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hi
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ab c
de f
g
G. Pajardi et al.
j
Fig. 14.3 Pollicization technique: (a) isolation of the
index nger, including the neurovascular bundles, tendons, and soft tissue attachments. (b) Isolation of dorsal
veins and extensor tendons. (c) Detached interossei mus-
14.6 Complications
andOutcomes
The common complications are wound dehiscence and maceration, necrosis of distal part of
the ap. Infection and hematomas are rare.
cles and reserved for later reconstruction. (d) Isolated
metacarpal bone (e). Fixation with anchor base and head
of metacarpal bone. (f) Reinsertion interossei muscles.
(g–i) Final skin suture. (j) Dressing and cast
Vascular compromise can occur but is extremely
rare and can happen if the dissection will not
respect the neurovascular bundle.
Long-term complications are: keloid or hypertrophic scar, insufcient rst web space, excess
of length caused for ablation’s failure growth
14 Thumb Hypoplasia: Genesia, Pollicization
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Fig. 14.4 Pollicization results
173
plate, hyperextension of MCP joint, malrotation
of the thumb, stiffness or instability, lack of
opposition.
Sometimes this result needs a second surgery
as revision of rst web space, tenolysis, epiphysiodesis and osteotomy of metacarpal, rotational
osteotomy, and opposition transfer [14].
The results following pollicization are dependent on the status of index nger and its surrounding musculature. Pollicization of index
nger provides a better result in isolated thumb
hypoplasia compared with patients with a hypoplastic or absent radius [15].
A mobile index nger transferred to the thumb
position provides stability for grasp and mobility
for ne pinch. A stiff index nger, however, provides a stable thumb for gross grasp but will not
be nimble enough to participate in pinch [16].
Pollicization is one of the most beautiful procedures in congenital disease but is a relatively
uncommon procedure that requires considerable
repetition to gain adequate experience. The surgeon must be expert to reach the best result and
avoid dramatic complications (Fig.14.4).
References
1. Upton J III.Hypoplastic or absent thumb. In: Mathes
S, Hentz V, editors. Plastic surgery, vol. 8. Amsterdam:
Saunders; 2006. p.323–67.
2. Rayan G.Congenital thumb hypoplasia. J Okla State
Med Assoc. 1995;87:546–50.
3. Edgerton M, Snyder G, Webb W.Surgical treatment
of congenital thumb deformities (including impact of
correction). J Bone Joint Surg. 1965;47(8):1453–74.
4. Kozin SH.Upper-extremity congenital anomalies. J
Bone Joint Surg. 2003;85:1564–76.
5. Entin M.Congenital anomalies of the upper extremity. Surg Clin N Am. 1960;40:497.
6. Flatt A.The care of congenital hand anomalies. St.
Louis: CV Mosby; 1977. p.55–79.
7. Manske PR, McCaroll HR Jr, James MA.Type IIA
hypoplastic thumb. J Hand Surg. 1995;20A:246–53.
8. Manske PR, Rotman MB, Dailey LA. Longterm functional results after pollicization for the
congenitally decient thumb. J Hand Surg Am.
1992;17(6):1064–72.
9. Buck-Gramcko D. Pollicization of the index nger:
method and results in aplasia and hypoplasia of the
thumb. J Bone Joint Surg Am. 1971;53(8):1605–17.
10. Littler JW. On making a thumb: one hundred years
of surgical effort. J Hand Surg Am. 1976;1(1):35–51.
11. McCarroll HR.Congenital anomalies: a 25-year overview. J Hand Surg Am. 2000;25(6):1007–37.
12. McDonald TJ, James MA, McCarroll HR, Redlin
H.Reconstruction of the type IIIA hypoplastic thumb.
Tech Hand Up Extrem Surg. 2008;12(2):79–84.
13. Foucher G, Medina J, Loréa P, Pivato G, Szabó
Z. Pollicization in congenital differences. Handchir
Mikrochir Plast Chir. 2004;36:146–51.
14. Kozin SH, Zlotolow DA. Common pediatric congenital conditions of the hand. Plast Reconstr Surg.
2015;136(2):241e–57e.
15. Kozin SH, Weiss AA, Webber JB, Betz RR, Clancy
M, Steel HH.Functional results after index nger pollicization for congenital aplasia or hypoplasia of the
thumb. J Hand Surg Am. 1992;17:880–4.
16. Kozin SH.Pollicization: the concept, technical details,
and outcome. Clinics Orthop Surg. 2012;4(1):18–35.
