CURRENT CONCEPTS

Radial Longitudinal Deficiency: Recent

Developments, Controversies, and an
Evidence-Based Guide to Treatment
David L. Colen, MD,* Ines C. Lin, MD,*† L. Scott Levin, MD,‡
Benjamin Chang, MD*†
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Learning Objectives
Upon completion of this CME activity, the learner should achieve an understanding of:

Embryology of upper limb development in relation to radial longitudinal
deficiency and thumb hypoplasia

Relative benefits and risks of wrist centralization on the ulna

Recent alternatives to wrist centralization

Classification and surgical indications for thumb hypoplasia

Reconstructive options and outcomes for thumb hypoplasia
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Radial longitudinal deficiency (RLD) is the most common congenital longitudinal deficiency
at birth and represents a wide spectrum of upper extremity anomalies, from mild thumb
hypoplasia to absent radius. Radial dysplasia may be isolated or associated with an array of
systemic anomalies that should be familiar to pediatric hand surgeons. The management
From the *Division of Plastic and Reconstructive Surgery, the ‡Department of Orthopaedic Corresponding author: Benjamin Chang, MD, Division of Plastic and Reconstructive
Surgery, Hospital of the University of Pennsylvania; and the †Division of Plastic Surgery, Surgery, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine,
Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA. South Pavilion - 14th Floor, 3400 Civic Center Blvd., Philadelphia, PA, 19104; e-mail:
Benjamin.Chang@uphs.upenn.edu.
Received for publication October 14, 2016; accepted in revised form April 20, 2017.
0363-5023/17/4207-0008$36.00/0
No benefits in any form have been received or will be received related directly or indirectly http://dx.doi.org/10.1016/j.jhsa.2017.04.012
to the subject of this article.

546 r  2017 ASSH r Published by Elsevier, Inc. All rights reserved.

 RLD DEVELOPMENTS AND CONTROVERSIES 547

of RLD has evolved greatly since its inception in the late 19th century, largely due to decades
of innovation that followed the thalidomide catastrophe of the 1960s. Yet controversy still
exists regarding many aspects of RLD. Traditional treatments of radial dysplasia (ie,
centralization) are unfortunately wrought with poor outcomes and high rates of recurrence,
leading some authors to recommend alternative techniques for this condition. Reconstruction
of the hypoplastic thumb, although less controversial, is just starting to see long-term out-
comes. This article reviews the etiology, classification, and treatment options for RLD,
highlighting recent developments and outcomes. (J Hand Surg Am. 2017;42(7):546e563.
Copyright  2017 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Radial dysplasia, radial longitudinal deficiency, centralization, thumb hypoplasia,
pollicization.

fibroblast growth factors (FGF) secreted in the apical

R
ADIAL LONGITUDINAL DEFICIENCY (RLD), or radial
dysplasia, is the most common congenital
longitudinal deficiency of the upper extremity
(1 in 5,000 live births)1 and is characterized by a spec-
trum of dysplastic development along the radial column
and includes thumb hypoplasia. The thalidomide-
induced epidemic of phocomelia of the 1960s turned
limb hypoplasia into a widespread congenital anomaly
and spurred advances in the treatment of RLD. The
decades that followed saw important innovations in the
surgical treatment of RLD. Two landmark articles were
published in the 1970s that established principles of
surgical management. Dieter Buck-Gramcko2 published
a series of 100 index pollicizations for congenital thumb
hypoplasia in 1971 based on the procedure conceived
by Littler3 and Riordan.4 In 1972, Lamb5 published
his experience in 41 children and stressed the importance
of early orthosis fabrication to stretch the fibrotic
radial anlage and centralizing the carpus over the ulna
with Kirschner wire fixation. Important innovations
and follow-up studies over the past few years have
both clarified and called into question several of these
principles. In this article, we review current literature
and updated recommendations for the treatment of RLD.
ETIOLOGY
Embryological development of the upper extremity
occurs along 3 axes of the limb bud: proximal/distal
(longitudinal), anterior/posterior (radial/ulnar), and
dorsal/ventral. According to the Oberg-Manske-Tonkin
classification, RLD is a malformation caused by
disrupted development along the radial/ulnar axis.6,7
The developmental biochemical pathways of these 3
axes are complex and intricately interrelated,8 and the
more severe forms of RLD have a proximal/distal
component of dysplasia as well.
Growth and patterning along the longitudinal
axis of the upper extremity is primarily the result of
ectodermal ridge in the distal limb bud. Fibroblast
growth factors, primarily FGF8, stimulate cell pro-
liferation and survival for nearby mesodermal cells,
inducing and maintaining outgrowth of the limb bud.
The apical ectodermal ridge is also maintained, not
only by FGF signaling via FGFR1&2, but also by
Wnt/beta-catenin, bone morphogenic protein (BMP)/
BMPR1a, retinoic acid, and Sonic hedgehog (Shh).8
The anterior-posterior axis differentiates due to Shh
expression in the zone of polarizing activity (ZPA), a
region of the distal posterior (ulnar) limb mesenchyme.
The ZPA is established owing to FGF signaling via
FGFR2. The Shh produced by the ZPA induces
development of posterior (ulnar) structures via Gli-3
and is thought to induce patterning from an ulnar to a
radial direction due to an Shh gradient, with develop-
ment of the anteriormost digit (ie, thumb) occurring
independent of Shh signaling8 (Fig. 1). Recently, Iro-
quois homeodomain transcription factors 3 and 5 (IRX
3/5) have also been implicated as the driver of anterior
limb development. A double knockout murine model
produced a phenotype of RLD and current thought is
that Shh has an inhibitory role on IRX 3/59 (Fig. 2).
Alternatively, aberrant expression of hairy2, a limb
molecular clock gene that is regulated both instruc-
tively by FGF and permissively by Shh, may be
involved in deficient radial ray development.8
RADIAL LONGITUDINAL DEFICIENCY
Classification and diagnosis
Although not commonly screened for, it is possible to
diagnose RLD prenatally with obstetric ultrasound
(sensitivity, 75%; specificity, 100%).10 Radial longi-
tudinal deficiency commonly occurs in conjunction
with other congenital anomalies. One-third of patients
have a named syndrome (Table 1), and 67% of RLD

