Postoperative Growth in Radial Polydactyly: A Clinical Study.

PURPOSE: This study was designed to evaluate thumb growth after surgical management of a duplicate thumb and investigate its developmental pattern. METHODS: We compared the thumbs and index fingers of 486 normal children (aged 1-18 y) (group A) with 15 children showing radial polydactyly (group B). All duplicate thumbs were treated with excision of the radial thumb and reconstruction of the ulnar thumb. Radiographs of groups A and B were used to compute the thumb-to-index finger length ratio and width ratio, and the thumb-to-index finger phalanx length ratio and phalanx width ratio. RESULTS: In group A, the length ratio, width ratio, phalanx length ratio, and phalanx width ratio did not change with age, and remained constant in males and females. In group B, after an average follow-up period of 41.0 months, the original findings were also similar to the final ratios. In group B, only the phalanx width ratio was obviously smaller than normal. CONCLUSIONS: A permanent developmental stability exists between the thumb and the index finger, even in patients with radial polydactyly. The development of the retained digit is not influenced by the ablation of the extra digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Supporting the collateral ligament complex in radial polydactyly type Wassel IV.

Despite anatomical metacarpophalangeal joint (MCPJ) reconstruction in radial polydactyly (RP) Wassel IV, the prevention of long-term deformity and instability is still an issue. We report on clinical results following our modified surgical procedure with additional support of the hypoplastic radial collateral ligament complex (RCLC) after musculoligamentous MCPJ reconstruction. Fourteen patients (male: 10, female: 4) with radial resection of isolated RP Wassel IV (1987-2006), average age at surgery 1.7 years (0.6-8.6) were included. Distribution to group A and B depended on the procedure for MCPJ reconstruction. In group A (N = 7), RCLC reinsertion + reinforcement using autologous tendon grafts was performed (follow-up: 4.6 years (1.4-6.9)). Group B (RCLC reinsertion without support) consisted of N = 7 patients; follow-up: 9.6 years (8.2-20.2). The healthy contralateral hand (control A/control B) served as a control. Results were evaluated using our modified Tada-score considering: range of motion (ROM), interphalangeal joint (IPJ) and MCPJ stability on stress examination, palmar abduction and grip strength. Better score results (maximum 10) were seen in A: 7.3 (6-9) compared to B: 6.6 (4-10). Subscore 'stability' A: 1.1 (0-2); B: 0.9 (0-2) and 'alignment' A: 0.86 (0-2); B: 0.57 (0-2) showed greatest influence on the score result. Ulnar angulation at MCPJ level compared to healthy thumbs (control A + B) was greater (p < 0.05), with 11.4° (10-20) in group A and 14.3° (-5 to 30) in group B compared to 0° in control A and 5.7° (0-17) in control B. MCPJ ulnar deviation in A + B: 25° (0-35) compared to healthy thumbs control A + B was higher (p < 0.05). Ulnar deviation was higher in B 45° (30-60) compared to 34° (20-50) in A. In B, instability was evident in four, in A, only in one patient. In B, one patient required two re-operations due to MCPJ instability. Equivalent results were recorded regarding pinch grip and palmar abduction. Anatomical MCPJ reconstruction in combination with autologous support of the hypoplastic RCLC to enhance long-term stability is recommended.

The first metacarpal is the thumb first phalange: EvoDevo implications / El primer metacarpiano es la primera falange del pulgar: implicaciones en EvoDevo

We examined the status of the first metacarpal bone whose shape, fetal and post-natal development correspond to those of the thumb proximal phalanx. Galen already described this, circa 170 CE. Our radiographic data confirm that the pre-axial (radial or anterior) side of the hand matures, later than the post-axial (ulnar or posterior) side, both, pre- and post-natally. A new perspective on thumb primate and human ontogeny is discussed and comparative observations on the Evolutionary Development (EvoDevo) of the thumb and the first toe are proposed along with a nomenclature honoring Galen's original roposition.

Se analiza el estado del primer metacarpiano cuya forma y desarrollo embrionario, fetal y postnatal corresponde a los de la primera falange del pulgar. Galeno notó que éste era la primera falange del pulgar cerca de 170 DC. Esto no es un simple cambio de nomenclatura, ya que da una nueva luz a los problemas evolutivos de ontogenia (EvoDevo). Nuestros datos radiográficos confirman que el lado radial (anterior o pre-axial) de la mano madura, pre y post-natalmente, mas tardíamente que el lado cubital (posterior o post-axial). Se discuten nuevas perspectivas sobre la ontogenia y filogenia humana y de primates, y se proponen estudios comparativos del desarrollo del pulgar y del ortejo mayor.

On the nature of thumbs.

Asymmetric regulation of Hox gene expression pre-dates the appearance of tetrapod digits, and was co-opted in the development of 'thumbness'. This asymmetric expression correlates with independent morphological evolutionary variation of digit 1.

Changes in EMG coherence between long and short thumb abductor muscles during human development.