Radial Longitudinal Deciency:
https://t.me/medicina_free
Classication andSurgical
Technique
StevenE.R.Hovius, MartijnBaas,
andChristianneA.van Nieuwenhoven
15
Abstract
Radial longitudinal deciencies comprise a
spectrum of anomalies that require typespecic surgical or conservative treatments.
This chapter reports our experience of over
300 arms. Multiple corrections have been
described, in general a treatment algorithm
should start with stabilisation of the wrist
before specic corrections are made to
improve hand function, such as a pollicisation
or an opponens plasty. If indicated, lengthening of the forearm or cosmetic corrections can
be performed, although one must consider that
these corrections could jeopardise obtained
S. E. R. Hovius (*)
The Xpert Clinics, Rotterdam, The Netherlands
Radboudumc University Medical Center,
Nijmegen, The Netherlands
e-mail: s.hovius@xpertclinic.nl;
steven.hovius@radboudumc.nl
M. Baas
Department of Plastic and Reconstructive Surgery,
Amsterdam University Medical Center, Amsterdam,
The Netherlands
e-mail: m.baas@erasmusmc.nl
C. A. van Nieuwenhoven
Department of Plastic and Reconstructive Surgery
and Hand Surgery, Erasmus University Medical
Center, Rotterdam, The Netherlands
e-mail: c.vannieuwenhoven@erasmusmc.nl
wrist stabilisation and hand function. Partial
recurrence of the radial deviation of the wrist
is commonly reported, however, this does not
necessarily lead to inability. Inability seems to
be mostly affected by overall hand function.
Keywords
Radial longitudinal deciency
Epidemiology · Classication · Surgical
management · Outcomes
15.1 Radial Longitudinal
Deciency and Syndromes
Radial longitudinal deciency (RLD) exhibits a
wide spectrum of radial anomalies of the upper
limb, ranging from thumb hypoplasia to a completely absent radius, humeral and shoulder
anomalies. It is the most common longitudinal
failure of formation with a prevalence estimated
between 1 in 15,000–25,000 live births [1, 2].
RLD is also one of the congenital upper limb
anomalies that most frequently present with associated anomalies, some of which have major surgical implications or can be life-threatening [3].
The most frequently associated syndromes/
associations include VACTERL association,
Holt–Oram syndrome, Thrombocytopenia absent
radius (TAR) syndrome, Fanconi anaemia and
Duane-Radial Ray syndrome [4]. However, the
differential diagnosis for radial longitudinal
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_15
175
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Table 15.1 RLD syndromes and their associated anomalies and suggested diagnostics
Syndrome Associated anomalies Recommended diagnostics
Holt–Oram syndrome Cardiac anomalies
Vertebral anomalies
Fanconi anaemia Blood Dyscrasias
Ear anomalies, deafness, facial anomalies
Renal anomalies
TAR syndrome Thrombocytopenia, present in the rst months of life
Cardiac anomalies
Renal anomalies
VACTERL syndrome Vertebral anomalies
Anal atresia
Cardiac anomalies
Tracheoesophageal stula/oesophageal atresia
Renal anomalies
Echocardiogram
Complete blood count
Abdominal/renal ultrasound
Radiographs of the spine
Chromosome breakage test
S. E. R. Hovius et al.
defects extends to over 30 syndromes and associations [5].
In patients with multiple severe anomalies, the
RLD will be one of the last anomalies to be (surgically) addressed. However, in our practice, it
occurs that the hand surgeon is the rst to be consulted in a patient who, after a thorough examination, appears to have additional congenital
anomalies. Therefore, the surgeon dealing with
RLD should be well aware of the spectrum of
anomalies that can present with RLD.Furthermore,
there are numerous anomalies that could inuence the per-operative condition of the patient,
e.g. thrombocytopenia in TAR syndrome or tracheomalacia in VACTERL patients which might
not be noticed till the rst sleep induction by the
anaesthesiologist. Thus, thorough clinical examination is warranted (Table 15.1) and paediatricians and/or geneticists should be consulted when
multiple congenital anomalies are present [6].
