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Spring 2009

Changing Children's Grasp on Their Lives

"Conditions such as hypoplastic thumb, syndactyly, polydactyly of the thumb, missing digits, amniotic bands and other conditions — such as cerebral palsy, spinal cord injury, brachial plexus injury and trauma — can cause significant functional challenges for children," says orthopaedic surgeon Lisa Lattanza, M.D., chief of the Hand and Upper Extremity Service at UCSF Medical Center. "So it's enormously gratifying that we can now treat many of these conditions to improve these children's quality of life."

Family First

Long before children with congenital deformities or traumatic injuries get to the operating room, says Lattanza, surgeons must work closely and sensitively with parents. These adults are often frightened and struggling to understand what they can expect from a surgical intervention on their child.

"One of the first questions I hear from the parents is, 'What did I do wrong?' There is grieving and the surgeon has to understand the issues that parents are dealing with in order to get their buy-in and appropriately treat the child," says Lattanza. "All parents want normalcy. It's the surgeon's job to help them understand what's possible."

Congenital Deformities of the Hand

Once that understanding is reached, experienced surgeons have a variety of surgical techniques available to restore function. In the case of reconstruction of a congenitally malformed hand, some of the techniques include syndactyly releases, excision of duplicated digits, postexcision reconstruction, pollicization, and in rare cases, transfer of toes to replace missing fingers.

"For example," says Lattanza, "a child born without a thumb would have two reconstructive options to restore thumb function: an index finger pollicization or a toe-to-thumb transfer."

Lattanza and plastic surgeon Scott Hansen, M.D., both perform all of these procedures. Hansen has particular expertise in toe transfers to replace missing digits. "Because children come in so many shapes and sizes, one of the keys to a successful transfer is an evaluation by an experienced surgeon," says Hansen. "The team approach is also critical because while one team is harvesting the toe, the other is prepping the hand for microsurgical transfer."

Palsies and traumas

For conditions like cerebral palsy, Lattanza notes that she often achieves good results by working with neurologists to combine neurotoxin treatments with precise surgical techniques that address tendon and muscle length.

As for trauma, Lattanza points out that because children are still growing, the surgeon can face some difficult challenges if growth centers are damaged. If the damage is caught early, interventions such as epiphyseodesis can prevent angular deformity when part of the growth center is disrupted.

"But if the deformity has already manifested, which is commonly seen after elbow trauma, the deformity can be corrected later with osteotomy," says Lattanza. She adds that there are also numerous potential surgical solutions for the many other types of trauma that affect children's bones, joints or tendons.

Brachial plexus palsies — which can occur at birth — are another area where surgery can play a role. "In the case of birth palsy, ideally we follow these children from infancy," says Lattanza. "If within three to six months they don't show any nerve recovery, we may recommend a brachial plexus exploration in conjunction with a neurosurgeon to remove scar tissue or graft nerves."

More typically, Lattanza and her team will follow these children closely and frequently evaluate them for potential surgical interventions, such as tendon transfers, that can improve function.

Lisa Lattanza, M.D. can be contacted at (415) 353–7584.

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