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Paediatric Upper Limb Conditions

105 citationsUpdated Oct 2026

Overview

Congenital upper limb differences encompass a spectrum of deformities managed according to the Classification of Congenital Upper Limb Deficiencies adopted by the American Society for Surgery of the Hand and the International Federation of Societies for Surgery of the Hand [1, 4]. Current care integrates evolving research, civil rights protections, and updated terminology to address these conditions [9]. The overall health of the child and the severity of deformities guide long-term treatment plans aimed at realigning the forearm, wrist, and hand while providing a functional thumb [2]. While specific surgical indications vary by pathology, primary indications for microvascular surgery include symbrachydactyly, radial-side deficiency, and long bone disorders such as congenital pseudarthrosis of the forearm [74]. Progressive bone distraction lengthening is primarily indicated for symbrachydactyly, followed by forearm lengthening and miscellaneous malformations [70].

The psychosocial impact of these conditions is significant, with caregivers reporting substantial effects on family life and parents experiencing wellbeing and family impact scores significantly lower than population norms [7, 78]. Children with congenital upper limb differences experience significant upper extremity functional impairment, where physical function is closely linked with psychosocial wellbeing [12]. Despite these challenges, affected children demonstrate good peer relationships and marked adaptability [8]. Surgical management addresses specific pathologies, including tendon transfers in tetraplegia [56], reconstruction of pronation contractures secondary to obstetric brachial plexus injury [76], and primary end-to-end repair for thumb injuries in zone 2 [66]. Amputation of digits in children is an absolute indication for replantation regardless of the number of digits involved [14].

Outcomes following congenital upper limb surgery are generally favorable, with an overall complication rate of approximately 5.3%, most of which are minor and do not require additional surgery [10]. Aesthetic results can be achieved without compromising hand function using thick split thickness grafts from the instep, with no donor site morbidity reported in children and adolescents [24, 25]. Full restoration of arm length is not required for a successful outcome in pediatric forearm deformity lengthening, as young patients are motivated and can adapt to almost all situations [77]. Postoperative management and long-term results have improved greatly with specific tenets regarding pediatric hand dressing [3].

Anatomy & Pathophysiology

Osseous Anatomy

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [46]. This structure is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [46]. The base of each metacarpal articulates with the distal carpal row, while the carpus connects to the forearm via its proximal row [46]. The radioulnocarpal articulation possesses two axes of movement, supplemented by a third axis of pronation and supination from the forearm [46]. These three axes permit the hand to assume any spatial configuration necessary for grasping [46]. The radial ray, or first ray, is the shortest, consisting of only a metacarpal and two phalanges [46]. It continues the external carpal column formed by the scaphoid and trapezium [46]. The trapezium is angled anteriorly out of the carpal plane, creating an approximately 45-degree angle between the first and second metacarpals in the sagittal plane [46]. The thumb metacarpal is the shortest, whereas the index metacarpal is the longest [46]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [46]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [46].

The index metacarpal is the most firmly fixed [91]. The ring metacarpal exhibits approximately 10 degrees of mobility in flexion and extension, while the fifth metacarpal has a range of approximately 20 degrees [91]. The second through fifth metacarpals are bound by fibrous structures, the most distal being the deep transverse intermetacarpal ligament [91]. This ligament is better termed the interglenoid ligament, as it connects the anterior “glenoid ligaments” of the metacarpophalangeal articulations, known as volar plates [91]. The metacarpophalangeal joints serve as keystones of the longitudinal arches; their thick anterior glenoid capsules, or volar plates, prevent hyperextension [91]. These volar plates are interconnected by the transverse interglenoid ligament [91]. Stability of the metacarpophalangeal joints is essential for supporting both the longitudinal and transverse metacarpal arches [91].

The hand presents a longitudinal and transverse concavity, forming a cup shape with palmar concavity when the thumb is placed next to the index finger [46]. When the thumb spreads to grasp an object, this cup becomes a gutter whose major oblique axis follows the thumb crease [46]. The transverse axis of the palm, corresponding to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis [46]. Instead, it is oblique, positioned more distally at the index metacarpophalangeal joint and more proximally at the fifth metacarpophalangeal joint [46]. This transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [46]. The third metacarpal acts as the axis of the hand and a landmark for wrist movements [99]. Its styloid process projects from the base and marks the line of the carpometacarpal joints [99]. The metacarpophalangeal joints lie approximately on a transverse line beginning in the distal palmar crease on the ulnar side and running into the proximal crease on the radial border [99]. The axes of flexion are arranged such that flexion of all metacarpophalangeal and proximal interphalangeal joints causes the fingers to converge toward the scaphoid [99].

Musculotendinous Anatomy

Extrinsic muscles originate outside the hand and insert on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [45]. Extrinsic muscles function as flexors or extensors, while intrinsic muscles contribute to both digital flexion and extension [45]. The extrinsic extensors traverse six fibroosseous retinacular compartments at the wrist [45]. The first, most radial compartment contains the abductor pollicis longus and extensor pollicis brevis [45]. The abductor pollicis longus has multiple slips inserting at the base of the thumb metacarpal to radially abduct the thumb [45]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the thumb’s proximal phalanx, actively extending the thumb metacarpophalangeal joint [45]. The second compartment contains the extensor carpi radialis longus and brevis [45]. The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexing and radially deviating the wrist [45]. The extensor carpi radialis brevis inserts into the base of the middle metacarpal, providing balanced wrist dorsiflexion [45].

The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm and turns abruptly radialward at Lister tubercle [45]. It inserts on the distal phalanx, providing forceful extension of the thumb interphalangeal joint [45]. The oblique course of this tendon provides a substantial adduction component to its pull [45]. The fourth compartment contains the extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis [45]. The fifth compartment contains the extensor digiti quinti [45]. The principal bony insertion of extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [45]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [45]. Distal interphalangeal joint extension is achieved through conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [45]. The extensor indicis proprius inserts on the index finger ulnar to the extensor digitorum communis [45]. The extensor digitorum communis inserts on the index, middle, ring, and, in some cases, little fingers [45]. The extensor digiti quinti tendon inserts on the little finger ulnar to the extensor digitorum communis insertion [45]. The extensor carpi ulnaris tendon runs through the sixth compartment and inserts at the base of the little finger metacarpal, providing wrist extension and ulnar deviation [45]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [45].

Digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by attachment to sagittal band fibers [45]. These fibers insert onto the volar proximal phalanx and the lateral borders of the volar plate [45]. They form a sling that transmits proximal extrinsic extensor tension to the proximal phalanx, permitting metacarpophalangeal joint extension without a direct tendinous insertion onto the proximal phalanx [45]. Rupture or attenuation of these fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [45]. The extrinsic finger flexors are the flexor digitorum profundus and flexor digitorum superficialis [45]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints [45]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [45].

The flexor digitorum profundus originates from the proximal ulna and interosseous membrane [95]. In the forearm, it divides into a radial component supplying the index finger and an ulnar component supplying the middle, ring, and little fingers [95]. The flexor digitorum profundus and flexor pollicis longus form the deep compartment of the volar forearm [95]. As they travel through the carpal tunnel, they occupy the floor of the tunnel [95]. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa, while the sheath to the little finger is continuous with the ulnar digital bursa [95]. In some patients, these bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either digit [95]. The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [95]. The profundus tendon passes through the bifurcation of the flexor digitorum superficialis before inserting into the proximal palmar base of the distal phalanx [95]. The flexor digitorum profundus of the index and middle fingers is innervated by the anterior interosseous branch of the median nerve, while that of the ring and little fingers is innervated by the ulnar nerve [95].

The flexor digitorum superficialis has two heads: a radial head originating from the proximal radius shaft and a humeral ulnar head originating from the medial humeral epicondyle and coronoid process of the ulna [95]. As the superficialis tendons pass through the carpal tunnel, those of the middle and ring fingers are more superficial and central than those of the index and little fingers [95]. In the proximal finger, the superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [95]. The tendon slips reunite distally at the Camper chiasm, with approximately half of the fibers staying on the ipsilateral side and half crossing to the contralateral side [95]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [95]. The entire muscle receives innervation from the median nerve [95]. Its primary function is digital flexion at the proximal interphalangeal joint [95]. The flexor pollicis longus originates from a radial head on the proximal radius and interosseous membrane, and an accessory head on the coronoid process of the ulna and medial epicondyle of the humerus [95]. In the palm, its tendon traverses between the abductor pollicis brevis and flexor pollicis brevis [95]. It inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [95]. The flexor pollicis longus flexes both the interphalangeal and metacarpophalangeal joints of the thumb [95].

As flexor tendons pass distal to the metacarpal neck, they enter the fibroosseous tunnel, or digital flexor sheath, which extends distally to the proximal aspect of the distal phalanx [95]. The tendinous sheath consists of annular pulleys providing mechanical stability and cruciate pulleys providing flexibility [95]. The first, third, and fifth annular pulleys (A1, A3, and A5) are located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [95]. The second and fourth pulleys (A2 and A4) are situated over the middle portion of the proximal and middle phalanges [95]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [95]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [95]. Proximal to the sheath, tendons are well vascularized by the peritenon [95]. Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [95].

There are seven interosseous muscles: four dorsal and three volar [88]. The dorsal interossei are abductors [88]. Because the anatomic axis of the hand coincides with the axis of the third metacarpal, the dorsal interossei lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [88]. The little finger is abducted by the abductor digiti quinti [88]. The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [88]. The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [88]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [88]. The superficial head arises dorsally from the shaft of contiguous metacarpals and inserts deeply by a medial tendon onto the lateral tubercle of the base of the proximal phalanx [88]. It abducts and weakly flexes the proximal phalanx, with no direct effect on the middle or distal phalanges [88]. The deep head forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [88]. It flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [88]. At the middle of the proximal phalanx, transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [88]. More distally, oblique fibers from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx, extending the middle phalanx at the proximal interphalangeal joint [88]. Further distally, the lateral bands are joined by lateral slips of the extensor tendon to form the conjoined lateral band [88]. The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [88]. The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [88]. The three volar interossei arise from adjacent surfaces of contiguous metacarpal shafts [88]. Each volar interosseous muscle has only one head and none insert onto the proximal phalanx [88]. They form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [88]. The abductor digiti quinti and flexor digiti quinti brevis are similar in structure and function to the superficial and deep heads of the dorsal interossei, respectively [88].

Classification

Historical and Current Systems

Swanson/IFSSH: The classification for congenital limb malformations was adopted by the American Society for Surgery of the Hand, the International Federation of Societies for Surgery of the Hand, and the International Society of Prosthetics and Orthotics [50]. This system is based on morphology and cannot indicate the site in the molecular pathway or the time of the insult [121].

OMT: The Oberg, Manske, and Tonkin (OMT) classification was proposed in 2010 as a replacement for the Swanson International Federation of Societies for Surgery of the Hand classification system [68]. The OMT system separates malformations from deformations and dysplasias [68]. Malformations are subdivided according to the axis of formation and differentiation that is primarily affected and whether the anomalies involve the whole limb or the hand plate [68]. The updated OMT classification reflects the latest knowledge on upper-extremity anomalies and is designed to be as straightforward as possible to employ [29]. It is reasonably practical for precise classification of congenital upper limb anomalies [124].

Structure and Categories

Congenital deformities of the upper extremity have traditionally been divided into 7 categories based on the morphologic characteristics of the deformity [13]. These categories include failure of formation, failure of differentiation, duplication, overgrowth, undergrowth (pure hypoplasia), constriction band syndrome, and generalized skeletal disorder [139].

Reliability and Application

An assessment of the efficacy of the OMT classification demonstrates acceptable inter- and intraobserver reliability [68]. A prospective review of 101 patients confirmed that all diagnoses could be classified within the OMT system [68]. The morphological or radiographic anatomy of a child's hand with congenital absent digits is a more logical indication for microsurgical reconstruction than any embryological classification [39]. The HWP severity grading system, which scores hand, wrist, and proximal defects, allows better comparison of radially deficient limbs and treatment results between patient groups [55]. The majority of type A ulnar polydactyly can be classified into one of five morphological subtypes that have potential clinical relevance regarding operative treatment [62].

