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Purpose: To determine whether preservation of blood supply to the index metacarpophalangeal joint decreases the rate of physeal arrest., Methods: A retrospective review of 41 pollicized digits in 35 patients with 2-year minimum radiographic follow-up was conducted at a single institution. Other complications evaluated included nonunion at the pollicized digit base and clinical instability at the new carpometacarpal joint. Findings were compared to historical controls, which were performed by our group prior to routine identification and sparing of the metacarpophalangeal joint blood supply. No other modifications to surgical technique were made between the previous and current patient cohorts., Results: Two pollicized digits in two different patients had radiographic evidence of physeal arrest, one of which was partial and the other complete, for an arrest rate of 4.9%. This was significantly less than the arrest rate in our historical cohort of 24.7% (21 of 85 patients). Five patients did not have radiographic bony union at the base of the index metacarpal, but only one patient had clinical instability at the new carpometacarpal joint., Conclusions: Significantly fewer patients who underwent index finger pollicization with preservation of the metacarpophalangeal joint blood supply went on to develop physeal arrest when compared to patients who underwent pollicization prior to adoption of this technique. This finding suggests that sparing of the physeal blood supply is preventative against proximal phalanx physeal arrest., Type of Study/level of Evidence: Therapeutic IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

A new classification for congenital upper-extremity anomalies was first published in 2010. It has come to be known as the OMT classification highlighting the thought leaders behind it: Kerby Oberg, Paul Manske, and Michael Tonkin. Based on a dysmorphology framework, the OMT has been adopted by the International Federation of Society for Surgery of the Hand and surgeons who treat congenital upper-extremity anomalies. As predicted in the first publication, updates will be necessary based on an improved understanding of morphogenesis; the first update was in 2014 and this represents the second update to the original OMT classification. We carefully reviewed all aspects of the OMT classification, its current stratification, and updated literature on the developmental basis of limb anomalies. We also considered the clinical usefulness and challenges of the classification through discussions with stakeholders and those who care for patients with congenital upper-limb anomalies. These factors guided the current modifications of the OMT classification. In providing the updated classification, we provide the rationale for these changes. The updated OMT classification is by no means final. As our understanding of congenital anomalies progresses, we anticipate subsequent updates in the years to come., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Congenital palmar nail (distal dorsal dimelia [dDD]) of the hand is a rare malformation most commonly affecting the little finger. The purpose of this report was to review the features and associations of this rare disorder and discuss the suspected underlying etiology in light of our current understanding of developmental biology., Methods: In this retrospective cohort study from 3 practices, we describe our collective experience and review the reported literature on this disorder both as an isolated condition and in conjunction with other anomalies., Results: We examined 15 fingers with dDD, 5 of which involved little fingers. We also found dDD in 6 cases with radial polydactyly (preaxial polydactyl type II [PPD2]) and in 1 case of cleft hand involving digits adjacent to the clefted web space (the index and middle fingers). Cases of little finger dDD were also associated with prominent clefting of the adjacent web space in 4 of 5 cases. All cases had stiffness of the interphalangeal joints and loss of palmar creases consistent with dorsalization of the palmar aspect of the digit. When combined with 63 fingers reported in the literature with dDD, 3 patterns were evident. The most common form occurred in little fingers (n = 50; 64%; dDDu). The next most common form was reported in association with cleft hands (n = 16; 21%; dDDc). Radial digits in association with either radial polydactyly (PPD2) or radial longitudinal deficiency were also susceptible to dDD (n = 12; 15%; dDDr)., Conclusions: Congenital dDD is a disturbance of terminal dorsal-ventral digit patterning. The distribution of this condition with little fingers, clefting, and altered radial digit formation (PPD2 or radial longitudinal deficiency), as well as recent genetic and animal studies, suggests that dDD and altered dorsal-ventral patterning are linked to abnormal apical ectodermal ridge boundary formation., Type of Study/level of Evidence: Diagnostic IV., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Camptodactyly of the lesser digits is commonly seen in patients with arthrogryposis. The flexed posture of the digit can be functionally limiting and necessitate surgical treatment to improve grasp function. In digits with normal bony anatomy, a lateral stiletto-shaped transposition flap combined with flexor digitorum superficialis tendon release, can improve finger deformity and function., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To introduce the "on-top plasty" technique and report our long-term outcomes., Methods: We evaluated 5 thumbs in 5 patients who underwent radial polydactyly reconstruction using the "on-top plasty" technique between 1998 and 2003. This technique was