The effect of congenital hand differences on handedness in children.

We investigated whether handedness is influenced by the presence of a congenital hand difference (CHD). Among 31 children with right-sided CHDs, 13 were left-handed and 18 were right-handed, regardless of severity. This was significantly different from the normal population, suggesting that CHD does influence handedness.

Re-examining the nomenclature of congenital failure of formation in the upper limb: a historical perspective.

In this study, we studied historical case notes to examine nomenclature of congenital upper limb anomalies and explore the changes in terminologies over time. Original diagnoses were reclassified according to previously published classifications and the most recent Oberg, Manske and Tonkin system. Two hundred and thirty-eight case notes were obtained from the period 1961-1991. Hand plate malformations where the diagnosis was obvious or traumatic defects, were excluded. Eighty-six cases (106 extremities) were finally included where an ambiguous diagnosis, such as 'congenital absence' was initially given. None of the re-classifications matched the original diagnoses except for cleft hand and radial dysplasia (n = 31). Eighteen phocomelia-type limbs were re-classifiable when seen as a continuum of longitudinal deficiency, but not as an intercalary deficit. This study provided further insights into the evolving nature of nomenclature in congenital upper limb anomalies, especially for the condition of phocomelia.Level of evidence: IV.

The Oberg, Manske, and Tonkin Classification of Congenital Upper Limb Anomalies: A Consensus Decision-Making Study for Difficult or Unclassifiable Cases.

PURPOSE: An ideal classification system promotes communication and guides treatment for congenital upper limb differences (CULDs). The Oberg, Manske, and Tonkin (OMT) classification utilizes phenotypic presentation and knowledge of developmental biology for the classification of CULDs. In this consensus decision-making study, we hypothesized that CULDs that are difficult to classify would be identically classified by a group of experienced pediatric hand surgeons. METHODS: An international consortium of 14 pediatric hand surgeons in 3 countries contributed a group of 72 difficult-to-classify CULD cases. These were identified from the clinical practices of the surgeons and from associated registries. Through a Delphi-type process, repeated efforts were made to obtain consensus for the correct OMT classification of each case utilizing clinical images and radiographs. RESULTS: The first round of discussion yielded a universal consensus for 57 cases. The remaining 15 cases continued to be put through additional rounds of the Delphi-type process. The repeat classification and discussion resulted in a final yield of 93% complete consensus in classification by the OMT. The primary challenge in diagnosis was differentiating cleft hand from ulnar longitudinal deficiency, identified as group A. Five cases were in this group, yet 2 remained without a clear consensus. Another controversial group, group B, was termed "brachy-polydactyly" and consisted of 3 cases where diagnoses varied between sympolydactyly, symbrachydactyly, or complex syndactyly. CONCLUSIONS: The Delphi-type process was feasible and effective and allowed a 93% consensus in the diagnosis of difficult-to-classify cases by the OMT Classification. There remain limitations and controversies with the OMT system, especially when classifying hands with less than 5 skeletal digits, syndactyly, and those with diagnostic overlap between ulnar longitudinal deficiency and cleft hand and those considered "brachypolydactyly." An improved understanding of the underlying etiology may be needed to determine the final diagnosis in difficult-to-classify conditions. CLINICAL RELEVANCE STATEMENT: A consensus-seeking approach is effective and feasible in addressing difficult-to-classify CULDs.

Changing face of medical education during a pandemic: tragedy or opportunity?

The COVID-19 pandemic has changed forever the way we do certain things. Although the race for a cure and vaccine has taken centre stage, traditional face-to-face medical education has slowly metamorphosised in the background to a virtual world with innumerable webinars, virtual tutorials and lectures in the World Wide Web. Despite this seemingly 'perfect' solution, there remains a hidden cost. Educators are forced to learn new skills to engage students as well as manipulate the electronic platform. Impact on learning for students, both undergraduate and postgraduate from a lack of social interactions, remains unknown. In this article, the authors share their experiences from different specialities about the pros and cons of virtual learning and teaching. Suggestions and practical tips are offered to enhance the learning experience. More emphasis may need to be placed on the creation of learning communities rather than lecture-based curricula. Hybrid curricula or conferences may become the future norm. As we slowly move out of lockdown into a changed world and new ways of doing things, lessons learnt can be harnessed for future hybrid models that can combine the best of technology and physical teaching to reduce worldwide inequalities.

Hand Surgery in Cambodia.

As a lower middle-income nation, Cambodia has made significant improvements in basic health but hand surgery development continues to lag behind due to scarcity of trained and quality surgical manpower. Most of the hand surgery development locally has been due to surgical volunteers from Asia, Europe, and the United States. The introduction of a structured and systematic community-oriented hand surgery training over a 5-year period was successful in producing local surgeons to meet the basic needs of hand surgery patients. Brachial plexus surgery has benefited significantly, with local surgeons able to independently manage cases with minimal support. With the expansion of local surgical manpower and guidance, motivation, and assistance of regional hand surgeons, the future of hand surgery in Cambodia looks promising.

