Congenital anomalies are deformities that your child has at birth. Congenital hand deformities are particularly disabling for children and present a challenge to the orthopedic specialist. These deformities vary from minor types, such as a digital disproportion, to severe forms, such as the total absence of a bone.

If your child has a congenital hand deformity, I recommend early consultation with an orthopedic specialist who specializes in hand surgery. Reconstructive surgery may not be an option for your child, but I have many different prosthetic devices that can increase hand function for your child.

What are the different classifications of congenital hand deformities?

I use the classification for hand deformities accepted by the American Society for Surgery of the Hand (ASSH). This classification system recognizes six groups of deformities.

Problems in Development of the Parts – This occurs when a specific part or parts of the body stop developing when the baby is in the womb. This results in either complete absences of the hand or a missing structure, such as the thumb. Two kinds of problems in development are radial clubhand and ulnar clubhand. Radial clubhand is a type of deformity involving the tissue on the thumb side of the forearm and hand. This condition could lead to shortening o the bone, absence of the thumb, or a small thumb.

I typically operate on radial clubhand at age 6 months. Ulnar clubhand is a deformity where there is underdevelopment of the bone on the side of the little finger (the ulna). This could result in absence of the little finger or a short fifth digit.

Failure of Parts of the Hand to Separate – This occurs when either the bones or the tissues fail to separate in the womb. The most common form of this congenital anomaly is syndactyly, the condition where two or more fingers fuse together. This condition typically involves both hands. Simple syndactyly involves the fusion between the tissues only, whereas complex syndactly involves the fusion between the bones.

Contractures of the hand develop when there is failure of the cells to differentiate during formation in utero. With a contracture, there is abnormal pulling forward of the digits of the hand, and the digits are unable to extend. Surgery is necessary for children with this condition and is recommended around the age of 3.

Duplication of Digits – This is also called polydactyly, and the little finger is most commonly affected. There are three types of polydactyly: 1, 2, and 3. With type 1, there is an extra digit attached by nerves and skin only. Type 2 involves an extra digit attached to the bone or joint. Type 3 is more complex, with an extra digit connected to extra normal metacarpal bone of the hand. Surgery can easily correct these types of deformities.

Undergrowth of Digits – When fingers or thumbs are underdeveloped, there could be a digit that is small, missing muscles or bones, or the complete absence of a digit. Surgery is not always necessary for the correction of these types of deformities.

Overgrowth of Digits – When there is an abnormally large digit, the medical term used is macrodactyly. Some conditions also involve the forearm. The most common digit that overgrows is the index finger. Surgical treatment is complex and I often recommend complete amputation of the large digit.

Congenital Constriction Band Syndrome – This condition is the result of the formation of a tissue band around a finger or limb. This causes problems of blood flow and normal growth. The cause of this syndrome is unknown, but some experts believe that amniotic banding leads to constrictions around a finger or limb. There are four degrees of severity, ranging from simple constrictions to serious constrictions where amputation is necessary.

What is the treatment for congenital hand deformities? 

I base treatment of congenital hand deformities on several factors. These include:

• The extent of the condition
• The cause of the condition
• The child’s age, medical history, and overall health status
• The child’s tolerance to procedures, medications, and therapies
• The parents’ opinion and preference

Treatment measures include:

• Splinting the affected limb
• Correction of contractures
• Limb manipulation and stretching
• Tendon transfer
• Skin grafting to replace or attach skin that is missing or removed during the procedure
• Physical therapy to increase function and strength
• External appliances to realign misshapen hands or digits
• Prosthetics used when surgery is not an option or in conjunction to surgery

Surgical Correction

When is surgical correction performed?

Surgery that is performed within the first 2 years of life is considered early surgery. There are several advantages to early surgery including potential for growth and development, improved scarring, early use of the reconstructed portion, and reduce psychological impact. The disadvantages to early surgery are possible increased anesthetic risk and technical difficulties. Most surgical correction is done after the age of 2 or 3.

What are the different types of surgeries to treat congenital hand deformities?