Limitations and Challenges

Naming congenital upper limb anomalies remains an ongoing challenge influenced by surgeon subjectivity and experience [20]. Some anomalies, such as thumb polydactyly with symphalangism, do not fit into the classification systems described for thumb polydactyly [110]. Anomalous hands with cleft formation between the fourth and fifth digits may represent a distinct type of hand anomaly for which an appropriate classification has not yet been established [105]. Consensus expert opinion allowed classification of conditions for which there is not a clear understanding of the mechanism of dysmorphology within the OMT system [68].

Clinical Presentation

Epidemiology and Prevalence

Congenital deformities of the upper extremity occur in as many as 1 in 626 live births [13]. The prevalence of babies born with upper limb anomalies is 1 in 506, or 1.97 per 1,000 live births [19]. The incidence of congenital hand and upper limb differences generally occurs in 19.2–27.2 per 10,000 live births [107]. Approximately 5% of all cases of upper limb malformations occurred as part of generalized developmental disorders [31].

Classification and Nomenclature

The updated Oberg-Manske-Tonkin (OMT) classification reflects the latest knowledge on upper-extremity anomalies and is designed to be as straightforward as possible to employ [29]. The IFSSH classification is based on growth anomalies in the various axes, instead of morphology [63].

Clinical Assessment and Function

The key components of body function for children with congenital hand anomalies include grip and pinch strength, range of motion, sensation, cosmesis, and prehension [59]. In cases of unilateral upper extremity abnormality, contralateral limbs can be used for comparison of length and circumference of the arm and forearm [53]. The relative size of the thumb remains constant during growth [57].

Specific Presentations and Syndromes

The hand malformation may be the first manifestation of a more complex syndrome, with other symptoms appearing later in life [16]. Dupuytren's disease of the hand is generally considered a disease of adults, but it has been presented in nine children who developed the condition before the age of 13 years [18]. A child with longitudinal cleavage of the upper extremity may present with two underdeveloped upper extremities on one side, one arising from the shoulder girdle and the second from the midthorax [33]. The predominance of involvement of the right hand in severe mincer injuries is probably due to right-handed children exploring with their right hand [35]. A child presenting with inability to flex the thumb should be evaluated for trigger thumb locked in extension [30]. Osteocartilaginous lesions are not commonly found in the digits of children and the initial diagnosis may be easily missed [54]. Digital schwannoma in a skeletally immature child illustrates the relative lack of neurologic symptoms and the need to include neurilemmomas in the differential diagnosis of hand masses in children [51]. The finding of specific hand features in Pfeiffer syndrome may be of more use in establishing clinical diagnosis than the traditional thumb assessment [49]. Unilateral hypertrophy of the upper extremity due to aberrant muscles is characterized by excessive muscle volume and particular deformity of the hand [58]. Infarction of the upper limbs associated with oligohydramnios and intrauterine compression has varying degrees of presentation [60]. Soft tissue calcification in children with terminal transverse defects of the upper limb is not necessarily the same condition as that previously reported as tumoral calcinosis [32].

Psychosocial and Family Impact

Observation of a congenital upper limb difference at birth or on an ultrasound scan is a traumatic experience for a parent [107].

Investigations

Classification and Systematic Evaluation

A careful physical examination is essential to direct care and future testing, as diagnostic tests such as imaging and serum laboratory studies can be expensive, time consuming, and often nonspecific [44]. Given the high density of structures within the hand and wrist, a systematic method for approaching the physical examination is essential [44].

Imaging and Vascular Assessment

Angiography: Angiography is an important and safe investigation in the pre-operative assessment of cases of complex congenital hand deformities [147]. Systematic angiographic research on congenital hand deformities has allowed for the observation of various anomalies of the vascular anatomy of the hand requiring treatment [160].

MRI: MRI is noninvasive and can demonstrate abnormalities of the unossified epiphysis [123]. In the context of Dupuytren's disease, MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [102].

Doppler Ultrasound: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, though false-negatives are possible [102].

Plain Radiography: The most significant change observed on the x-ray film in cases of epiphyseal destruction after frostbite was the absence of the epiphyses [172]. In cases of unilateral upper extremity abnormality, contralateral limbs can be used for comparison of length and circumference of the arm and forearm [53].

Specific Clinical Findings and Diagnostic Pitfalls

Subcondylar Phalangeal Neck Fractures: Subcondylar phalangeal neck fractures with 180° of rotational deformity are more common in the infant despite this younger group having the lowest incidence of phalangeal fractures as a whole amongst children [26]. Detection of these fractures is difficult in small "chubby" fingers, where there is often no obvious angular deformity and only mild swelling and tenderness [26]. A clinical history, coupled with a high index of suspicion and good AP and true lateral X-rays of the injured finger are essential for diagnosis [26]. A "grouped lateral" X-ray is misleading and may serve to obscure rather than reveal the diagnosis [26]. Injundicious attempts at manipulation, particularly longitudinal traction, may convert fractures with a 90° deformity into those with an "upside down" head configuration with "apparent reduction" [26].

Ligamentous and Congenital Anomalies: When evaluating pediatric abduction thumb injuries, the physician must consider complete ligamentous UCL disruption, especially when x-ray films show significant joint subluxation [169]. The finding of great toe hypoplasia similar to a grade 3b thumb hypoplasia with absence of the proximal two-thirds of the first metatarsal on plain X-ray may be of more use in establishing clinical diagnosis than traditional thumb assessment in patients with VACTERL association [171]. Similarly, the finding of hands in Pfeiffer syndrome may be of more use in establishing clinical diagnosis than the traditional thumb assessment [49].

