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Anomalies of the thumb development are not uncommon and may be associated with a number of syndromes also. These anomalies range from total absence to duplication. Reconstructive surgery for the creation of an opposable thumb is the most rewarding aspect of Hand Surgery and also the most challenging. Classification systems have been modified for better description. A number of procedures have been introduced to improve the functionality of the hand in anomalies and age old concepts are undergoing a metamorphosis to further this. A brief description of the common conditions and their treatment are discussed here and highlighted by selected clinical cases.

The treatment objective in the five-finger hand is to create an opposable thumb with two phalanges and a first web space having a normal appearance. We report three cases of pollicization of the most radial finger in two patients evaluated by the Percival Score. Currently, the treatment of reference of five-finger hand is the pollicization of the most radial finger. We present a particular technical enhancement, which is the adaptation to a shorter osseous skeleton and the utilization of extrinsic or intrinsic motors present in the radial side of the hand.

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. Type of study/level of evidence Prognostic, Level III.

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.

Duplicated triphalangeal thumb is a surgical challenge to create a satisfactory thumb with good mobility opposition, stability, alignment and size. Some authors consider it as a thumb deletion with index duplication or preaxial polydactly due to its lack of opposition, but it does belongs to group VII of Wassel classification. The frequency of his malformation is 1/25,000. The authors report a familial serial of 10 children treated bilateraly by pollicisation with the same technique, by two senior surgeons. The mean age for surgery was 20 months and the average follow-up is 7 years and a half at the time of the study. The goal of the study is to point out the functional and cosmetic improvement, with a focus on pre- and post-surgical radiographic aspect of the trapezometacarpal joint. The results are compared with parents whose some have been operated on one side by resection of the radial component. All patients improved their pinch and mainly cosmetic appearance. An efficient opposition was achieved and is compared with non-operated parent's thumbs. The authors report 2 tourniquets incidents on the same child, a malignant hyperthermy. Wound healing was delayed in 2 cases. Author review literature to considerate other surgical methods than pollicisation in Wassel VII thumb duplication but pollicisation of the duplicated index seems the best cosmetic procedure.

The biennial meeting of the Scandinavian Society for Surgery of the Hand was held May 15 and 16, 1981, in Gothenburg , Sweden . The Society was founded in 1951 as the first Hand Society in Europe . The founder, DR. ERIK MOBERG, was honored at this 30th Anniversay Meeting . DR. MOBERG presented scientific papers and also reviewed the development of the Society and the field of hand surgery in Scandinavia. The ERIK MOBERG lecture , "Observations on the joints of the hand, " was given by MR. K. KUSCZYNSKI, Edinburgh. DR. SVANTE EDSHAGE, Gothenburg , Sweden, was elected President and DR. TORE HAGA, Bergen , Norway, was elected Secretary-Treasurer for 1982. Following is a condensation of papers presented at the meeting. Giant cell reparative granuloma-Unusual location to the bone of the hand. K. BERTHEUSSEN and S. HOLCK, Copenhagen , Denmark, presented a case of giant cell reparative granuloma, localized within the bones of the hand and mimicking a giant cell tumor (osteoclastoma). A review of the literature had failed to disclose any previous reports of this disorder outside the skull and facial bones. Angiomatosis osteohypotrophica. l. NIECHAJEV, Malmo, Sweden, reported a syndrome consisting of congenital hemangiomas with arteriovenous fistulae involving the soft tissues and bones, with shortening of the involved extremity . He had studied seven patients clinically and radiologically and suggested the name angiomatosis osteohypotrophica. Angioma, varicose veins, and/or arteriovenous fistulae with an increase in limb length has been widely known since the beginning of this century as Klippel-Trenaunay syndrome. Although DR. NIECHAJEV'S patients presented all other features of that syndrome, thinning and shortening of the long bones occurred, resulting in an overall reduction of limb length. Intraosseous hemangiomas of the metacarpal or metatarsal bones was a common characteristic finding. The influence of arteriovenous fistulae on the skeletal growth was discussed. Small finger tendon anomaly. T. BARFRED, Odense, Denmark, described two cases with tendon-slip from extensor carpi ulnaris to the small finger extensor tendons. One of the patients, unable to play her violin professionally , was cured by resection of the tendonslip. Deltaphalanx in thumbs. A. W EILB Y, Copenhagen, Denmark, discussed delta phalanges in thumbs . He stated that those cases where it occurs in biphalangeal thumbs should be treated early with osteotomy to gain length. When this condition occurs as a middle phalanx in a triphalangeal thumb , the bone should be excised, and reconstruction of the joint ligament and extensor aponeurosis should be performed. The results of treatment in the two different types was illustrated, and the problems of frequently accompanying deformities in bilateral triphalangeal thumbs was discussed. Closed compartment syndrome in the first dorsal interosseous muscle. P. FORSSBLAD, CH SOLLERMAN, and A. BACH, Gothenburg, Sweden, stated that closed compartment syndrome in the legs with exerciseinduced pain probably has an analogy in the upper extremity , although it is not reported . Writer's cramp is considered to be a behavioral disorder because of lack of organic explanation . However, there is evidence in some cases that this disorder may be caused by an overuse reaction in the compartment of the first dorsal interosseous muscle and the thumb adductor. These muscles especially take part in performing a pinch grip. Since 1978, three cases of writer's cramp have been treated by a plain incision of the fascia overlying the first interosseous muscle, with prompt relief. This would indicate that a compartment syndrome could be the explanation for many cases of writer's cramp. Reconstruction of the median nerve in children. M. VASTAMAKI , Helsinki, Finland , presented five cases of reconstruction of the median nerve in children. All the injuries were in the wrist area. Operative delay was from 1 to 17 months, with an average of 7 months . The sural nerve was used as a graft with 3 to 5 strands, and the length of the graft was 3 to 13 em, with an average of 5 cm. The follow-up time was 3 to 8 years. The two-point discrimination was 3 to 7 mm in those four patients who had been followed longest; all the patients, even the fifth patient with two-point discrimination of 8 to 12 mm, reported sensibility to be normal.

