Club Hand

Ribka Theodora – Hand 3

Mentor : dr. Betha Egih Riestiano, SpBP-RE
Classification (Swanson, 1976 )

Grabb and Smith's Plastic Surgery, 6th Edition, 2007

2
 INTRODUCTION
Radial longitudinal deficiency (RLD)/Radial Club
Hand
• a spectrum of deformity affecting the forearm, wrist, and hand
• Swanson  IB group (failure of formation – longitudinal arrest)

Frequently bilateral and asymmetric

Commonly associated with several congenital

syndromes, syndactily and/or polidactyly
Classification
 INTRODUCTION

Ulna Club Hand

• Ulnar longitudinal deficiency

• Swanson  IB group (failure of formation –
longitudinal arrest)

Commonly associated with elbow

instability, congenital scoliosis,
syndactily and/or polidactyly
Classification
 CLINICAL EXAMINATION

Look Feel Move

• ROM at the shoulder, elbow, wrists, and fingers
• Degree of thumb hypoplasia as well as the nature of the fingers (supple or stiff)

Child grasps objects  thumb–index finger (if thumb present); index–

middle finger; or ring–little finger
• surgical intervention  primarily between the ring and little fingers any attempt to
formally centralize the wrist may actually worsen function

Grip strength, key pinch, forearm length, and elbow and digital motion
are more important than radial angulation the wrist for daily activity
 CLINICAL EXAMINATION

Imaging
• Plain radiographs of both hands and forearms

Many children have associated systemic

or musculoskeletal abnormalities
• spine radiographs, an echocardiogram, a renal
ultrasound, and a complete blood count (to
evaluate for thrombocytopenia or anemia that
is associated with RLD), DEB test  Fanconi’s
anemia
 INDICATION

Thumb dysfunction, wrist instability, and short upper extremities difficulty in daily living

Occupational therapist is crucial  as stretching of the wrist is begun when the newborn 
when the child is of adequate size a splint is fashioned to aid in the stretching of the wrist

Type 0,1,mild 2  stretching and static progressive splints or serial casting beginning shortly
after birth

Whereas centralization may be done children with type >2 with preliminary serial casting or soft
tissue distraction using an external fixator
• Centralization of the wrist : 9 - 12 months

Contraindicated : elbow extension contracture (<90 degrees of flexion)

 SURGICAL ANATOMY

• The radius is hypoplastic, partially

absent, or totally absent
• The radius/ulna is bowed
Skeletal posteriorly and may be shortened
anomalie 60%-75% of normal length.
s
• The articulation between the
carpus and ulna does not form a
normal joint --> fibrous but can be
lined by hyaline cartilage
SURGICAL ANATOMY

• The extensor carpi radialis longus and brevis muscles : absent or fused
to the extensor digitorum communis
• The presence of the extensor pollicis longus, extensor pollicis brevis,
and abductor pollicis longus can be predicted by the presence of a
thumb metacarpal
• The supinator, pronator quadratus, and palmaris longus : absent
• The pronator teres is absent if the radius is absent
Muscle • The flexor carpi radialis : absent
anomalies
• The extensor carpi ulnaris (ECU), flexor carpi ulnaris, and flexor
digitorum superficialis : present and normal
• The flexor pollicis longus is present only if the thumb metacarpal is
present
• If the thumb is present, the thenar muscles are usually present
• The hypothenar, interosseous, and lumbrical muscles are usually
normal
SURGICAL ANATOMY
• brachial and ulnar arteries : present
Vascular and normal
anomalie • the radial artery and palmar arch :
s absent or attenuated
• interosseous arteries : developed

• Nerve
anomal • The median and ulnar nerves : present
ies
Centralization for Radial Longitudinal Deficiency
1. Preliminary soft tissue distraction using an external fixator device

2. Design of a bilobed skin flap that transfers the redundant skin on

the ulnar side to make up for the skin deficiency on the radial side

3. Centralizing the carpus over the ulna

4. Balancing the tendons to counteract recurrent radial deviation

Centralization for Radial Longitudinal
Deficiency
Under GA : arm is placed on a hand table with a tourniquet placed
high on the arm

Preliminary Soft Tissue Distraction

• 6 - 9 months
• A uniplanar external fixator device is applied on the ulnar side
of the affected limb (pins traverse the small finger metacarpal
and the ulna
• distraction at a rate of 1 mm per day a week after device
placement  observed weekly clinic visit and radiograph 
until the hand is in an approximately neutral position or slightly
beyond neutral
Circumferential frame : two half-pins and one
transfixion wire are used proximal to the
osteotomy, one half-pin and two transfixion
wires (one in the ulna and one in the
metacarpals) are placed distal to the osteotomy