15.2 Presentation
Patients with RLD can present at the outpatient
clinic with a variation of malformations in the
upper limb (Table15.2). The mildest form is hypoplasia of the thumb with or without stiffness of the
radial-sided ngers. Patients may only present
because of the hypoplastic thenar musculature. The
most severe forms of RLD can affect both entire
arms with complete absence of the radius, humeral
and shoulder deformities. The time of presentation
depends on the severity of the anomaly and the
Table 15.2 Clinical presentation of radial longitudinal
deciencies can include
Hypoplastic or absent thumb, sometimes radial
polydactyly
Absent, hypoplastic or stiff ngers predominantly on
the radial side of the hand
Radial deviation of the wrist
Agenesis or hypoplasia of scaphoid, trapezium,
trapezoid and lunate
Agenesis or hypoplasia of the radius
Growth decit of the ulna with or without bowing
Growth decit of the humerus
Hypoplastic gleno-humeral development
High prevalence of bilateral occurrence, although
contralateral anomalies can be minor
general development of the child: in mild anomalies, the rst signs might be the aberrant employment of the hand when the child starts to grasp
small objects or even at a moment when the child
nds problems with writing. This is in contrast
with cases with severe anomalies which are referred
directly postnatally or even prenatally.
Commonly, patients present with unilateral
complaints but have bilateral anomalies at physical examination. Left – right differences can
occur randomly, but also predisposition for leftsided anomalies have been described in HoltOram syndrome [7].
15.3 Function
Like Flatt pointed out, RLD is an abnormal hand
joined to a poor limb by a bad wrist [8]. The functional decit depends on the bilateral or unilat-
15 Radial Longitudinal Deciency: Classication andSurgical Technique
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177
eral occurrence of RLD, the quality and strength
of the thumb and remaining digits, radial deviation of the wrist and the length of the forearm.
Patients who are affected bilaterally have a bad
upper limb function in terms of washing, dressing, feeding, in essence most activities of daily
life. However, they compensate very well by
using alternative methods to achieve their activities in daily life. Unilateral cases use the affected
limb mainly as an aid. Depending on the stiffness
of the ngers either the index and the middle nger or the ring nger and the little nger are used
for a scissors grip. In a very young child, hand
function analysis is not well established, while in
an older child, hand function analysis should be
included in decision-making.
15.4 Classication
To establish a treatment algorithm, it is useful to
classify the observed anomalies. In current literature, the most accepted classication scheme is the
modied Bayne and Klug classication
(Table15.3) [9, 10]. The modied Bayne and Klug
classication takes into account the developmental
defects in the thumb, the carpus, both the proximal
and the distal radius, and the humerus. Based on
the observed defects, the limb is classied in a
range from Type N, including just a hypoplastic
thumb or absent thumb, to Type 5 which would
include an absent radius and hypoplasia of the
proximal humerus and glenoid (Fig.15.1).
The type N RLD only comprises thumb hypoplasia or the total absence of the thumb. The
severity of thumb hypoplasia or aplasia does not
necessarily correlate with the severity of other
radial defects, for example patients with TAR
syndrome often have thumbs. Therefore, the
thumb is a separate entity in the classication but
the severity of thumb hypoplasia does not differentiate between any of the other RLD types in the
classication. The severity of hypoplasia of the
thumb does inuence the surgical algorithm
regarding opposition plasty or pollicisation and
should therefore be thoroughly evaluated.
Type 0 RLD comprises of either carpal bone
defects or proximal radial defects such as radioulnar synostosis or congenital radial head dislocation or easy subluxation. The distal radius is
normally developed in Type 0 RLD.Differentiation between a Type N or Type 0 RLD might not
be possible at the rst consultation, as the radial
carpal bones will start ossifying at the age of
4–6 years, with complete ossication at
12–14 years. Before ossication, only radial
deviation of the wrist without distal radial anomalies indicates carpal bone defects. However,
radial deviation is not a formal component of the
modied Bayne classication.
Table 15.3 The modied Bayne and Klug classication for RLD
Type Thumb Carpal bones Distal radius Proximal radius Humerus
N Absent or
Hypoplastic
0 Absent or
Hypoplastic
1 Absent or
Hypoplastic
2 Absent or
Hypoplastic
3 Absent or
Hypoplastic
4 Absent or
Hypoplastic
5 Absent or
Hypoplastic
Normal Normal Normal Normal
Absent, hypoplasia
or coalition
Absent, hypoplasia
or coalition
Absent, hypoplasia
or coalition
Absent, hypoplasia
or coalition
Absent, hypoplasia
or coalition
Absent, hypoplasia
or coalition
Normal Normal, radioulnar
synostosis, radial head
dislocation
>2mm shorter
than ulna
Hypoplasia Hypoplasia Normal
Physis absent Hypoplasia Normal
Absent Absent Normal
Absent Absent Abnormal glenoid and
Normal, radioulnar
synostosis, radial head
dislocation
Normal
Normal
proximal humerus
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S. E. R. Hovius et al.