From the literature we found reports of 105 patients whom we judged had a triangular deformity of one of the bones of the hand or foot. We found 49 patients of our own with 84 delta-shaped phalanges limited strictly to the hand. This represents an incidence of 3.5 percent of our congenital abnormalities of the upper extremity. The deformity is associated with many abnormalities; syndactyly, Polydactyly, symphalangism, triphalangeal thumb, cleft hand, and hypoplastic hand are the most frequent. Triangular deformity of the bone of the index finger usually is associated with Apert's syndrome. Triangular deformity of the proximal phalanx of the ring finger often is found with central Polydactyly. Our average follow-up time on these 49 patients was 14 years, giving us a chance to establish some guidelines and general rules about the natural history and treatment of the delta bone.

Polydactyly associated with triphalangeal thumb is not rare, as among the records of 1,269 patients with congenital deformation of the upper extremity at the University of Iowa there were 21 patients with 32 hands with such involvement. More detailed classification based on Wassel's work was made. Treatment should be early, with removal of the radial digit if equal in size, excision of all accessory parts including delta bone when present, reconstruction of joint ligaments or joint fusion and osteotomy for correction of deviations. Care should be taken to avoid leaving a narrow first web space.

Two families with the Holt-Oram syndrome are described. These families demonstrate a wide variety of thumbs including a “fingerized” hypoplastic thumb, a triphalangeal thumb, a long clumsy-appearing thumb, and a normal thumb. Three of the patients studied had an atrial septal defect. Three affected patients do not have heart disease but do have an abnormal thumb. The cardiac defect in 1 is uncertain. These families are reported on to emphasize that the thumb may be normal or long rather than hypoplastic. Diagnosis of the Holt-Oram syndrome thus offers the excitement of making a cardiovascular diagnosis merely by looking at the hand as well as the discovery of a surgically curable lesion.

deafness. 9 Konigsmark 1~ has reviewed six types of dominantly inherited ear anomalies with deafness; none of these conditions had other abnormalities similar to those reported by Townes and Brock. 1 The syndrome described by Townes and Brock therefore would appear to form a distinct entity with all the features observed in our index patient. Imperforate anus and triphalangeal thumb or bony abnormalities of the hand were present in all cases. Satyr ears were observed, with sensorineural deafness in all the cases tested for hearing. Our Patient 2, the stillborn fetus, had an imperforate anus only, but this is consistent with dominant inheritance and a variable expression evident in the initial family. CONCLUSION We believe that the cases reported here support the view of Townes et al that the pattern of malformation with imperforate anus they described is a distinct condition with dominant inheritance. This report also further affirms that a small proportion of imperforate anus cases, more likely of the low type, are hereditary in nature. REFERENCES