Chondrodesis of the wrist in children with severe paralytic hand deformities.

We examined the anatomical and clinical results of a new wrist subphyseal arthrodesis method called chondrodesis, which relies on resorbable suture-bone fixation for children with severe paralytic hand deformities and does not require fixation devices or bone grafting. Four children's wrists underwent the procedure, resulting in three successful wrist bone fusions. The wrists were stabilized by joint fusion in 4-5 months in good positions, ranging from neutral to extension 15°, while still allowing the forearm to keep growing since the radial growth plate remained open as of the last follow-up. The procedure improved hand function (House score, Raimondi score) and appearance. It also increased control over gripping motions with the operated hand, and even restored key pinch ability in one of the patients. The youngest patient was not able to achieve bone fusion at the key sites and will need further corrective procedures at a later and more optimal age. This novel procedure is appealing because of its technical reproducibility, low cost, encouraging outcomes, ease of rehabilitation, and because it spares the physeal cartilage.

Assessment of hand function using the functional dexterity test after opponensplasty in young children with Blauth type 2 hypoplastic thumb.

The functional dexterity test (FDT) is a timed pegboard test based on the manipulation of each peg and suitable for young children as it is both simple and quick to perform. We assessed the postoperative FDT values for children with Blauth type 2 hypoplastic thumbs after opponensplasty. We evaluated hand function using FDT for 12 hands of 11 patients with Blauth type 2 hypoplastic thumbs. Opponensplasty was performed in all hands following by Huber's procedure. All patients were evaluated from 6 to 12 months after surgery for hand function using three types of FDT scores: time in seconds to complete the test (FDT time), combined total time with penalty seconds added to the initial time (FDT total), and the number of pegs per second to complete the task as a percentage against normative values (FDT speed). We compared the postoperative FDT scores with those for Blauth type 1 or 2 hypoplastic thumb patients without surgical treatment. FDT time and FDT total for the patients postoperatively were both significantly shorter than those in the type 2 patients without surgical treatment. FDT speed was significantly higher than that for the patients without surgical treatment. There were no significant differences in the three FDT scores between the postoperative patients and the type 1 patients. There were several limitations including small sample size, large ranges of the data, and high number of variables. FDT reflected postopponensplasty improvement in hand dexterity in young children with Blauth type 2 hypoplastic thumb.

Inter- and Intrarater Reliability of the Thumb Grasp and Pinch Assessment for Children Following Index Pollicization for Congenital Thumb Hypoplasia.

PURPOSE: The Thumb Grasp and Pinch (T-GAP) assessment quantifies functional hand use in children with congenital thumb hypoplasia by categorizing grasp and thumb use patterns during assessment activities that encourage a variety of grasp and pinch styles. This study aims to demonstrate interrater and intrarater reliability results of the T-GAP. METHODS: A retrospective review was performed of children who had undergone index finger pollicization for congenital thumb hypoplasia and subsequent evaluation with videotaping of the T-GAP assessment. Following a training period, 4 occupational therapists scored 11 T-GAP videos on 2 separate occasions, separated by at least 2 weeks. Intraclass correlation coefficients (ICCs), standard error of measurements, minimum detectable change (MDC), and Pearson correlation coefficients were calculated. RESULTS: The T-GAP raw scores were 16 to 55, demonstrating a range of mild to severe hand grasp differences. The ICCs for the interrater reliability trials were 0.887 and 0.901. Intrarater ICCs were all above 0.88. The MDC for each trial was 8.1 and 6.7 points. Pearson correlation coefficients calculated for each rater and each pair of raters were above 0.8 in all cases. CONCLUSIONS: Interrater and intrarater reliability testing results for the T-GAP were excellent in all cases; this strongly suggests that results from T-GAP assessments are reliable. The high ICCs suggest that raters can classify and score children's hand function consistently. CLINICAL RELEVANCE: This study, in conjunction with previous work, suggests that the T-GAP may be an ideal approach to assessing the outcomes of pollicization and provide a means of ongoing assessment of children's grip and pinch function.

A Case of Thumb Polydactyly which Ulnar Thumb Has No Active Motion in Ring Chromosome 4.