Soft Tissue and Vascular Pathology: Dupuytren's disease of the hand is generally considered a disease of adults, but it can present in children before the age of 13 years [18]. All infantile digital fibromas appear early in life at the distal or proximal interphalangeal joint level, characteristically involve the ulnar three digits, may be multicentric, and undergo rapid growth within a short time [85]. The case of digital schwannoma in a skeletally immature child illustrates the relative lack of neurologic symptoms and the need to include neurilemmomas in the differential diagnosis of hand masses in children [51]. Soft tissue calcification in children with limb deficiencies is not necessarily the same condition as that previously reported as tumoral calcinosis [32]. The patient with avascular necrosis of the scaphoid in association with congenital radial ray defects may have developed the condition in a hypoplastic but otherwise normal scaphoid, potentially influenced by negative ulnar variance altering biomechanics [84].

Treatment

General Principles and Classification

The OMT classification is accepted for classifying congenital upper limb anomalies and is based on the developmental biology of the upper limb [27]. Treatment for congenital upper extremity disorders requires an understanding of the classification system used to categorize each disorder to allow for education of the patient and family regarding anatomic differences and potential treatment options [28]. Not all deformities require surgery, and each child and their function must be taken into consideration separately, often involving observation as the child grows before creating a definitive treatment plan [28]. Surgical intervention for congenital upper limb anomalies is dependent on the needs of the child and the perspective of his or her family [27]. Unilateral anomalies are often well tolerated, as the child is able to compensate with the well-developed limb for function [27]. The surgeon may be the first physician to identify a specific congenital anomaly in a child and must be aware of associated conditions and syndromes to recommend appropriate testing or referral [27]. A careful history and stepwise examination of the affected extremity is required before providing the patient with a definitive treatment plan [28]. Occupational therapy and/or hand therapy are often vital to the function and postoperative recovery of the child’s upper extremity who is born with a congenital difference [28].

Specific Condition Management

Radial Club Hand: Severity grading of Radial Club Hands improves assessment of functional prognosis, treatment planning, and comparison of similar extremity groups before and after treatment [73]. The patient with radial club hand presents with shortened, tight radial structures that usually require immediate therapeutic intervention once a diagnosis is made [146]. Initial treatment for radial club hand includes casting, followed by splinting to stretch the soft tissue and improve the deformity, frequently performed prior to surgical intervention to gain maximal range of motion [146]. When fabricating the orthosis for radial club hand, the objective is to centralize the hand over the ulna [146]. The splint for radial club hand is based radially and includes 80% of the volar and dorsal surface of the hand and forearm [146]. The splint for radial club hand is cut out volarly and dorsally at the distal ulna in a small semicircle, with a Velcro strap placed across this area with thick padding to allow pressure at the ulna, thus pulling the wrist into ulnar deviation [146]. Additional straps are placed proximally and distally to secure the splint for radial club hand [146]. The elbow is left free to move in the splint for radial club hand, though the proximal portion has "wings" that come just below the epicondyles to include as much of the forearm as possible while still allowing elbow range of motion [146]. If a thumb is present in radial club hand, it is left free, along with the digits, to promote mobility [146]. The splint for radial club hand is worn fulltime, with the exception of removal for hygiene and range-of-motion exercises [146]. Parents should be instructed in passive range of motion (PROM) techniques for the digits, wrist, elbow, and shoulder in all planes of movement for radial club hand [146]. The digits frequently present with decreased flexion ability, and the elbow joint may be stiff or ankylosed in radial club hand [146]. As the elbow is being bent during PROM for radial club hand, the hand must also be corrected on the forearm both by distraction and ulnar deviation [146]. Ulnar lengthening has a unique role in the management of long neglected functional and cosmetic problems in congenital radial club hands originating from severe shortening and angular deformity of the ulna [41]. Full restoration of arm length is not a requirement for a successful outcome in pediatric forearm deformities treated with the Ilizarov technique, since these young patients are motivated and can adapt to almost all situations [77].

Thumb and Mirror Hand: The treatment objective in the five-finger hand is to create an opposable thumb with two phalanges and a first web space having a normal appearance [71]. Successful outcome in thumb reconstruction for Apert syndrome requires addressing the deforming forces present and maintaining length in the thumb, and an understanding of the pinch patterns of each child [52]. All surgical procedures for thumb reconstruction without formal pollicization in mirror hand deformity were completed before 20 months of age [137]. No pollicizations were done in the series of mirror hand deformity cases; instead, thumb reconstruction was done by keeping one of the radial fingers as the new thumb [137]. A secondary osteotomy procedure was felt to be needed to rotate the new thumb into more pronation in all cases of mirror hand deformity, but performed in only Cases 1, 2, and 3 [137]. Splinting improved the flexion deformity at the wrist in the two cases with the non-classic deformity of mirror hand [137]. Surgery was required to improve wrist extension in the other two cases with classic mirror hands [137]. Surgery at the elbow was required in Cases 2 and 4 of the mirror hand deformity series [137]. No postoperative complications occurred in any of the patients in the mirror hand deformity series [137].

Soft Tissue and Nerve Injuries: Microvascular toe transfer in children can be a daunting procedure justified for most surgeons only if substantial functional gain ensues [162]. Reliable survival of the transplant and the low morbidity of the second toe donor site have allowed indications for toe transfer in children to be extended to include aesthetic considerations [162]. The aesthetic considerations in a child are very important because the hand is constantly on view and can be the focus of teasing [162]. Congenital hand anomalies can be bizarre, and making them more bizarre or aesthetically unappealing by transferring toes is only justified if substantial functional gains accrue [162]. Even minor functional gains may be justified in patients in whom cosmesis is also improved [162]. A good aesthetic result can be achieved without compromising hand function using thick split thickness grafts from the instep in paediatric hand surgery, but only in children and adolescents among whom there was no donor site morbidity [24, 25]. Dermal substitutes such as Integra are particularly useful in growing children to cover large skin losses in upper extremity degloving injuries [163]. Most patients presenting with recurring digital fibroma of childhood should be treated conservatively [173]. The current accepted approach to trigger thumb of childhood is an initial period of observation [166]. There is a 30% chance of spontaneous resolution of the trigger thumb in the patient with diagnosis at birth if the child is observed for 12 months [166]. In approximately 7% of patients who had diagnosis some time later than birth, but before the age of 3 years, the condition will resolve spontaneously if watched for 6 months or more [166]. None of the 11 patients (17 thumbs) with diagnosis before 6 months of age resolved without surgery despite an average of 40 months of conservative therapy [166]. Of the 29 thumbs in 24 patients diagnosed some time after birth, there was no spontaneous resolution of the trigger thumb deformity [166]. Conservative treatment for infantile trigger thumb is considered a useful method despite the long treatment period, and surgical release is recommended if signs of deformity are noted [148]. Trigger thumb locked in extension should be considered in any child presenting with inability to flex the thumb [30]. A functional hand can be expected after flexor tendon repair in children [65]. Excellent and good results were achieved in six of seven thumbs treated surgically using primary end-to-end repair in zone 2 for flexor pollicis longus lacerations in children [66]. Early mobilization is advocated in children in whom a partial division of the flexor tendon is diagnosed clinically [175]. Primary epineural repair of the ulnar nerve was performed in 17 children within 24 hours of injury and in 2 children within 10 days of injury [79]. The mechanism of injury for ulnar nerve transection involved a fall onto broken glass in 17 patients, an accidental knife injury in one patient, and a fall onto a piece of metal in the other [79]. Associated injuries to other structures occurred in 13 children with ulnar nerve transection, including laceration of the flexor carpi ulnaris in 6 patients and injury to the extrinsic digital flexors in 10 patients [79]. Four patients sustained injury to the ulnar artery, and 2 of these patients had their arteries repaired [79].

