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Summer 2011

Reconstructing Children's Hands for Functionality

UCSF hand surgeons treat a wide range of anomalies related to genetic mutations, amniotic band syndrome, burns, trauma and other causes. "Every child is different," said Assistant Professor Scott Hansen, M.D., chief of Hand and Microvascular Surgery. "As a pediatric hand surgeon, my goal is to reconstruct a useful hand."

The most common congenital hand condition is syndactyly. Surgeons can separate webbed fingers, which otherwise will contract the hand because of the different lengths of connected digits. Patients with Apert syndrome display bony abnormalities of the hand.

By studying X-ray images, surgeons can determine which fused digits are possible to release. "We can always separate one or two of the digits, but sometimes we leave the hand as a mitten hand," Hansen said. "The decision is based on what structures are there, and whether you can make a useful digit."

Creating a Thumb

Forty percent of the hand's functionality comes from the thumb. If a child is born with four functional fingers but no thumb, often the best option is pollicization, in which the index finger is moved over to the thumb position, providing a thumb and three fingers.

In other cases, the best treatment is pediatric toe-to-thumb transfer. For example, a young child with a thumb amputation is likely to do better by transferring a toe onto the partial thumb rather than pollicization. Likewise, if a child has only two fingers on the ulnar portion of the hand, transferring a toe to the thumb position would likely be the best solution.

For pediatric toe transfer, surgeons generally transfer the second toe rather than the great toe, because its absence is less noticeable to the casual observer.

Toe-to-thumb Transfer

UCSF is one of only a few centers in California to offer this technically challenging procedure. The operation takes about six hours, and requires two teams of microsurgeons to prepare the hand and the foot.

Surgeons dissect the toe and transfer it to the hand, connecting it with nerves and blood vessels, which are only 1 mm in diameter. Postoperative hospitalization usually lasts five to seven days. The cast is removed after three weeks, and the patient immediately begins therapy to learn how to use his or her new thumb. If necessary, thumb position can be perfected by using serial, moldable splints.

The range of eventual nerve function in the new thumb ranges from protective to near normal, and the thumb continues to grow with the child's hand. The foot has no healing issues, and after recovery, children can run and perform normal activities.

For toe-to-thumb transfer and pollicization, surgery is recommended before 3 years of age, while children's brains are still very pliable and easily accept a transferred toe as a thumb. "Around 3 or 4, the brain starts patterning what the child has, and after the age of 5, the child cannot adapt as well," Hansen said.

Hansen has transferred both second toes to the hands of children with no fingers at all, giving them a thumb and a finger and the ability to have a pincer grasp. "That's obviously given them a lot, to go from nothing to being able to pick things up and use their hand appropriately," Hansen said. "We don't do these operations to give a child five functional digits. We really focus on what we can do functionally for these children to be able to play sports and get on with their lives."

Consultations and Referrals

For more information, please contact Scott Hansen, M.D., at (415) 353-4217 or shansen@sfghsurg.ucsf.edu.

Web Resources

To read two of Dr. Hansen's recent articles related to pediatric toe-to-thumb transfer, see www.ncbi.nlm.nih.gov/pubmed/19568146 and www.ncbi.nlm.nih.gov/pubmed/17478259.

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