儿童先天性拇指多指畸形的手术时机及方法

目的 探讨儿童先天性拇指多指畸形的手术时机及方法.方法 对2007年12月至2012年2月进行手术治疗的132例154指先天性拇指多指畸形的临床资料进行回顾性分析.男性85例,女性47例;年龄2个月至13岁,平均(1.53±2.47)岁.所有患者术前均进行详细专科检查和影像学评估,根据患儿年龄、Wassel分型及畸形程度制订个体化的手术方案,包括单纯多指切除术,合并各种皮瓣成形、肌腱移位(移植)、韧带重建、关节囊修复等矫形手术,11例6岁以上的患儿酌情行截骨矫形术.结果 132倒154指中104例117指获得随访,时间为6～55个月,平均36.7个月,根据改良Tada评分进行评估,优77指,良21指,中15指,差4指;3指术后2年出现继发性成角畸形,1指术后3年掌指关节桡侧残留骨骺,再次手术后外形及功能基本恢复正常.结论 先天性拇指多指畸形的手术时机应根据拇指骨化中心出现时间而定,Wassel Ⅰ、Ⅱ型手术选择在1岁6个月远节指骨骨化中心出现后,Ⅲ、Ⅳ型则选择在1岁近节指骨骨化中心出现后,而Ⅴ、Ⅵ型选择在2岁6个月掌骨骨化中心出现后,Ⅶ型可选择在2岁6个月后进行;手术方法应遵循个体化治疗原则,侧副韧带、肌腱及关节囊重建、矫正尺偏(或桡偏)畸形是手术重点.     

龙虾钳样复拇指畸形的治疗体会

[目的]探讨龙虾钳样复拇指畸形的治疗方法.[方法] 2009年3月～2012年7月,对7例采用两复拇指相对应的背侧和掌侧1/3处纵向S设计皮肤切口,用骨刀将暴露相对应拇指骨纵向截骨并合并,细钢丝将近节两指骨捆扎,使相对应的两指骨合并成一根指骨,将两指甲相对应的1/3～1/4部分切除,合并为一指甲外形.[结果]7例术后随访3个月～2年,矫形拇指外形指体接近正常指,骨轴线正常,矫形拇指对指及外展功能正常和感觉正常,MP关节0～25°屈伸运动,IP关节僵直.其中5例儿童矫形拇指骨骺同步生长,切口无瘢痕挛缩.[结论]通过拇指骨纵向截骨和细钢丝近节两指骨捆扎法,使相对应的两指骨合并成一指骨方法,恢复矫形拇指外形及功能,是矫形龙虾钳样复拇指畸形的一种可行途径.     

双手拇指三节指骨1例报道

患者,女性,9岁,因发现双手拇指末节指骨尺偏畸形9年入院。患者出生时即发现双手拇指末节指骨尺偏,随年龄增长,畸形无明显加重,拇示指做精细活动稍有影响,为追求美观和改善拇指功能入院治疗。查体:双手拇指末节指骨尺偏畸形达60°,指间关节屈伸正常。X线片示:双手拇指指骨间见一三角形骨块(delta骨)(图1)。1治疗指根麻醉,左手取拇指指间关节桡侧纵切口,长约2cm,切开指间关节囊,见指骨间一独立的delta骨,其远端与末节指骨部分关节面接触,近端与近节指骨形成关节且可屈伸活动。将delta骨取出(图2),紧缩缝合桡侧关节囊及皮肤。同法处理右手,不…     

复拇指畸形矫治术后的继发性畸形

目的探讨先天性复拇指畸形手术后的继发性畸形和处理方法。方法．对12例先天性复拇指畸形经矫治术后出现拇指侧偏、内收、虎口狭窄、骨骺残留等继发性畸形的患者，进行拇指指间关节融合、掌骨截骨、骨骺切除、虎口成型、拇短展肌止点重建等手术；以纠正畸形、改善拇指的外形及功能。结果术后随访3至6个月，除1例较术前稍有改善外，11例拇指的外形明显改善，拇指对掌、对指功能基本恢复。结论先天性复拇指畸形单纯手术切除后又出现继发性畸形，和过早(2岁以前)手术有关。患儿手指细小，组织结构辨认不清，可导致畸形矫治不彻底而出现继发性畸形。作者认为复拇指畸形的手术时机在2—6岁为好，畸形复杂者在学龄前手术为佳。     

