The Windblown hand

Red Cross Childrens Hospital Experience 2003-2011

Dr Steve Carter

Introduction• Congenital ulna drift first described by Boix in 1897• Extremely rare• Three essential features

1. Thumb adduction and flexion contracture

2. Ulna drift of the fingers at the metacarpophalangeal joint

3. Flexion contracture of fingers

Aetiology• Zancolli and Zancolli (1985) – Segmental Arthrogryposis• Associations – Freeman Sheldon Syndrome

(Craniocarpotarsal dysplasia)

- Digitotalar dysmorphism• Red Cross – Syndromic or Idiopathic (MCP Dysplasia)

-” Extensor Failure theory”

History• Wood,Biondi (1990) J Hand Surg 15A:431-38

20 yr study 11 patients operated on 7 hands in 4 patients• Gavaskar,Chowdary(2009) J Child Orthop 3:109-114

7 yr study operated on 23 hands in 18 patients

• Mc Carrol,Manske (1992) Hand Clin 8:147-59

25 yr study operated on 29 thumbs in 18 patients

Surgery LiteratureBiondi and Gavaskar

Pathology Surgical procedure

Thumb Contracture Z plasty,Dorsal rotation Flap,Adductor release as necessary.EIP Transfer to supplement extension

Ulna deviation of the Digits

Recentralize extensor tendonRelease or transfer ulna intrinsic

Volar flexion contracture fingers

Full thickness skin graft

Surgery LiteratureMcCarroll

Pathology Surgical procedure

Thumb Contracture First 15 years volar release and extensor transfer – poor resultsNext 10 years volar release and MCP Arthrodesis

Ulna deviation of digits

nil

Volar flexion contracturre

nil

Surgery Red Cross

Pathology Surgical procedure

Thumb Contracture Volar ZplastyMetacarpophalangeal Joint ChondrodesisEIP transfer

Ulna deviation of the digits

Ulna intrinsic Transfer

Flexion contracture fingers

Nil

Surgery

Volar skin shortening Unstable MCP

Surgery

Volar Z Plasty

SurgeryChondrodesis MCP Thumb

SurgeryEIP Transfer

SurgeryCrossed Intrinsic Transfer

RXH Experience

• 9 years (2003-2011) 10 Patients• 5 patients Operated on 9 hands • 5 patients not operated on – 1 Mother

- 2 males Bilateral hands 16 yrs old functional

- 2 males Bilateral awaiting surgery

Patients

Gender Age Uni/Bilat Pathology Surgery

Female 3 Bilat Digitotalar Thumbs only bilat

Male 2 Bilat Windblown R ThL Th and crossed intrinsic

Male 2 Bilat Windblown R Th

Male 3 Bilat Windblown R ThL Th and crossed intrinsic

Male 2 Bilat Windblown R ThL Th

Results• Wood and Biondi 1991 classification based on cosmesis and

function• Evaluation subjective, hard set of criteria unrealistic• Excellent – Normal function and cosmesis• Good – Almost normal function,satisfactory appearance• Fair - Some contractures that interfere with function• Poor – Contracted hand no function

• Rxh 7 good results and 2 fair results in 9 hands

Conclusions• Priority is treatment of thumb deformity –Volar release, stability MCP

and extensor transfer

• Extensors are the problem therefore need EIP transfer

• Intrinsic transfer improves appearance but not necessarily function

• No volar grafting

• Early surgical management < 2rs