Fig. 15.1 (a) Type 1: radius >2mm shorter with devia-
tion of the wrist. (b) Type 2: adult with absent and hypoplastic carpal bones and short radius. (c) Type 3: very
Types 1 to 3 are dened by increasing severity
of radial hypoplasia, with a minimum difference
of 2mm shortening of the distal radius compared
to the ulna in Type 1. When the proximal radius is
also hypoplastic, it is considered a Type 2
RLD.Lastly, when there is no physis of the distal
radius, the anomaly is classied as a Type 3 RLD.
Types 4 and 5 are both dened by a completely
absent radius and, in Type 5, also proximal hypoplasia of the humerus and glenoid co-exist. It is
noteworthy that also in less severe RLD, the
humerus might be shorter as compared to healthy
individuals. However, this hypoplasia is different
to the humeral anomalies observed in Type 5
RLD [10].
short radius with absent physis and hypoplastic thumb and
carpus. (d) Type 4: absent radius and hypoplastic thumb
and hypoplstic and absent carpal bones
Alternative to the modied Bayne and Klug
classication, Simo Vilkki published his severity
grading, which focuses more on the quality and
range of motion of the remaining digits, the wrist
and the elbow joint (Table 15.4) [11]. Although
this severity grading has not been psychometrically validated, it has been used as a predictor for
less favourable outcomes of RLD surgery [12].
The Vilkki severity grading scores the Hand,
Wrist radial deviation and Proximal decits
(WHP) (Table 15.3). Higher points reect the
severity of the condition. A separate chapter in
this book written by Simo Vilkki will be provided
on longitudinal radial deciency containing a different treatment algorithm.
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Table 15.4 Vilkki HWP severity grading
Severity
points
HAND Useful thumb
Stiff MCP II-V, exion
<45 degrees
Stiff or camptodactylic
PIP II-V, extension decit
>20 degrees
Absence of digit or ray
II-V
Syndactyly between digits
II-III
Ulnar pinching pattern 1
WRIST Mild radial deviation
(10–30 degrees)
Moderate radial deviation
(30–60 degrees)
Severe radial deviation
(60–90 degrees)
Extreme radial deviation
(>90 degrees)
Ulna bow 20–40 degrees 1
Ulna bow >40 degrees 2
Neglected early splinting
(start >6months)
PROXIMAL Elbow extension decit
>15 degrees
Elbow exion: Weak
active 60–80 degrees
Below 60 degrees 3
No active exion 4
Shoulder abduction or
exion <120 degrees
Intercalary bone defect,
major shoulder instability
Total maximum 30 (max 10
−2
1/digit
1/digit
2/ray
1
2
4
6
8
2
1
2
3
6
points/
domain
15.5 Treatment
The treatment options for RLD comprise conservative methods, surgical correction or a combination of both. Conservative methods of
treatment should start early, if possible, a few
days after birth. Both splinting and soft tissue
manipulation by the parents have been described.
Splinting however in very small children is cumbersome. Therefore, we advise frequent manipulation and stretching of the wrist instead of
Table 15.5 The aims of surgery
1. To stabilise the wrist on the distal end of the ulna,
without further compromising the growth potential
2. To improve hand functions like prehension, grip and
pinch strength
3. To increase the overall length of the forearm,
without comprising hand function
4. To create a better appearance, without
compromising hand function
splinting to overcome as much of the radial deviation as possible before starting surgical correction of the wrist, or continuing with correction of
the thumb. Many surgical corrections have been
described; our surgical algorithm has four aims
(Table15.5).
Contraindications for surgery are seriously
associated congenital differences. If possible,
they should be corrected rst. Next, the patient
should be able to gain functional benet from the
correction. For instance, in patients with severe
congenital differences or severe mental or other
physical disabilities, we choose not to operate the
RLD. Lastly, a stiff elbow is a contraindication
since positioning of the hand in line with the ulna
will prohibit moving the hand to the face [13, 14].
Note however that the elbow tends to become
less stiff, thus this contraindication should be reevaluated over time.
Relative contraindications are Types I and II
RLD according to Bayne and adolescents or
adults who present with a primary, untreated,
RLD.These patients are used to their deformity
and do rather well in activities in daily living and
their wish is mostly to be more socially accepted.
However, correcting their deformity could jeopardise their hand function. Furthermore, a stiff
wrist in radial deviation with stiff ngers is a relative contraindication for centralisation because
the forearm will be short as the distal physis of the
ulna will be damaged; and the wrist and ngers
will not improve in function as they are stiff. To
minimise the risk for range of motion loss, growth
potential and complications due to extended surgery in RLD correction, some congenital hand
surgery centres advocate to only do a soft tissue
release and a bilobed ap for coverage [15].
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S. E. R. Hovius et al.
15.6 Surgical Algorithm
Over the years, we developed a treatment algorithm based on a series comprising 308 arms (see
Table15.6). Treatment options will be discussed
based on the type of deformity according to the
Bayne and Klug classication.
15.6.1 Type N–0
The treatment for hypoplastic thumbs is described
in a different chapter. However, the type N anomaly
can be contralateral to a more severe RLD.In these
cases, a personalised surgical planning should be
made, taking into consideration the dexterity and
the motor development of the child together with
the general condition and the wish of the parents. In
our practice, we would rst do soft tissue distraction and wrist stabilisation and subsequently evaluate which side comes rst to correct or create a
thumb. In general, we would do the (supposed)
dominant hand rst. If possible, this enables the
operated hand to train more when the contralateral
side is treated [16]. The dominant hand however
needs about 4–6 years to become obvious while
treatment in our unit mostly starts much earlier.
15.6.2 Type I–II
In Types I and II, the distal radius is hypoplastic
and the wrist is more radially deviated than normal wrists. Typically, the wrist can be passively
corrected to central but it is not possible to ulnar
Table 15.6 Arms treated in our centre, according to the
modied Bayne and Klug classication
Type Arms
N 24
0 111
1 32
2 13
3 21
4 104
5 1
Not classiable 2
Total 308
deviate the wrist. In type II the radial deviation
can become quite extensive with growth due to a
growth decit of the distal end of the radius in
relation to the ulna. In most cases, Type I RLD
does not require surgical intervention. In Type II
RLD, often a tendon rebalancing with or without
a wrist stabilisation is performed. Soft tissue distraction is seldom needed prior to wrist stabilisation in these cases. However, if soft tissue
manipulation did not result in any correction of
radial deviation and the radial deviation cannot
be redressed, it can well be considered.
In the growing child, length discrepancies
between radius and ulna in Type II RLD are difcult to correct. Non-vascularised bone grafts have
been used, but the lengthened radius will always
be too short as it doesn’t have enough growth
potential compared to the ulna. Vascularised bone
with a growth plate does have this growth potential. Both proximal bula and metatarsal phalangeal joint transfers have been described [17–22].
15.6.3 Type III–V
Treatment of radial deviation in RLD Types
III–V is most challenging and has been extensively studied [13, 23–33]. At the Department of
Plastic and Reconstructive Surgery of the
Erasmus University Medical Center Rotterdam,
children with these anomalies have been treated
from 1972 onwards. Before 1987 arthrodesis of
the wrist was mostly performed [34, 35]. Since
1987, the wrists in radial dysplasia Type III or IV
were stabilised with as much preservation of the
carpus and soft tissues as possible, using a modied Bayne’s technique [30]. Our current algorithm is presented in Table15.7.
Table 15.7 Treatment algorithm in Types III–V RLD
1. Preoperative manipulation and splinting to decrease
radial deviation
2. Soft tissue distraction
3. Wrist stabilisation with or without ulna osteotomy
4. Pollicisation or opposition plasty
5. Forearm lengthening
Treatment starts in the rst year, if no contraindications exist
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181
In the earlier days, during wrist stabilisation
procedures the distal ulna was often shaved, carpal bones were partially excised, tightness of soft
tissues could be difcult to overcome, and wrist
mobility could be severely impaired. Several
authors have tried to overcome the same problems by pre-treatment with distraction [36–41] to
facilitate stabilisation. Therefore, we started to
distract from 1993 onwards at our department
before stabilisation of the wrist.