The objective of this study was to clarify the difference in thumb deformity between our case with ring chromosome 4 and thumb polydactyly, in which ulnar side was small and had no active motion, and other cases of ring chromosome 4, by analyzing previous reports. Our case had bilateral atypical thumb polydactyly, which was classified as type 4 on the right side and type 5 on the left side, according to the Japanese Society for Surgery of the Hand: Modified International Federation of Societies for Surgery of the Hand classification. Of the 39 cases in previous reports, 20 (51.3%) had thumb deformities. Among them, 19 cases (95%) showed radial ray deficiency and only 1 case (5%) showed bilateral thumb polydactyly. Clinodactyly was seen in 5 cases (12.8%). Foot deformities were present in 6 cases (15.4%). We discussed about thumb polydactyly with and without chromosomal deformities.

The frequency and diagnostic accuracy of hand deformities in Parkinson's disease.

Hand deformities are well-known abnormalities observed in patients with Parkinson's disease (PD). We determined the frequency and diagnostic accuracy of hand deformities in PD. We studied 44 consecutive patients with PD, 44 age- and gender-matched normal controls and 22 patients with essential tremor (ET). By means of photographs taken in both hands of all participants, the degree of metacarpophalangeal (MCP) joint flexion was quantified by software and by blinded evaluations using a semiquantitative scale from the radial aspect, we grouped hands into four grades. The presence of classical striatal hand deformity (CSHD), defined as MCP joint flexion, proximal interphalangeal joint extension and distal interphalangeal joint flexion was also evaluated. Patients with PD had a higher frequency of MCP joint flexion and CSHD compared to normal controls and patients with ET. Mean MCP joint flexion was higher in both hands in patients with PD: 20.8° vs. normal controls (3.3°-3.9°) and patients with ET (2.8°-6.3°), P = 0.001. Concordance between evaluators for MCP joint flexion was fair: κ = 0.34 (P < 0.001), but poor for CSHD: κ = 0.142-0.235 (P < 0.05). A right hand MCP joint flexion of 12.5° and left hand of 10.5°, showed similar sensitivity (0.70) and specificity (between 0.75 and 0.80) than any degree of MCP joint flexion for the diagnosis of PD. CSHD had a sensitivity (0.60-0.80) and specificity (0.78-0.98) for the diagnosis of PD. Hand deformities are commonly observed in patients with PD, they may aid in the diagnosis of PD when compared to normal controls and patients with ET.

Change in Hand Function and Dexterity with Age after Index Pollicization for Congenital Thumb Hypoplasia.

BACKGROUND: Little is known about how performance on strength, range of motion, and dexterity measures changes as children with index finger pollicization mature. The authors reviewed performance in range of motion, strength, and dexterity over a 7-year period and report outcomes over time. METHODS: Data from children treated with index finger pollicization for congenital thumb hypoplasia from 2007 to 2014 were reviewed retrospectively. Children were followed for an average of 3.9 years (range, 1 to 7 years) during the study period. Standardized assessments included range of motion, grip, key pinch and tripod pinch strength, the Box and Block Test, the Nine Hole Peg Test, and the Functional Dexterity Test. Average score by age and average yearly change were calculated for each assessment, and scores were plotted against published age-matched scores of normal children when available. RESULTS: Twenty-three patients with 29 affected thumbs were included. Distal grasp span increased 0.17 inch and Kapandji opposition improved 0.26 point with each year of age; however, proximal web-space size did not increase over time. Grip strength improved an average of 2.69 kg/year, and tripod and key pinch improved 0.58 kg and 0.67 kg with each year of age. Box and Block Test scores improved an average of 4.11 blocks/year. Scores on the Nine Hole Peg Test improved 3.83 seconds/year, and scores on the Functional Dexterity Test improved 0.026 peg/second each year. CONCLUSIONS: Children with pollicized thumbs improve in dexterity and strength with growth. Web-space size did not change with age; therefore, the thumb should be carefully positioned at the time of surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Analysis of surgical results and of residual postoperative deformities in preaxial polydactyly of the hand.