J Hand Surg Am. r Vol. 42, July 2017

548 RLD DEVELOPMENTS AND CONTROVERSIES

FIGURE 1: Development of the upper limb bud. A The ZPA-Shh is established in early limb development owing to mutually antag-
onistic Gli3 (anterior) and Hand2 (posterior) in the lateral plate mesoderm (LPM). Retinoic acid (RA), apical ectodermal ridge (AER)
FGFs, Hand2, and 5’Hox genes cooperatively facilitate shh induction in the ZPA, which in turn leads to FGF4 expression in the
posterior AER. B Longitudinal growth of the limb bud is primarily due to FGF expression at the AER, which through a feedback loop is
mediated via Grem via BMP. C Dorsal-ventral patterning of the limb is due to opposing Wnt7a and BMP signals. Wnt7a induces Lmx1b
expression exclusively in dorsal mesenchyme whereas BMP signaling in the ventral ectoderm causes En-1 expression leading to DV
limb patterning. Wnt7a is also required for ZPA-Shh signaling and BMP expression for the establishment of the AER.8 All limbs are
represented anterior on top and proximal to the left. (Reproduced with permission from “Sheeba CJ, Andrade RP, Palmeirim I. Getting
a handle on embryo limb development: molecular interactions driving limb outgrowth and patterning. In: Seminars in Cell & Devel-
opmental Biology. 2016;49:92e101. Academic Press.”)

patients have an associated medical or musculoskel-
etal anomaly. This association grows stronger with
more severe cases of RLD, reaching 100% in type 5
RLD.11 The limb discrepancy may be the only out-
ward manifestation of these multiorgan syndromes;
thus, the hand surgeon must be aware of the appro-
priate work-up for RLD patients12 (Table 1).
Skeletal anomalies along the radial column vary from
isolated thumb hypoplasia to complete absence of the
radius, carpus, and radial digits (Fig. 3). The current
classification scheme, originally developed by Bayne
and Klug13 and updated by James et al,14 is based on the
severity of the radiographic phenotype and has been
expanded to include proximal longitudinal dysplasia as
well15 (Table 2). The most subtle cases have simple
hypoplasia of the thumb, radial carpus, or thenar mus-
cles. With more severe dysplasia, the underdeveloped
(or absent) radius may take the form of a fibrous anlage
that does not support the radial carpus, which, in
conjunction with aberrant radial musculature, results in
a radially deviated and volarly subluxated hand (Fig. 3).
Treatment and outcomes
The goals of treatment of RLD are to straighten radial
bowing of the forearm, correct the radial and volar
subluxation of the carpus, and optimize limb length in

J Hand Surg Am. r Vol. 42, July 2017

 RLD DEVELOPMENTS AND CONTROVERSIES
FIGURE 2: Development of the anterior upper extremity. IRX 3/
5 promotes development of anterior limb and is inhibited by Shh.
(Reproduced with permission from Li D, Sakuma R, Vakili NA,
et al. Formation of proximal and anterior limb skeleton requires
early function of Irx3 and Irx5 and is negatively regulated by Shh
signaling. Developmental cell. 2014;29(2):233e240.)
order to provide the best functional and aesthetic upper
extremity possible. This is followed by reconstruction
of the hypoplastic thumb as needed. Repositioning the
hand relative to the forearm also improves the excur-
sion of digital flexor and extensor tendons,16
improving digital range of motion. How to achieve
the aforementioned goals depends on the severity of
the anomaly and the degree of functional impairment.
Patients with subtle radial bowing (< 20 ) can be
treated nonsurgically. Historically, the impetus to
operate on more severe RLD was based on the gradual
loss of prehensile function in these patients over
time,17 but a recent large series comparing surgical
with nonsurgical treatment for types 3 and 4 RLD
proved that surgery resulted in substantially better
outcomes.18 Kotwal et al18 analyzed radiographic and
functional outcomes in 446 patients with type 3 or 4
RLD over 20 years. The authors compared patients
who had conservative treatment alone, including pas-
sive stretching and splinting (n ¼ 137), with those who
had passive stretching followed by surgical correction
(n ¼ 309), either by centralization (n ¼ 205) or
radialization (n ¼ 107). With a mean follow-up of 10.1
and 11.1 years in the nonsurgical and surgical groups,
respectively, the authors showed that surgical correc-
tion improved wrist alignment (hand-forearm angle
[HFA], 12 vs 85 ) as well as digital range of motion in
the long finger (157 vs 86 )18 (Table 2).
J Hand Surg Am.
549
TABLE 1. Syndromes Associated With RLD
Systemic Recommended
Syndromes Comorbidities Tests
Holt-Oram Congenital Complete
Fanconi heart anomalies blood count
anemia Blood dyscrasias Echocardiogram
TAR Renal dysfunction Abdominal
VACTERL Gastrointestinal ultrasound
association dysfunction Scoliosis
radiograph
Chromosome
breakage test
TAR, thrombocytopenia-absent radius syndrome; VACTERL, verte-
bral abnormalities, anal atresia, cardiac abnormalities, trache-
oesophageal fistula and/or esophageal atresia, renal agenesis and
dysplasia, and limb defects.
Traditional treatment of RLD has been focused on
repositioning the carpus onto the ulna. Centralization
was first described in 1893,19 but substantial refinements
followed the thalidomide epidemic, including release of
the ligamentous anlage, advancement of ulnar muscles,
and local tissue rearrangement during carpal reposi-
tioning. The introduction of soft tissue distraction by
Kessler in 198920 further simplified these issues, facili-
tating carpal repositioning and solving the skin deficit at
the time of surgery (Fig. 4).
Centralization remains the most common and
trusted procedure for the treatment of significant RLD;
however, recurrence of deformity is expected21,22
even with the use of soft tissue distraction22 (Fig. 5).
Manske et al23 recently found no improvement in
reducing deformity relapse in centralization even with
soft tissue distraction. No difference was appreciated
between patients who underwent centralization alone
or distraction prior to centralization and both groups
had significant recurrence of their radial angulation
(36%e47%)23 (Table 3).
Buck-Gramcko16 also introduced the radialization
procedure of transposing the ulna under the radial side
of the carpus and transferring radial wrist musculature
to the ulnar wrist. This levers the wrist and hand on the
ulna fulcrum, countering radial angulation. However,
Dana et al24 recently described that 7 of 8 arms with
type 3 or 4 RLD had recurrence of the radial deformity
and there was no difference between preoperative and
postoperative HFA (Table 3).
Recurrence of angulation after ulnocarpal trans-
position may be significant, and for patients who desire
a straight wrist after a failed centralization procedure,
fusion of the ulnocarpal joint is a salvage option.
Goldfarb and colleagues25 recently published their
experience with 12 patients who underwent ulnocarpal
r Vol. 42, July 2017
550 RLD DEVELOPMENTS AND CONTROVERSIES

