The hand is considered to be one of the great master pieces of Nature. Its structure is so much linked to function and is controlled by the human brain. Sometimes, Nature does experiment and some children are born with differences in structure of the hand. The variations of hand and upper limb differences are almost endless. It also causes endless questions in the minds of the parents about the future prospects of the child. The Hand Surgery Department of Ganga Hospital is very keen to address this issue.
In the management of these children, we share the goal of the parents – that is to provide the child as functional a hand as possible with good aesthetic outcome.
We are able to provide a comprehensive care in addressing common problems like joined finger, extra fingers to complex issues like Symbrachydactyly and Radial Club Hand. The Unit is also capable of providing microsurgery solutions for congenital hand differences.
Thumb is an important part of the hand and is useful in activities of pinch, grasp and power grip. Reconstruction of the thumb is one of the challenges of hand surgery. Children may be born without a thumb (thumb aplasia) , a thumb like structure being attached to the hand by a fringe of soft tissue (floating thumb), or a small thumb may be attached to the hand, but the bony attachment is so underdeveloped that the structure cannot be made stable and strong to do the activities of the thumb.
This is a common birth difference found in the hands of children. The fingers instead of being separate may be joined by various extent , some only by skin (then called simple) , in some bones are also joined (then called complex), they can be joined
for the full extent (complete) or called incomplete when only part of the finger is joined. The middle and ring fingers are usually involved.
The joined fingers can be separated by surgery. When fingers of unequal length like the thumb and the index finger are joined together the separation is done early so that the growth of the longer finger is not held back by the shorter finger. When the middle and ring fingers are joined the surgery can be done by about 2 to 3 years of age. When the fingers are separated some extra skin may be needed, which is usually got from the groin region. The donor area heals well without any problem.
Joined fingers can be part of syndromes like Apert's syndrome. Even here we separate the fingers so that the function of the hand is improved.
This again is a common birth difference seen in children. When the extra finger is attached by a small tag of skin, and the other fingers are normal, the removal of the extra finger is a minor procedure. Sometimes the finger may be attached to the normal fingers at the level of the joint. The two fingers then share a common joint cavity. In such instances after removal of the extra finger the joint is reconstructed to retain the stability.
Special efforts and skill are necessary to reconstruct double thumbs or duplicated thumbs. Though the child may have two thumbs, but each component will be smaller than the normal single thumb. The plan is to create as normal and a stable thumb as possible. The bigger of the two thumbs is usually retained as the main thumb and tissues from the other thumb can be utilized to augment the retained thumb or provide stability.
If the two components are linked at the joint level, then reconstruction of the joint after removal of the extra thumb is a must.
Sometimes children are born with shorter or absent fingers. In some children there will be some soft tissue in the stump with no bone. Such children need creation of new fingers or lengthening of the existing fingers.
To provide stability to the existing extra soft tissue in the position of fingers, we can introduce bone into the soft tissue sleeve. Usually one of the phalanges from the toes is taken and placed inside the finger. Since it is not taken with its blood vessels it is called a Free Phalangeal bone transfer. They in many instances significantly improve the functional status of the hand.
Microsurgical transfer of a toe usually yields better results. When many fingers are involved or when parents are not willing to sacrifice the whole toe, free phalangeal bone transfer is a viable alternative. Sometimes, we have combined both the procedures to give good results.
We prefer to do the free phalangeal bone transfer before one year of age. Though we have done them even in later ages, it is believed that early surgery keeps the growth potential of the transferred toe for a longer period.
Free phalangeal bone transfer has been done in all the fingers. Xray taken 3 years later shows that the transferred toe bone is surviving in the hand and allows the child to do useful function.
Radial club hand is a deformity in which the hand is bent at the wrist and deviated towards the thumb. It is rarely hereditary. It is sometimes associated with some malformations. Radial club hand is a very complex malformation that affects all tissues in the hand and forearm. Skeletal malformations occur not only in the radius but also in the whole arm. It is usually associated with the absence or under developed thumb.
Treatment consists of straightening of the hand and stabilisation of the wrist. The absence of thumb is usually corrected by shifting the index finger in the place of the missing thumb thereby making the hand functional. The first stage which consists of straightening of hands should be done at the age of 6 months followed by thumb correction at 1-2 years of age.
Many cases of radial club hand present with no thumb or they may be so small and weak to serve any useful function. For such children a new thumb is created by rotating the index finger to the position of the thumb. This procedure is usually done around one year of age. Some children may be born without the thumb or a weak thumb with no obvious problems in the forearm. This condition is called as Hypoplastic thumb. For these children the thumb is created from the index finger. The muscles are readjusted so that they function in the new position. This is regularly done at Ganga hospital.