Corrective Surgery For Infant Hands
Cameron B. Hall, M.D.
Major long bone deficiencies in children are frequently accompanied "by digital anomalies. This association is obvious in the patient population of our amputee clinic; yet, in the presence of severe anomalies, we have tended to ignore finger and hand deformities, dismissing them as minor difficulties in light of the patient's major deficiencies. A review of our cases following a realization of this situation revealed that we had often failed to describe hand problems accurately in our otherwise complete clinical records; and that photographs, which usually covered the major problem in detail, were generally inadequate or absent.
Parents seem to accept the principal loss or deformity with some degree of equanimity, and are willing to continue with a long-term program of prosthetic replacement and training. From the initial discussion following birth of a deformed child, through the fitting of arms and legs, and the training of the steadily maturing child, anxious parents are promised hand correction "before he starts to school". Hand deformities have been brushed aside as "something that can be operated on later". Time-honored platitudes which are still seen in most surgical texts - wait until tissues are large enough to work with, wait until the child is old enough to withstand an anesthetic, wait until the tissues are sufficiently mature to heal well - are used to parry the parents' queries. The family, meanwhile, is constantly being reminded of the deformity, since the hand is one of the most eye-catching features of a child., repeatedly attracting attention as the baby plays, eats, or expresses his emotions. With each successive visit to the clinic the repetition of the question "When can it be fixed?" has gradually revealed to us the magnitude of such a step in the eyes of the parents, however small the surgical procedure might seem. They have to accept the major problems, but here is something that can be done to improve their baby. Why wait so long?
This same question has bothered the surgeon. In certain instances, restrictive soft tissue structures interfere with the growth and development of residual elements. Was it really necessary to wait until a child was six or seven to attack a syndactylism of the thumb-index complement, where length differences in the unseparated digits produced gross deformities?(Fig. 1 )
From the surgeon's point of view, four possible contraindications to early surgery merit consideration: l) anesthesia in the infant; 2) post-operative complications; 3) size of the tissue elements, and k) questionable healing capability of "immature" tissue.
Anesthesia. With the development of anesthetic methods which permit pediatric surgeons to repair major cardiac defects and atresias of the gastrointestinal tract, it is apparent that with proper management infants can withstand prolonged, surgery with very little apparent difficulty. With the newer anesthetic agents, endotracheal tubes, and intravascular catheterization for fluid balance, surgical procedures of 6 to 8 hours have been performed on infants only 24-hours-old. Physiological-chemical balance has been maintained with little difficulty by careful electrolytic assay.
Post-Operative Complications. The post operative complications characteristically suffered by infants seemed to have been obviated by careful life-support systems during surgery. In addition, the techniques of post-operative observation and assay have revealed that this age group withstand the rigors of surgery without undue difficulty.
Tissue Size. With anesthetic and postoperative problems seemingly overcome, the size of the tissue still remains a significant difficulty. However, we note that in other specialties, magnifying glasses are being used for size amplification, and that small instruments have been used for years in ophthalmological and otolaryngological surgery.
Healing Capability. Discussions with cardiovascular surgeons revealed that six-month-old thoracotomies roll around in bed without a dressing on the day of surgery, and one-year-old patent ductus repairs are running around the wards two days after their operation without so much as a piece of tape on their sutured thoracic incisions. These surgeons were highly amused at our ideas of delayed healing in the infant.
Decision on Early Surgery
With these factors in mind, the decision was made to attempt early correction of hand defects which heretofore had been deferred until the fifth, sixth, or seventh year of life.
1. Anesthesia. We are fortunate, both at the University and the local private hospitals, in having a group of anesthetists skilled in the handling of infants, with experience extending down to the children born six weeks prematurely. The same services are undoubtedly present in the communities of all participating child amputee clinics. The choice of anesthetic should be left completely in their hands. The agents to be employed, and the techniques of administration, will not be discussed here.
Few Post-Operative Complications
Post-operatively, there are surprisingly few complications, and these youngsters are usually running about the ward on the evening following surgery. Cases of prolonged surgery (over two hours) certainly should have the attention of a competent pediatrician. Too much activity, rather than post-surgical morbidity, has been our prime problem. The maintenance of post-operative dressings in these highly-active children is sometimes difficult. Skin glue and casts seem to have solved the problem.
2. Instrumentation. Admittedly, the structures under treatment are small. Adequate visual magnification is an absolute necessity. A few cases were attempted, employing the unassisted eye, but with little success even before presbyopia set in.