Brachial Plexus and Other Conditions: Patients with better functional recoveries of the affected upper extremities in obstetric brachial plexus palsy showed smaller differences in limb length [37]. All 15 children with Erb's palsy and humeral head deformity who underwent rotation osteotomy of the humerus had improved shoulder function and obtained a modified Mallet score of 4 at final follow-up [38]. Surgical reconstruction can improve both form and function in the limb in properly selected and evaluated children with pronation contractures of the forearm secondary to obstetric brachial plexus injury [76]. Non-performance-related injuries in pediatric musicians are the most common and must be treated to preserve the span of the hand and maximize hand function [64]. Performance-related injuries in pediatric musicians require consideration of the child's size and strength, often aided by simple modifications to the instrument or technique [64]. This rare disorder of infarction of the upper limbs associated with oligohydramnios and intrauterine compression has varying degrees of presentation, and limbs have been salvaged with conservative management coupled with appropriate surgical intervention and neonatal intensive care [60]. The authors report successful treatment of a child with a distal phalangeal non-union and associated finger tip deformity [122]. An excellent result for the windblown hand would be a hand with excellent function and appearance, but almost no patient can fit this criteria even after extensive treatment [136]. The surgical management of the upper extremity anomalies in Du Pan syndrome has not been described previously [5]. A 4-year-old boy with longitudinal cleavage of the upper extremity had a normal right upper extremity and two underdeveloped left upper extremities, one arising from the shoulder girdle and the second arising more inferiorly from the torso [33]. The more superior left extremity in the longitudinal cleavage case originated in a relatively normal position with full active range of shoulder motion, but the elbow was fixed at 140° of flexion with no wrist motion and no motion of the single 2-phalanx digit [33]. The inferior left extremity in the longitudinal cleavage case originated from the midthorax [33]. The reported case of infantile haemangiopericytoma affecting the hand of a 7-week-old child required urgent treatment via amputation of the affected digit as a life-saving measure [23].

Cerebral Palsy and Spasticity

Patients with cerebral palsy frequently have spastic upper extremity manifestations, including joint contractures and deformities, which may make performing hygiene tasks, ADLs, and use of assistive devices challenging [106]. The treatment of patients with upper extremity cerebral palsy includes a diverse team of caretakers from family and social support to therapists, surgeons, and neurologists [106]. Many patients with upper extremity cerebral palsy can be treated nonsurgically [106]. Tenotomies, tendon transfers, and selective arthrodesis can be very useful in attaining improved function in upper extremity cerebral palsy where appropriate [106]. Most common joint deformities in upper extremity cerebral palsy include shoulder adduction and internal rotation, elbow flexion, forearm pronation, wrist and finger flexion, and thumb-in-palm contractures [106]. Management of upper extremity cerebral palsy should include a multidisciplinary approach with a thorough family/caregiver discussion regarding functional needs and surgical outcome expectations [106]. Goals of surgical intervention for upper extremity cerebral palsy include improving hygiene, function of the affected extremity, and aesthetics as appropriate [106]. Nonsurgical treatment is the first-line treatment for upper extremity cerebral palsy and includes a combination of hand therapy, splinting, casting, bracing treatment, and neuromuscular medications [106]. Surgical treatment options for upper extremity cerebral palsy involve a combination of tendon lengthenings, transfers, and/or releases and joint arthrodesis [106]. Care must be taken to fully evaluate each area of the upper extremity to correctly indicate patients for surgical treatment in cerebral palsy [106]. Data from young persons treated with upper extremity surgery for cerebral palsy resolved into three main themes: functional improvements are interwoven into daily life, the hand is easier to use and is used more, and changes in the appearance and in the internal feeling of the arm are of importance [82].

Arthrogryposis

Arthrogryposis refers to a constellation of syndromes characterized by multiple joint contractures [108]. Treatment of arthrogryposis of any type can be challenging, but improvement can be seen in many patients with early intervention and proper nonsurgical and surgical management [108]. The goal of any treatment plan for a child with arthrogryposis is to maximize function and independence [113]. The goal for any treatment strategy in arthrogryposis should be to maximize function with the minimal amount of hospitalization necessary to achieve that goal [108]. Surgical treatment for arthrogryposis should be reserved for enhancing function, not just improving the appearance of the deformity [108]. Physical and occupational therapy in conjunction with bracing can help improve function in many children with ar

Complications

General Outcomes: The overall complication rate following congenital upper limb surgery is approximately 5.3% [10]. Most of these complications are minor and do not require additional surgery [10].

Growth Disturbance: In neonatal compression ischaemia of the forearm, growth arrest of the distal radial epiphysis and shortening of the affected forearm relative to the contralateral side can occur [43].

Soft Tissue Contracture: In neonatal compression ischaemia of the forearm, muscle contracture may recover with full hand function by age 6 years [43].