Developing a Parental-Friendly Scoring System for Children with Congenital Hand Differences.

Background: Congenital hand differences (CHD) exhibit enormous diversity and heterogeneity. Surgeons and parents often have different concepts of severity, making things difficult during parental consultation. This study aims to align surgeon/parental views on the severity of the child's CHD using a novel severity classification. Methods: Parents of affected children were asked to score the severity of their child's abnormality pre- and post-consultation using a subjective scale (1-4) without any explanation. Furthermore, parents were asked to rate their concerns about the future function and appearance of their child's hand condition using a similar scale of 1-4. They were then asked to rate the severity of the CHD post-consultation and three months post-operatively following explanation of the 4-point scale, as follows: 1 = treatment possible to normal; 2 = treatment possible to near normal; 3 = treatment possible but always some hand differences; 4 = treatment not possible. The surgeon also independently scored all children using his perception of the scale. Results: Forty-three children with a range of CHD were recruited into the sample. Linear weighted kappa analyses comparing inter-rater agreement showed no agreement between surgeon and parents during the initial scoring without any explanations. However, with explanations added, agreement rose significantly (kappa = 0.437 post-consultation and kappa = 0.706 three months post-op). No correlation was found between severity with both appearance and function (r = 0.277 and r = -0.184, respectively). Conclusions: This study demonstrated that the use of a simple scoring system was able to improve parental understanding of the severity and prognosis of CHD. The system demonstrated a good correlation between surgeon and parents. Such a scoring system can be easily utilised in the outpatient department to manage expectations and reduce anxiety.

Congenital peripheral nerve hypoplasia: a report of seven cases.

We report the clinical findings of congenital peripheral nerve hypoplasia in seven patients. All seven children presented with unilateral ulnar or median nerve palsy or both. They were assessed clinically, and nerve diameters were assessed with ultrasonography and compared with the contralateral limb. Nerve conduction studies were performed in five children, and the nerves were explored in the four children who presented with accompanying constriction bands. By ultrasonography, the mean diameter of the ulnar nerve was 63% and 29% when compared with the normal arm and forearm, respectively, and the mean diameter of the median nerve was 63% and 46%. Hypoplasia in the nerve was not confined to constriction points but occurred in the entire upper limb in all seven cases. These patients were followed for an average of 12 months (range 6 to 30). Despite neurolysis and surgical decompression in four patients, none of the nerve palsies had recovered. The clinical findings suggest that this condition cannot be explained by simple mechanical compression, and more extensive pathological changes in the involved upper limb are evident in this rare disease.Level of evidence: IV.

A model for surgical volunteerism: a qualitative study based in Cambodia.

Medical volunteerism continues to attract many doctors from high-income nations to low- or middle-income countries (LMIC). In spite of the wealth of positive experiences of these volunteers documented in the literature, there is little evidence concerning the impact and effectiveness of their activity. We documented our model of five-year experience in the delivery of hand surgery in Cambodia, attempting a qualitative approach with attempts to understand the perceptions of local and volunteer surgeons. We conducted independent qualitative interviews with five visiting and 12 Cambodian surgeons who participated in our community-based and outcome-oriented hand surgery training programme between 2013 and 2015. Data were coded and analysed using a content analysis method and then individually grouped into categories; software was used to generate frequencies and quotations of codes. Our results highlighted factors contributing to the success of the medical volunteering programme, to its success, with suggestions for sustainability, motivation and commitment to such a programme. A clearly defined strategy by the volunteer group and a commitment to time and resources by both partners were found to be effective.

Compartment Syndrome of the Forearm Following Dermofasciectomy-A Rare and Devastating Complication.

We present a case of compartment syndrome of the forearm following harvesting of a full thickness skin graft from the medial forearm for a double digit dermofasciectomy. The patient underwent forearm fasciectomy followed by multiple surgical debridements. At 18 months, despite intensive physiotherapy, the patient was left with a very significant residual functional deficit. This case highlights a previously undescribed but devastating complication of closure of a forearm skin graft donor site.

The Role of Selective Peripheral Neurectomy in the Treatment of Upper Limb Spasticity.

