4.3 Pollicization 17.5 Results 17.5.1 Early Prognosis 17.5.2 Long-Term Results 17.5.3 Donor Side Morbidity 17.5.4 Observations on the Results 17.5.4.1 The Metatarsal: Distal Ulna Ratio 17.5.4.2 MTP-II Joint Alignment and Stability 17.5.4.3 Necessity for Long-Term Follow-Up 17.6 General Remarks about Microvascular Reconstruction of Radial Club Hand 17.6.1 Positive Remarks 17.6.2 Negative Remarks 17.7 Conclusion References 18: Metacarpal Synostosis 18.1 Introduction 18.2 Genetics 18.3 Embryology 18.4 Clinical Exam 18.5 Radiographic Exam 18.6 Classification 18.7 Treatment 18.8 Complications 18.9 Summary References 19: Epidermolysis Bullosa 19.1 Definition and Classification 19.2 Systemic Compromission 19.3 Treatment 19.4 Natural History 19.5 Conclusions Further Reading 20: Arthrogryposis: Introduction and Classification 20.1 Classification of Upper Limbs Deformities Due to Amyoplasia 20.2 Isolated Forms of Upper Limb Deformities Due to Amyoplasia 20.2.1 Type 1: Level of Spinal Cord Injury: C6-C7 20.2.1.1 Clinical Picture 20.2.2 Type 2: Level of Spinal Cord Injury: Partial C5, C6-C7 20.2.2.1 Clinical Picture 20.2.3 Type 3: Level of Spinal Cord Injury: C5-Th1 20.2.3.1 Clinical Picture 20.2.4 Type 4: Level of Spinal Cord Injury: C6 20.2.4.1 Clinical Picture 20.3 Summary References 21: Thumb in Arthrogryposis References 22: Vascular Malformations 22.1 Introduction 22.2 Epidemiology 22.3 Classifications 22.4 Aetiology and Embryology 22.5 Diagnosis 22.6 Haemangioma 22.7 Imaging 22.7.1 Echo-Doppler 22.7.2 Magnetic Resonance Angiography (MRA) 22.7.3 Angiography 22.7.4 Lymphoscintigraphy 22.8 Treatment Principles 22.9 Surgical Treatment 22.10 Complications 22.11 Syndromic Forms 22.11.1 Maffucci Syndrome (MS) 22.11.2 Klippel-Trenaunay Syndrome (KTS) 22.11.3 Park-Weber Syndrome (PKWS) 22.11.4 Proteus Syndrome (PS) 22.11.5 CLOVES Syndrome 22.11.6 Characteristics of CLOVES (Fig. 22.8) References 23: Macrodactilies 23.1 Introduction 23.2 Clinical Presentation 23.3 Evaluation 23.4 Treatment 23.5 Conclusion References 24: Palliative Surgery in Obstetrical Brachial Plexus Palsy 24.1 Introduction 24.2 Clinical Features and Therapeutic Options 24.2.1 Shoulder 24.2.1.1 Limited External Rotation 24.2.1.2 Limited Abduction 24.2.1.3 Limited Internal Rotation 24.2.1.4 Posterior Subluxation 24.2.2 Elbow 24.2.2.1 Lack of Active Elbow Flexion 24.2.2.2 Lack of Elbow Extension 24.2.2.3 Flexion Deformity for Limited Extension 24.2.3 Forearm 24.2.3.1 Defect of Supination or Pronator Deformity 24.2.3.2 Defect of Pronation or Supination Deformity 24.2.4 Wrist and Hand 24.3 Conclusions References 25: Nerve Injuries 25.1 Introduction 25.2 Types and Sites of Nerve Lesions 25.3 Diagnosis 25.4 Treatment 25.5 Conclusion References 26: Flexor Tendon Lesions in Children: Diagnosis, Treatment, and Early Active Motion Rehabilitation References 27: Pediatric Hand Fractures 27.1 Introduction 27.1.1 Wrist Region Fractures 27.1.2 Carpal Bone Fractures 27.1.3 Metacarpal Fractures and Dislocations 27.1.4 Phalangeal Fractures and Dislocations 