先天性拇指多指畸形的治疗

目的:探讨先天性拇指多指畸形治疗方法及时机。方法:①发育较小的均等型多指,采用Bilhaut-Cloquert氏法是将末节掌侧、背侧皮肤、指甲和指骨以楔状切除后再缝合的方法,肌腱止点与共同的远侧指间关节囊同样做相应切除。当保留指大小是健侧2/3以上时,采用将多指的指甲、甲床、指骨切除,保留适当大小的皮瓣,与保留拇指组合,改进拇指形状。②对于不均等型的拇指多指,保留指大小是健侧拇指的75%以上时,可单纯切除多指。保留指大小是健侧的65%以上时,则只能切除多指的指甲、甲床和指骨,保留皮瓣,增宽保留指的宽度,以改进外形。③近节、掌骨型的多指畸形,要重建大鱼肌止点,保留恢复拇指的对掌功能。④关节型,要注意重建侧侧副韧带;伸、屈肌腱异常时可行肌腱移位术;虎口狭窄可行“Z”字成形术。⑤掌骨成对型,将发育良好的尺侧拇指带血管神经蒂移位于桡骨上,用保留的切除指皮瓣扩大和改进拇指的外形。⑥三节指拇指,将一侧指从带血管神经蒂的移植方法移位至切除指的残端。通过肌腱移植来重建手指屈伸功能。在切除多指后,还需做指间关节切除和内固定术。本组治疗共23例,男12例,女11例。左手8例,右手9例,双手6例。结果:多指畸形的早期疗效比较满意,但随着患儿的发育,继发畸形也并不少见。本组由4例,在术后3～11年作了二期矫形、重建手术。其中虎口挛缩畸形1例,行Z字成形术。拇指对掌功能障碍2例,用肌腱移位重建对掌功能,伸指功能障碍1例,行示指伸腱移位术。结论:对简单型多指,出生后6～8个月手术较好;对有严重畸形、组织缺损的复杂多指,在1岁后行多指切除,组织移植或移位,功能重建等手术,并应定期复查直至发育停止期。对于有可能损伤骨骺的手术和影响手指生长的骨融合术,应等到患儿10岁以后再进行手术。有些病例如果第1次手术处理不当,或复发者,可进行二次手术。     

多指畸形第二指转位拇指再造术1例

多指畸形病人较常见。1995年11月,作者等采用第2指近节指骨及掌骨摘除,拇指近节指骨中段截除,带血管、神经蒂第2指中、末节转位行拇指再造治疗右手6指畸形并拇指发育不良1例,效果良好。 1 临床资料     

多指畸形第二指转位拇指再造术1例

多指畸形病人较常见。1995年11月，作者等采用第2指近节指骨及掌骨摘除，拇指近节指骨中段截除，带血管、神经蒂第2指中、末节转位行拇指再造治疗右手6指畸形并拇指发育不良1例，效果良好。     

先天性3节指骨复拇指畸形的显微组合治疗

<正>拇指多指畸形是先天性手部畸形最常见的畸形之一,拇指多指的表现形式复杂多样[1³],3节指骨复拇指为先天性Ⅶ型复拇指畸形,其外形及功能不良,2010年4月3],3节指骨复拇指为先天性Ⅶ型复拇指畸形,其外形及功能不良,2010年4月²013年7月,作者对4例3节指骨的拇指畸形并伴有赘生多指的Ⅶ型多指畸形利用显微外科的组合矫形方法进行治疗,获得良好的临床效果。1资料与方法1.1一般资料本组4例,男3例,女1例。年龄10个月2013年7月,作者对4例3节指骨的拇指畸形并伴有赘生多指的Ⅶ型多指畸形利用显微外科的组合矫形方法进行治疗,获得良好的临床效果。1资料与方法1.1一般资料本组4例,男3例,女1例。年龄10个月⁵岁。其中左手1例,右手3例。按Wassel分型法为Ⅶ型[4〗。畸形特点:桡侧主干拇指为3节指骨呈勾型畸     