Magnification Devices Tried
A magnifying viewer (Fig. 2 ) was obtained and used on several cases. It provided some magnification but caused considerable technical difficulty because of the short focal distance and the annoying bulk of the device. Also, the possibility of contamination of the surgical field was great.
A second device was then obtained (Fig. 3 ) which provided better working distance, less weight on the operator's head, and some improvement in the overall field; but working distances were still too short.
Success with Keeler Loupe
Realizing that the opthalmologist had undoubtedly progressed through this annoying sequence many years ago, one was consulted. A Keeler loupe (Fig. 4 ) was suggested and has proven completely successful and of tremendous benefit. This device provides a small central field of tremendous magnification at approximately the same working distance as the basic presbyopic lenses of the spectacles. The device is not heavy; within fifteen minutes of initial trial, use of the two fields of magnification becomes automatic and one is unaware of their presence. True, this unit is expensive. It must be individually fitted, and it cannot be used successfully by another individual.
I have since found the unit most practical in a goodly number of routine orthopedic cases. The central magnifying lenses are easily detached, leaving the excellent "Ben Franklin" type of spectacles for normal operating-room use. The open top allows distant vision, and even more important, the escape of steam, so that they rarely ever fog.
Other Ophthalmological Instruments Used
Again borrowing from the experience of the opthalmologist, minute tissue forceps and small self-retaining retractors, available in most surgical theaters, have been found to be well suited to this type of surgery. The needle holders and scissors shown in Fig. 5 should be purchased for and limited to this use alone, as their extreme delicacy demands restricted utilization. The periosteal elevator was designed for nasal surgery. The needle holder is self-locking and releasing, and is a delight to use. It is again an opthal-mological instrument.
Hand Table Needed
Use of a hand table is almost a necessity. Adequate support for the surgeon's and assistant's elbows, forearms, and wrists provides necessary stabilization for this sometimes tedious and always delicate work.
A bloodless field is best obtained by an Esmarch rubber bandage wrapped in a broad band about the tiny forearm. Skin marking the planned flaps with methylene blue applied with a toothpick is routine, and works well. The dagger-point No. 11 scalpel blade is used much as the point of a pencil in retracing the lines of methylene blue, and cuts through the skin at right angles with excellent accuracy. Small, intricate patterns can be followed without difficulty. Bleeding is controlled, after release of the tourniquet, by simple pressure, tiny ligatures, or the use of a small electrocoagulation tip. In surgery of this type, one rarely encounters a major vessel. With the magnifying lenses, one can avoid even the tiniest of vascular structures, and their preservation enhances the viability of skin flaps.
Split skin grafts are taken with an electric dermatome, and I have found .015 to .020 inch to be the best thickness. The proximal thigh serves as the common donor site. Full thickness skin can often be salvaged from sacrificed anomalies and works well when all subcutaneous fat is removed.
Suturing of grafts on the small skin flaps is the most technically-difficult feature of all of these procedures. The visual magnification, the small instruments, and the steady support, all facilitate this delicate task, but it is the use of No. 5-0 plain gut on atraumatic cutting needles that really simplifies the procedure. It can be used on all layers of closure, including the skin; it causes very little reaction, and results in beautiful hairline scars. It sloughs from the external wound in 8-10 days, and no harrowing suture removal on a screaming, squirming child Is necessary.
Dressings and Casts
Dressings of Telfa or scarlet red gauze have worked well in our hands. Meticulous care in the overlying copious padding is necessary, and the use of Ace Adherent on the skin of the forearm and arm will prevent post-operative loss of the dressing.
We usually apply a cast, no matter what the magnitude of the procedure, finding that it provides the best measure of protrection (Fig. 6 ).
1. Annular Constricting Bands. In our clinical population a high incidence of circumferential constricting difficulties is encountered at all levels of the extremity. The etiology is still undetermined. Bands about the fingers and hands are by far the most common, and are often found girdling a digit, just distal to the metacarpal phalangeal joint. The depth of the constriction may vary from a barely discernible crease in the skin (Fig. 7 ) to such a depth that even the skeletal framework is transected (Fig. 8 ), resulting in a flail digit - details of which will be discussed below.
Most Frequent Type
The type which includes skin and subcutaneous tissue, but does not appreciably interfere with the function of the digit, is most frequent. Parents are informed that these constrictions are cor-rectible, and the result is a never-ending series of queries as to when the correction can be accomplished. Heretofore it was deferred until just before the start of school.
Originally, a few of these entities were attacked during the course of major surgery on other extremities at a very early age. Excellent results were seen and we now attack these conditions between the twelfth and eighteenth month.