used when it was felt that neither thumb possessed adequate proximal and distal structures to provide a functional and aesthetically pleasing thumb. Our study group included 1 Flatt type III and 4 Flatt type VII thumbs. The average age at time of surgery was 1.4 years and at final follow-up was 13.5 years. Subjective patient evaluation, objective outcomes values, and validated patient-oriented outcome measures were obtained., Results: There was no soft tissue loss and union was achieved in all thumbs with no further surgery required in any thumb. Mean flexion-extension arc for the metacarpophalangeal joint was 60° (range, 10° extension to 70° flexion) and at the interphalangeal joint was 19° (range, 25° extension to 35° flexion). Mean percentage of age-matched norms for lateral, tripod, and tip pinch were 47.0%, 45.9%, and 47.8%, respectively. Mean grip strength was 54.2% of age-matched norm. The mean Pediatric Quality of Life Inventory (PedsQL) score for parent questionnaires was 89.0 and for teen/child questionnaires was 89.1. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire revealed a mean score of 4.3., Conclusions: For patients with radial polydactyly in which neither thumb possesses adequate distal and proximal components, the on-top plasty is a reliable method of polydactyly reconstruction with durable results at longer than 10 years' follow-up., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the functional outcomes associated with the flexor digitorum superficialis (FDS) opposition transfer for types II and IIIA thumb hypoplasia and determine if there is any noteworthy difference in the outcome dependent on the pulley used., Methods: We included patients who underwent a ring FDS opposition transfer and had at least 2 years follow-up. The study group consisted of 36 patients with 40 treated thumbs. All patients underwent follow-up examination and standardized testing. Outcome functional measures were recorded using the Pediatric Outcomes Data Collection Instrument (PODCI). There were 9 type II and 31 type IIIA hypoplastic thumbs. All patients underwent a ring FDS opposition transfer and a 4-flap z-plasty for first web space deepening. The pulley for opposition was flexor carpi ulnaris in 19 and the transverse carpal ligament in 21. Thirty-six thumbs had ulnar collateral ligament reconstructions, with 5 of the 36 undergoing combined ulnar collateral ligament/radial collateral ligament stabilizations. Average follow-up was 7.6 years (range, 2-16 years)., Results: Average postoperative Kapandji score was 8 (range, 4-10). Grip, lateral pinch, and tripod pinch strengths averaged 46%, 49%, and 48% of age- and sex-matched normal controls, respectively. There was no significant difference between surgical pulleys used. The Pediatric Outcomes Data Collection Instrument global was 91 (range, 53-100), and PODCI happiness was 87 (range, 15-100)., Conclusions: We found the ring FDS opposition transfer to be an effective method for providing opposition for both type II and IIIA thumb hypoplasia. At follow-up, excellent opposition function and PODCI scores were noted, with no difference related to the type of pulley used. Type II thumbs had significantly greater grip and pinch strengths when compared with type IIIA thumbs., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the distinguishing morphological characteristics of children with radial longitudinal deficiency (RLD) in Holt-Oram syndrome (HOS)., Methods: One hundred fourteen involved extremities in 62 patients with a diagnosis of HOS were identified at 3 institutions. Medical records and radiographs were evaluated. Radial longitudinal deficiency and thumb hypoplasia were classified according to the modified Bayne and Klug classification and Blauth classifications, respectively, when possible. Other unusual or distinguishing characteristics were catalogued., Results: There was bilateral involvement in 84% of patients. The forearm was involved in 81% of the extremities and a shortened distal radius (Bayne and Klug type I RLD) was the most commonly identified forearm anomaly (40%). Radioulnar synostosis was present in 15% of the extremities, all in the proximal forearms with reduced radial heads. Thumb aplasia (Blauth type V hypoplastic thumb) was the most common type of classifiable thumb abnormality and occurred in 35% of involved thumbs. Twenty-seven percent of abnormal thumbs affected were not classifiable according to the Blauth classification, and 19% of involved thumbs (hypoplastic or absent) had first-web syndactyly., Conclusions: The upper extremity in HOS differs from the typical presentation of RLD. The forearm is more often involved and may demonstrate radioulnar synostosis. The thumb is frequently unclassifiable by the Blauth classification and has first-web syndactyly. The presence of radioulnar synostosis and syndactyly of the radial 2 digits in RLD should prompt the hand surgeon to obtain a cardiac evaluation and consider genetic testing for HOS., Type of Study/level of Evidence: Diagnostic III., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Macrodactyly, enlargement of one or multiple digits, was described in the literature nearly 200 years ago. This is an exceptionally uncommon diagnosis that has led to a paucity of descriptive literature on the treatment options. Because the literature is scarce, and the frequency with which hand surgeons encounter macrodactyly is even scarcer, treatment can be a formidable task often left exclusively to those trained in congenital hand deformity. This article presents our algorithm and surgical techniques for dealing with children with macrodactyly in such a way that should make a complex problem more easily