In fact, in my aforementioned article “Overview of polydactyly”, I have already given a more detailed answer: polydactyly with well-developed trunk fingers can be operated at around 3-6 months of age, complex polydactyly should be operated at 1 year of age, and those requiring osteotomy and fusion of the finger bones should be operated at 1-3 years of age. For complex polydactyly, the surgery should be performed at the age of 1 year, and for osteotomy and fusion, the surgery should be performed at the age of 1-3 years.
But there are still more parents worried about the risks and results of polydactyly surgery at a young age. To answer parents’ questions, today, I took a picture of a 5-month-old baby’s left thumb polydactyly surgery, so that parents can understand how this surgery is done, which also saves me time in clinic. I am a little slow in seeing patients.
The child, 5 months old, had a polydactyly of the left thumb and no significant movement of the polydactyly on preoperative examination. After entering the operating room, the anesthesiologist first administered an appropriate amount of sedation through an intravenous indwelling needle to put the child to sleep, and then performed a precise left brachial plexus nerve block under the guidance of a nerve explorer. A balloon tourniquet was placed on the left upper arm so that there would be no intraoperative bleeding. Sterilized towels were laid, as shown in the picture. The child’s left thumb trunk finger was still developing, but the ulnar side was deviated and the tiger’s mouth was small.
Preoperative X-rays
Operating under 3X surgical magnification, the fine tissue structures can be observed more clearly.
An incision is made at the root of the polydactyly, taking care to preserve part of the dorsal skin of the polydactyly so that the incision is not on the extensor surface of the thumb after suturing.
A dysplastic tendon on the dorsal side of the multifidus was explored and peeled off and retained, intended to be used to strengthen the dorsal extension of the thumb.
The trunk vessels and nerves on the palmar side of the polydactyl were separated, the vessels were cut and ligated, and the nerves were cut and allowed to retract into normal soft tissue to avoid the formation of neuromas.
No flexor tendon attachment was found on the palmar side, and there was no significant flexion activity consistent with the preoperative examination, but the thumb short adductor muscle stop was attached to the radial side of the polydactyly
The thumb abductor stop was dissected from the multifidus to expose the metacarpophalangeal joint shared by the multifidus and the dominant finger
Dissect the joint capsule and remove the polydactyly distal to the joint.
Excise the cartilage corresponding to the polydactyly on the metacarpal, noting that the cut surface should be curved rather than raw and flat, as the normal metacarpal is also cylindrical in shape
5-0 prolene wire repair of the periosteum, joint capsule, and lateral collateral ligament.
The stop of the short thumb extensor muscle with ectopic attachment to the polydactyly is sutured to the proximal radial side of the proximal phalanx of the thumb, and the post-suture tension is slightly strengthened in order to abduct the thumb to the radial side and correct the ulnar deviation.
The retained dorsal extensor pollicis brevis tendon is sutured to the dorsal side of the proximal phalanx of the thumb.
After 5-0 absorbent sutures are placed in the subcutaneous tissue, the wound edges are already aligned and the incisional skin is preserved just right, essentially eliminating the need for further skin revision.
The incision is closed with absorbent sutures, and the distal end of the suture is just the right shade to match the incision, as if the wound is longer, but it is not that long. 2 weeks later, the sutures are autolyzed and do not need to be removed.
Finally, a mini rubber sheet was placed to drain the bleeding, because the large blood vessels were ligated during the operation, and the small vessels were not treated, so drainage was needed to prevent subcutaneous blood accumulation, and the skin sheet was removed 2 days after the operation.
Sterile dressing and bandage wrapping thumb, small infant finger activity force is small, no need to play bulky plaster, bandage more than a few turns enough to fix the thumb can not move, postoperative can be bag flexion elbow hanging in front of the chest.
After the pressure bandage, then loosen the blood repellent bandage, the wound usually has no obvious bleeding, even if there is a little bleeding, it can be drained out through the rubber sheet, but the finger tip should be left to observe the blood supply, in case the bandage is too tight. After the operation, we will wait for the child to wake up in the anesthesia resuscitation room and then return to the ward. At this time, although the child has woken up, he or she will not feel any pain because the blocking effect of the brachial follower nerve has not yet disappeared. After returning to the ward, the child will be given mild sedation and pain relief, and the child will usually sleep comfortably the night of the surgery.