There are several methods of surgery I perform to treat congenital hand deformities. These include:

Reduction and Fixation of a Broken Bone – This procedure can be open or closed depending on the type of deformity or injury. Many times, I employ a combination of the open and closed approaches using internal fixtures to realign broken or misshapen bones. Immobilization of the hand with a splint follows to assure that the fracture heals properly.

Drainage and Debridement – This technique is done when there is formation of an abscess from infection. This promotes faster healing of the affected region.

Micro-Surgical Replantation – This procedure involves the reattachment of the finger, part of the finger, or hand by way of precise micro-surgical methods.

Skin Grafting – During this method, skin is taken from a healthy body area and used to replace the skin missing on the hand. This is done when there is an amputation of a finger or portion of a finger and in burn deformities.

Skin Flap – This procedure is used when there is damage to the deep tissues of the hand. The tissue take from an area of the body has fat, muscles, and blood vessels that must be attached during the operation.

Tendon and Nerve Repairs – Some hand deformities require repair of a tendon and/or nerve component. These deformities cause decreased movement of the hand, numbness, and weakness.

The treatment of sprains and strains involves the “R.I.C.E.” method. You should take the advice of your orthopedic specialist before you begin this regimen. The following is a brief description of this treatment modality:

REST – Our orthopedic specialists consider the first 24 to 48 hours after an injury to be a critical treatment period and activities should be limited. You can gradually use the injured extremity, as long as your doctor advises it. Sometimes it is necessary for you to use a sling, splint, or crutches while the injured body part heals.

ICE – It is wise for you to apply ice to the sprain or strain for the first 48 hours after the injury. You do this for 20-minute intervals every 3 or 4 hours. Do not apply the ice directly to the skin; use a towel or soft cloth between the skin and the ice bag. One popular way to ice an area is to use a bag of frozen vegetables, such as peas or corn.

COMPRESSION – It is recommended by our orthopedic specialists that you used a compression wrap in early treatment of your sprain or strain. Wrap the ACE bandage over the region by one-half of the width of the wrap. Make sure this bandage is not too tight, as cutting off circulation to the extremity prevents healing. If your toes or fingers turn blue, cold, or tingle, re – wrap!

ELEVATION – As much as possible, you should elevate your sprain or strain. Our surgeons recommend that you make the elevation higher than your heart if possible. You can achieve elevation by placing pillows under your leg or arm.

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You will walk thousands of miles during your lifetime. This is the reason that you need to wear proper footwear and avoid shoes that are too loose, too tight, or unsupportive. Uncomfortable shoes that do not fit properly can cause stress on the feet, ankles, lower legs, hips, and spine. Pain and injuries result from this ongoing pressure, and this can alter your sporting activities, work duties, and hobbies. Simply wearing appropriate shoes that fit your feet, body, and lifestyle can prevent many foot-related disorders and injuries.

Types of Shoes

• Children’s Shoes – Infants need only booties and socks in the first months of life. However, as the infant begins to walk upright, shoes are necessary to prevent injury and should be worn outside of the house at all times. For toddlers, a sneaker or soft-soled shoe is appropriate. These shoe types allow the child to develop the muscles and ligaments around the ankle that help with balance and foot stabilization. Be sure the toe box is wide enough for the toes to wiggle.

  A finger’s breadth of extra length allows for around 3 to 6 months of growth. Since young children’s feet grow fast, you should check the fit of your child’s shoes periodically. Signs that the shoes are too small include difficulty putting the shoes on and the child wanting the shoes off.

• Women’s Shoes – Wearing high heels with a narrow toe box causes deformities like corns and hammer toes, knee pain, bunions, and lower back pain. An ideal women’s shoe is one that has a square, wide toe box with a heel that is lower than two inches. If you must wear higher heels, choose a shoe with a platform under the toe box to decrease the overall stress on the foot pad.

• Men’s Shoes – Leather soled shoes are more stable and durable. A softer-soled shoe is often better if you walk long distances on a regular basis.

• Sandals – Many people prefer to wear sandals in warm weather. These shoes do not offer much stability and foot support. If you must wear sandals, choose a pair that has straps that secure around the ankle. Make sure the sandal has a cork midsole rather than a rubber sole, as these provide more support. Specially designed sandals for hiking and rafting have supportive arches and are good choices.

• >Athletic Shoes – There are many good brands of athletic shoes available. Choose one that allows flexibility and optimizes stability to minimize injury and improve performance.

• Rocker Sole Shoes – These shoes have a thick sole that curves upward at the toe and heel. Many find that wearing rocker sole shoes reduces arthritis pain in the heel or ball of the foot. You should avoid these types of shoes if you have balance difficulties or an unsteady gait.

Shoe Buying Recommendations

• To decrease the risk of developing foot problems, choose a shoe that conforms to the shape of your foot.
• If you have problems with swelling, purchase shoes toward the end of the day when your feet are the largest.
• Try on shoes to avoid purchasing ones that do not fit. Shoe size varies from brand to brand and style to style.
• Have your foot measured each year. Adult feet can grow and change with age. Make sure you are standing when you have your feet measured, as your body weight expands your foot size.
• Make sure there is a ½ inch space between your longest toe and the tip of the shoe. Also, do not wear shoes that are too long for your feet to avoid blisters and pain.
• Try your shoes out before buying them by walking around on different surfaces. Be sure that they are a comfortable fit before you leave the store.
• Do not purchase a shoe that requires stretching or pads to keep your feet from slipping.

Shoe Quality

The stability of a shoe is related to the material from which it is made. Leather shoes are considered sturdy and durable whereas mesh and other man-made materials often lose their shape and do not provide support. Shoes are divided into upper and lower parts. The upper section includes the toe box, the heel counter, and the vamp. The lower section consists of the insole, the shank, the midsole, and the outsole.

• Toe Box – This is the front area where the toes rest. Choose a shoe with a roomy toe box, especially if you have hammertoes or crossover toe.
• Vamp – This section covers the top of the foot and may be closed with snaps, laces, or fabric. The vamp should be snug to hold the foot firmly in place but loose enough to avoid pain and numbness.
• Heel Counter – This is the back of the shoe where the heel rests. A stiff counter is best, as it provides control and stability. People with pronated flat feet should choose shoes with a stiff counter.
• Insole – This is the area inside the shoe where the main part of the foot rests. Some shoes have removable insoles to provide more flexibility.
• Shank – This is the area under the arch of the foot. A stiff shank allows for more support for your foot.
• Midsole – The material that sits between the top area of the shoe and the outer sole is the midsole. Soft material should be used for the midsole to provide shock absorption.
• Outsole – This area is the hard bottom of the shoe. Choose a shoe where the outsole conforms to your foot.

Types of Athletic Shoes

• Running Shoes – Running shoes are grouped into three categories. Cushioned running shoes (also called neutral shoes) are made for the runner with high-arched, rigid feet. These shoes have a cushioned midsole made up of ethylene vinyl acetate. Stability running shoes provide support to the arch.These shoes are best for the pronator runner. Motion control running shoes are designed for severe pronators. These shoes support flat feet and heavier body weight. To determine if you are a pronator or a supinator, have a professional evaluate your feet.
• Barefoot Running Shoes – These specially designed shoes are made for those who prefer running without shoes, or barefoot running.
• Cross Trainers – These shoes are designed to take you from sport to sport. Good cross trainers are made of a combination of leather, fabric, and mesh materials.
• Walking Shoes – These provide shock absorption, have a smooth tread, and allow for stability in the arch.
• Court Shoes – These shoes are specially made for tennis, basketball, and volleyball. Court shoes are made of soft leather with a solid tread.
• Hiking Shoes – These shoes provide stability for walking across uneven surfaces. Most hiking shoes have a cushioned insole and good tread.

What are Bunions

A bunion is a bump that forms at the joint of the big toe that is made up of bone and soft tissue. This abnormal bony mass forms when your big toe pushes against your other toes, making the big toe joint go in the opposite direction. This abnormal position causes the toe joint to enlarge, and this crowds your other toes and leads to pain. This deformity is also known as hallux valgus.

What causes bunions?

Tight-fitting narrow shoes and high heels can cause bunions. When a bunion forms, the big toe joint grows in size and protrudes outward. The skin over this toe gets tender and red, and bursitis or arthritis may occur. Bunions can also develop from foot injuries, and sometimes are congenital in nature.

Several factors increase your risk of developing bunions:

High heels – Wearing high heels can overcrowd your toes and can lead to bunions.
Ill-fitting shoes – People (particularly women) who wear shoes that are too tight, too narrow, or too pointed are at risk for bunion formation.
Arthritis – Pain from arthritis could alter the way you walk and lead to bunions.
Heredity – An inherited structural foot defect can cause bunions.

What is an adolescent bunion?

An adolescent bunion forms at the base of the large toe and affects girls aged 10 to 15 years of age. Unlike the adult bunion, the teen can move the affected joint normally but has pain wearing certain shoes. Treatment involves having the child’s shoes stretched or buying wider-sized shoes. Surgery is almost always avoided until growth is complete.

What is a bunionette?

A bunionette is a swollen, painful lump on the outside of your foot near the base of your small (fifth) toe. Also called a tailor’s bunion, bunionettes have a hard corn and painful bursitis. Just like bunions, bunionettes are caused from wearing ill-fitting shoes. For those cases of persistent pain and deformity, surgical correction is necessary.

Nonsurgical Treatment for Bunions

Most bunions are treatable without surgical intervention. If the bunion causes you to have difficulty walking, the orthopedic specialist will recommend special shoes, avoidance of certain shoe types, padding and taping, shoe inserts, and/or medications.

• Changing Shoes – The orthopedic specialist will recommend comfortable, roomy shoes with adequate space for your toes. These special shoes will conform to your foot shape as well as have a wide instep, broad toes, and soft soles.
• Avoiding Shoes – Treatment involves avoidance of pointed shoes, tight-fitting shoes, and high heels.
• Padding and Taping – Your doctor will show you how to tape and pad your foot to hold it into normal position. These measures reduce stress on the bunion and relieve pain.
• Shoe Inserts – Padded shoe inserts help redistribute the pressure evenly to reduce your symptoms. In addition, these devices may prevent your bunion from getting worse. Some people also find relief with the use of over-the-counter arch supports.
• Medications – Our orthopedic specialists recommend acetaminophen (Tylenol), ibuprofen (Motrin), or naproxen (Aleve) to control bunion pain

Bunion Surgery

When your bunion causes you to have difficulty walking and persistent pain exists, the orthopedic specialist may recommend surgery. Bunion surgery realigns the bone, tendons, ligaments, and nerves so your big toe is in the correct position. Surgery is typically done on a outpatient basis using ankle-block anesthesia. The reasons for bunion surgery include:

• Chronic large toe inflammation and swelling that does not improve with conservative treatment
• Severe pain that affects walking and everyday activities
• Toe stiffness and inability to straighten or bend the toe
• Toe deformity with a drifting in of the big toe

What are the types of bunion surgeries?

Our orthopedic specialists use different surgical approaches to treat bunions. These procedures include:

• Arthrodesis – This is the removal of the damaged joint surfaces and insertion of wires, screws, or plates to hold the joint together as it heals. This measure is used for those with severe arthritis.
• Osteotomy – This procedure involves the cutting and realignment of the joint.
• Repair of the Tendons and Ligaments around the Big Toe – The structures around the big toe could be causing the toe to drift toward the others. This procedure, often combined with an osteotomy, shortens the loose tissues and elongates the tight ones.
• Exostectomy – This technique involves the removal of the bump on the toe joint and is used only when there is no drifting of the large toe.
• Resection Arthroplasty – The orthopedic specialist will remove the damaged part of the joint. This is mostly used for those who have had previous surgery that failed or for those with severe arthritis.
• MIS Bunion Surgery – Minimally invasive bunion surgery
. This surgery involves small “pokehole” incisions that can be as small as a few millimeters as opposed to the larger incisions associated with more traditional bunion correction techniques. Special instruments and x-ray’s are used to perform surgery.

What is involved in the recovery process?

Your recovery will be successful if you follow your orthopedic specialist’s instructions the first few weeks following your procedure.