Usually the correction is divided into a two-stage procedure, each including approximately one-half of the circumference. The characteristic techniques described in surgical texts advocate the use of Z-plasties, preserving and elevating all skin leading into the depths of the crease.
In following this accepted technique, one finds some improvement, but the annular depression is not completely obliterated. The soft, resilient tissue of a baby allows one to excise completely the annular ring on both sides, and then to construct the Z-plasty from the margins of the normal elevated skin. This results in no residual depression and a marked improvement in appearance. An identical second-stage procedure on the opposite surface of the digit then completes the repair. The gain in cosmesis and function has been worth the effort. The thumb in Fig. 9 , originally identical to the thumb in Fig. 8 , has been corrected on its dorsal surface. Deep dorsal and volar bands of the index, mid and ring fingers have also been corrected. The volar surface of the thumb (see Fig. 10 ) is still uncorrected.
2. Pedunculated Digits. These are undoubtedly more severe forms of annular constriction rings, and may range from relatively normal size to flail, markedly foreshortened, rudimentary digits that often contain a single nail (see Fig. 8 ). Their preservation or removal depends on size, offensiveness to the patient and possible employment in future prosthetic devices.
Their removal can be accomplished by a simple encircling devitalizing ligature in the newborn, or a surgical amputation in the older baby. These digits are often preserved until the youngster is In school, at which time he will often demand their removal.
When a digit has skeletal elements, suggesting that some stabilization can be accomplished, one should eliminate the annular constriction and prepare a broad base through which a stabilizing bone graft may be inserted at the pre-adolescent period. This approach is particularly applicable to the flail thumb.
Pedunculated thumbs are a problem of themselves. The foreshortened, obviously useless member shown in Fig. 11 should be removed early. Quite different is the thumb shown in Fig. 12 and Fig. 13 , which promises to serve as a stable opposition post when suitably supported by a bone graft to the carpal-metacarpal junction. The infant may be provided with a large base to the thenar eminence (Fig. 14 ). It is our clinical impression that this will result in better growth characteristics as the child matures. Correction certainly reduces danger from trauma, and the appearance is much improved. A few youngsters have used this boneless thumb as a very unstable opposition post, with some benefit.
3. Syndactylism. Lack of separation of digital elements may include simple, small skin bridges in the terminal clump of foreshortened digits, as well as completely unseparated skeletal masses running the full length of all the phalanges. Variations and degrees of "fusion" occur in a galaxy of patterns between these extremes, and the magnitude of surgical repair will run from constrictive ligation of the simple small skin bridges - a very effective age-old procedure - to multiple-stage procedures requiring the splitting of tendons, nerves, and skeletal elements.
Effects of Delayed Surgery
Fig. 15 illustrates a post-operative case of partial adactylia with terminal syndactylism of all four digits. Constrictive ligation of the skin bridges, four to six weeks after birth, resulted in complete separation of all elements, with the resultant development of a broad, flat, normal-appearing palm.
Originally we delayed complicated surgery on the basis of size and immaturity of this child. This delay resulted in progressive deformity, as the restrictive effect of small elements in one finger - by nature destined to be shorter than its adjacent mate - has resulted in marked angular deformities as the child grows. The benefit of early separation of these elements, to prevent such deforming forces, is obvious.
When the ease of working with these small structures finally becomes apparent, we attempted these infant procedures much more frequently. The resulting benefits nave been most gratifying, and we regret not having attacked some of our cases sooner. Note the deforming effect of the left thumb on the hand of the preschool child shown in Fig. 1 . Her partially-corrected hand is shown in Fig. 16 . Obviously, further procedures are anticipated.
"Skin Sandwich" Technique Tried
Surgical techniques used for "routine" syndactylism separation closely followed the technique of Bunnell until a local plastic surgeon persuaded me of the simplicity of the "skin sandwich". This latter procedure consisted primarily of longitudinally splitting the skin and soft tissue to separate digits through their full length, and inserting a piece of skin, doubled upon itself, into the digital interspace. The entire incision, with the interposing skin, was then completely closed with a running suture and left for fourteen days. The reattached fingers then served as their own dressing and stent. The results, at fourteen days, looked beautiful; the fingers were completely divided and graft viability was usually 100 percent.
However, by the end of the first year, progressive scar healing of the apex of the web space had usually obliterated one-third of the proximal separation completely, resulting in a post-operative syndactylism of the proximal phalanges, a complication discussed many years ago by Bunnell. (Fig. 17 is a pre-operative and Fig. 18 a postoperative illustration of a case presenting just such an undesirable result. Note the web space overgrowth.)
