Factors affecting hand cosmesis and the aesthetic impact of surgery on congenital hand differences in Finland.

We assessed the appearance and cosmetic impact of surgery in congenitally different hands in Finland. A questionnaire was sent to 1165 respondents (786 female) with a mean age of 33 years (range 3-84). Participants were shown nine image pairs and seven pairs of pre- and postoperative images twice in a random order and asked to choose the more cosmetically pleasing one. We found that the appearance and number of fingers had an important aesthetic role, with higher number and more normal appearing digits consistently scoring higher than its counterpart (range 59-99%). Postoperative appearances were perceived as better than preoperative ones in syndactyly (98%), thumb duplication (92%), cleft hand (93%) and radial dysplasia (99%). Toe transfer and pollicization had little impact on cosmesis. This study demonstrated that surgery could improve cosmesis in congenitally different hands and overall, most respondents prefer an appearance that is as close as possible to normality. Level of evidence: IV.

Appearance of congenital hand anomalies.

BACKGROUND AND OBJECTIVE: Impact of appearance of congenital hand anomalies has not previously been reported. The purpose of this study was to describe the common perception about how different congenitally malformed hands look. METHODS: We developed a questionnaire in a game format to evaluate the appearance of different hands. Altogether 1450 (954 females) 4- to 84-year-old residents (296 children) of two European and one Asian (n = 102) country were asked to rate the appearance of different looking hands on a five-point pictorial Likert-type scale. Standardized photographs of the dorsal aspect of 17 different congenitally malformed non-operated hands and a normal hand were presented to respondents. Significance of age, gender, nationality, and profession of the respondents was assessed. RESULTS: The respondents' ranking order of the hands was nearly consistent. The normal hand (mean = 4.43, standard deviation = 0.85, Md = 5) and clinodactyly (mean = 4.37, standard deviation = 0.86, Md = 5) were perceived to have the best appearance. Symbrachydactyly (mean = 1.42, standard deviation = 0.68, Md = 1) and radial club hand (mean = 1.40, standard deviation = 0.68, Md = 1) received the lowest scores. Adults rated the appearance of hands higher than children regarding 14 hands, females higher than men regarding 15 hands, and Europeans higher than Asians in 4 hands (p < 0.05, respectively). Europeans rated four-finger hand (mean = 3.21, standard deviation = 1.18, Md = 3) better looking than six-finger hand (mean = 2.92, standard deviation = 1.18, Md = 3, p < 0.005), whereas Asians gave higher scores to six-finger hand (mean = 2.66, standard deviation = 1.26, Md = 3) compared to four-finger hand (mean = 2.51, standard deviation = 1.14, Md = 2). Medical doctors and nurses gave higher scores compared to the other profession groups, school children, and high school students in five hands (p < 0.05). CONCLUSIONS: A normal hand is perceived distinctly better looking than most congenitally different hands. Different malformations' appearance was ranked very coherently in the same order despite of participants' age, gender, nationality, or profession. Asians seem to prefer an additional digit to a four-finger hand.

9 years' follow-up of 168 pin-fixed supracondylar humerus fractures in children.

Background and purpose - The long-term outcome of pin-fixed supracondylar humerus fractures (SCHF) in children is not well known. We assessed the 7- to 12-year outcome in 168 children. Patients and methods - During 2002-2006, 210 domestic children (age 7 (1-14) years) with SCHF (Gartland III 79%, Gartland II 19%, and flexion type 2%) were pin fixed in Helsinki. 36 (17%) patients had a nerve palsy. Radiographic alignment was regarded as satisfactory in 81% of patients (Baumann angle (BA) within ±10˚ of normal range and whose anterior humeral line (AHL) crossed the capitulum). After a mean follow-up of 9 (7-12) years, 168 (80%) patients answered a questionnaire regarding elbow appearance (scale 0-10), function (scale 0-10), and pain (scale 0-10), and symmetry of range of motion (ROM) and carrying angle (CA). 65 (31%) patients also attended a clinical follow-up examination. Results - Mean subjective score for appearance was 8.7 (2-10) and for function 9.0 (2-10) (n = 168). Elbow ROM asymmetry was experienced by 28% and elbow CA asymmetry by 17% of the patients. Elbow pain was reported by 14%, and was more common in children with nerve injuries. Long-term outcome was good or excellent in 60/65 and CA in 56/65 of the follow-up visit patients using Flynn's criteria. BA exceeding normal values by 10˚ was associated with lower subjective outcome; AHL crossing point with the capitulum was not associated with outcome. Interpretation - Long-term subjective outcome is satisfactory with few exceptions if elbow ROM and CA are restored within 10° of the uninjured elbow. Radiographs at fracture union have little prognostic value. Nerve injuries can cause long-term pain.

Outcome after pin fixation of supracondylar humerus fractures in children: postoperative radiographic examinations are unnecessary.

Background and purpose - The quality of pin fixation of displaced supracondylar humerus fractures in children has not been assessed, and the clinical value of radiographic examinations after pin fixation is unclear. We evaluated pin configuration, quality of osteosynthesis, and outcome in 264 supracondylar fractures. The clinical significance of postoperative radiographs was analyzed. Patients and methods - 252 Gartland-III and 12 flexion-type supracondylar humerus fractures were pin-fixed in the periods 2002-2006 and 2012-2014. During 2012-2014, staff were intructed that postoperative radiographs should not be taken. Quality of reduction was assessed by measuring Baumann and lateral capitellohumeral angles (LCHA) and also by recording the crossing point of the anterior humeral line (AHL) with bony capitellum. Rotatory alignment was registered as normal or abnormal. Pin configuration and quality of osteosynthesis were evaluated. The clinical significance of postoperative radiographs was analyzed. Results - Postoperatively, Baumann angle was normal in 66% of the fractures, AHL crossed the capitellum in 84%, and no malrotation was evident in 85% of the fractures. Crossed pins were used in 89% of the cases. 2 or more pins fixed both fracture fragments in 66%. Radiographic examinations were inadequate for assessment of LCHA in 13%, of Bauman angle in 8%, of AHL in 2%, of rotation in 1%, and of pin fixation in 2% of the cases. Postoperative radiographs did not give useful information except in 1 patient who had corrective osteotomy. All 94 patients with follow-up (97%) who were treated during 2012-2014 were satisfied with the outcome. Interpretation - Despite pin fixation being deemed unsatisfactory in one-third of the cases, significant malunion was rare. Postoperative radiography did not alter management or outcome.