The most frequent lesion found in obstetrical brachial plexus injuries involves:
Upper plexus C5, C6 and C7.
The parents of a 2-week old boy bring the child to your clinic because he was born with a unilateral complete syndactyly of the thumb and the index finger. He has no other congenital abnormality. You examine the patient and order an X-ray that shows it to be a complex complete syndactyly of the first web space. You decide to:
Wait until the child is 3-6 months old and release the syndactyly using a full thickness skin graft from the groin. Release of syndactyly of unequal length digits should be performed as early as possible; between 3 and 6 months is a good time as the child is old enough to withstand the procedure without undue anaesthetic risk, whilst the chances of damage to the joints are reduced, especially the PIP joint of the longer digit. If the procedure is delayed the child will develop permanent changes to the PIP joint. Syndactyly is more common in males, is present bilaterally in 50% of affected patients, and often is associated with other musculoskeletal malformations or systemic syndromes. The goal of syndactyly release is to create a functional hand with the fewest surgical procedures while minimising complications. For simple syndactyly, surgical reconstruction can begin at approximately 6 months, although many surgeons prefer to wait until the infant is 18 months old. Special situations, such as complex syndactyly and involvement of border digits, may warrant surgical intervention earlier than 6 months. Reconstruction of the web commissure is the most technically challenging part of the operation, followed by separation of the remaining digits. Full thickness skin grafting is almost always required for soft-tissue coverage. Complex syndactyly and syndactyly associated with other hand anomalies warrant special consideration. After reconstruction, patients should be examined periodically until they have achieved skeletal maturity because late complications such as web creep can occur.
1. Dao KD, Shin AY, Billings A, Oberg KC, Wood VE. Surgical treatment of congenital syndactyly of the hand. J Am Acad Orthop Surg 2004; 12(1): 39-48.
Correction of radial hand deformity is not indicated in patients that present:
As well-adapted adults. Adults well adjusted to the use of their radial dysplastic hand are not candidates for surgical reconstruction as they are able to perform all the activities of daily living with the hand as it is. Bayne outlined five categories of patients in which treatment is contraindicated: 1) patients with minimal anomalies; 2) patients with severe associated anomalies, who have severe retardation, poor prognosis and short predicted lifespan; 3) adult or older patients, who have adjusted to the disability and have acquired dexterity in performing activities of daily living; 4) patients with stiff elbows in which the straightened hand will not be able to reach the mouth or the perineum; and, 5) patients with severe soft tissue contractures that also involve the neurovascular structures.
Which is not a test for thoracic outlet syndrome?
Sunderland’s. Sunderland’s test is not a described test.
Hypoplastic thumbs Type II of the Blauth classification can be treated successfully by:
Releasing the contracted first web space, reconstruction of the ulnar collateral ligament, transposition flap to release the first web space, a full thickness skin graft and opponensplasty. In hypoplasia of the thumb, Blauth Type 2, the thumb is smaller and less stable than normal. The hypoplasia has three elements: 1) adduction contracture of the first web space is apparent because of 2) the lack of thenar muscles, and the hand compensates by exhibiting 3) laxity of the ulnar collateral ligament that allows abduction of the MCP joint. The skeleton, although small, has normal articulations. Treatment of this condition requires: a) release of the first web space using a dorsal flap from the thumb - preferably, as described by Strauch, and closing the thumb defect with a full thickness skin graft; b) reconstruction of the ulnar collateral ligament, as described by Lister using the division of the flexor digitorum superficialis (FDS) that is utilized for c) an opponensplasty, as described by Royle. There are other methods for soft tissue release, ligament reconstruction and opponensplasty, but this is the simplest and probably the least invasive while reducing morbidity of donor sites.
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