15.7 Distraction oftheSoft
Tissues at Wrist Level
Since 1993, we used an external device, a modied Orthox external distractor (EBI Medical
Systems, Inc., Parsipanny, NJ) for distraction of
the soft tissues at wrist level. The external distractor was modied with a longer body for distraction. Using an open technique, the pins are
manually inserted at the radial side, and placed in
the distal ulna (two pins), and in the second and
third metacarpal (two pins). Initially, the xator
was placed at the ulnar side. However, the pins
are inclined to be pulled out by the forces during
distraction. Great forces are needed to reposition
the wrist on the distal end of the ulna, thus pushing seems better than pulling. Furthermore, the
deformation is mainly on the radial side therefore
distraction seems logical on the pathologic side
when using a uni- or biplanar external xator.
Soft tissue distraction is carried out by the parents (if possible once or twice daily half turns,
resulting in approximately 0.25–0.5 mm per
day). When the proximal carpal conguration is
distracted distally to the distal end of the ulna in
preferably a central position, distraction is
stopped. The main complication was the loosening of pins with or without pin track infection.
The xator is maintained about 4 weeks after
completion of the distraction before the wrist stabilisation procedure is performed preserving
mobility at wrist level (Fig.15.2).
Fig. 15.2 Long term follow-up from early manipulation of the hand, soft tissue distraction, stabilisation of the wrist,
Xrays and pictures of the distal forearm and hand show an increase in radial deviation over 18 year follow up
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S. E. R. Hovius et al.
15.8 Wrist Stabilisation
In this chapter, we will use the term wrist stabilisation. This has been done to prevent misunderstanding with the terms centralisation and
radialisation.
Centralisation has been popularised by
Douglas Lamb [42]. In centralisation, an ulnocarpal arthrodesis is performed following soft tissue release. In this technique, a slot is created in
the carpus following which the distal end of the
ulna is shaved and inserted into the slot.
The term radialisation is introduced by BuckGramcko [43]. The main difference in his technique is that he preserves the pseudo-wrist.
Following thorough release of the soft tissues and
capsule, the distal end of the ulna is shaved as
well as the proximal carpus. The carpus is shifted
more to the ulnar side thus the distal end of the
ulna is subsequently more radial. If possible, the
tight radial structures are transposed to the ulnar
side.
In our unit, the treatment of longitudinal radial
deciency and especially the repositioning of the
wrist can be divided in the period before distraction and after distraction.
Before distraction, radial and ulnar skin incisions were used, and a bilobed ap according to
Evans [26, 44] was performed. The pseudo capsule was extensively released in a circular manner. Furthermore, in Bayne’s technique [30] the
remnants of the radial muscles should be transposed to the ulnar side. In a number of cases,
these remnants were mostly inactive and very
brotic, and therefore were not transposed. If
necessary carpal bone (mostly partial lunate) was
excised, the distal ulna was ‘shaved’, and/or osteotomy of the ulna was performed in severe bowing. Shortening of the extensor carpi ulnaris was
performed in all wrists together with tightening
of the ulnar capsule.
From 1993 onwards, following distraction, it
was not necessary to perform an Evans bilobed
transposition ap anymore because of an ade-
quate soft tissue cover. Also, it was hardly necessary to partially or totally excise carpal bones and
shave the distal ulna as was nearly always performed before distraction.
15.9 Pollicisation
Pollicisation is described extensively in a different chapter; thus, we will only emphasise our
indications. There is no consensus when a pollicisation should be performed in RLD.Usually,
pollicisation is performed in the hand with
severe hypoplastic or absent thumbs with relatively normal forearms. In some cultures, the
emphasis is more towards maintaining the hypoplastic rst digit and attempts are made to
reconstruct the hypoplastic thumb. In general, if
a patient has a scissor grip between the two most
ulnar digits, pollicisation might not be feasible
because the pollicised index nger-mostly stiff
will not be used. Furthermore, in severely hypoplastic or absent radial bones, the indication for
pollicisation can be debated. In these cases, the
new ‘thumbs’ are very weak in strength in contrast to the pollicised index ngers in the fourngered hand without forearm problems [45].
Therefore, our indication for pollicisation in
RLD Types III and IV is when the index and
middle nger are used as scissors grip, together
with the wish of the parents and/or child depending on their age. When the index and the middle
nger are used, the position of the index nger
changes in time with pronation of the index nger itself and widening of the ‘second’ web,
obtaining a thumb like position. Seemingly, the
index nger is already represented in the brain
as a thumb, making incorporation of the pollicised index nger practicable to the child. In
bilateral RLD Types III and IV with a radial
scissors grip, the pollicisation’s do better as in
the unilateral cases as the need to use them is
more urgent. A typical result of pollicisation is
presented in Fig.15.3.
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