家族性三节指骨拇并复拇畸形一例

患者 男，18岁。因双手拇指末节指骨尺偏并左拇多指畸形18年入院。患者出生时即发现双手拇指末节指骨尺偏并伴有左拇多指畸形，随年龄增长，畸形加重，做精细活动时稍有影响，为追求美观和改善拇指功能而入院治疗。临床检查：左手复拇并指畸形，桡侧指体细小（有独立指甲，可扪及三节指骨至掌指关节）为赘生指；尺侧指体粗大，较右拇大小相近，为主干拇指。     

复拇指畸形矫形术后继发畸形15例的临床治疗

目的探讨先天性复拇指畸形术后出现的继发畸形及处理方法。方法对15例先天性拇指多指畸形经矫形术后残留拇指偏斜,虎口狭窄,瘢痕挛缩,骨、软骨及骨骺残留,韧带及动力系统不均衡等继发性畸形的患者,进行切除异常残留骨、软骨组织,截骨矫形等重建拇指正常轴线;肌腱修复或转位等重建动力系统平衡;彻底松解挛缩的瘢痕组织、虎口开大等改善拇指的外形及功能的治疗。结果术后随访12-36个月,本组15例均保留拇指外形,且功能明显改善。结论先天性复拇指畸形早期矫形手术后继发畸形,与手术时机及方式的选择、术者操作水平等因素有关,再次有效地矫形手术能纠正畸形、改善拇指功能。     

Combined reduction osteotomy for triphalangeal thumb

Triphalangeal thumb is an uncommon congenital deformity. The thumb is long, awkward, frequently angulated, and may have a broad, unsightly nail. When the middle phalanx has an abnormal C-shaped ("delta") epiphysis, the deformity worsens if untreated. Three triphalangeal thumbs in two patients who were 2 1/2 and 8 1/2 years of age were treated with single-stage combined longitudinal and transverse reduction osteotomy, which included narrowing, shortening, and deangulation by ablating the extra joint and abnormal epiphysis. The patients were followed 48 to 59 months after surgery. Realignment, corrected relative length, and interphalangeal motion have been preserved in all thumbs. Neither patient has developed instability or angulation or had a recurrence after surgery.     

Three-phalangeal thumbs

Many teratogenic mechanisms converge to create a three-phalangeal thumb: duplication, fusion and deletion. Fine observation of the position of growth centres and of associated hand malformations suggests that the intermediate delta phalanx of the three-phalangeal thumb results of the fusion of a three-phalanx ray with a two-phalanx thumb. The ulnar or radial side of the deviation is determined by the radial or ulnar position of this three-phalangeal ray fusing with the thumb. An opposable three-phalangeal thumb ulnarly deviated with a radial intermediate delta phalanx is the result of the fusion of a duplicated Wassel VII type thumb composed by a radial three-phalangeal ray and an ulnar two-phalangeal ray. In split hands, the three-phalangeal thumb is most often radially deviated because it presumably results from the fusion of a radial two phalanx thumb with the index, deleted in this fusion. The aligned opposable three-phalangeal thumb is quite uncommon and is probably the result of a fusion of two Wassel VII-type duplicated three-phalangeal rays. Conversely, the five-fingered hand or non-opposable three-phalangeal thumb, usually has no deviation and could result of a thumb deletion associated to an index duplication. This understanding of three-phalangeal thumbs makes usual classifications obsolete, but explains the various pathologic associations found in literature and in our own series. Treatment varies with age and takes in account all fundamental aspects of this congenital hand anomaly: the extraphalanx, the clinodactyly due to a delta phalanx, the thumb duplication or the absence of opposable thumb.     

Triphalangies du pouce

Many teratogenic mechanisms converge to create a three-phalangeal thumb: duplication, fusion and deletion. Fine observation of the position of growth centres and of associated hand malformations suggests that the intermediate delta phalanx of the three-phalangeal thumb results of the fusion of a three-phalanx ray with a two-phalanx thumb. The ulnar or radial side of the deviation is determined by the radial or ulnar position of this three-phalangeal ray fusing with the thumb. An opposable three-phalangeal thumb ulnarly deviated with a radial intermediate delta phalanx is the result of the fusion of a duplicated Wassel VII type thumb composed by a radial three-phalangeal ray and an ulnar two-phalangeal ray. In split hands, the three-phalangeal thumb is most often radially deviated because it presumably results from the fusion of a radial two phalanx thumb with the index, deleted in this fusion. The aligned opposable three-phalangeal thumb is quite uncommon and is probably the result of a fusion of two Wassel VII-type duplicated three-phalangeal rays. Conversely, the five-fingered hand or non-opposable three-phalangeal thumb, usually has no deviation and could result of a thumb deletion associated to an index duplication. This understanding of three-phalangeal thumbs makes usual classifications obsolete, but explains the various pathologic associations found in literature and in our own series. Treatment varies with age and takes in account all fundamental aspects of this congenital hand anomaly: the extraphalanx, the clinodactyly due to a delta phalanx, the thumb duplication or the absence of opposable thumb.     