FIGURE 3: Radial dysplasia in a 3-year-old girl with a history of VACTERL (vertebral abnormalities, anal atresia, cardiac abnormalities,
tracheoesophageal fistula and/or esophageal atresia, renal agenesis and dysplasia, and limb defects) association and bilateral type 4 RLD.
Multiple systemic comorbidities including tracheoesophageal fistula and congenital cardiac defects precluded earlier intervention on radial
angulation of her wrists. A, B Right arm Type 4 RLD with severe radial angulation deformity, contracted radial soft tissue, and absence of the
radial two digits. C, D Left arm type 4 RLD with severe radial angulation and Blauth type V thumb hypoplasia.

epiphyseal arthrodesis after recurrence of wrist angu-
lation. Eleven wrists were successfully fused with 1
operation, and 1 nonunion was successfully managed
with revision arthrodesis. The authors achieved a mean
radial angulation of 20 after arthrodesis (range,
0 e35 ), with a mean improvement of 42 . The mean
postoperative Disabilities of the Arm, Shoulder, and
Hand score was 24.5 (12.3; range, 6.8e36.4) and the
mean visual analog score was 8 for function (range,
4e10) and 7 for appearance (range, 5e10). However,
with improved angulation, prehension decreased. To-
tal active range of motion in the digits both decreased
from 140 to 105 in the middle finger, from 139 to
100 in the ring finger, and from 180 to 143 before
and after arthrodesis, respectively.
Limb length is another important consideration. At
baseline, the ulna of a limb with RLD will only reach
60% to 65% of normal length.26,27 Centralization
worsens this discrepancy, because ulnae only grow to
be 48% to 58% of normal length (P > .01)25 (Table 3).

J Hand Surg Am. r Vol. 42, July 2017

 TABLE 2. Modified Classification of RLD7,10,13,14,15
Relative
Type Thumb Carpus Distal Radius Proximal Radius Humerus10 Incidence (n ¼ 245)7

N Hypoplastic or absent Normal Normal Normal Normal 16.3%

0 Hypoplastic or absent Absence, hypoplasia, Normal Normal, radioulnar Normal

RLD DEVELOPMENTS AND CONTROVERSIES

J Hand Surg Am.

or coalition synostosis, congenital

radial head dislocation
1 Hypoplastic or absent Absence, hypoplasia, > 2 mm shorter Normal, radioulnar Normal 12.2%
or coalition than ulna synostosis, congenital
radial head dislocation
2 Hypoplastic or absent Absence, hypoplasia, Hypoplasia Hypoplasia Normal 6.9%
r
Vol. 42, July 2017

or coalition
3 Hypoplastic or absent Absence, hypoplasia, Physis absent Variable hypoplasia Normal 7.3%
or coalition
4 Hypoplastic or absent Absence, hypoplasia, Absent Absent Normal 52.2%
or coalition
5 Hypoplastic or absent Absence, hypoplasia, Absent Absent Proximal upper extremity 4.9%
or coalition hypoplasia including
abnormal glenoid and
proximal humerus
Distal humerus articulates
with ulna.

551
552 RLD DEVELOPMENTS AND CONTROVERSIES

FIGURE 4: Staged centralization of type 4 RLD. The same patient as in Figure 3 undergoing treatment to correct radial angulation of the left
hand. This patient failed initial attempts at serial orthosis fabrication to stretch tight radial fibrous tissue. A At the initial operation, this patient
underwent release of the radial anlage with care taken to protect the median nerve (blue arrow) or radial artery (green arrow), which may be
absent in RLD. B At the same time as radial release, a modified Ilizarov distractor was placed to distract radial soft tissues. C Secondary
operation included z-plasty along radial-sided skin to lengthen the soft tissue envelope along with centralization via an ulnar incision. D An
ellipse of skin of excess ulnar skin was excised, and E complete ulnocarpal capsulotomy was done in order to transpose the carpus onto the
ulna while protecting the ulnar neurovascular bundle (blue arrow) and extensor carpi ulnaris (green arrow). F A pin placed down the long
axis of the ulna and G the third metacarpal is used to keep the centralized carpus internally fixated for 2 to 3 months.