Joint Stiffness: In severe congenital PIP joint flexion contractures treated with FDS tendon lengthening alone, no improvement in extension was observed [151]. In severe congenital PIP joint flexion contractures treated with extensor mechanism realignment and augmentation, 9 of 12 digits had residual flexion contracture [151].

Other Considerations: In children with Apert syndrome, revision of the webs was necessary in 16% of cases [157]. In children with congenital isolated upper limb hypertrophy and hand abnormality, no recurrence of deviation was observed at latest follow-up after corrective osteotomies and ligament reconstruction [129].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or timing for sling or brace removal.

Functional milestones: In a series of 15 children with Erb's palsy and humeral head deformity treated with rotation osteotomy of the humerus, all patients obtained a modified Mallet score of 4 at final follow-up [38].

Other Considerations: Children with congenital upper limb differences experience significant upper extremity functional impairment, and physical function is closely linked with psychosocial wellbeing [12]. In a series of children with spastic hemiplegic cerebral palsy, upper-limb function and the health-related quality of life physical health domain were poorer with greater hand deformity [132]. In a series of children with obstetric brachial plexus palsy, patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length [37].

Regarding specific conditions and outcomes, in a series of nine children with Dupuytren's disease, the condition developed before the age of 13 years [18]. In a case of neonatal compression ischaemia of the forearm, muscle contracture had recovered and full hand function was present at age 6 years, although growth arrest of the distal radial epiphysis resulted in the affected forearm being shorter than the other at that age [43]. In a case of congenital neuroepithelioma in an infant hand, clinical evaluation up to age 4 years and repeated MRI showed no evidence of recurrent disease, and hand function was normal at all follow-up examinations up to age 4 years [67]. In a case of infantile haemangiopericytoma of the hand, urgent treatment via amputation of the affected digit was required as a life-saving measure [23]. In a case of humeral lengthening for septic neonatal growth arrest, there was a full range of shoulder, elbow, and hand motion at 1-year follow-up, and the humeri were virtually the same length at that time [128].

In a series of 15 children with Erb's palsy and humeral head deformity treated with rotation osteotomy of the humerus, all had improved shoulder function at final follow-up [38]. In a series of four cases of distal ulnar growth arrest in children aged 7 to 13 years, follow-up duration ranged from 2 to 10 years [177]. In a series of children and adolescents treated with thick split thickness grafts from the instep for hand surgery, a good aesthetic result was achieved without compromising hand function, and there was no donor site morbidity [24].

In a series of children with proximal phalangeal neck fractures with 180° rotational deformity, four out of five sustained their injuries in cupboard doors [26]. The injury was suggested to be more common in infants despite the lowest incidence of phalangeal fractures in that age group [26]. Injudicious attempts at manipulation, particularly longitudinal traction, may convert fractures with a 90° deformity into those with an “upside down" head configuration [26]. A “grouped lateral" X-ray is misleading and may obscure the diagnosis [26]. Detection is difficult in small "chubby" fingers where movements are restricted and painful but there is often no obvious angular deformity [26]. A clinical history coupled with a high index of suspicion and good AP and true lateral X-rays are essential for diagnosis [26].

Key Evidence

• [Paper] The classification adopted by the American Society for Surgery of the Hand and the International Federation of Societies for Surgery of the Hand is practical and useful to differentiate the types of deformities seen in the upper limbs. [1] (10.1016/s0363-5023(83)80249-4)
• [L5] The overall health of the child and the severity of deformities guide long-term treatment plans aimed at realigning the forearm, wrist, and hand while providing a functional thumb. [2] (10.5435/00124635-200701000-00005)
• [L5] The postoperative management and the long-term results in treating pediatric hand conditions have improved greatly with this tenet. [3] (10.1016/j.jhsa.2005.02.014)
• [Paper] It clearly explains and demonstrates the practical management of each category of hand and upper limb defects organized around the Classification of Congenital Upper Limb Deficiencies. [4] (10.1016/s0363-5023(88)80076-5)
• [L4] Surgical management of the upper extremity anomalies in Du Pan syndrome has not been described previously. [5] (10.1016/s0266-7681(98)80220-9)
• [L2] Caregivers of children with congenital upper extremity differences report a significant impact on family life. [7] (10.1016/j.jhsa.2024.02.011)
• [L4] Treatment for radial longitudinal deficiency remains controversial, but radialization has shown promise in early follow-up for severe deformities, while children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability. [8] (10.2106/jbjs.22.01323)
• [L5] The article provides information on the changing landscapes in research, treatment, civil rights' protection, disability awareness, and accepted terminology in the care of children with congenital upper limb differences to guide clinical and nonclinical conversations between patients and their families. [9] (10.1016/j.jhsa.2021.07.001)
• [L2] The overall complication rate following congenital upper limb surgery was approximately 5.3%, with most events being minor and not requiring additional surgery. [10] (10.1016/j.jhsa.2025.11.004)
• [L3] Children with congenital upper limb differences experience significant upper extremity functional impairment, and physical function is closely linked with psychosocial wellbeing. [12] (10.1177/17531934251355084)
• [L5] [13] (10.1053/jhsu.2001.9419)
• [L4] Amputation of the digits in children is an absolute indication for replantation, no matter whether a single digit or many digits are involved. [14] (10.1016/s0363-5023(98)80049-x)
• [L5] The hand malformation may be the first manifestation of a more complex syndrome, the other symptoms appearing later in life. [16] (10.1016/j.main.2008.07.011)
• [L4] Dupuytren's disease of the hand is generally considered a disease of adults, but this series presents nine children who developed the condition before the age of 13 years. [18] (10.1016/s0266-7681(96)80024-6)
• [L4] The prevalence of babies born with upper limb anomalies was 1 in 506, or 1.97 per 1,000 live births. [19] (10.1053/jhsu.2001.26121)
• [L4] This historical case note study observed an evolution of nomenclature for congenital upper limb anomalies over the last few decades and highlighted that naming these conditions remains an ongoing challenge influenced by surgeon subjectivity and experience. [20] (10.1177/17531934231160400)
• [L4] The principles of management of congenital varicella of the upper limb are similar to those applied to other paralytic conditions. [21] (10.1016/s0266-7681(05)80029-4)
• [L5] The reported case of IHP affecting the hand of a 7-week-old child required urgent treatment via amputation of the affected digit as a life-saving measure. [23] (10.1016/s0266-7681(96)80026-x)
• [L4] A good aesthetic result can be achieved without compromising hand function—but only in children and adolescents among whom there was no donor site morbidity. [24] (10.1016/0266-7681(85)90012-9)
• [L4] A good aesthetic result can be achieved without compromising hand function—but only in children and adolescents among whom there was no donor site morbidity. [25] (10.1016/0266-7681_85_90012-9)
• [L4] [26] (10.1016/s0266-7681(05)80093-2)
• [L5] The updated OMT classification reflects the latest knowledge on upper-extremity anomalies and is designed to be as straightforward as possible to employ, with future updates anticipated as understanding of limb formation progresses. [29] (10.1016/j.jhsa.2020.01.002)
• [L4] It should be considered in any child presenting with inability to flex the thumb. [30] (10.1142/s2424835516500247)
• [L4] The survey found that approximately 5% of all cases of upper limb malformations occurred as part of generalized developmental disorders. [31] (10.1016/s0363-5023(82)80101-9)
• [L4] We believe that the characteristic histological appearance may be the end result of different aetiological factors in different clinical conditions, and that calcification in children with limb deficiencies is not necessarily the same condition as that previously reported as tumoral calcinosis. [32] (10.1016/0266-7681(94)90135-x)
• [L4] [33] (10.1016/j.jhsa.2010.07.017)
• [L4] The predominance of involvement of the right hand is probably due to right-handed children exploring with their right hand. [35] (10.1016/0266-7681(84)90034-2)
• [L3] Patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length. [37] (10.1007/s11552-010-9270-z)
• [L4] All 15 children had improved shoulder function and obtained a modified Mallet score of 4 at final follow-up. [38] (10.1053/jhsu.2002.33198)
• [L4] The morphological or radiographic anatomy of a child's hand with congenital absent digits is a more logical indication for microsurgical reconstruction than any embryological classification. [39] (10.1007/s11552-013-9534-5)
• [L4] Ulnar lengthening has a unique role in the management of long neglected functional and cosmetic problems in congenital radial club hands originating from severe shortening and angular deformity of the ulna. [41] (10.1097/00130911-199803000-00010)
• [L5] At the age of 6 years, the muscle contracture had recovered and there was full hand function, but there was growth arrest of the distal radial epiphysis and the affected forearm was shorter than the other. [43] (10.1016/s0266-7681(97)80358-0)
• [L4] This finding may be of more use in establishing clinical diagnosis than the traditional thumb assessment. [49] (10.1016/s0266-7681(97)80285-9)
• [Paper] The classification for congenital limb malformations adopted by the American Society for Surgery of the Hand, the International Federation of Societies for Surgery of the Hand, and the International Society of Prosthetics and Orthotics is presented. [50] (10.1016/s0363-5023(76)80021-4)
• [L5] The case illustrates the relative lack of neurologic symptoms and the need to include neurilemmomas in the differential diagnosis of hand masses in children. [51] (10.1016/s0363-5023(10)80105-4)
• [L5] Successful outcome requires addressing the deforming forces present and maintaining length in the thumb, and an understanding of the pinch patterns of each child. [52] (10.1097/bth.0b013e3181da07c1)
• [L4] Contralateral limbs can be used for comparison of length and circumference of the arm and forearm in cases of unilateral upper extremity abnormality. [53] (10.1177/1558944718824706)
• [L4] Osteocartilaginous lesions are not commonly found in the digits of children and the initial diagnosis may be easily missed. [54] (10.1016/s0363-5023(83)80167-1)
• [L4] The HWP severity grading system, which scores hand, wrist, and proximal defects, allows better comparison of radially deficient limbs and treatment results between patient groups. [55] (10.1177/1753193413518709)
• [L5] Tendon transfers in the upper limb and hand are a main indication in tetraplegia, with potential benefits not yet fully realised by many hand surgeons. [56] (10.1016/0266-7681_89_90114-9)
• [L4] The relative size of the thumb remains constant during growth. [57] (10.1016/j.jhsa.2005.02.017)
• [L5] We present a congenital anomaly characterized by excessive muscle volume with unilateral hypertrophy of the entire upper extremity and particular deformity of the hand. [58] (10.1016/s0266-7681(97)80075-7)
• [L1] [59] (10.1197/j.jht.2005.04.005)
• [L5] This rare disorder has varying degrees of presentation, and limbs have been salvaged with conservative management coupled with appropriate surgical intervention and neonatal intensive care. [60] (10.1016/s0363-5023(88)80020-0)
• [L4] The majority of type A ulnar polydactyly can be classified into one of five morphological subtypes that have potential clinical relevance regarding operative treatment. [62] (10.1016/s0363-5023(12)60072-0)
• [L5] [63] (10.1016/j.hansur.2018.03.007)
• [L5] Non-performance-related injuries are the most common and must be treated to preserve the span of the hand and maximize hand function, while performance-related injuries require consideration of the child's size and strength, often aided by simple modifications to the instrument or technique. [64] (10.1016/s0894-1130(12)80267-5)
• [L4] A functional hand can be expected after flexor tendon repair in children. [65] (10.1016/0266-7681(94)90237-2)
• [L4] We achieved excellent and good results in six of seven thumbs that we treated surgically using primary end-to-end repair in zone 2 in children. [66] (10.1016/s0266-7681(99)90029-3)
• [L5] Clinical evaluation up to the age of 4 years and repeated magnetic resonance imaging (MRI) showed no evidence of recurrent disease, and hand function was found to be normal at all follow-up examinations. [67] (10.1016/s0266-7681(96)80025-8)
• [L4] [68] (10.1016/j.jhsa.2013.03.019)
• [L4] The main indication in the series was symbrachydactyly (21 cases), followed by forearm lengthening (9 cases) and miscellaneous malformations. [70] (10.1097/00130911-200012000-00007)
• [L4] The treatment objective in the five-finger hand is to create an opposable thumb with two phalanges and a first web space having a normal appearance. [71] (10.1016/j.main.2010.10.011)
• [L4] Severity grading of Radial Club Hands improves assessment of functional prognosis, treatment planning, and comparison of similar extremity groups before and after treatment. [73] (10.1177/1558944716660555at)
• [L5] Primary indications remain the treatment of symbrachydactyly, radial-side deficiency, and long bone disorders such as congenital pseudarthrosis of the forearm. [74] (10.1016/s0749-0712(21)00147-5)
• [L4] This analysis of outcome provides evidence that in properly selected and evaluated children with pronation contractures of the forearm, secondary to obstetric brachial plexus injury, surgical reconstruction can improve both form and function in the limb. [76] (10.1016/s0266-7681(99)90023-2)
• [L4] Full restoration of arm length is not a requirement for a successful outcome since these young patients are motivated and can adapt to almost all situations. [77] (10.1053/jhsu.1999.0331)
• [L3] Parents of children with congenital upper limb differences have unique psychological experiences and needs, with wellbeing and family impact scores significantly lower than population norms. [78] (10.1177/17531934241256793)
• [L4] [79] (10.1053/jhsu.1999.jhsu25a0016)
• [L5] Data resolved into three main themes: functional improvements are interwoven into daily life, the hand is easier to use and is used more, and changes in the appearance and in the internal feeling of the arm are of importance. [82] (10.1197/j.jht.2007.04.003)
• [L4] They postulate that the patient with avascular necrosis developed the condition in a hypoplastic but otherwise normal scaphoid, potentially influenced by negative ulnar variance altering biomechanics. [84] (10.1016/0266-7681(91)90179-r)
• [L4] All infantile digital fibromas appear early in life at the distal or proximal interphalangeal joint level, characteristically involve the ulnar three digits, may be multicentric, and undergo rapid growth within a short time. [85] (10.1016/s0363-5023(05)80152-2)
• [L4] It is possible that they may represent a distinct type of hand anomaly for which an appropriate classification has not yet been established. [105] (10.1016/s0363-5023(83)80093-8)
• [L4] [107] (10.1177/17531934241249014)
• [L4] Finally, the anomaly does not fit into the classification systems described for thumb polydactyly. [110] (10.1016/j.jhsb.2005.04.011)
• [L5] The Swanson/IFSSH classification is currently the most used classification of congenital limb anomalies, but it is based on morphology and cannot indicate the site in the molecular pathway or the time of the insult. [121] (10.1016/j.main.2008.08.001)
• [L5] The authors report successful treatment of a child with a distal phalangeal non-union and associated finger tip deformity. [122] (10.1016/j.jhsb.2006.08.002)
• [L4] MRI is noninvasive and can also demonstrate abnormalities of the unossified epiphysis. [123] (10.1016/j.jse.2003.12.008)
• [L4] The updated OMT classification system is reasonably practical for precise classification of these anomalies. [124] (10.1016/j.jhsa.2023.05.016)
• [L5] At 1-year follow-up, there was a full range of shoulder, elbow, and hand motion; the humeri were virtually the same length. [128] (10.1016/s0363-5023(89)80100-5)
• [L4] [129] (10.1054/jhsb.2001.0643)
• [L4] Upper-limb function and the HRQOL physical health domain were poorer with greater hand deformity in children with hemiplegic CP. [132] (10.1016/j.hansur.2021.08.009)
• [L4] At a mean follow-up time of 24 months, grip strength and range of movement were improved in all cases. [133] (10.1016/s0363-5023(03)80360-x)
• [L4] An excellent result would be a hand with excellent function and appearance, but almost no patient can fit this criteria even after extensive treatment. [136] (10.1016/0266-7681(94)90234-8)
• [L4] [137] (10.1177/1753193412475129)
• [L4] [139] (10.1016/s0363-5023(82)80102-0)
• [L5] [146] (10.1016/s0894-1130(99)80021-0)
• [L4] Angiography is an important and safe investigation in the pre-operative assessment of cases of complex congenital hand deformities. [147] (10.1016/0266-7681(90)90121-j)
• [L4] The authors consider conservative treatment to be a useful method despite the long treatment period, and recommend surgical release if signs of deformity are noted. [148] (10.1097/00130911-200303000-00008)
• [L4] [151] (10.1016/s0363-5023(09)90019-3)
• [L4] All children have a rudimentary but functional pinch grip, and revision of the webs was necessary in 16% of the cases. [157] (10.1016/j.main.2008.07.014)
• [L4] Systematic angiographic research on congenital hand deformities has allowed us to observe various anomalies of the vascular anatomy of the hand requiring treatment. [160] (10.1016/0363-5023(89)90111-1)
• [L4] [162] (10.1016/s0266-7681(96)80177-x)
• [L5] [163] (10.1016/j.jhsb.2006.11.013)
• [L4] [166] (10.1016/s0363-5023(10)80165-0)
• [L5] When evaluating pediatric abduction thumb injuries, the physician must consider complete ligamentous UCL disruption, especially when x-ray films show significant joint subluxation. [169] (10.1016/0363-5023(94)90115-5)
• [L5] The great toe hypoplasia is similar to a grade 3b thumb hypoplasia with absence of the proximal two-thirds of the first metatarsal on the plain X-ray. [171] (10.1142/s2424835518720402)
• [L5] The most significant change observed on the x-ray film was the absence of the epiphyses. [172] (10.1016/s0363-5023(86)80073-9)
• [L5] Most patients presenting with RDFC should be treated conservatively. [173] (10.1016/s0266-7681(05)80215-3)
• [L3] We advocate early mobilization in children in whom a partial division of the flexor tendon is diagnosed clinically. [175] (10.1016/s0266-7681(97)80406-8)
• [L4] Four cases of arrest of distal ulnar physeal growth occurring in children ages 7 to 13 years had follow-up for 2 to 10 years. [177] (10.1016/s0363-5023(84)80134-3)

See Also

• Dupuytren's Disease
• Flexor tendon repair
• Contractures and Deformities

References

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