Abnormal triangular epiphysis causing angular deformity of the thumb

PURPOSE: To present a triangular-shaped abnormal secondary ossification center of the distal phalanx causing angular deformity of the thumb and the surgical outcome of corrective closing-wedge osteotomy for this deformity. METHODS: We treated 6 patients with abnormal triangular epiphysis in the distal phalanx of the thumb, including 3 bilateral cases. The average age was 43 months and there were 2 boys and 4 girls. Of the 9 thumbs intraepiphyseal closing-wedge osteotomy was performed in 5 and proximal phalangeal closing-wedge osteotomy was performed in 4. We measured the deformities in degrees of angulation and the range of motion of the interphalangeal (IP) joint. The average duration of the follow-up period was 27 months after the surgery. RESULTS: Preoperative angular deformity of ulnar deviation averaged 30 degrees , which was reduced to an average of 12 degrees after osteotomy at the last follow-up assessment. All osteotomies healed and there was no evidence of physeal or articular damage. Interphalangeal joint range of motion did not decrease after surgery in all cases. Patients and parents were satisfied with the results of the surgery, although mild deformity persisted in the interphalangeal joint when in the flexed position after proximal phalangeal osteotomy. CONCLUSIONS: Abnormal triangular epiphysis causing angled thumb is different from delta bone and can be treated with either intraepiphyseal or proximal phalangeal closing-wedge osteotomy. The intraepiphyseal procedure, however, could achieve better deformity correction regardless of the interphalangeal joint position. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

The effect of the epiphyseal growth plate on the length of the first metacarpal in triphalangeal thumb

PURPOSE: Triphalangeal thumb is characterized as a congenital difference of the thumb with an extra phalanx. Additional thumb length is attributed mostly to the extra phalanx. The influence of the epiphyseal plate positions on growth in congenital hand anomalies is unclear. The purpose of this article was to compare the length of the first metacarpal in triphalangeal thumbs with the length of the same bone in normal thumbs and to investigate the influence of the often aberrant metacarpal epiphyseal plates on the length of the triphalangeal thumb metacarpal during growth. METHODS: The positions of the epiphyseal plate and the relative length of the first metacarpal were examined retrospectively in 37 patients with triphalangeal thumb. Ratios of the measurements were calculated (metacarpal II/metacarpal I) and compared with a normal population. Subjects were divided into 3 groups based on the position of the epiphyseal plate (double, proximal, distal). RESULTS: The distally placed growth plate was the most common variety, present in 22 of patients, followed by the proximal position in 14, and double epiphyseal plates in 6. All ratios of patients with triphalangeal thumb were significantly smaller than those of a normal population, indicating a longer first metacarpal in this condition. First metacarpals in triphalangeal thumb with double epiphyses grew disproportionately more than those of a normal population, whereas those with distal epiphyses grew disproportionately less than normal. First metacarpals with proximal epiphyses grew at the same rate as normal first metacarpals. CONCLUSIONS: In this study population the most common growth plate location was distal whereas the most common location in the normal population is proximal. The different positions of the epiphyseal plates correlate with growth differences in patients with triphalangeal thumb.     

Clinodactyly. A review of a series of cases

A review of 50 patients with clinodactyly is presented in which six patients required surgery for a combination of functional and cosmetic problems. It is suggested that patients with a delta phalanx at the proximal phalangeal level should have a reversed wedge osteotomy early, while those with brachymesophalangism requiring surgery have a closing wedge osteotomy performed late. Delta phalanges in the triphalangeal thumb should be excised early and the joint reconstructed. An ulnar abduction deformity was noted in a minority of patients with clinodactyly. This deformity is relieved when the clinodactyly is corrected.     