J Hand Surg Am. r Vol. 42, July 2017

 RLD DEVELOPMENTS AND CONTROVERSIES
FIGURE 5: Outcome after centralization with soft tissue
distraction. The same patient as in Figures 3 and 4 at 1-year
follow-up demonstrates recurrence of radial angulation with a
hand-forearm angle of 60 .
This effect is likely due to trauma to the ulnar physis
during centralization.
Vilkki28 described a vascularized second meta-
tarsophalangeal (MTP) joint as a radially oriented strut
off of the radial platform of the ulna as an alternative to
centralization and its trauma to the ulnar physis (Fig. 6).
This construct supports the radial carpus and provides
growing bone stock to minimize recurrence and
maximize limb length. Long-term follow-up (mean, 11
years) of 19 wrists in 18 patients who underwent soft
tissue distraction and second MTP transfer for types 3
and 4 RLD showed an HFA of 28 and significantly
improved ulnar growth compared with centralization
(67% of contralateral side)28 (Table 3).
Similarly, Yang et al29 recently published 4 cases
of soft tissue distraction followed by a vascularized
fibular head transfer. This flap, based on the inferior
lateral genicular artery, is used in the same manner
described by Vilkki28 with similar results. The au-
thors report preserved ulnar growth (67.9% of
contralateral limb) and promising improvement in
radial angulation (11 ), although their patients had
less severe RLD (all were type 3) and follow-up only
reached a mean of 42 months. Benefits of this method
J Hand Surg Am.
553
include possibly a more robust stock of growing bone
compared with the second MTP and avoiding the
cosmetic implications of sacrificing the second toe.
Longer follow-up and greater volume of cases are
required to confirm these findings.
Noting the unsatisfying results of soft tissue
distraction followed by centralization, Oishi and co-
authors30 recently published their series of 18 wrists in
16 patients in which they used a bilobed flap (Fig. 7)
along with soft tissue release and ulnar osteotomy. The
authors report a mean clinical resting angle of 64 , a 24
improvement (mean follow-up, 9.2 years), and ulnar
length that is 62% of the contralateral side.31 Although
there was statistically significant improvement in the
radial angulation, the radial deviation of the wrist was
greater than other methods (HFA, 64 vs 11 e63 )
(Table 2). The authors recommend this procedure be
done in advance of a second MTP transfer procedure,
but find that patients commonly are satisfied with their
function and opt not to pursue further surgery.
THUMB HYPOPLASIA
Thumb opposition is a crucial component of a fully
functional hand and is required for prehension, fine
pinch, and power grip. Hypoplasia of the thumb
occurs along a spectrum that ranges from minor
hypoplasia to its complete absence and includes a
variable range of hypoplastic skeletal, ligamentous,
and musculotendinous components.
Classification and diagnosis
Previously considered a separate clinical entity, thumb
hypoplasia is now categorized as a component of the
overarching condition, RLD14 (Table 1). Subtypes of
thumb hypoplasia are commonly classified based on
radiographic findings according to Manske’s modifica-
tion32 of Blauth’s original anatomical descriptions33
(Table 4). This system unfortunately ignores the impor-
tant contribution (or lack thereof) made by the extrinsic
muscles of the thumb. Thus, Tonkin34 recently put
forth an amended classification scheme that reorganizes
hypoplastic thumbs based on carpometacarpal laxity,
metacarpal morphology, and quality of extrinsic thumb
musculature to better inform the surgeon on reconstruc-
tive requirements and compare outcomes (Table 5).
Treatment and outcomes
The surgical treatment to restore opposition depends
on the severity of thumb hypoplasia, particularly joint
stability and extrinsic and intrinsic muscle function.
Traditionally, the mildest form (Blauth type I) does
not require surgery whereas moderate forms (types II
and IIIA) require procedures to improve function of
r Vol. 42, July 2017
 554
TABLE 3. Comparison of Surgical Methods for Types 3 and 4 RLD17,20,22,23,25,27e30
Preoperative
Preoperative Ulnar Ulnar Ulnar
Ulnar Length Length Length
Preoperative Postoperative HFA Length (% (% (%
Study Procedure Follow-Up HFA HFA Final HFA Recurrence (% Normal) Normal) Contralateral) Contralateral)

Kotwal et al
(2012)18
No surgery 10.1 y 66 ( 21 ) 85 ( 23 )* -
(n ¼ 137) (5e18.5 y)
Surgery (n ¼ 309); 11.1 y 63 ( 19 ) 12 ( 16 )† -
centralization (5.5e19.2 y)
with carpal
notch (n ¼ 202),

RLD DEVELOPMENTS AND CONTROVERSIES

J Hand Surg Am.

radialization
(n ¼ 107)
Sestero et al
(2006)26
No surgery 5.44 y 50 - 62 - 64%‡
(n ¼ 9)
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Vol. 42, July 2017

Centralization 5.31 y 49 3 38 35.4 58%

(nonnotched)
(n ¼ 7)
Centralization 7.31 y 46 0 15 14.7 48%
(notched)
(n ¼ 26)
Damore et al
(2000)21
Centralization 6.5 y 83 25 63 38
(n ¼ 19) (1.5e22.2 y) (55 e110 ) (5 e60 ) (20 e120 )
Dana et al
(2012)24
Soft tissue 2.6 y 61 12 44 32
distraction þ (26 e91 ) (14 e40 ) (20 e69 )
Radialization
(n ¼ 8)

(Continued)
 TABLE 3. Comparison of Surgical Methods for Types 3 and 4 RLD17,20,22,23,25,27e30 (Continued)
Preoperative
Preoperative Ulnar Ulnar Ulnar
Ulnar Length Length Length
Preoperative Postoperative HFA Length (% (% (%
Study Procedure Follow-Up HFA HFA Final HFA Recurrence (% Normal) Normal) Contralateral) Contralateral)

Manske et al
(2014)23
Centralization 10.0 y 53 13 27 14
alone (n ¼ 13) ( 2.7 y) ( 31 ) ( 11 ) ( 24 )
Soft tissue 6.0 y 53  21 36 15
distraction þ ( 2.2 y) ( 26 ) ( 15 ) ( 20 )§
Centralization
(n ¼ 13)

RLD DEVELOPMENTS AND CONTROVERSIES

J Hand Surg Am.

Vuillermin
(2015, 2016)30,31
Bilobed flap 9.2 y 88 64 e24 63.90% 62%
( ulnar (3e16.3 y) (45 e120 ) (35 e88 )
osteotomy)
(n ¼ 18)
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Vol. 42, July 2017

Vilkki
(2008)28
Soft tissue 11 y 28 67%
distraction þ (4e19.5 y) (51%e78%)
second MTP
transfer
(n ¼ 19)
Yang et al
(2015)29
Proximal 42 m 39 11 66.20% 67.90%
fibular (24e65 m) (22 e57 ) (5 e20 )
physeal
transfer
(n ¼ 4)

*P ¼ .081.
†P < .001.
‡Significant difference between nonsurgical group and centralization (both notched and nonnotched), P < .01.
§No significant difference between centralization alone or centralization with soft tissue distraction, P ¼ .31.