PURPOSE: Polydactyly is the most common congenital anomaly of the hand. It may occur as a separate event or as part of a syndrome, with preaxial polydactyly of the hand (or thumb duplication) being the most common among Caucasians. The present study analyzed the surgical results and the residual postoperative deformities of patients with thumb duplication. METHODS: Thirty-one patients with duplicated thumbs were surgically treated from January 2002 to April 2008 and 19 of them, who had returned during the late postoperative period, were evaluated. Each case was typed according to Wassel's classification into seven types and the most common category was type IV. Removal of radial component was done in 18 patients aged on average 51 months. RESULTS: Patients and parents were satisfied with both the functional results and the appearance of the reconstructed thumb. In the subjective evaluation of residual deformities, axis deviation and residual prominence were commonly found. There were coherencies in data between both subjective and objective outcomes. The children that had difficulty in holding very small objects in the subjective functional result were the same children with residual deformities in the objective result. Patient's age at surgery and Wassel's type influenced the analysis of residual postoperative deformities. There was statistically significant difference in cases of type VII and in patients operated at more than three years of age. Correlation between type VII and patient's age at time of surgery was found. The children with type VII duplication were operated later. CONCLUSIONS: For a better result, surgical correction should be performed before three years of age, thus correcting all the changes detected, mainly in type VII, in order to reduce the incidence of residual deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[A boy with functional impairment of his thumb]. / Een jongen met een functiebeperking van zijn duim.

An 11-year-old boy was referred with poorly understood atrophy of his thenar and functional impairment of his right thumb. Sensation in the median nerve distribution was normal but the affected thumb was smaller with decreased skin creases, an unstable metacarpophalangeal joint and diminished strength. He was diagnosed with a type 2 hypoplastic thumb and we advised an opponensplasty.

Assessment of Wrist Function After Simulated Total Wrist Arthrodesis: A Comparison of 6 Wrist Positions.

Background: There is poor consensus in the literature regarding associated functional limitation and the preferred wrist position for total wrist arthrodesis. The purpose of the current investigation was twofold: (1) to assess the functional limitations of wrist arthrodesis and (2) to determine the optimal position for wrist arthrodesis using a simulated wrist fusion model. Methods: Twenty healthy volunteers underwent simulated wrist arthrodesis in 6 different positions using custom-molded wrist splints: 15° extension with 0° radio-ulnar deviation, 15° extension with 10° ulnar deviation, 15° extension with 10° radial deviation, 0° extension with 0° radio-ulnar deviation, 0° extension with 10° ulnar deviation, and 0° extension with 10° radial deviation. Each volunteer was independently assessed for wrist function using the Jebsen-Taylor hand function test, grip strength, and satisfaction in the simulated wrist fusion positions. Comparisons between all simulated fusion wrists and the baseline unsplinted wrist as well as among the 6 simulated fusion positions were performed. Results: Turning over a card (5.1 vs 4.3 seconds), picking up small objects (7.1 vs 5.8 seconds), and simulated feeding (8.3 vs 7.1 seconds) as well as total Jebsen-Taylor test duration (41.8 vs 37.9 seconds) was significantly longer in simulated fusion wrists. Both grip strength (55.9 vs 80.7 kg) and satisfaction scores (6.4 vs 9.6) were lower in simulated fusion wrists. Wrists in 0° extension also demonstrated significantly shorter durations in stacking checkers than wrists in 15° extension. Conclusion: Our findings suggest that wrist arthrodesis may only compromise select wrist functions. Among the tested wrist fusion positions, wrists fused in neutral may demonstrate better function than wrist fused in slight extension. However, grip strength and satisfaction seem to be unaffected by wrist fusion position.

Outcome of flexor digitorum superficialis opponensplasty for Type II and IIIA thumb hypoplasia.

UNLABELLED: This study reports on outcomes of the flexor digitorum superficialis tendon transfer from the ring finger in Type II and IIIA hypoplastic thumbs. We included 22 patients with 27 involved hands: 16 Type II thumbs and five Type IIIA treated by transfer and six non-operated Type II thumbs. The outcomes were assessed by range of motion, strength, sensibility, joint stability and patient/parent satisfaction. Compared with normative data, the range of motion was diminished in all patient groups. Opposition strength in operated Type II thumbs was significantly better than in non-operated thumbs. Grip strength, pinch strength, tripod strength and key pinch strength were approximately 50% of normal in Type II thumbs and 35% in Type IIIA thumbs. Metacarpophalangeal joint stability was restored in all operated Type II thumbs and in 40% of Type IIIA thumbs. We conclude that the flexor digitorum superficialis tendon transfer of the ring finger is a good functioning opponensplasty in both Type II and IIIA thumbs. The transfer provides excellent stability of the metacarpophalangeal joint in Type II thumbs. LEVEL OF EVIDENCE: Level IV.