approachable., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the hand position, range of motion, functional results, and radiographic outcomes associated with treating radial longitudinal deficiency with release of constricting or deforming soft tissue and resurfacing of the radial skin deficiency with a bilobed flap., Methods: We recalled and reviewed patients with at least a 3-year follow-up who had undergone soft-tissue release and coverage with a bilobed flap. The study group consisted of 16 patients and 18 wrists. All patients underwent follow-up examination and radiographs. Outcome measures using Pediatric Outcomes Data Collection Instrument (PODCI), Disabilities of the Arm, Shoulder, and Hand (DASH), and visual analogue scale (VAS) scores were recorded., Results: At a mean of 9.2 years follow-up, the average final resting wrist radial deviation angle was 64° compared with 88° preoperatively. The average active wrist flexion-extension arc was 73°. Average DASH score was 27 (range, 5-54). PODCI global was 88 (range, 75-97), PODCI happiness was 86 (range, 70-100), and VAS overall satisfaction (range, 0-10) was 1.2 (range, 0-8). At final follow-up, no physeal growth arrests were noted on radiographs, and no patients to date have required ulnocarpal arthrodesis., Conclusions: Soft-tissue release and coverage with a bilobed flap should be considered in the treatment algorithm for patients with radial longitudinal deficiency. Outcome measures show that these patients maintain useful active motion, and along with their parents, are satisfied with both the appearance and function. Some recurrence of radial deviation was noted, which was similar to results previously reported following centralization/radialization procedures, although with a lower inherent risk of both physeal injury to the ulna and stiffness. In addition, potential future procedures are not compromised by this surgical approach., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To report long-term outcomes (> 10 y) after radial polydactyly reconstruction., Methods: We evaluated 43 surgically reconstructed thumbs in 41 patients with radial polydactyly whom we had observed for more than 10 years. The study group included 12 Flatt type II, 8 type III, 17 type IV, and 6 type V. The average age of surgery was 1 year and mean follow-up was 17 years. Objective outcome values and validated patient-oriented outcome evaluations were obtained., Results: No early postsurgical complications were encountered. Eight patients had 10 revision procedures at an average of 8 years after the initial procedure. Five patients had interphalangeal joint arthrodesis, all for angulation with accompanying pain. The average Tada score was 4.1. Lateral, tripod, and tip pinch strengths were 96%, 86%, and 92%, respectively, of the unaffected side. As a group, the treated thumbs had significantly weaker tip and tripod pinch strengths than the untreated thumbs. The average Disabilities of the Arm, Shoulder, and Hand score was 4.5 and the average Pediatric Quality of Life Inventory score was 87 when administered to both the patient and the parent., Conclusions: Long-term results after surgical reconstruction for radial polydactyly were excellent but the revision rate trended upward over time despite maintenance of favorable scores on the objective outcome measures used., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To propose a classification system for type A ulnar polydactyly based on radiographic findings and characterize the demographic features of patients with these deformities., Methods: We identified 49 patients with type A ulnar polydactyly of the hand who were seen in our institution over 20 years. Patients' medical records and radiographs were retrospectively reviewed and used to distinguish morphological subtypes., Results: Ninety-six percent of the deformities (64/67) were allocated to 1 of the 5 subgroups of our suggested classification, and the type that originated from the metacarpophalangeal joint was the most common. Sixty-nine percent of patients in our series (34/49) had either bilateral type A or a contralateral type B ulnar polydactyly, and 63% (31/49) had ulnar polydactyly of one or both feet. Twenty-four percent of patients (12/49) had associated syndromes or congenital anomalies involving areas other than the hand or foot. The most common syndrome associated with type A ulnar polydactyly was chondroectodermal dysplasia (n = 3). Sixty-five percent of the patients (32/49) were Caucasian, 20% were Hispanic (10/49), 12% were African American (6/49), and one was Asian. The percentage of African Americans in our series was similar to that in the general patient population seen in our institution., Conclusions: The majority of type A ulnar polydactyly can be classified into 1 of 5 morphological subtypes that have potential clinical relevance regarding surgical treatment. In patients with type A ulnar polydactyly, contralateral hand and foot polydactyly is frequent. Associated congenital anomalies and syndromes can also be present., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Correction of a rigid forearm deformity in children is often desired in congenital radioulnar synostosis, brachial plexus palsy, cerebral palsy, or posttraumatic torsional deformity. Osteotomies at the diaphyseal level present difficulties with maintenance of reduction, whether or not internal or pin fixation is used. The stabilizing and healing potential of the periosteum in these cases can be used to advantage in the correction of these deformities., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To characterize the complications that occur at the index metacarpophalangeal (MCP) joint following pollicization and to identify the blood supply of the