Classification of congenital anomalies of the hand and upper limb.

The Oberg, Manske, Tonkin Classification of congenital anomalies of the hand and upper limb utilizes dysmorphological concepts to distinguish Malformations from Deformations and Dysplasias. Malformations are abnormalities of Formation and/or Differentiation of tissues. Deformations are abnormalities which occur after tissue is formed. Dysplasias are abnormalities which result from a lack of normal organization of cells into tissue. Malformations are sub-grouped according to whether the abnormality affects the hand alone or the whole of the upper limb; and according to which, if any, of the three main axes of development are primarily involved. It is not possible to satisfy all criteria which would define an ideal classification. However, this system is practical in that it retains the surgical diagnoses and sub-classifications familiar to surgeons and is easily utilized; it is expandable and may be modified without destroying its structure; it may be used to accumulate prevalence data; and, in the future, gene and chromosomal defects which are identified for specific diagnoses may be incorporated into the system.

The results of pollicization for congenital thumb hypoplasia.

We assessed pollicizations performed by one surgeon; compared function of the pollicized digit in patients with and without forearm/wrist anomalies; and determined if hand function changed with age. A total of 42 hands were assessed an average of 5.7 years post-operatively, 21 with a forearm/wrist anomaly (Group 1) and 21 without (Group 2). Fourteen patients with 16 pollicizations were assessed on two occasions 3.5 years apart. Carpometacarpal joint motion was near normal in both groups (decreased retropulsion in Group 1). Metacarpophalangeal and interphalangeal joint flexion, grip, thumb lateral and tip pinch strengths, and Jebsen timed test were superior in Group 2. Subjective assessment by patients/parents found 72% excellent/good results for function and 94% for appearance. Doctor excellent/good assessments were 60% and 70%, respectively. Forearm/wrist anomalies significantly compromised results but are not a contraindication for pollicization. Strength and Jebsen timed test measurements improved at the second assessment of 16 thumbs, but this was consistent with age-related improvement. LEVEL OF EVIDENCE 4.

Factors affecting surgical results of Wassel type IV thumb duplications.

The aim of this study is to review the outcomes of Wassel type IV thumb duplications with a minimum of one year follow-up, and to identify any factors that may compromise the quality of results. Forty one patients (42 thumbs) returned for assessment of thumb alignment, metacarpophalangeal joint and interphalangeal joint stability and motion; carpometacarpal joint motion; pinch and grip strengths; and thumb size. The subjective assessment considered thumb shape and contour, scarring, nail deformity and examiner and patient/parent satisfaction. The mean age at surgery was 16 months and the mean follow-up time was 79 months. Metacarpophalangeal joint and interphalangeal joint mal-alignment was present in 56% and 38% of cases, respectively. Interphalangeal ulnar collateral ligament laxity was significant. Metacarpophalangeal joint and interphalangeal joint motion was significantly decreased. Pinch and grip strength measurements were normal. A novel and comprehensive assessment scale is introduced, which revealed results of one (2.5%) excellent, 23 (59%) good, 14 (36%) fair and one (2.5%) poor. We consider that greater attention should be directed to the avoidance of mal-alignment and instability to improve these results.

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.

Outcome of axillary nerve injuries treated with nerve grafts.

This study evaluates the outcome of axillary nerve injuries treated with nerve grafting. Thirty-six patients were retrospectively reviewed after a mean of 53 months (minimum 12 months). The mean interval from injury to surgery was 6.5 months. Recovery of deltoid function was assessed by the power of both abduction and retropulsion, the deltoid bulk and extension lag. The deltoid bulk was almost symmetrical in nine of 34 cases, good in 22 and wasted in three. Grade M4 or M5* was achieved in 30 of 35 for abduction and in 32 of 35 for retropulsion. There was an extension lag in four patients. Deltoid bulk continued to improve with a longer follow-up following surgery. Nerve grafting to the axillary nerve is a reliable method of regaining deltoid function when the lesion is distal to its origin from the posterior cord.

Keloid formation after syndactyly release in patients with associated macrodactyly: management with methotrexate therapy.

We present a series of cases of keloid formation after release of syndactyly in the hands and feet of children with associated digital overgrowth. The use of methotrexate to suppress keloid formation after release of syndactyly and for control of recurrence after surgery for keloid is effective.

Spiralling of the neurovascular bundle in Dupuytren's disease.

