Issue link: http://viewer.e-digitaledition.com/i/620826
T H E D E V E L O P M E N T O F fingers occurs early in feta l g row t h . By week fou r i n- utero, the fetus' hands form and look like tiny paddles; by week nine, fingers are clearly visible. In some insta nces, this complex process results in abnormalities. Estimates place the incidence of abnor- malities at 2.3 per 1,000 total bi r t h s worldw ide. W h i le some deformities are minor a nd do not requ i re i nter- vention, others may need a surgica l solution. The goa l of treatment is twofold: an aesthetica lly pleasing hand and a functional finger. Over the years, both the surgica l approa ch a nd t i m i n g for inter vention have changed i n a cont i nuou s ef for t t o achieve the best outcomes for patients. POSTAXIAL POLYDACTYLY One of the most common c o n g e n i t a l h a n d a b n o r - ma lities is a n ex tra dig it , or polydactyly. Sometimes there is a clear genetic cau- sation, and patient families have a lready encountered relatives with similar condi- tions. More often, however, there is no clea r cause for extra digits, and parents may be understandably alarmed. Many pediatric orthopedic surgeons, myself included, find it 's impor ta nt to reas- s u r e p a r e n t s t h e r e w a s nothing they could have done to either cause or prevent the abnorma lity. Extra digits on the ulnar can appear as a slight out- cropping from the side of the hand or can be more formed — the variation ranges from a piece of soft tissue to a com- plete digit. Historically, these extra digits would have been tied ož to trigger necrosis. Drawbacks to this procedure include a slight infection risk and a more significant issue with neuroma and accompa- nying pain. The unappealing finger appearance may also cause emotiona l distress , especially as these children grow older. PREAXIAL POLYDACTYLY Another common type of polydact yly is a duplicate thumb, or a preaxial polydac- tyly. This happens when the thumb divides at the dista l phalanx (distal) or proximal. O f t en when t h i s occurs, one of the "thumbs" is only partially formed and appears smaller when compared to the other digit. As with postaxial treatment, in the past this extra thumb may have been tied ož or amputated. Another surgical approach involves combining the two thumbs into one f inger; however, this technique inva riably leads to an unusual-looking f ingerna i l a nd other cos- metic discrepancies. Today, surgeons are more likely to ablate the sma ller of the two thumbs and use the extra tissue and bone to construct a single, function- ing dig it . Compa red w it h t h e p r e v i o u s t r e a t m e n t approaches, this surgery is more complex, but it yields more desirable outcomes in appearance and functional- ity. Typica lly it's the ulnar component that makes for a better candidate to preserve. PATIENT CONSIDERATIONS The prevailing philosophy around when to treat used to be as soon as possible. Besides aesthetics, the concern was developmenta l difficulties if the child did not have a properly functioning digit. More recently, or thopedic specialists are encouraging fa m i lies to delay su rger y until the child is older and his or her fingers are more fully formed. With less mature digits, there is a greater risk of the child's fingers shift- ing as they grow, potentially ne c e s sit at i n g a dd it ion a l treatment. This is especially true of syndactyly, where the webbed linkage between fin- gers has a tendency to grow back (this is called web creep) if the surgery is performed too soon. Another shift in care is the ability to diagnose abnormal- ities sooner, even in-utero, so parents are more prepared at birth. Early diagnosis allows families time to process their child's condition and think through treatment options with the assistance of their primary care physician and hand specialists. D r. E n g l e s i s a b o a rd - certified, fellowship-trained o r t h o p e d i c s u r g e o n . H e is a me mbe r of the Akron Children's Hospital Hand and Upper Extremity Clinic. ■ BY DREW ENGLES, MD 1 8S P E C I A L S E C T I O N : O R T H O P E D I C S How Surgical Approaches Have Evolved Common Congenital Hand Abnormalities: