Multidisciplinary management of congenital hand anomalies

March 27, 2020

Mayo Clinic takes a multidisciplinary approach to managing pediatric congenital hand differences. Hand surgeons collaborate with highly experienced pediatric anesthesiologists when surgery is indicated. Children whose anomalies may be associated with a specific syndrome can be seen by Mayo geneticists and other specialists. All pediatric patients can seamlessly transition to adult care at Mayo when the time comes.

"We seek to provide the right answer with a single visit. When needed, we have all of our specialists here on campus so families can get plugged into seeing the right people quickly," says Nicholas A. Pulos, M.D., an orthopedic surgeon specializing in pediatric hand and microvascular surgery at Mayo Clinic in Rochester, Minnesota. "Our approach is to address every aspect of care — from diagnosis to treatment to emotional support — so the family feels well taken care of."

Managing complex and straightforward conditions

Early referral is key to optimal outcomes. Complex conditions such as radial longitudinal deficiency can be associated with life-threatening pathologies and syndromes. More-straightforward problems, such as postaxial polydactyly, can often be treated right away in the office.

However, Mayo Clinic recommends evaluation by a pediatric hand surgeon who can determine if surgery might be beneficial. "Without a lot of experience with these cases, it's sometimes difficult to know which children need surgery and when," Dr. Pulos says. "Based on our experience, we like to assess these children early to avoid future complications."

Mayo Clinic also performs reconstructive surgery for children born with syndactyly. Hand surgery is generally performed between 2 and 3 years of age to minimize risks from anesthesia, although surgery for conditions involving the thumb might be performed earlier. Mayo Clinic has fellowship-trained pediatric anesthesiologists who have published extensively in the field.

"My son had surgery at age 6 months, so I know how anxiety-provoking it can be for parents to have a child under anesthesia. We are able to provide reassurance," Dr. Pulos says.

Another common problem is stenosing tenosynovitis, which in children affects the thumbs more often than other fingers and is sometimes called trigger thumb. "Although trigger thumb may resolve over time, the thumb doesn't always return to normal on its own. Also, fingers are often more complicated in children than in adults," Dr. Pulos says. "This is another condition where evaluation by an experienced hand surgeon can help determine whether surgery is appropriate. Depending on the child's age and how long the child has had trigger thumb, we can make a shared decision with the parents about whether the child should undergo surgery."

Follow-up care for children with hand anomalies involves occupational therapy and support. "We want to make sure, before kids start formal schooling at age 5, that they can keep up with their peers to the best of their abilities," Dr. Pulos says. "As children mature, we try to ensure that they can do sports or other after-school activities that bring them pleasure, and that they feel comfortable with their hand differences. We also see children at skeletal maturity to make sure they're achieving their goals. After that, we are able to follow these children into adulthood."

The goal is to provide all aspects of care needed by children with hand differences and to provide support for their families. "Parents are understandably very anxious when a child has a congenital hand difference," Dr. Pulos says. "We are happy to talk to parents during the first months of their child's life to discuss these concerns and to help answer questions about their child's future."