555
556 RLD DEVELOPMENTS AND CONTROVERSIES

FIGURE 6: An RLD reconstruction with soft tissue distraction followed by microvascular transfer of the second MTP joint. A, B Type 5
RLD after soft tissue distraction using an external fixator. C Exposure of recipient vessels on the radial aspect of distal forearm. In this
case, a radial artery (blue arrow) was present and was used to anastomose the second MTP joint flap. D, E Dissection of the left second
MTP joint along with its pedicle, first dorsal metatarsal artery and vein. F Patient after inset of the second MTP flap. (Images courtesy of
Dr. L. Scott Levin and Dr. Scott Kozin, Shriners Hospitals for Children, Philadelphia, PA)

the existing thumb: opponensplasty, MTP stabiliza-
tion, and deepening of the first web space.a,b Two
primary methods of opposition transfer are used for
types A II and IIIA hypoplastic thumbs. The Huber
transfer utilizes the abductor digiti minimi to sup-
plement thumb opposition, whereas the flexor dig-
itorum superficialis (FDS) transfer uses the superficial
flexor tendon of the ring or middle finger, which
provides enough tendon length to use a slip of tendon
for reconstruction of the ulnar collateral ligament of
the metacarpophalangeal (MCP) joint.35e37
Unfortunately, no objective data exist regarding the
outcomes of Huber transfers for thumb hypoplasia;
however, 2 recent studies have shown good results
with FDS transfers. de Kraker and authors35 report
that 0 out of 16 type II thumbs had MCP instability
and they were significantly stronger than nonoperated
type II thumbs (72% of normal opposition strength
compared with 33%, respectively; P ¼ .01). Vuiller-
min et al36 also showed good results, with no differ-
ence between using the flexor carpi ulnaris or the
transverse carpal ligament as pulleys for the FDS
tendon. Both studies report adequate oppositional
range of motion (mean Kapandji scores, 6.8e8.0).
The most severe forms of thumb hypoplasia (types
IIIB, IV, and V) require amputation of the existing

J Hand Surg Am. r Vol. 42, July 2017

 RLD DEVELOPMENTS AND CONTROVERSIES 557

MCP joint stabilization with opponensplasty;

Amputation of hypoplastic thumb followed

by pollicization of the radialmost digit
No surgical treatment necessary

deepening of first web space

Treatment

Deficient CMC joint with absence of trapezium, aplastic proximal first

metacarpal head. Absence of active motion at MCP or IP joint
FIGURE 7: Bilobed flap designed over the dorsal wrist. After
Minimal hypoplasia with full complement of neurovascular and

No muscular or skeletal attachments between thumb and hand;

persistent neurovascular structures within hypoplastic thumb
determining the point of maximal skin deficiency on the radial side
of the ulnocarpal articulation, a longitudinally oriented flap over the collateral ligament of MCP joint. Thenar hypoplasia.
dorsum of the hand is designed along with a transversely oriented
All bones present, but hypoplastic. Instability of ulnar

flap over the ulnar aspect of the ulnocarpal joint with a wide base left
musculoskeletal elements that are small in size

between them. The flaps are raised off of deep fascia, making sure to
keep the sensory branch of the ulnar nerve down. After all fascial
Description

bands are released, radial wrist flexors are transferred. In case of

Poor active motion at MCP and IP joints

ulnar angulation greater than 30 , Vuillermin et al30 recommend

performing a middiaphyseal ulnar osteotomy followed by Kirschner
wire placement under direct visualization. Importantly, finger
Blauth classification of Thumb Hypoplasia33

CMC, carpometacarpal; IP, interphalangeal; MCP, metacarpophalangeal.

flexors and neurovascular structures are preserved and trauma to the
ulnar physis and ulnocarpal joint are avoided.30
CMC joint unstable

thumb and reconstruction, most commonly by index

Absent thumb
Pouce flottant

pollicization (Fig. 8). With more severe RLD,

intrinsic and extrinsic components of the index may
too be hypoplastic or stiff and a fixed flexion
contracture of the index proximal interphalangeal
joint may be present—a finding many consider a
relative contraindication to pollicization. However,
Al Qattan38 recently reported a small series of such
patients in which pollicizations were followed by
arthrodesis of the new thumb MCP joint (former in-
dex proximal interphalangeal joint) using K wires
with the joint held in 10 to 30 of flexion. He reports
TABLE 4.

that all patients (n ¼ 5) used their new thumbs in daily

Type

IIIA

IIIB

activities and were satisfied with their result. Tech-

IV

V
II
I

nical details of index pollicization vary among

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 558
TABLE 5. Proposed Classification of Thumb Hypoplasia by Tonkin34
Type Description Treatment

I Small thumb with some hypoplasia of the thenar musculature;
mild extrinsic anomalies may be present
II Thumb hypoplasia more severe than type I.
CMC joint is present. Intrinsic and extrinsic anomalies are more
significant; underdeveloped first web space; there is MCP joint instability.
No surgical treatment necessary
Opponensplasty, reconstruction of deficient ligamentous
and extrinsic structures as indicated (see later)

RLD DEVELOPMENTS AND CONTROVERSIES

J Hand Surg Am.

