Surgery for Congenital Hand Deformities
Surgery is a common treatment for a hand deformity. Most procedures are performed early in a child’s life. Orthopaedic hand surgeons at Hassenfeld Children’s Hospital at NYU Langone recommend a surgical plan based on your child’s age, the deformity he or she has, and how developed the hand is.
Our physical therapists and occupational therapists are often involved in evaluating and treating children with congenital hand deformities. Stretching exercises and splinting—the use of a cast-like device to immobilize bones—can sometimes correct mild deformities without surgery or allow children to adapt to minor deficiencies.
Surgery to correct syndactyly, in which two or more fingers are fused, resulting in webbed fingers, is typically performed after a child is about one year old to lessen the risks posed by anesthesia and give the surgeon larger anatomic structures to work with during surgery.
During this procedure, which is called syndactyly release, an orthopaedic surgeon makes zigzag incisions between the digits to divide them. The zigzag approach gives the surgeon pointed flaps of skin to wrap around each digit. This method helps prevent scars that could constrict movement later. Sometimes a small piece of skin from another area of the body, called a skin graft, may be needed to cover the space between the fingers after they are separated.
When the pinky finger or thumb is involved, the operation is done earlier, often when a child is around six months old. This avoids growth problems with the adjacent ring or index finger, because the thumb and pinky finger are shorter than their neighboring digits.
Most forms of polydactyly, in which a child has an extra finger, are treated surgically when a child is between one and two years old. For children with radial polydactyly, a single thumb is created from two duplicated, or split, thumbs. This procedure involves reconstructing the skin, soft tissues, tendons, joints, and ligaments. Sometimes the smaller, less functional thumb is simply removed.
For children with ulnar polydactyly, the extra pinky finger may be removed through surgery or, if the finger is attached by soft tissue, by using a suture or a clip to stop blood flow to the digit so that it falls off, similar to the stump of a baby’s belly button. This can be done in the hospital after birth.
If the extra digit is well formed, surgery may involve reconstructing skin, tendons, joints, and ligaments, as in radial polydactyly. The surgeon may need to move or reconnect some structures, such as tendons or ligaments, so the hand works well and looks normal.
Central polydactyly requires surgery to reconstruct the soft tissues, tendons, ligaments, and joints of the hand. In some cases, more than one operation is required to make the hand look normal and function well.
Radial and ulnar clubhand do not always require surgery if the deformities are mild. With radial clubhand, the hand turns inward and results in a limited range of motion at the wrist. With ulnar clubhand, the bone in the forearm on the side of the pinky finger is short or absent, as are other tissues on that side of the hand or wrist.
Shortly after your baby is born, your child’s orthopaedist may use a splint to straighten the hand, stabilize the wrist, and prevent soft tissues from shortening. The doctor may also recommend stretching exercises and physical therapy. If your child needs surgery later on, early splinting and stretching can help increase the procedure’s effectiveness.
If surgery is necessary, the type performed depends on the severity of the condition. Soft tissue stretching or bone lengthening can be achieved with an external fixator, a device used to keep bones aligned and stabilized, attached to the forearm and hand. Pins are placed into the bone, and the fixator frame is attached to the pins from outside the skin, where it can be adjusted to ensure the bones remain in position as the hand and arm heal, usually over a period of one to two months.
Surgery can release tightness in the tissues responsible for the abnormal angle of the wrist. The hand typically needs to be centered on the dominant forearm bone. In ulnar clubhand, elbow problems often need to be addressed with subsequent therapies.
Some mild forms of symbrachydactyly, in which there are small or missing fingers, webbed fingers, or a short hand or forearm, don’t need any surgical treatment. But in moderate to severe cases, surgery, performed around one year of age, can improve the function and appearance of the hand.
The type of surgery needed depends on the severity of the deformity. An orthopaedic surgeon may deepen the webbed space between short fingers by making incisions.
During a phalangeal transfer, the surgeon removes bones from the toes—or phalanges—and places them inside the projections of skin and soft tissue on the hand. Short bones can be lengthened. In this procedure, the surgeon cuts through the bone and uses metal pins and rods to gradually move pieces of bone away from each over the course of many weeks during a series of office visits. A toe-to-hand transfer might be performed to replace a missing finger. The entire toe might be transplanted to the hand.
Children with symbrachydactyly may also be fitted for a prosthetic, such as an artificial hand or fingers. Prostheses are used for cosmetic or functional purposes—for example, to hold a pencil or cup. They may also be used if a deformity is unreconstructable, if a child is not a good surgical candidate due to other medical issues, or if a family opts to avoid surgery.
NYU Langone’s Rusk Rehabilitation is at the forefront of developing sophisticated devices for limb function.
What to Expect After Surgery
Reconstructive surgery is performed using general anesthesia, and most children stay in the hospital for one or more nights so doctors can monitor their recovery. After surgery, your child may need to wear a cast.
Your child sees the doctor for follow-up visits every few weeks to ensure he or she is healing well. During an appointment, the doctor removes the cast, and an occupational therapist, who helps people perform their daily activities, may fit your child with a splint. This helps prevent scarring and shortening of tissue, called contractures. The length of time a child wears a splint varies, depending on the severity of the condition.
Each child receives a customized postoperative recovery plan, which may include physical and occupational therapy, based on the age and health of the child and the procedure that was performed.