The above is basically the whole procedure, which was taken by the nurses, some of which are not very clear. I wonder if you parents still have questions after reading this? There was not a drop of blood during the surgery, and there was only a little blood on the inner gauze after the surgery. The surgery of polydactyly in small infants is actually not complicated, and a good repair can be completely achieved by familiarity with anatomy and microscopic operation. Operating under magnification, it is possible to repair the joint capsule very precisely, reconstruct the lateral collateral ligament, complete the reconstruction of tendons and muscle stops, and completely avoid complications such as postoperative joint instability and residual bone fragments (but it is still not recommended to follow suit in hospitals that do not have the conditions). Returning a healthy finger to the child at the age of 3-6 months is beneficial to the development of fine motor movements of the child’s hand, because it is from the age of 3 months that the motor development of a normal child’s finger begins.
Due to traditional beliefs and the limitations of technical skills, there are many doctors who will tell parents that polydactyly surgery in small infants is not safe and that the bones and joints, etc. can leave sequelae if not handled properly. This is true for doctors who do not have experience in infant polydactyly surgery, but for me, as long as the child’s condition meets the requirements, polydactyly in small 3-month-old infants can be done with equally good management of bones, joints, ligaments and tendons. There are pictures, and I will post another case of polydactyly in a small infant.
The child, a female, just 3 months old, had polydactyly of the right thumb with a well-developed trunk finger, thus allowing early surgery.
The x-ray showed the polydactyly attached to the metacarpal of the thumb.
The anatomy was clear when operated under a tourniquet to stop bleeding and under 3x magnification.
The main vascular nerve of the polydactyly was addressed first
The flexor digitorum longus tendon, which was ectopic to the multifidus, was isolated and set aside.
Separate the ectopic thumb extensor tendon and set aside
Detach the lateral collateral ligament and the short thumb extensor muscle that are ectopic to the multifinger.
The tissues on the multifinger are clean, the multifinger is full of treasures, the above separated structures are useful, can not be cut off with the multifinger ah!
The bone connection between the polydactyl and the metacarpal of the thumb was removed, and the bone wax was used to stop the bleeding of the bone wound and then the periosteal suture was closed.
The joint capsule and lateral collateral ligament were repaired, the thumb short extensor muscle stop was reset to the radial base of the proximal phalanx, the thumb short extensor tendon was reset to the dorsal base of the proximal phalanx, the flexor length of the polydactyly was cut off at the bifurcation with the flexor length of the thumb, and the severed end was sutured with a stitch to make it smooth so as not to cause adhesions. In this way, the muscle strength is increased and the thumb will function better after surgery than it did before surgery.
Immediately after surgery, this baby’s sutured incision completely overlaps the natural skin pattern at the base of the thumb, and the incision will be completely invisible in a few years. Of course, whether the incision can be completely hidden in the dermatoglyph depends on the specific conditions of the child’s multifidus, but in any case, try to conform to the dermatoglyph.
The child is too young to be put in a cast after surgery, but the bandage can also completely fix the baby’s metacarpophalangeal and carpometacarpal joints, playing the effect of cast fixation. The baby is very comfortable after surgery.
The first change of medication was made 7 days after the operation, and the wound had no obvious swelling and normal shape. Because it is absorbable thread, there is no need to remove the thread, and then bandage for 2-3 weeks to let the bones and joints, muscles and tendons heal, and parents can open the bandage at home. It is very convenient for out-of-town patients to visit the doctor because there is no need to change the medication during this period.
This is last week’s surgery (2011.12.29), this baby’s future thumb function will be uploaded after the follow-up, you can see whether there are any sequelae. I’m sure there won’t be!
This child’s phone has been out of service, and he has not heard back for a month after sending a letter. More than 10 of the patients who did this before and after the Chinese New Year were like this, so I guess he came back from the Chinese New Year to have surgery and then went out to work.
So, today I had to shoot another just 3 months old baby multi-finger surgery, because the intraoperative process and the same as the previous, the process did not shoot, after all, it is not good to bother the nurses, they are also very busy.
The child, female, 3 months 5 days, left thumb polydactyly, type 7, preoperative main finger ulnar deviation is obvious, tiger mouth is small.
X-rays with the age of the child
Intraoperatively, the polydactyly was excised, the metacarpophalangeal joint was shaped, the lateral collateral ligament and the stop of the short thumb extensor were reconstructed, and the ulnar deviation was corrected immediately after surgery.
The surgery lasted 40 minutes and was performed on April 10. We will wait for another 3 months to see the results, which is an acquaintance of one of the doctors in our hospital, so we should be able to follow up. The dressing will be opened only 3-4 weeks after the operation, during which there is no need to change medication or remove stitches.