IIA (mild) MCP joint instability is uniaxial. Mild extrinsic anomalies MCP joint stabilization (UCL reconstruction)
with opponensplasty; deepening of first web space
IIB (moderate) More severe intrinsic hypoplasia and web insufficiency than IIA; As earlier, along with reconstruction of extrinsic anomalies
multiplanar MCP joint instability. CMC joint is adequately stable and mobile.
Radiographic evidence of proximal flare at the first metacarpal base.
IIC (severe) Severe global MCP joint instability, gross extrinsic hypoplasia, As earlier along with chondrodesis or fusion of
r
Vol. 42, July 2017

and inadequate CMC joint (unstable or immobile). MCP joint and reconstruction of CMC joint.
Radiographically absent flare of proximal first metacarpal base For most severe IIC patients, amputation
and pollicization can be considered
III Increasing hypoplasia of all structures Amputation of hypoplastic thumb followed
CMC joint absent. by pollicization of the radialmost digit
IIIa Absence of the proximal metacarpal
IIIB Only a distal metacarpal remnant remains
IV Pouce flottant
No muscular or skeletal attachments between thumb and hand;
persistent neurovascular structures within hypoplastic thumb
V Absent thumb

CMC, carpometacarpal; UC, ulnar collateral ligament.

 RLD DEVELOPMENTS AND CONTROVERSIES 559

FIGURE 8: Thumb hypoplasia subtypes requiring index finger pollicization. A, B Type 3A, with deficient carpometacarpal seen on
radiograph. C Type 4 (pouce flotant). D Type 5, absent thumb.

authors, in particular regarding the reconfiguration of
the extrinsic musculature of the index and design of
skin incision39e42 (Fig. 9).cee
Function of the new thumb after pollicization
(Fig. 10) is invariably weaker and stiffer than the
thumb of a nonoperated hand.33,43,44 The degree of
function greatly depends on the original state of
the pollicized digit prior to surgery with better out-
comes in hands with preoperatively supple index
fingers.1,42 Both active and passive range of motion
are diminished in pollicized fingers, ranging from
40% to 77% of normal hands,45e47 with worse
impairment in patients with more severe RLD.46
Strength also falls short relative to a normal thumb:
grip, lateral (key) pinch, and tripod pinch in hands
after pollicization without radial dysplasia range from
44% to 60% of patients’ nonoperated contralateral
hands and 25% to 38% of hands of unaffected control
patients44,46,48 (Video 1; available on the Journal’s
Web site at www.jhandsurg.org).

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560 RLD DEVELOPMENTS AND CONTROVERSIES

FIGURE 9: Index pollicization. A, B Skin incisions and CeE skin closure of pollicization to treat type 4 thumb hypoplasia.

de Kraker et al46 showed that the severity of radial severe radial dysplasia (types 3 and 4) were signifi-
dysplasia correlates with the quality of the post- cantly more stiff in MCP flexion and thumb opposi-
pollicization functional deficit. Compared with hands tion and significantly weaker in grip, pinch, key
with mild forms of RLD (Types 0e2), patients with pinch, and tripod pinch.46 Dexterity of the new thumb