27.1.5 Metacarpal-Phalangeal Dislocations 27.1.6 Collateral Ligament of the Thumb 27.1.7 Interphalangeal Dislocations References 28: Replantation 28.1 Background 28.2 Terminology 28.3 Epidemiology 28.4 Mechanisms, Classifications and Causes of Injury 28.5 Care for and Transportation of Amputated Parts 28.6 Indications for Replantation in Children 28.7 Contra-indications to Surgery 28.8 Initial Evaluation 28.9 Pre-operative Preparation 28.10 Operative Technique 28.11 Post-operative Medical Therapy and Monitoring 28.12 Complications 28.13 Physical Therapy 28.14 Outcomes 28.15 Paediatric Fingertip Composite Grafts 28.16 Psychological Aspects 28.17 Prosthetic Usage in Children 28.18 Bone Growth After Replantation 28.19 Reconstruction Surgery 28.20 Prevention References 29: Hand Transplantation in Children 29.1 Introduction 29.1.1 Hand and Upper Extremity Transplantation 29.1.2 Upper Extremity Transplantation in Children 29.2 Case Report of the First Pediatric Bilateral Hand Transplant 29.2.1 Ethical Considerations 29.2.2 Psychosocial Considerations 29.2.3 Donor Considerations 29.2.4 Surgical Considerations 29.2.4.1 Surgical Team 29.2.4.2 Procedure 29.2.4.3 Early Postoperative Monitoring 29.2.5 Immunological Considerations 29.2.6 Posttransplant Rehabilitation 29.2.7 Follow-Up and Outcomes 29.3 Future of Hand/Arm Transplantation in Children References 30: Rehabilitation in Pediatric Hand Trauma 30.1 Fractures 30.1.1 Conservative Treatment 30.1.2 Surgical Treatment 30.1.3 Apical Traumas: Rehabilitative Part 30.2 Tendon Lesions in Pediatrics 31: Toe-to-Hand Transfers for Posttraumatic and Congenital Reconstruction in Children: Indications and Surgical Technique 31.1 Introduction 31.2 Conventional Reconstruction of Amputations in Children 31.3 Toe-to-Hand Transfers After Trauma in Children 31.4 Indications for Toe-to-Hand Transfers After Trauma in Children 31.5 Conventional Reconstruction of Congenital Hand Differences 31.6 Toe-to-Hand Transfers for Congenital Hand Differences 31.7 Indications for Toe-to-Hand Transfers for Congenital Hand Differences 31.8 Timing of Toe Transfers for Congenital Hand Differences 31.9 Evaluation of a Child for a Toe-to-Hand Transfer 31.10 Anatomy of the Great Toe and Second Toe 31.11 Surgical Technique 31.11.1 Dissection of the Donor Foot 31.11.2 Dissection of the Recipient Hand 31.11.3 Transfer of the Toe to the Hand 31.11.4 Closure of the Donor Foot 31.12 Postoperative Care 31.13 Conclusions References 32: Compartment Syndromes (CS) and Volkmann’s and Upper Limb Vascular Pathology in the Peri- and Neonatal Period 32.1 Introduction 32.2 Affected Locations and Pathophysiological and Aetiological Classification 32.3 Aetiological Factors in Atypical Upper Limb CS: Differences Between the Newborn and the Adult 32.4 Upper Limb Intrauterine Compartment Syndrome 32.4.1 General Aspects 32.4.2 Clinical Symptoms 32.4.3 Stabilized Peri- and Neonatal Volkmann’s Syndrome 32.4.4 Clinical Picture 32.4.5 Clinical Symptoms 32.4.6 Complementary Investigations in the Adult 