index MCP joint., Methods: Eighty-five pollicized digits in 74 patients (1974-2007) were followed after surgery and had documented clinical examinations and radiographs to evaluate physeal arrest, nonunion at the pollicized digit base, and instability of the new carpometacarpal joint at a minimum of 2 years following surgery., Results: Proximal phalanx physeal arrest was the most common complication. Radiographic nonunion at the juncture of the index metacarpal head and base occurred with and without instability. Twenty-one of 85 pollicized digits showed radiographic evidence of physeal arrest, 12 of which were complete and 9 partial. No clinical factor was found to significantly correlate with a physeal arrest, although the 9 patients with the diagnosis of Holt-Oram syndrome trended toward a higher percentage, with 6 digits in 5 patients with Holt-Oram syndrome showing this complication. Twenty pollicized MCP joints did not have bony union to the base of the index metacarpal, but only 3 were clinically unstable and required surgical stabilization. Ten pollicized digits developed some degree of instability and subluxation at the new carpometacarpal joint, but only one required surgical intervention. In recent cases, a search for the blood supply to the MCP joint has demonstrated a consistent vessel deep to the interosseous muscles that arborizes on the volar metacarpal neck. Our surgical technique has evolved to preserve this vessel whenever possible., Conclusions: Our complications are most likely due to technical factors. Careful dissection of the index MCP joint during pollicization should help reduce physeal growth arrest. Patients with Holt-Oram syndrome might have an increased risk of growth arrest. However, the majority of patients did not require secondary surgery and have good function., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe a type of nonhereditary unilateral transverse deficiency, which we have named hypodactyly, that is distinct from symbrachydactyly or amniotic disruption sequence., Methods: We identified 19 patients with unilateral congenital anomalies consisting of absent or short bulbous fingers that lack terminal ectodermal elements. Medical records and radiographs were retrospectively reviewed and contrasted with the typical findings of symbrachydactyly and amniotic disruption sequence., Results: No associated syndromes or potentially causative diagnoses were identified in the hypodactyly patients. The digital absences were of a truncated pattern with thickened, tubular soft tissue coverage. Radiographs revealed a pattern of severity progression that is different from that of symbrachydactyly. Distal phalanges were the bony elements absent most frequently, followed sequentially by the middle phalanx and proximal phalanx. In all cases, metacarpals were present. Unlike symbrachydactyly, the ulnar 2 digits were more involved than the index and long fingers, and the thumb was the least involved digit., Conclusions: Hypodactyly appears to be a congenital hand anomaly that is clinically and radiographically different from symbrachydactyly or amniotic disruption sequence and is presumed to be caused by a distinct pathomechanism., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Hand surgeons are often the first specialists to see patients with oculodentodigital dysplasia (ODDD), when infants with ulnar-sided syndactyly are referred. Major associated problems include neurologic, ophthalmologic, dental, and other skeletal abnormalities. The purposes of this study were to investigate the incidence of the reported associated conditions in the families of our patients with ODDD, correlate them with the severity of syndactyly, and provide better counseling with more accurate information for these patients and families., Methods: We reviewed medical records from Texas Scottish Rite Hospital for Children from 1980 to 2009 to identify patients with ODDD. These patients and families were invited to return for a detailed medical and family history and physical examination documenting hand, foot, eye, dental, and facial findings., Results: A total of 73 pediatric patients from 47 families were diagnosed with ODDD, and 38 individuals in 31 families agreed to participate in the study. We observed bilateral syndactyly in 32 patients, with symmetric involvement in 31 of these. Abnormalities of the shape and size of the middle phalanx of the small finger were common. Ophthalmological findings were present in 31 and dental abnormalities identified in 33 patients. Neurologic findings likely related to ODDD were found in 11 patients. There appeared to be an association between the severity of syndactyly and the severity of dental and urologic findings, but not ophthalmologic or neurologic findings such as paraparesis or cognitive deficits., Conclusions: We found a 29% incidence of neurologic manifestations in patients with ODDD. In addition, associated ophthalmologic, dental, and developmental conditions are frequent and a heightened awareness will allow appropriate referrals for patients with ulnar-sided syndactyly in ODDD., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Patients with large venous malformations are at risk for deep venous thrombosis and pulmonary embolus. Currently, there is no general consensus on the proper treatment for these patients. We present 3 preadolescent patients with large upper extremity venous malformations, who developed deep venous thrombosis; 2 had documented pulmonary emboli, one of which was fatal. It is imperative that patients and families be educated regarding the potential life-threatening sequelae that may be associated with these large vascular malformations., (Copyright 2010. Published by Elsevier Inc.)