Displacement of the neurovascular bundle within a digit affected by Dupuytren's disease can occur when disease superficial to the neurovascular bundle is connected to disease deep to it. Contraction of such cords results in spiralling of the neurovascular bundle, classically when a pretendinous cord connects with the lateral digital sheet and Grayson's ligament via the oblique cord, but also in association with an isolated digital cord. We describe six cases in which cord formation and contraction resulted in a distal spiral, which may occur in isolation or in combination with a classical proximal spiral, creating a double spiral or corkscrew neurovascular bundle.

[Classification of congenital hand anomalies]. / Classification des anomalies congénitales de la main.

Increasing knowledge of the molecular basis of embryonic development has improved our understanding of congenital limb malformations. The most popular current surgical classification of congenital limb anomalies is the Swanson/IFSSH classification. This is based on morphology (appearance). Such a classification is unable to indicate the site in the molecular pathway and/or the anatomical site in the limb bud, nor the time at which the insult occurs. Attempts to alter a classification based on morphology according to increased knowledge of the molecular basis of limb development are flawed. Perhaps it is better to simply describe and document the malformations appearing in any particular limb until such time as a valid classification relating to causation and aetiology at a molecular level can be established.

Keloid formation resulting in acquired syndactyly of an initially normal web space following syndactyly release of an adjacent web space.

We present a case of acquired syndactyly secondary to keloid formation in a previously normal web space following release of syndactyly in the adjacent web space.

The Bilhaut-Cloquet procedure for Wassel types III, IV and VII thumb duplication.

Five cases of Wassel types III, IV and VII thumb duplication underwent a Bilhaut-Cloquet procedure. A stable and mobile metacarpophalangeal joint was achieved in all cases. Interphalangeal joint motion was limited but this joint was stable in all cases. The nail ridge in these thumbs was minimal. A strong, stable thumb of normal size and good appearance can result from the Bilhaut-Cloquet procedure. When one nail is 70% of normal width, a modified procedure using the whole of one nail will avoid the nail ridge, but the nail will still differ from normal.

The use of a proximally based posterior interosseous adipofascial flap to prevent recurrence of synostosis of the elbow joint and forearm.

We report on four children in whom a proximally based, posterior interosseous artery adipofascial flap was used as an adjunct to surgical resection of synostoses of the forearm and elbow. Three traumatic radio-ulnar and one congenital humero-radial synostoses were treated. The postoperative pronation to supination arc of motion was excellent in all of the traumatic cases and fair in the congenital case.

Plexiform neurofibroma with dual nerve origin within the palm: a case report.

We describe a unique case of a 44-year-old gentleman who presented to our hand department with a history of a lump within his right palm that spanned several decades. Its gradual increase in size together with pain on palpation merited further investigation and subsequent surgical excision. Extensive tumour emanating from both ulnar and median nerves was resected, the histopathological diagnosis of which was plexiform neurofibroma. We believe this is the first description of an isolated plexiform neurofibroma of the hand with dual nerve origin.

Description of congenital hand anomalies: a personal view.

A series of four congenital hand cases exhibiting central clefting are presented. The cases are morphologically similar and exhibit characteristics of both symbrachydactyly and central longitudinal deficiency. The cases demonstrate difficulties in classification by either the IFSSH classification system or the JSSH modification of it. An alternative descriptive approach to classification is suggested.

Long term follow-up of composite non-vascularized toe phalanx transfers for aphalangia.

The results of 21 non-vascularized toe phalanx transfers in 13 patients were reviewed radiologically with respect to function, physeal patency, growth and donor site morbidity at a mean follow-up of 7.4 (range 2.9-13.6) years. Physeal patency was maintained in 4 of 18 surviving transfers. The length of the transferred phalanx averaged 75% of the contralateral comparable toe phalanx and 44% of the contralateral digit proximal phalanx. Most patients had good or simple use of the hand with active joint motion. There was universal shortening of the donor toe with hypoplasia of the middle and distal phalanges. This review suggests that transfer of a non-vascularized toe phalanx provides a reliable but limited means for increasing length of a digit, stabilizing soft tissue "nubbins" and improving function. Longer follow-up has shown more modest gains in growth than in some previous reports.

¿Cómo se presenta la espondilitis infecciosa? / How does the infectious spondylodiscitis appear?

No disponible

Dorsal Dupuytren's disease causing a swan-neck deformity.

A previously undescribed lesion of Dupuytren's disease is presented. An oblique cord coursed parallel to the oblique retinacular ligament of Landsmeer, but inserted proximal to the proximal interphalangeal joint, tethering the central slip and radial lateral band across the intervening transverse retinacular ligament. Contraction of this cord caused a rigid swan-neck deformity. Excision of the cord resulted in complete resolution of the deformity and a full range of motion in the affected digit.