32.4.7 Complementary Investigations in the Child 32.5 Surgical Treatment in Perinatal Volkmann’s Contracture 32.5.1 General Aspects 32.5.2 Surgical Techniques 32.6 Vascular Lesions 32.6.1 Spontaneous Vascular Lesions 32.6.2 Iatropathic Causes 32.6.3 Complications in Stabilized Outcomes 32.6.4 Differential Diagnosis 32.6.5 Long-Term Outcomes 32.7 Prevention 32.8 Conclusions References 33: Postoperative Dressings and Care 33.1 Introduction 33.2 Authors’ Preferred Method 33.3 Alternative Approaches 33.4 Summary References 34: Rehabilitation in Congenital Hand and Forearm Defects: Rehabilitation of the Child’s Hand—General Aspects 34.1 Setting 34.2 Rehabilitative Program 34.3 Assessment 34.3.1 0–3 Months 34.3.2 3–6 Months 34.3.3 6–9 Months 34.3.4 9–12/18 Months 34.3.5 18–24 Months 34.3.6 24–36 Months 34.4 Splinting 34.5 Scar Management 34.5.1 Introduction 34.5.2 Evaluation 34.5.3 Treatment 34.6 Trigger Finger 34.6.1 Conservative Treatment 34.6.2 Splinting 34.6.2.1 Passive Mobilization and Stretching 34.6.2.2 Tendon Gliding 34.6.3 Taping 34.6.4 Rehabilitation After Surgical Treatment 34.6.4.1 Edema and Pain Management 34.6.4.2 Active Mobilization and Tendon Gliding Passive Mobilization and Stretching 34.6.4.3 Scar Management 34.7 Syndactyly 34.7.1 Post-surgery Treatment 34.7.1.1 Time 0 34.7.1.2 From the Third Week On 34.8 Symbrachydactyly 34.8.1 Introduction 34.8.2 Phalanx Transfer 34.8.3 Rehabilitation After Toe-to-Hand Transfer 34.9 Polydactyly 34.9.1 Radial Polydactyly 34.9.1.1 0–4 Weeks 34.9.1.2 4–6 Weeks 34.9.1.3 6–8 Weeks 34.9.1.4 8 Weeks 34.9.2 Central Polydactyly 34.9.2.1 0–4 Weeks 34.9.2.2 4–6/8 Weeks 34.9.3 Ulnar Polydactyly 34.9.3.1 0–4 Weeks 34.9.3.2 4–6/8 Weeks 34.10 Arthrogryposis 34.11 Amniotic Band Syndrome (ABS) 34.11.1 Postoperative Rehabilitation 34.11.1.1 Splint 34.11.1.2 Active Mobilization 34.11.1.3 Passive Mobilization 34.11.1.4 Scar Treatment 34.11.1.5 Edema Treatment 34.11.2 Preoperative Treatment 34.11.2.1 Splint 34.11.2.2 Passive Mobilization 34.11.2.3 Active Mobilization 34.12 Epidermolysis Bullosa 34.13 The Rehabilitative Treatment of the Obstetrician Paralysis 34.13.1 Summary of the Rehabilitative Project of the Obstetrician Paralysis 34.13.1.1 Activation of the Biceps? 34.13.1.2 3–4 Years Old: Sufficient Functionality for ADL? 34.13.1.3 Supervision of FKT Until the End of the Development 34.13.2 Post-surgery Treatment 34.13.3 General Principles of Post-surgery Treatment 34.14 Thumb Hypoplasia and Pollicization 34.14.1 Rehabilitation Protocol Post-surgery in Thumb Hypoplasia 34.14.1.1 21 Days 34.14.2 Early Rehabilitation Program After Pollicization 34.14.2.1 Days 0–10 34.14.2.2 Days 10–21 34.15 Radial Cleft Hand: Rehabilitation 34.15.1 Conservative Treatment 34.15.2 Post-surgery Treatment 34.16 Psychomotor Therapy 34.17 Pediatric Hand Trauma 34.17.1 Fractures 34.17.1.1 Conservative Treatment 34.17.1.2 Surgical Treatment 34.17.2 Apical Traumas: Rehabilitative Part 34.17.3 Tendon Lesions in Pediatrics 35: Association to Support Babies and Families References Index