Pediatric Plastic and Craniofacial Surgery

At the Center for Pediatric Hand Anomalies, we provide advanced treatment for children with a variety of conditions affecting the appearance and function of the hand, including:

Brachial plexus

The brachial plexus is a set of nerves that exit the spinal column at the neck and provide feeling and movement to the upper extremities, including the shoulder, arm and hand. The plexus is composed of five nerve roots (C5, C6, C7, C8 and T1). These five roots combine to form three trunks:

• C5-C6 form the upper trunk of the brachial plexus
• C7 becomes the middle trunk of the brachial plexus
• C8-T1 from the lower trunk of the brachial plexus

Each trunk then splits in two, to form six divisions, which then regroups to form three cords, which are responsible for bending and straightening the arm, wrist and fingers.

Brachial plexus injury in a newborn is thought to be related to the delivery, due to excessive stretching of the neck. This injury affects sensation and movement of the upper arm. Studies have found an incidence of 1.03 per 1,000 live births.

There are different types of brachial plexus injury. When the nerve is pulled away from the spinal cord, it’s called an avulsion, and it’s the most severe form. The nerve can tear after it exits the spinal cord, and this is called a rupture. Less severe types but sometimes with unpredictable prognosis are when the nerve gets stretched, neuropraxia, or partially injured and there is scaring around the nerve, a neuroma.

If a brachial plexus injury is diagnosed in a newborn, serial exams will allow the determination if surgical intervention would be required. If by the third month the child is able to bend the elbow, this is a good prognostic sign of probable recovery. If after three months there are no signs of improvement, surgery is usually recommended. Some of these procedures include:

• Surgical exploration
• Neurolysis
• Neurotization
• Nerve transfers
• Excision of neuroma
• Tendon transfers – restoring motion by moving a non-essential tendon to another area
• Muscle transfers – restoring motion by transplanting a muscle into the area

Therapy and rehabilitation is also a critical part of the treatment process for brachial plexus and necessary for future management.

Amniotic band syndrome

Amniotic band syndrome is a congenital abnormality caused by bands of protein that form in the lining of the uterus during gestation. These bands can wrap or attach to the fetus and cause mild deformities such as webbing of fingers and toes, as well as lead to amputation of limbs.

Though there are many theories as to the cause of this syndrome, the most widely accepted is a rupture of the amnion forming cord-like bands that can become entwined with the limbs and constrict them, compromising the growth and development of the limbs. This can happen between the first and fourth month of gestation. The reported incidence varies from one in 1,000 to one in 15,000 births.

Depending on the severity of the abnormality, there are different treatment options. For example, if webbing of the fingers and toes occurs, these can be separated surgically. If there’s a loss of a finger/thumb, either one of the adjacent digits can be moved, called pollicization, or a toe can be transferred to the hand to make a new thumb or finger. If the fingers are short, joints can be transferred from the foot that will lengthen the digit as the child grows. For milder deformities, a surgical release of the constricting scar that formed due to the band is needed to allow growth of the affected body part.

Hypoplastic thumb

The thumb is the most important digit in the hand. Deficiency in thumb development can range from mild weakness to complete absence of the thumb. There are five subtypes:

• Type 1: The thumb is slightly smaller in size but functions normally
• Type 2: The thenar muscles (base of thumb) are mildly underdeveloped and the joint is mildly unstable. The web (skin) between the index finger and the thumb is often tight and shallow
• Type 3: Unstable joint, small thumb, poor function
• Type 4: A small nubbin of tissue only is seen and is not movable
• Type 5: No thumb

Moderate thumb deformities require tendon transfer and ligament reconstruction to allow for the thumb to touch the tips of the other fingers. Severe deformities may require pollicization, a technique where the index finger is moved into the thumb position, creating a functional four-finger hand.

Syndactyly (webbed fingers)

Webbing of the fingers and toes is known as syndactyly. The involved fingers or toes can be fully fused at the level of the bone, or simply by the skin. The release of the involved structures often begins around age 12 months and typically requires a skin graft to resurface the digits.

If multiple fingers are involved, the surgery may be staged over three to six months to prevent wound healing complications. All patients are sent for physical therapy after the healing process concludes to improve grip strength and range of motion.

Polydactyly (extra fingers)

Supernumary, or extra fingers and toes, are relatively common. A family history of polydactyly is very common. In the past, it was treated by simply tying a string around the extra digit and letting it fall off. This unfortunately left a tell-tale sign of extra skin in the area.

Simple polydactyly can be treated in the office by excising the extra tissue and placing a few stitches. More complex polydactyly (well-formed bone and joints) requires more extensive surgical treatment.

When it involves the thumb, polydactyly is more complex given the unique muscles and ligaments inherent to this most important finger. Treatment typically involves removing the extra finger at 1 year of age. The tendons are extended to rebalance the hand and the ulnar collateral ligament is reconstructed. A pin is often placed for three to four weeks to protect the reconstruction.  Patients often require physical therapy.