BACKGROUND: Management of upper limb spasticity remains challenging. Selective peripheral neurectomy (SPN) is a relatively recent intervention for cases refractory to medical therapy. The aim of this study was to conduct a systematic review looking at the efficacy and outcomes of SPN, in order to clarify the patient selection criteria and surgical technique. METHODS: A search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Open Grey and CINAHL was conducted. Inclusion criteria included studies comparing pre- and post-operative outcomes for SPN, neurectomy, fasciculotomy and upper limb spasticity. RESULTS: Only case series were reported with no randomised controlled trials found. 7 studies met the inclusion criteria with a total of 174 patients. A meta-analysis was not possible due to the degree of baseline heterogeneity. All studies had no control arm for comparison of outcomes, with a high risk of bias due to poor internal and external validity, as well as design and performance bias. Surgical techniques differ vastly between studies, with percentage of fascicles ablated between 30-80% and length of neurectomy between 5-10 mm. Some advocated removing end branches while others performed fascicular SPN proximally. 13 patients underwent orthopaedic or neurosurgical procedures, which are both confounding factors. All studies reported an improvement in spasticity although functional outcomes were reported with non-standardized measures. Recurrence rates were reported to be 0-16.1% (mean 3.72%). CONCLUSIONS: From this systematic review, SPN appeared to be a useful technique in selected cases, but overall no firm conclusions can be drawn regarding the best surgical technique, or the extent of functional improvement.

Microsurgery Fellowships-Development of a Clinical Curriculum.

BACKGROUND: Microsurgery fellowships have become an integral part of every plastic surgery training program. While each subspecialty differs in terms of reconstructive requirements, the basic tenets and skill sets remain the same. We explore the possibility of designing a clinical curriculum for microsurgery that can provide residents and fellows with a more foundational and structured approach to microsurgical training. METHODS: Thirteen core and desired skills to accommodate an "ideal" microsurgery curriculum were listed and categorized according to the level of difficulty. The curriculum was then sent to plastic surgery trainees, fellows, and consultants within Scotland in the form of a survey. They were asked to assign a level of difficulty, basic, intermediate, or advanced, to each of the 13 skill sets. RESULTS: A total of 27 surgeons were surveyed; the majority of which were plastic surgery registrars. Overall a broad, generic clinical curriculum was felt to be lacking, but would be beneficial at the start of training. The curriculum should emphasize a step-wise progression, starting from achieving competency in safe, efficient anastomosis at the basic level to eventually mastering the principles of complex reconstruction at a more advanced level. CONCLUSIONS: A generic clinical curriculum offers a framework for tracking progress, the potential for competency-based assessment, and aid in designing a microsurgery fellowship. The curriculum should reflect the evolving nature of the specialty and provide a foundational platform for future innovations.

Using pneumo-computerized tomography as a quantitative assessment of result in submucous fibrosis patients treated with surgical release and free flap reconstruction.

OBJECTIVE: This study investigates the efficacy of oral submucous fibrosis release and free flap reconstruction. STUDY DESIGN: Pneumo-computerized tomography (pneumo-CT) was used to evaluate postoperative changes in the buccal vestibular volume during maximum blowing. METHODS: From March 2003 to November 2008, 9 patients underwent 18 microvascular flap reconstructions after oral submucous fibrosis release. The preoperative and postoperative buccal vestibular volumes were determined by capturing the air density in the selected region on CT images, which were composed of 0.75-mm-thick slices that were then summated using analysis software (Biomedical Imaging Resource; Mayo Foundation, Rochester, MN). RESULTS: Postoperative results were measured for a mean follow-up period of 15 months (range, 6-36 mo). There was significant improvement in the interincisal distance from 12.44 (8.35) mm preoperatively to 32.56 (7.322) mm postoperatively (P = 0.000). There was an accompanying significant increase in the buccal vestibular volume from 5.66 (3.92) mL preoperatively to 9.38 (4.96) mL postoperatively on the right side (P = 0.032) and from 6.44 (4.20) mL preoperatively to 9.64 (4.65) mL postoperatively (P = 0.048) on the left side. CONCLUSIONS: Adequate release of the mucosa and resurfacing with a free flap can increase the interincisal distance and improve the maximal buccal vestibular volume. Air-contrast pneumo-CT studies demonstrate an improvement in buccal mucosal elasticity.

Sarcomatoid carcinoma in head and neck: a review of 30 years of experience--clinical outcomes and reconstructive results.

PROBLEM PRESENTED: Sarcomatoid carcinoma (SaCa) is a rare variant of squamous cell carcinoma (SCC) with sarcomatoid features. This study investigated the clinical presentation and outcomes of head and neck SaCa. In addition, reconstructive outcome for a subset of patients was also evaluated. STUDIES UNDERTAKEN: Seventy-eight SaCa cases including 72 men and 6 women were identified from 13,777 head and neck SCC cases. Clinical outcomes were evaluated based on locoregional control, distant metastases, and multivariate analyses. Reconstructive outcome was evaluated by flap survival rate. RESULT: Of the 78 cases, 71% (55) of cases were located in the oral mucosa; 64% (50) of patients were classified as T3 or T4 at the time of diagnosis. The 5-year survival was only 16%. Multivariate analysis revealed better outcomes only when the patient had a history of previous SCC. Forty-five patients underwent flap reconstruction, with 98% flap survival rate but the functional result varied because of the inevitable adjuvant radiotherapy and advanced stage of tumor. CONCLUSIONS: Sarcomatoid carcinoma is a different entity from the conventional SCC of the head and neck. Sarcomatoid carcinoma carries a poorer prognosis despite aggressive surgical intervention and concurrent adjuvant therapies. It remains a great challenge for clinical oncologists, and the optimal treatment strategy requires further studies. Free flap is still preferred for defect reconstruction but the design should be simplified to avoid complications.