In adults, motoneurone pools of synergistic muscles that act around a common joint share a common presynaptic drive. Common drive can be revealed by both time domain and frequency domain analysis of EMG signals. Analysis in the frequency domain reveals significant coherence in the range 1-45 Hz, with maximal coherence in low (1-12 Hz) and high (16-32 Hz) ranges. The high-frequency range depends on cortical drive to motoneurones and is coherent with cortical oscillations at approximately 20 Hz frequencies. It is of interest to know whether oscillatory drive to human motoneurone pools changes with development. In the present study we examined age-related changes in coherence between rectified surface EMG signals recorded from the short and long thumb abductor muscles during steady isometric contraction obtained while subjects abducted the thumb against a manipulandum. We analysed EMG data from 36 subjects aged between 4 and 14 years, and 11 adult subjects aged between 22 and 59 years. Using the techniques of pooled coherence analysis and the chi(2) difference of coherence test we demonstrate that between the ages of 7 and 9 years, and 12 and 14 years, there are marked increases in the prevalence and magnitude of coherence at frequencies between 11 and 45 Hz. The data from subjects aged 12-14 years were similar to those obtained from adult controls. The most significant differences between younger children and the older age groups were detected at frequencies close to 20 Hz. We believe that these are the first reported results demonstrating significant late maturational changes in the approximately 20 Hz common oscillatory drive to human motoneurone pools.

The effect of hormones on bone growth is mediated through mechanical stress.

Mechanical stresses play a key role in regulating cell growth and cell differentiation. Using mechanical and physiological data available in the literature, we are able to construct a growth curve of a child, which we compare to the standard curve. It appears likely that the impact of hormones on pubertal growth rate sprout followed by growth arrest can be solely explained by increased mechanical stresses. The uptake of hormones by the muscles results in increased mechanical stress on the chondrocyte before and at the puberty, resulting in a peak in growth followed by growth cessation.

Normative values for thumb length, girth, and width in the pediatric population.

PURPOSE: To determine the normal relative length, girth, and nail width of the pediatric thumb with respect to the index finger in children ages 1 through 18 years. METHODS: Measurements of relative thumb length, girth, and nail width were performed on 546 hands in 273 volunteers ages 1 through 18 years. At least 22 hands were included for each age group. The data were analyzed by age, gender, and hand, with the thumb compared with the index finger for all measurements. RESULTS: The adducted thumb tip reached an average of 70% of the length of the index finger proximal phalanx and 32% of the length of the index finger from the metacarpophalangeal joint to its tip. The thumb girth and nail width as a percentage of corresponding levels of the index finger girth and nail width were 133% and 105%, respectively. Relative thumb size remained constant with no significant difference in length, width, or girth between age groups. CONCLUSIONS: The relative size of the thumb remains constant during growth. These normative data will allow a more objective assessment of thumb size and appearance.

Ossification of the distal phalanx of the first digit as a maturity indicator for initiation of orthodontic treatment of Class III malocclusion in Japanese women.

The influence of mandibular growth on the stability of orthodontic treatment has been well established. A particular problem is late mandibular growth in patients with Class III malocclusions, because of skeletal jaw discrepancies that may influence the timing and course of treatment, as well as the stability of posttreatment. We have used the ossification of the distal phalanx of the first digit as an indicator of the skeletal maturity of the patient and of their potential for further growth. Our previous studies have shown that fusion of the epiphysis and the diaphysis of the distal phalanx of the first digit occurs from 1 to 3 years after the pubertal growth maximum in Japanese women. In these case reports, the orthodontic treatment of two female patients with mild Class III skeletal malocclusions is presented to show the possible clinical application of the ossification of the first digit as an indicator of the completion or near cessation of mandibular growth in the timing of treatment of Class III malocclusions. The case reports show that, although both patients experienced some mild degree of mandibular growth after treatment, this method can be helpful in determining residual mandibular growth potential in Japanese female patients with Class III malocclusions and mild skeletal discrepancies.

Bone growth after replantation in children.

Bone growth and the development of epiphyseal plates are disturbed after the replantation of amputated extremities in children, but the potential for continued skeletal growth is almost always maintained in the replanted part. In this reported series of 12 children, all younger than 15 years old, 13 amputated parts of the upper limb have been successfully replanted. After long-term follow-up (from 21 to 216 months), bone growth of the replanted parts was clinically and radiologically evaluated. Two different growing segments were distinguished: the proximal bone segment, directly injured from the initial trauma, and the distal replanted part. Average longitudinal growth recorded was 94.5 percent and 92.7 percent, respectively. Two young patients demonstrated overgrowth of the proximal bone segment, which attained 110 percent and 118 percent of expected growth. Although it is difficult to determine all the parameters affecting the prognosis of post-traumatic reactions in growing cartilaginous plates, the level of amputation is considered to be a significant prognostic factor for the epiphyseal growth of the replanted part.

Embryological development and prevalence of thumb flexion creases.

A study of the embryological development and morphology of the thumb flexion creases is presented. We used 178 human fetuses, at 6-20 weeks of gestational age, and 225 normal adults, aged 19-81 years, to observe the morphology and the timing and location of the appearance of the flexion creases. Most creases, that is, the regular, extra, and oblique creases, were found to develop concurrently with the appearance of the fetal volar pads, apparently independently of the thumb flexion movements. Although the regular creases usually appear to be simple, single creases, they seem to be formed by the radial and ulnar lateral crease segments that develop inwards from each lateral side. Our observations also suggest that the oblique and extra creases on the proximal phalanx of the thumb should be considered as common or "regular" creases, rather than anomalies, because of their high frequency in fetuses and in normal healthy adults.

Retardation of finger growth after injury to the flexor tendons.

The absence of any part of the total mechanical force (i.e., flexor tendons) may be responsible for retardation of bone growth during a child's growth phase. The cause of retardation may be dedifferentiation of cartilage cells at the epiphyseal plate. Four cases in which unrepaired flexor tendons in digits caused retardation of growth illustrate this possible phenomenon. We feel that this is not a well recognized problem and thus deserves mention to stimulate further study. We believe that meticulous primary repair in children is desirable not only to preserve function, but also to prevent growth disturbances.