Bifid thumb type IV in children: transferring an epiphyseal segment of the proximal phalanx with insertion of the abductor pollicis brevis tendon

Objective

To evaluate the clinical and functional results of the surgical treatment of bifid thumb type IV in children.

Materials and methods

A retrospective study was undertaken from January 1995 to December 2006. Clinical and radiographic evaluations were made according to Wassel’s classification. The patients were performed by transferring an epiphyseal segment of the proximal phalanx with insertion of the abductor pollicis brevis tendon into the radial side of the epiphyseal proximal phalanx of the ulnar thumb. All patients were operated using one of five surgical procedures for bicephalous metacarpus, cartilaginous connection between the radial and ulnar proximal phalanges, the angular deformity of the metacarpophalangeal joint (MPJ) is >20°, and zigzag deformities. The postoperative results of the patients were evaluated for both function and cosmesis according to Tien’s modified Tada scoring system.

Results

One hundred and sixty-four patients (102 females, 62 males) were included in this study. The MPJ was stable in 170 thumbs, 15 thumbs had 10° of radial instability, and new collateral ligaments were augmented in 27 thumbs. The alignment was normal in 75 thumbs, with alignment of the interphalangeal joint (IPJ) in 101 thumbs and alignment of the MPJ in 75 thumbs. Postoperatively, there were zigzag deformities in four thumbs (developed zigzag in two thumbs, recurrent zigzag in two thumbs); there was no first web space in those hands. There were four of 185 thumbs with thumb stiffness. The abductor function of 185 thumbs was as follows: >70° in 158 thumbs (85.4%), 50°–70° in 21 thumbs (11.4%), and <50° in six thumbs (3.2%). At the latest follow-up evaluation, no evidence of physeal growth injury or growth arrest was observed in any patient. Overall, we attained good results in 140 thumbs (75.7%), fair results in 36 thumbs (19.4%), and poor results in nine thumbs (4.9%).

Conclusion

We recommend the use of an epiphyseal segment of the proximal phalanx with insertion of the abductor pollicis brevis tendon into the radial side of the epiphyseal proximal phalanx of the ulnar thumb and to restore anatomical insertion of the abductor pollicis brevis muscle. The technique is simple, safe, and effective for thumb abductor function in the treatment of bifid thumb type IV in children.     

Reduction osteotomy for triphalangeal thumb: an 11-year review.

Since 1977 we have operated on 13 of 15 triphalangeal thumbs in nine children (five boys, four girls). Follow-up ranged from 22 to 134 months (mean, 65 months). Total active motion averaged 63 degrees at the interphalangeal joint and 79 degrees at the metacarpophalangeal joint. There was no evidence of instability or laxity of ligaments. Reduction osteotomy was insufficient to shorten grossly long thumbs of two patients, and it was necessary to shorten the metacarpal. Premature closure of the phalangeal physis occurred in two thumbs but did not result in inadequate length; one postoperative pin-tract infection resulted in nonunion that required reoperation. This long-term experience supports reduction osteotomy for triphalangeal thumbs because it addresses the deformities and preserves both motion and stability.     

Familial congenital hypoplasia of the thumb--report on a family

Congenital hypoplasia of the thumb is not a rare condition in clinical practice, but a familial occurrence of this condition is exceedingly rare. We report a family with familial congenital hypoplasia of the thumb. In three generations, five members were proved to be affected and another two were presumed to be affected. To our surprise, a younger sister of the propositus had tetralogy of Fallot and triphalangeal thumbs on both hands.     

Triphalangeal thumb

Triphalangeal thumb is often thought to be a rare congenital abnormality; it has an incidence of 1 in 25,000 births. We reviewed 49 triphalangeal thumbs in 28 Mexico City patients at the Diaz Lombardo Hospital from 1974 to 1979, Shriners Hospital from 1979 to 1982, Instituto Nacional de Ortopedia from 1981 to 1982, and at the ABC Hospital from 1971 to 1998. A total of 21 patients (75%) had bilateral deformity. Patients were classified according to Dieter Buck-Gramcko system and Müller teratologic line. All were surgically treated and evaluated with Cheng graduation scale, finding good results in 48 patients (97%), fair results in one (3%), and no poor results.