Long term functional outcomes after early childhood pollicization.

STUDY DESIGN: Retrospective Cohort INTRODUCTION: Important outcomes of polliciation to treat thumb hypoplasia/aplasia include strength, function, dexterity, and quality of life. PURPOSE OF THE STUDY: To evaluate outcomes and examine predictors of outcome after early childhood pollicization. METHODS: 8 children (10 hands) were evaluated 3-15 years after surgery. Physical examination, questionnaires, grip and pinch strength, Box and Blocks, 9-hole pegboard, and strength-dexterity (S-D) tests were performed. RESULTS: Pollicized hands had poor strength and performance on functional tests. Six of 10 pollicized hands had normal dexterity scores but less stability in maintaining a steady-state force. Predictors of poorer outcomes included older age at surgery, reduced metacarpophalangeal and interphalangeal range of motion, and radial absence. DISCUSSION: Pollicization resulted in poor strength and overall function, but normal dexterity was often achieved using altered control strategies. CONCLUSIONS: Most children should obtain adequate dexterity despite weakness after pollicization except older or severely involved children. LEVEL OF EVIDENCE: IV.

Quantitative assessment of dynamic control of fingertip forces after pollicization.

Dexterity after finger pollicization (reconstruction to thumb) is critical to functional outcomes. While most tests of hand function evaluate a combination of strength, coordination, and motor control, the Strength-Dexterity (S-D) paradigm focuses on the dynamic control of fingertip forces. We evaluated 10 pollicized and 5 non-pollicized hands from 8 participants ages 4-17 years (2 female, 6 male; 10.6 ± 4.5 years). Participants partially compressed and held an instrumented spring prone to buckling between the thumb and first finger to quantify dynamic control over the direction and magnitude of fingertip forces. They also completed traditional functional tests including grip, lateral pinch, and tripod pinch strength, Box and Blocks, and 9-hole peg test. Six of 10 pollicized hands and all non-pollicized hands had S-D scores comparable to typically developing children. However, dynamical analysis showed that pollicized hands exhibit greater variability in compression force, indicating poorer corrective action. Almost all pollicized hands scored below the normal range for the traditional functional tests. The S-D test Z-scores correlated moderately with Z-scores from the other functional tests (r = 0.54-0.61; p = 0.02-0.04) but more weakly than amongst the other functional measures (r = 0.58-0.83; p = 0.0002-0.02), suggesting that the S-D test captures a different domain of function. A higher incidence of radial absence in the hands with poor S-D scores (3/4 vs. 0/6 in hands with normal S-D scores, p = 0.03) was the only clinical characteristic associated with S-D outcome. Overall, these results suggest that while most pollicized hands can control fingertip forces, the nature of that control is altered.

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.

The Neurological Hand Deformity Classification for children with cerebral palsy.

BACKGROUND/AIM: The purpose of this study was to evaluate the reliability of the Neurological Hand Deformity Classification and use it to describe changes in hand deformity over time in children with cerebral palsy. METHODS: We identified 114 video clips of 26 children with cerebral palsy, aged 1-18 years (mean = 8.4, SD = 4.2), performing upper-limb tasks at multiple time points (n = 3-8) at least 6 months apart. Using the Neurological Hand Deformity Classification, three observers classified hand deformity in the video clips. Inter- and intra-observer reliabilities were estimated using Fleiss and Cohen's kappa (κ) and the temporal changes in classification of hand deformity were investigated. RESULTS: Inter- and intra-observer reliability respectively were κ = 0.87 and κ = 0.91. Hand deformity was identified in all children at all time points, even before the age of 2 years. Ten children did not change hand classification, wrist flexion increased in eight, and eight showed changes from wrist flexion to extension or vice versa. CONCLUSIONS: The Neurological Hand Deformity Classification is a reliable tool to classify hand deformity in children with cerebral palsy. For more than one-third of children hand deformity classification did not change. For the remaining children, two patterns of change in hand deformity over time were identified. It is recommended that children with cerebral palsy involving their upper limbs be monitored regularly. SIGNIFICANCE OF THE STUDY: This is the first study to document longitudinal changes in hand deformity in children with cerebral palsy.

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.