Purpose: Common clinical manifestations associated with thrombocytopenia absent radius (TAR) syndrome have been reported in the literature since its initial description in 1959. The purpose of this study was to report a clinical observation and describe the anatomic location of this brachiocarpalis muscle., Methods: The radiographs of 20 patients (39 extremities) with TAR syndrome were reviewed and are the focus of this report. The presence or absence of an abnormal muscle crossing both the humero-ulnar and ulno-carpal joint, and its anatomic origin and insertion, were documented by radiographs, surgery, or both. A total of 12 patients underwent surgery on 19 extremities. Furthermore, we compared the radiographs of these 20 patients (39 extremities) with the radiographs of 20 arbitrarily selected patients with non-TAR type IV radial dysplasia, which were part of our database., Results: An abnormal brachiocarpalis muscle was noted radiographically in all 39 of the extremities and was observed surgically in all 19 patients who underwent surgery. It was absent in all 40 extremities of the non-TAR type IV radial dysplasia patients. One TAR patient had only unilateral radial dysplasia. This anomalous muscle has an abnormally high origin on the anterolateral aspect of the proximal humerus, and an insertion into the radial side of the carpus. As such, it has a deforming force at both the wrist and the elbow., Conclusions: We report the consistent finding of a brachiocarpalis muscle in patients with TAR syndrome. Because of its location, the presence of this muscle may influence the surgical treatment of these patients., Type of Study/level of Evidence: Diagnostic IV.

Purpose: Madelung's deformity is usually recognized near the completion of skeletal growth and corrective osteotomy of the radius is frequently performed to treat the deformity and reduce pain. This study reviewed the clinical and radiographic results of a volar approach, ligament release, and dome osteotomy technique for treatment of this deformity., Methods: Between 1990 and 2000, 26 wrists in 18 patients were treated with a volar ligament release and dome osteotomy of the distal radius. The average age of the patients at the time of surgery was 13 years. All patients were available for review at an average of 23 months after surgery. Radiographs before surgery and at final follow-up evaluation were analyzed for the extent of correction., Results: All patients treated with this corrective osteotomy reported a reduction in pain and improved appearance. Patients showed improvements in forearm supination and wrist extension, with no loss of pronation or flexion. Improvements in the radiographic parameters of radial inclination and lunate subsidence also were observed. Four wrists required concurrent ulnar-sided surgery, and 3 additional wrists required staged ulnar shortening. One patient required a Darrach resection 3 years after the index procedure., Conclusions: The results of volar dome osteotomy provide improved range of motion, improved appearance, radiographic correction, and pain relief while preserving soft-tissue support for radial rotation around the distal ulna. Long-term follow-up evaluation is ongoing.