J Hand Surg Am. r Vol. 42, July 2017

 RLD DEVELOPMENTS AND CONTROVERSIES
FIGURE 10: A, B Type 4 thumb hypoplasia before CeE pollicization of a fully functional index finger and F, G outcome at 4 years
follow-up shows good opposition and prehension of the new thumb.
is similarly deficient: pollicized hands take longer and
score lower on functional hand tests.46 Whereas this
is inextricably tied to the poor strength and flexibility
of the thumb, pollicized hands also have poor
dynamic control of their thumb, a function of
neuromuscular coordination.48 Nonetheless, polli-
cized hands tend to develop at a rate comparable with
that of age-matched controls in both strength and
dexterity.49 By and large, patients and their parents,
including those with more advanced radial dysplasia,
tend to be satisfied with the function and cosmesis of
their new thumb.46
Discussion
Treatment of RLD must address both the deficiency
of the radius and thumb hypoplasia. Centralization
has historically been the treatment of choice to cor-
rect the abnormality at the wrist, but it often results
in recurrence of angulation and exaggerates limb
shortening. Recent advances have focused on soft
tissue release or distraction and vascularized epiph-
yseal transfer of the second MTP or fibula. The short-
and medium-term results of these transfers show
promise, with maintenance of radial column support
J Hand Surg Am.
561
that may favor this technique over others, although
recent papers also indicate that there may be suffi-
cient satisfaction with less technically demanding
reconstructions.30,31 Treatment of thumb hypoplasia
is less controversial: opponensplasty and MCP sta-
bilization remains the treatment of choice for hypo-
plastic thumbs with an intact carpometacarpal joint
whereas index pollicization is the well-described
treatment of choice for more severe thumb hypopla-
sia. However, as we continue to elucidate the long-
term outcomes of function, strength, and motion of
these reconstructive techniques, there remains some
controversy regarding the optimal way to stratify
these patients for which operation best serves them.
ACKNOWLEDGMENTS
The authors thank Dr Scott Kozin for contributing
images to this manuscript.
REFERENCES
1. Koskimies E, Lindfors N, Gissler M, Peltonen J, Nietosvaara Y.
Congenital upper limb deficiencies and associated malformations in
Finland: a population-based study. J Hand Surg Am. 2011;36(6):
1058e1065.
r Vol. 42, July 2017
562 RLD DEVELOPMENTS AND CONTROVERSIES
2. Buck-Gramcko D. Pollicization of the index finger. Method and
results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am.
1971;53(8):1605e1617.
3. Littler JW. The neurovascular pedicle method of digital transposition
for reconstruction of the thumb. Plast Reconstr Surg (1946).
1953;12(5):303e319.
4. Riordan DC. Congenital absence of the radius. J Bone Joint Surg Am.
1955;37-A(6):1129e1139; discussion, 1139e1140.
5. Lamb D. The treatment of radial club hand absent radius, aplasia of
the radius, hypoplasia of the radius, radial paraxial hemimelia. Hand
(N Y). 1972;4(1):22e30.
6. Oberg KC, Feenstra JM, Manske PR, Tonkin MA. Develop-
mental biology and classification of congenital anomalies of the
hand and upper extremity. J Hand Surg Am. 2010;35(12):
2066e2076.
7. Tonkin MA, Tolerton SK, Quick TJ, et al. Classification of
congenital anomalies of the hand and upper limb: development and
assessment of a new system. J Hand Surg Am. 2013;38(9):
1845e1853.
8. Sheeba CJ, Andrade RP, Palmeirim I. Getting a handle on
embryo limb development: molecular interactions driving
limb outgrowth and patterning. Semin Cell Dev Biol. 2016;49:
92e101.
9. Li D, Sakuma R, Vakili NA, et al. Formation of proximal and
anterior limb skeleton requires early function of Irx3 and Irx5 and is
negatively regulated by Shh signaling. Dev Cell. 2014;29(2):
233e240.
10. Piper SL, Dicke JM, Wall LB, Shen TS, Goldfarb CA. Prenatal
detection of upper limb differences with obstetric ultrasound. J Hand
Surg Am. 2015;40(7):1310e1317.e3.
11. Goldfarb CA, Wall L, Manske PR. Radial longitudinal deficiency:
the incidence of associated medical and musculoskeletal conditions.
J Hand Surg Am. 2006;31(7):1176e1182.
12. Wall LB, Ezaki M, Oishi SN. Management of congenital radial
longitudinal deficiency: controversies and current concepts. Plast
Reconstr Surg. 2013;132(1):122e128.
13. Bayne LG, Klug SM. Long-term review of the surgical treatment of
radial deficiencies. J Hand Surg Am. 1987;12(2):169e179.
14. James MA, McCarroll HR Jr, Manske PR. The spectrum of radial
longitudinal deficiency: a modified classification. J Hand Surg Am.
1999;24(6):1145e1155.
15. Goldfarb CA, Manske PR, Busa R, Mills J, Carter P, Ezaki M.
Upper-extremity phocomelia reexamined: a longitudinal dysplasia.
J Bone Joint Surg Am. 2005;87(12):2639e2648.
16. Buck-Gramcko D. Radialization as a new treatment for radial club
hand. J Hand Surg Am. 1985;10(6 Pt 2):964e968.
17. Bora FW Jr, Osterman AL, Kaneda RR, Esterhai J. Radial club-hand
deformity. Long-term follow-up. J Bone Joint Surg Am. 1981;63(5):
741e745.
18. Kotwal PP, Varshney MK, Soral A. Comparison of surgical
treatment and nonoperative management for radial longitudinal
deficiency. J Hand Surg Eur Vol. 2012;37(2):161e169.
19. Sayre RH. A contribution to the study of club-hand. Trans Am
Orthop Assoc. 1894;1(1):208e216.
20. Kessler I. Centralisation of the radial club hand by gradual distrac-
tion. J Hand Surg Br. 1989;14(1):37e42.
21. Damore E, Kozin SH, Thoder JJ, Porter S. The recurrence of
deformity after surgical centralization for radial clubhand. J Hand
Surg Am. 2000;25(4):745e751.
22. Lamb DW. Radial club hand. A continuing study of sixty-eight
patients with one hundred and seventeen club hands. J Bone Joint
Surg Am. 1977;59(1):1e13.
23. Manske MC, Wall LB, Steffen JA, Goldfarb CA. The effect of soft
tissue distraction on deformity recurrence after centralization for
radial longitudinal deficiency. J Hand Surg Am. 2014;39(5):
895e901.
24. Dana C, Aurégan JC, Salon A, Guéro S, Glorion C, Pannier S.
Recurrence of radial bowing after soft tissue distraction and
J Hand Surg Am.
subsequent radialization for radial longitudinal deficiency. J Hand
Surg Am. 2012;37(10):2082e2087.
25. Pike JM, Manske PR, Steffen JA, Goldfarb CA. Ulnocarpal
epiphyseal arthrodesis for recurrent deformity after centralization for
radial longitudinal deficiency. J Hand Surg Am. 2010;35(11):
1755e1761.
26. Sestero AM, Van Heest A, Agel J. Ulnar growth patterns in
radial longitudinal deficiency. J Hand Surg Am. 2006;31(6):
960e967.
27. Heikel HV. Aplasia and hypoplasia of the radius: studies on 64 cases
and on epiphyseal transplantation in rabbits with the imitated defect.
Acta Orthop Scand. 1959;30(Suppl 39):3e155.
28. Vilkki SK. Vascularized metatarsophalangeal joint transfer for radial
hypoplasia. Semin Plast Surg. 2008;22(3):195e212.
29. Yang J, Qin B, Li P, Fu G, Xiang J, Gu L. Vascularized proximal
fibular epiphyseal transfer for Bayne and Klug type III radial longitu-
dinal deficiency in children. Plast Reconstr Surg. 2015;135(1):
157ee166e.
30. Vuillermin C, Wall L, Mills J, et al. Soft tissue release and bilobed
flap for severe radial longitudinal deficiency. J Hand Surg Am.
2015;40(5):894e899.
31. Vuillermin C, Butler L, Ezaki M, Oishi S. Ulna growth patterns after
soft tissue release with bilobed flap in radial longitudinal deficiency.
J Pediatr Orthop. 2016 Jun 8. Epub ahead of print.
32. Manske PR, McCarroll HR Jr. Reconstruction of the congenitally
deficient thumb. Hand Clin. 1992;8(1):177e196.
33. Blauth W. The hypoplastic thumb [in German]. Arch Orthop
Unfallchir. 1967;62(3):225e246.
34. Tonkin MA. On the classification of congenital thumb hypoplasia.
J Hand Surg Eur Vol. 2014;39(9):948e955.
35. de Kraker M, Selles RW, Zuidam JM, Molenaar HM, Stam HJ,
Hovius SE. Outcome of flexor digitorum superficialis opponensplasty
for Type II and IIIA thumb hypoplasia. J Hand Surg Eur Vol.
2016;41(3):258e264.
36. Vuillermin C, Butler L, Lake A, Ezaki M, Oishi S. Flexor digitorum
superficialis opposition transfer for augmenting function in types II
and IIIA thumb hypoplasia. J Hand Surg Am. 2016;41(2):244e249.
37. Kozin SH, Ezaki M. Flexor digitorum superficialis opponensplasty
with ulnar collateral ligament reconstruction for thumb deficiency.
Tech Hand Up Extrem Surg. 2010;14(1):46e50.
38. Al-Qattan MM. Pollicization of the index finger requiring secondary
fusion of the new metacarpophalangeal joint. J Hand Surg Eur Vol.
2016;41(3):295e300.
39. Foucher G, Medina J, Lorea P, Pivato G. Principalization of polli-
cization of the index finger in congenital absence of the thumb. Tech
Hand Up Extrem Surg. 2005;9(2):96e104.
40. Kozin SH. Pollicization: the concept, technical details, and outcome.
Clin Orthop Surg. 2012;4(1):18e35.
41. Goldfarb CA, Monroe E, Steffen J, Manske PR. Incidence and treat-
ment of complications, suboptimal outcomes, and functional
deficiencies after pollicization. J Hand Surg Am. 2009;34(7):
1291e1797.
42. Taghinia AH, Littler JW, Upton J. Refinements in pollicization:
a 30-year experience. Plast Reconstr Surg. 2012;130(3):423ee433e.
43. Lightdale-Miric N, Mueske NM, Lawrence EL, et al. Long term
functional outcomes after early childhood pollicization. J Hand Ther.
2015;28(2):158e166.
44. Netscher DT, Aliu O, Sandvall BK, et al. Functional outcomes of
children with index pollicizations for thumb deficiency. J Hand Surg
Am. 2013;38(2):250e257.
45. Tan JSW, Tu Y. Comparative study of outcomes between pollici-
zation and microsurgical second toe-metatarsal bone transfer for
congenital radial deficiency with hypoplastic thumb. J Reconstr
Microsurg. 2013;29(9):587e592.
46. de Kraker M, Selles RW, van Vooren J, Stam HJ, Hovius SE.
Outcome after pollicization: comparison of patients with mild and
severe longitudinal radial deficiency. Plast Reconstr Surg.
2013;131(4):544ee551e.
r Vol. 42, July 2017
 RLD DEVELOPMENTS AND CONTROVERSIES 563