Improving the extensor lag and range of motion following free vascularized joint transfer to the proximal interphalangeal joint: Part 1. An observational and cadaveric study.

BACKGROUND: Extension lag is a common occurrence following free vascularized joint transfer reconstruction of the proximal interphalangeal joint, thus limiting the range of motion that is achievable. In this Part 1 study, the anatomical and biomechanical arrangements of the toe proximal interphalangeal joint extensor mechanism were investigated. METHODS: Twelve second toes from 12 fresh cadavers were dissected for examination of the extensor mechanism. Similar observations were performed in nine clinical cases. A total of 21 toes were therefore examined with dynamic and static testing. RESULTS: In 17 toes, the central tendon attenuated before inserting onto the middle phalangeal base (type I). In four toes, a thicker tendinous insertion analogous to a central slip was identified (type II). In type I toes, traction of the extensor digitorum brevis and digitorum longus did not correct the extensor lag. The extension lag decreased when the metatarsophalangeal joint was flexed passively or when both extrinsic and intrinsic tendons were pulled simultaneously. In type II toes, a full extension of the proximal interphalangeal joint was achieved when the extensor tendons were pulled with or without pulling the intrinsic tendons. In both types of toes, there was an increase in the extension lag caused by dorsal bowstringing when separated from the extensor sling. CONCLUSIONS: The lesser toe proximal interphalangeal joint adopts a naturally flexed posture for evolutionary reasons, with corresponding adaptations in extensor mechanism arrangements. The most significant limiting factor to full extension could be the presence of an attenuated central slip in the majority of toes.

Improving the extensor lag and range of motion following free vascularized joint transfer to the proximal interphalangeal joint: Part 2. A clinical series.

BACKGROUND: Free vascularized joint transfer for reconstructing the posttraumatic proximal interphalangeal joint has enjoyed limited popularity because of the low range of motion typically achieved after transfer. One of the commonest complaints is the significant extensor lag. Part 2 of this two-part study is focused on the clinical outcomes following a more anatomical approach to extensor tendon reconstruction. METHODS: Nine patients (eight male and one female), with a mean age of 31.7 years, underwent free vascularized joint transfer for posttraumatic proximal interphalangeal joint injuries using the second toe proximal interphalangeal joint. In Part 1, two arrangements of the central slip mechanism were found: type I with an attenuated and type II with a distinct central slip. An algorithm was constructed using this information: in a type I toe with sufficient recipient lateral bands, a centralization procedure was carried out; and when the lateral bands were insufficient, a modified Stack procedure was carried out. In type II toe joints, a tight repair of the corresponding extensor tendons was performed. RESULTS: Four patients underwent centralization procedures, two underwent a modified Stack procedure, and three underwent tight extensor repair. At 23.4 months, the average extensor lag was 18.3 degrees. A total range of motion of 53.9 degrees (mean flexion, 72.2 degrees) was achieved that approximated 81.1 percent of the pretransfer passive range of motion at the toe proximal interphalangeal joint. CONCLUSION: This preliminary result demonstrates that much improved range of motion can be achieved by reducing the extensor lag using an anatomical reconstruction that takes into account the recipient finger and toe joint anatomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Subcutaneous tissue expansion and subsequent subpectoral implantation for breast reconstruction in Asian patients: safety and outcome.

Asian women are generally thin with smaller breasts. The objective was to investigate the outcomes for patients who underwent 2-stage breast reconstruction using subcutaneous expansion followed by subpectoral implantation. Between 2003 and 2008, 22 patients underwent subcutaneous expansion and subsequent submuscular implantation for 23 breast reconstructions. Mean age was 44.6 ± 7.0 years. The outcome was assessed with a pain visual analog scale, a questionnaire, and the cosmesis. Mean expansion volume was 350.3 ± 80.8 mL. Mean implant size was 306.7 ± 84.6 mL. The complication rate was 8.6%, 13.0% in first and second stages. Mean pain scale was 2 ± 1.4. At a mean follow-up of 42.5 ± 18 months, patient's satisfaction was 3.2 ± 0.9. Overall shape of the reconstructed breast was rated as 2.8 ± 0.5. Subcutaneous expansion with subsequent subpectoral implantation is feasible and reliable in low body mass index, nonsmoking, nonradiated patients with small and projective breasts.