Bunnell or Boyes Technique Preferred
I have since learned my lesson, and now perform either the overlapping, triangular-flap web construction, or use the dorsal apron technique, more recently described by Boyes. (See Fig. 19 , pre-operative, and Fig. 20 , post-operative.) The shafts of the fingers are separated, not with the straight splitting technique of ray plastic-surgeon friend, but with carefully zigzagged incisions which heal well and result in no linear-constricting-and deforming bowstrings. I am indebted to my erstwhile advisor for the technique of the "skin sandwich", which can be utilized with many first-stage procedures of syndactylism repair. Whenever viability of distal elements might be jeopardized, I have preferred to separate only the middle and distal phalanges, deferring the proximal web space construction for a second procedure.
In the separation of a full-length syndactylism, one should recognize the magnitude of the procedure, and plan for at least two hours of operative time.
Forked Phalangeal Rays
A second cousin of syndactylism is the bifid, or forked, phalangeal rays appearing on a single metacarpal. Angular deformities are present, and, in two of our cases, adjacent finger syndactylism also. The problem then becomes a decision as to which element of the fork should be sacrificed. We have fileted these sacrificed units and utilized the skin in thumb web space construction with excellent results. Fig. 21 is a poor photograph of a thumb-index syndactylism, and index-mid finger forked phalanx on a single metacarpal, and a mid-ring finger syndactylism. Initial surgery separated the thumb and ring finger from the forked complex (see Fig. 22 ). A second procedure fileted the index fork for thumb web space reconstruction (Fig. 23 ).
4. Nubbins. An unsightly anomaly that may accompany annular constricting rings or partial adactylias is the nubbin, or knob, of firm soft tissue that is usually located on the dorsal aspect of the phalanges. Some will be spherical (Fig. 24 ), and others will be elongated to cover the entire surface of the fore-shortened extremity. There is no evidence of skin creasing over the knuckles, and their true nature is not understood. They present an unsightly deformity that is particularly disturbing to the mothers of little girls.
Removal Techniques Still Unsatisfactory
No completely satisfactory technique has been evolved for handling these masses: one can remove seemingly huge quantities of amorphous fatty and fibrous tissue, and the post-operative result will still be the rather obvious presence of an enlarged mass. Fig. 25 is a post-operative view of the case shown in Fig. 24 . My most recent technique has been a Z-plasty type of dorsal removal, closing the Z from adjacent sides of the finger. I would prefer to keep an unscarred dorsal surface if possible, but have not yet perfected a technique for accomplishing this. On several large specimens I have removed the dorsal skin in the shape of an elongated X, in which triangular proximal and distal flaps interdigitate with trapezoid-shaped lateral flaps, much as one would close the top of a cardboard carton (see ring finger in Fig. 9 ).
5. Phalangeal Flexion Contractures. This deformity can accompany all types of extremity deficiencies, but the incidence is fairly high in both terminal and intercalary longitudinal deficiencies of the forearm. Two types may occur: one shows complete symphalangism (complete lack of articular separation between phalanges) even to the absence of epiphysial plates; the second will reveal a fibrous ankylosis of the interphalangeal joints. Both types may have functioning extensor tendons to the more proximal joints; but both, in our cases, fail to show any extensor mechanism to the distal phalanges. Lateral deviation is frequently present. There is usually some active flexor motion to the distal phalanx. The deformity may be as great as 90 degrees of flexion attitude, and seems most frequent in the mid and ring fingers.
Where some interphalangeal motion is present, we have attempted to release soft tissue contractures, repairing the skin deficiencies by diamond-shaped, full-thickness grafts placed in the flexor surfaces. The grafts take well, the finger shows excellent correction during the first postoperative year, and then reverts to its previously-flexed position. Our only truly successful cases, in terms of appearance alone, have been in the rare interphalangeal fusion in the position of function. This procedure we have deferred until the youngster is seven or eight years old.
These highly rewarding little surgical procedures on little hands provide a measure of definite functional and cosmetic improvement in the period between birth and first prosthesis fitting, when the lack of active treatment seems to prey on the conscience of distraught parents. The infant suffers no apprehension of the procedure, no homesickness in the hospital, and no interruption of his schooling. There is excellent tolerance of the anesthetic and operative procedures, healing is rapid, and no post-operative complications have occurred in our cases.
Cameron B. Hall, M.D, is Assistant Clinical Professor, Orthopedic Surgery, U.C.L.A. School of Medicine; Orthopedic Consultant, CAPP. Child Amputee Prosthetics Project, University of California at Los Angeles, Los Angeles, California