47. Manske PR, Rotman MB, Dailey LA. Long-term functional results
after pollicization for the congenitally deficient thumb. J Hand Surg
Am. 1992;17(6):1064e1072.
48. Lightdale-Miric N, Mueske NM, Dayanidhi S, et al. Quantitative
assessment of dynamic control of fingertip forces after pollicization.
Gait Posture. 2015;41(1):1e6.
49. Aliu O, Netscher DT, Staines KG, Thornby J, Armenta AA. 5-year interval
evaluation of function after pollicization for congenital thumb aplasia using
multiple outcome measures. Plast Reconstr Surg. 2008;122(1):198e205.
EDITOR’S SUGGESTIONS FOR MORE
INFORMATION
The Editor chose to include these references and videos to provide
readers with additional information.
a. Christen T, Dautel G. Type II and IIIA thumb hypoplasia recon-
struction. J Hand Surg Am. 2013;38(10):2009e2015.
b. Light TR, Gaffey JL. Reconstruction of the hypoplastic thumb. J Hand
Surg Am. 2010;35(3):474e479.
c. Taghinia AH, Upton J. Index finger pollicization. J Hand Surg Am.
2011;36(2):333e339.
d. TSRH pollicization (Video D; available on the Journal’s Web site
at www.jhandsurg.org). Oishi S. Presented at: American Society
for Surgery of the Hand Annual Meeting: September 10e12,
2015; Seattle, WA. Also available at: Hand-e: http://www.assh.
org/hand-e.
e. Pollicization: Buck-Gramko incision (Video E; available on the
Journal’s Web site at www.jhandsurg.org). Bednar MS. Presented
at: American Society for Surgery of the Hand Annual Meeting:
September 10e12, 2015; Seattle, WA. Also available at: Hand-e:
http://www.assh.org/hand-e.

JOURNAL CME QUESTIONS

Radial Longitudinal Deficiency: Recent 3. Patterning of the upper extremity along the
Developments, Controversies, and an anterior posterior axis during fetal development is
Evidence-Based Guide to Treatment primarily due to which of the following pairs of
structures and signaling pathways?
1. Compared to an unaffected limb, the ulna in
a. Apical ectodermal Ridge (AER), Fibroblast
limbs with type 3 and 4 radial longitudinal
Growth Factor 8 (Fgf8)
deficiency (RLD) grows to be:
b. Apical Ectodermal Ridge (AER), Wnt7a
a. 35% of normal ulnar length
c. Zone of Polarizing Activity (ZPA), Bone
b. 50% of normal ulnar length
Morphogenic Protein (BMP)
c. 65% of normal ulnar length
d. Zone of Polarizing Activity (ZPA), Sonic
d. 85% of normal ulnar length hedgehog (Shh)
e. Normal in length e. Zone of Polarizing Activity (ZPA), Fibroblast
Growth Factor 8 (Fgf8)
2. In types II and IIIA thumb hypoplasia, compared
to the Huber transfer, a particular advantage of the 4. A 3-week-old female patient with type 3 RLD
flexor digitorum superficialis (FDS) tendon transfer and thumb hypoplasia is also found to have an
opponensplasty is that: atrial septal defect and first degree heart block on
a. It has a more advantageous vector of force for electrocardiogram. A full work-up reveals she has a
thumb opposition normal complete blood count (CBC) and no
b. A slip of the FDS tendon can be used to reconstruct anomalies of the genitourinary or gastrointestinal
an incompetent thumb MP joint ulnar collateral systems. Which of the following is the most likely
ligament syndromic diagnosis in this child?
c. It provides a better thumb abduction force a. Holt-Oram Syndrome
d. It has greater oppositional strength b. Thrombocytopenia Absent Radius (TAR)
Syndrome
e. A slip of FDS is used to augment thumb meta-
carpophalangeal extension c. VACTERL association
d. Duane Syndrome
e. Fanconi Anemia

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.

J Hand Surg Am. r Vol. 42, July 2017