• Bearing Weight – Your doctor will advise you to use a cane, crutches, or walker after your surgery. You will be allowed to gradually put weight on your foot as it heals.
• Dressing Care – After surgery, you will have bandages holding your toe in position. Also, you will wear a special surgical shoe or cast to protect your foot. The sutures are removed approximately two weeks after the procedure. To allow proper healing, you should keep your dressings dry and clean. The doctor will advise you on changing the bandages.
• Swelling and Shoe Wear – You should keep your foot elevated for the first week following surgery, and ice is recommended to relieve pain and swelling. Expect your foot to have swelling for about six months.
• Exercises – To strengthen your foot, the orthopedic specialist may recommend particular exercises. The doctor could also prescribe a course of physical therapy for you.
• Medications – The doctor may prescribe antibiotics and pain medications following your procedure. The antibiotics are used to prevent infection. It is important that you follow the instructions and complete this medication.

Ankle Sprain

An ankle sprain can happen to anybody: athletes or non-athletes, children or adults, men or women. An ankle sprain involves ligaments that have been stretched beyond their normal position. The ligaments are structures that hold the bones of the ankle and joint in alignment, and they protect the ankle from abnormal twisting, rolling, or turning.

These elastic ankle components become sprained when there is actual tearing of the fibers. Recurrent sprains can result in long-term joint damage with pain and weakness. Proper treatment of an ankle sprain is necessary to prevent ongoing ankle problems.

What causes ankle sprains?

The ankle gets sprained when you make a fast, shifting movement with your foot planted on the ground. Many times, the ankle rolls outward while the foot turns inward, causing the ligaments on the outside to stretch and tear. The ligaments on the inside of the ankle can be injured when the ankle rolls inward as the foot goes outward. Any movement that causes the ligaments to stretch beyond their normal capacity causes an ankle sprain.

How is an ankle sprain diagnosed?

Ankle sprains are “graded” by our orthopedic specialists as mild (grade 1), moderate (grade 2), or severe (grade 3). With a grade 1 sprain, there is only slight stretching of the fibers with minimal damage to the ligament. With a grade 2 sprain, there is partial tearing of the ligament and laxity (looseness) of the ankle joint. An ankle sprain is a grade 3 when there is a complete tear of the ligament.

If you suspect you have an ankle sprain, see our doctors to be properly evaluated. He may order X-rays or an MRI. Also, doctors diagnose ankle sprains based on your injury history, the appearance of the ankle, and other physical examination techniques.

How is an ankle sprain treated?

If you have a sprained ankle, proper treatment and care is necessary for it to heal correctly. Most ankle sprains only need rest in order to heal while others require casting, a special splint or boot, or even surgery.

For a grade 1 ankle sprain, you should use R.I.C.E (rest, ice, compression and elevation):

• REST – Don’t walk on your ankle for a specified amount of time. Use crutches to get around.
• ICE – Apply ice wrapped in a soft cloth to the ankle. Do this for 20 minutes, four or five times a day to reduce swelling and ease pain.
• COMPRESSION – Use an ace-wrap type of dressing to immobilize the ankle and give it support.
• ELEVATE – Raise your ankle above the level of your heart. This is especially useful during the first 48 hours after the injury.

If your doctor tells you your sprain is a grade 2, the RICE method should be observed. Also, this level of injury takes more healing time. In addition, the orthopedic specialist may use a device to splint or immobilize your ankle while it heals. Grade 3 sprains are often associated with long-term instability.

While surgery is rarely necessary, a short leg cast or brace could be required for around three weeks. To prevent chronic ankle problems, the doctor may order physical therapy, ultrasound, or electrical stimulation.

A Grade 3 sprain can be associated with permanent instability. A short leg cast or a cast-brace may be used for two weeks to three weeks. If your ankle does not heal with conventional nonsurgical treatment and persistent instability exists, the orthopedic specialist may recommend surgery.

Reconstructive surgery involves repair of the torn ligament and grafting with other ligaments. Arthroscopic surgery is done when the doctor needs to look inside the joint for loose bone fragments or pieces of cartilage.

How does the ankle sprain resolve?

Ankle sprains recover in a stepwise method with three phases:

1. Phase 1 – resting and protecting the ankle while reducing swelling (one week)
2. Phase 2 – restoring range of motion, flexibility, and strength (one to two weeks)
3. Phase 3 – gradually returning to normal activities (weeks to months)