I was so busy that I forgot to add the photos, the child came back once, but I was not found, another doctor took the photos, the child kept moving his hands, the photos were very blurred, only a slightly clear one, the current form and activities are normal. Because the incision is on the side, the scar is almost invisible on the front.
The last child was not yet followed up, but now, a child with type 4 polydactyly who was operated at 3 months old is back for follow-up after 6 months. Usually, post-operative recovery is very good, and it is very good to come back at 3 months, but it is rare to come back at half a year.
The child, male, underwent right thumb polydactyly, joint capsule reconstruction, lateral collateral ligament repair, and short thumb abductor stop reconstruction at 20 days in March.
Preoperatively, the right thumb was type 4 polydactyly with a developable trunk finger.
On X-ray, the polydactyly was co-articulated with the trunk finger.
More than six months after surgery, the thumb abduction was normal. The child was not cooperative, it was not easy to get a picture of this position, and I couldn’t delay too much time in the outpatient clinic, so many times the pictures were not good, and they were all blurred when I was moving.
The thumb flexion is normal, some of the incisions are hidden in the skin lines, the scar is not obvious, and should not be visible when they grow up.
The reason why I am posting these cases of polydactyly in small babies is that in China, even among my colleagues in the field of hand surgery, most of them still believe that surgery at 3 months is too early for polydactyly with osteoarthritic connections and that postoperative function is not good. In contrast, my philosophy is that as long as the main finger is well developed, even if it is osteoarthritic, it can be operated at an early age of 3-6 months, which is in line with the international concept. The operation is performed under a magnifying glass, which allows for very fine anatomical repositioning and joint reconstruction, and postoperative joint stability can be normal. And because it is done at a very young age, the scar is lighter and the appearance is better!
Of course, to be able to perform polydactyly at the age of 3-6 months requires not only the skill of the surgeon, but also the technical support of the hospital’s anesthesia. I would like to thank the director of our hand anesthesia department, Mr. Park, and his colleagues for their excellent infant brachial plexus block technique, which made my surgery worry-free!
At present, the weather is gradually turning hotter and many parents are starting to worry about the effect of thicker dressing on the wound. Although Chongqing really heats up at the end of July to the beginning of September, I have started to change to the cool summer dressing method for the baby’s comfort.
See also my post (Tianxiao 0702) http://www.handsurgery.cn/forum.php?mod=forumdisplay&fid=9019&filter=typeid&typeid=49
Update January 1, 2014
It has been a long time since I opened this post, and I know that it is not only the parents of the children who read my posts, but also some doctors who check in from time to time. It still needs to be updated in order not to mislead people.
In fact, it is really a pity that very few multifingers are done for small infants under half a year old nowadays, because the waiting time for appointments is too long. However, last year, I followed up more than 20 cases of early removal of polydactyly and metacarpal osteotomy in infants under half a year old, and the results were better than my estimation, and parents generally reported that the size difference between the two thumbs became smaller after surgery, while I thought the size ratio would not change after surgery. The reason for this is that after the early removal of the polydactyly and the correction of the ulnar deviation, the tiger’s mouth was enlarged and the child’s thumb movement increased. I will continue to observe this phenomenon and wonder if the same effect is seen in older children after surgery.
There are also some updates that need to be made. Nowadays, there is no medication change after polydactyly surgery, and for those who don’t have kleenex pin fixation, the dressing will be wrapped for 3 weeks after surgery, and parents can remove the gauze at home. For those with klebsiella needle fixation, the medication is changed 3-4 weeks after surgery and the needle is removed at the same time. This is more in line with my principle of minimizing the pain of the child. Moreover, the surgery is not affected by any season, and even if the surgery is performed in July or August, there is no infection.
Update again in 2015
It has been a long, long time since I read this article again, and now, some opinions and surgical details have changed.
First, there is no need to pursue surgery at a very young age, although some types of polydactyly are operable up to the age of half a year, and I have done many of them before. However, there are compromises to be made when considering the effects of anesthesia, not only on safety, but also on brain cells.
Secondly, about the “chasing growth” of the fingers after surgery, according to my picture data, it is not obvious, but it is true that some parents feel this way, especially those with multiple fingers on the right thumb after surgery, I think it is because the right hand is used more, while the opposite is true for left-handed children.
Therefore, it is correct to let the child use the hand more often for surgery, as to whether there is “chasing growth”, parents do not need to dwell on it, if there is, which doctor will do it, if not, there is none.