Purpose: Isolated cases of ischemia, compartment syndrome, or Volkmann's ischemic contracture in the forearm of the newborn infant have been reported in the past. The purpose of this study is to review a large series of patients with neonatal forearm compartment syndrome and to report the important clinical features., Methods: A search of medical records from 1980 to 2000 identified 24 children with evidence of ischemia of the forearm at the time of birth. Records and images were reviewed for prenatal and birth history, maternal factors, medical conditions, pattern of involvement, treatment, and outcomes. Patients were grouped according to the extent of initial soft-tissue involvement., Results: All patients presented with a sentinel forearm skin lesion. Patterns of involvement ranged from mild skin and subcutaneous lesions to dorsal and volar compartment syndrome with or without distal tissue loss. Early treatment intervention was limited to a single case in which the diagnosis of compartment syndrome was made and an emergency fasciotomy was performed with a good outcome. In other cases tissue loss, compressive neuropathy, muscle loss, and late skeletal changes were responsible for impaired function. Distal bone growth abnormality was common., Conclusions: Forearm compartment syndrome in the newborn is not as uncommon as previously thought. The skin lesion was the common, salient, initial diagnostic finding. Early diagnosis and appropriate referral led to the salvage of a functional limb in 1 of the patients in this series. The severity of the initial insult correlated with the degree of impairment in growth and function. The delayed diagnosis and treatment of an evolving compartment syndrome may compromise further final function.

Purpose: The purpose of this study is 3-fold: to review our cases of keloid formation after syndactyly release, to report a clinical association between primary enlargement of the digits and risk of keloid formation, and to report treatment using low-dose, short-term methotrexate as an adjunct to revision surgery., Methods: A retrospective review of patients identified with keloid formation after syndactyly reconstruction showed associated enlargement of the involved digits. A search of medical records for cases in which both syndactyly and digital enlargement occurred was carried out. Charts and images, where available, were reviewed for information about age, gender, involved site, associated conditions, and treatment., Results: Eight cases of keloids occurred in 1004 surgical procedures in 681 patients carried out during the 20-year period reviewed. Seven patients were white and 1 was Hispanic. Seven of the 8 had associated primary digital enlargement. Two patients who had enlarged syndactylized digits did not develop keloids after surgery. There was no family history in any case. Standard treatment (pressure, topical or intralesional corticosteroids, and re-excision) was unsuccessful in resolving the keloids. Two children treated with adjunctive methotrexate had successful treatment of their keloids and near-normal healing. Length of follow-up time after the last treatment ranged from 6 months to 11 years (average, 5.5 years)., Conclusions: Primary digital enlargement is highly predictive of risk of keloid formation after syndactyly reconstruction. Very-low-dose, short-term methotrexate was successful as an adjunct to surgical treatment in 2 cases.

A new method of measuring digital range of motion (the Littler line method) is presented. When a Gaussian curve is centered over the Littler line and the appropriate area under the curve is computed, this area can provide a measure of the functional range of motion regained by an injured digit. Seventeen children (24 digits) with flexor tendon injuries were evaluated at an average follow-up period of 58 months (range, 12-121 months). The Littler line/Gaussian curve method was found to be more reproducible than total active motion, particularly in zone I and II injuries. This method can serve as a more meaningful functional assessment tool than a linear measurement such as total active motion, because it emphasizes digital motion in the mid-ranges of digital motion. (J Hand Surg 2001;26A:23-30., (Copyright 2001 by the American Society for Surgery of the Hand.))

At the Texas Scottish Rite Hospital for Children, 239 trigger digits in 176 children were seen and treated surgically over a 10-year period. Trigger fingers accounted for 33 (14%) of these digits in 18 (10%) of the patients. In 8 of 18 patients (44%) the fingers continued to trigger after A-1 pulley release. In children, trigger fingers are different from trigger thumbs. Trigger fingers in children are uncommon and have variable causes, and an A-1 pulley release alone will not always correct the triggering. Additional treatments, such as resection of one or both limbs of the sublimis tendon or an A-3 pulley release, may be required. An awareness of other contributing factors and readiness to explore the entire flexor mechanism should help prevent failure of surgical treatment.

Composite grafts of skin and subcutaneous fat harvested from the glabrous non-weight-bearing areas of the foot were used to graft 34 fingertips after separation of 23 complete syndactyly webs in 13 patients. Simple complete syndactylies accounted for 17% and complex complete syndactylies accounted for 83%; synonychia was encountered in 70%. Follow-up averaged 13.9 months (minimum, 2 months, maximum 33 months). All patients had 100% take of the composite graft. Subjective gradings were 94% good, 6% fair, and there were no poor results. This technique provides a relatively normal contour and satisfactory pad to the fingertip.