Uniplane fixator : two pins each are placed

proximal and distal to the osteotomy

Distraction is initiated approximately 1 week after

application of the fixator and is continued at 1
mm/day divided into two to three increments
Centralization for Radial Longitudinal
Deficiency
Elevation of Bilobed Flap
• The first flap can be marked on the
dorsum of the wrist, based proximally
(flap A), with another corresponding
flap at 90o that lies on the area of
greatest skin redundancy on the ulnar
side (flap B)
• The flaps are raised in a plane
superficial to the extensor retinaculum
Centralization for Radial Longitudinal
Deficiency
Dissection of Nerve and Tendons
The median nerve is identified first during the
exposure  most superficial structure on the
radial aspect of the distal forearm
• The ECU is identified distal to the
retinaculum  shortened/tightened by
detaching and advancing/imbrication after
centralization
• The extensor carpi radialis (ECR) is divided
at its insertion to facilitate later transfer to
the ECU
• The dorsal ulnar sensory nerve is identified
and retracted to prevent inadvertent injury
 Centralization for Radial Longitudinal Deficiency

Ulnocarpal Joint Reduction and Centralization

• Centralization  aligning the third metacarpal over the
distal ulna
• The wrist capsulotomy is created distal to the ulnar
physis
• A progressive soft tissue release is carried out until the
carpus can be aligned over the distal ulna. (carpus
mobilized off of the palmar capsule)
• Occasionally, centralization is only possible after partial
carpectomy or limited shaving of the distal ulna
Centralization for Radial Longitudinal
Deficiency

Fixation
• The ulnocarpal reduction is maintained by
0.062-inch (1.57-mm) K-wire placed
antegrade through the carpus & 3rd
metacarpal and then retrograde into the
ulnar shaft under fluoroscopic guidance
• If the ulna has an angular deformity >30o 
diaphyseal closing wedge osteotomy is
performed at the apex of the deformity and
the same K-wire from centralization is
driven retrograde across the osteotomy site
Centralization for Radial Longitudinal Deficiency

Wrist Stabilization
• The ECR tendon is transferred to the distal stump of
the ECU passing below the extensor digitorum
communis (EDC)
• The proximal end of the ECU is advanced and sutured
to the dorsal wrist capsule. Tendon repairs are done
using 2-0 Ethibond horizontal mattress sutures
• The extensor retinaculum is repaired using 4-0
absorbable or retinacular flap passed underneath
the finger extensors to reinforce the wrist capsule
• Skin is closed with 5-0 non-absorbable sutures
If the carpus cannot be passively reduced onto the end
of the ulna = a soft tissue release and balancing
procedure is performed instead of a formal
centralization
Ulnar Deficiency Surgical Treatment

Indication
• Treatment is dependent on forearm stability, available elbow motion, and
function.
• The thumb deficiency limits prehensile activity and is treated by
principles similar to those for isolated thumb hypoplasia.
Ulnar Deficiency Surgical Treatment

In a skeletally mature patient with wrist pain, there are multiple options for
correction of the deformity and relief of pain, including
(1) ligament resection and dome osteotomy
(2) radial closing wedge osteotomy and ulnar shortening
(3) radial opening wedge osteotomy
(4) radial osteotomy and distal ulnar resection
(5) radial osteotomy and the Sauvé-Kapandji procedure.
Physiolysis + Fat Graft
Dome Osteotomy + Physiolysis
 Postoperative Care and Expected Outcomes

The patient is placed in a well-padded

long-arm cast with the elbow in at
least 90 degrees of flexion --> k-wire
& immobilized for at least 4 weeks

A long-arm orthosis to maintain the

centralized wrist position for 6 weeks
 3 - 6 months nightly until skeletal
maturity
 Postoperative Care and Expected Outcomes

• Recurrence or persistence of the deformity is common

• Intraoperative : lack of complete correction during surgery, inadequate radial soft

tissue release, and failure to adequately balance forces acting across the wrist

• Postoperative : early pin removal, poor compliance with the postoperative

orthosis, and soft tissue memory

Wrist stiffness and forearm growth impairment

• Foreshortening of the ulna (60% of normal) is common

 References

● Kevin C. Chung. Hand Operative Techniques 3rd Ed., 2018

● Green Operative Hand Surgery, 6th ed. 2011
● Nelligan Plastic Surgery, 4th ed. Vol 6. 2018
HATUR NUHUN