eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Radial Clubhand: Follow-up
Updated: Feb 5, 2009
Outcome and Prognosis
Comparison of results following centralization is difficult due to the many surgical modifications, variations in technique to determine the degree of deformity, and potential inconsistencies in measurement. Measurements to determine the deformity have been discussed by numerous authors (see Image 4).16,17
Ilizarov device applied for correction of recurrent deformity.
Heikel described the construction of lines to calculate ulna curvature and overall deformity.18 He also discussed the difficulties with measurements of angles in radial clubhand, including inexact determination of lines and the difficulties in obtaining a standardized radiographic view of the radial clubhand. Manske and colleagues, as well as Bayne and Klug, recommended the hand-forearm angle using the longitudinal axis of the third metacarpal and distal ulna, while Bora and colleagues used the ulnar bow to assess deformity and recurrence.19,20,21,22 Damore and coworkers used total angulation, which is the combination of radial deviation of the hand and the ulna bow.8 This represents the clinical deformity by combining the radial deviation of the wrist and ulna bow.
Lamb monitored 31 centralizations for an average of 5 years and measured a preoperative radial deviation of 78° and a follow-up angle of 22°.23 Bora and colleagues reported on 14 extremities at an average of 14.6 years following centralization and showed a gradual increase in the hand-forearm angle to an average of 25°.22 Manske and colleagues reported on 21 radial clubhands and measured the hand-forearm angle at 58° preoperatively and 26° at an average 34-month postoperative period.19
Watson and coworkers monitored 12 centralizations for 10 years and reported a recurrence to an average of 30°.24 Bayne and Klug monitored 53 patients for an average of 8.6 years and reported 81% good or satisfactory results, defined as a hand-forearm angle of less than 30°.20 Damore and colleagues monitored 14 patients for an average of 7 years.8 An initial significant improvement from a preoperative total angulation of 83° to an immediate postoperative angle of 25° was noted. At follow-up, total angulation had increased to 63°, with a 38° loss of correction.
These results highlight the importance of continued follow-up and emphasize recurrence as a considerable problem. The exact cause appears to be multifactorial, with surgical and nonsurgical factors contributing. In addition, the functional impact after centralization is questionable, as many children function well without centralization.25
Future and Controversies
Numerous modifications and advances have been made in the technique of centralization. Improved methods have been developed to balance the wrist with additional tendon transfers or overcorrection of the wrist into ulnar deviation (ie, radialization). Better attempts at stretching the soft tissue with distraction techniques and bone-lengthening procedures to increase length also are used today (see Image 5). In addition, microsurgical transfer of a viable growth plate (fibula, second toe) to the radial side of the forearm provides a support of the radial carpus that continues to grow over time.
Construction of lines to calculate ulna curvature, hand-forearm angle, and total angulation.
A successful centralization still results in a shortened forearm segment secondary to altered growth of the ulna. The short forearm is both a cosmetic and functional problem for the teenager with radial deficiency. Lengthening of the ulna can be accomplished using distraction osteogenesis. Uniplanar and multiplanar devices have been employed depending on the deformity, forearm size, and surgeon preference. Successful lengthening results in functional improvement because an increased volume of space becomes available for the hand, although complications are common.26 Restoration of near-equal forearm length promotes use of the extremity during activities of daily living.27 However, serious complications can occur with lengthening procedures in children with radial deficiencies. The appropriate indications and age for surgery and amount of length obtainable remain profound questions.
These procedural changes represent new concepts to correct radial clubhand. These technological advances in limb lengthening and microsurgery add innovative methods to better correct the deformity and provide osseous support. However, follow-up results of these techniques are too limited in number and length to draw definitive conclusions.
More on Radial Clubhand |
| Overview: Radial Clubhand |
| Workup: Radial Clubhand |
| Treatment: Radial Clubhand |
 Follow-up: Radial Clubhand |
| Multimedia: Radial Clubhand |
| References |
| Further Reading |
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References
Buck-Gramcko D. Radialization as a new treatment for radial club hand. J Hand Surg [Am]. Nov 1985;10(6 Pt 2):964-8. [Medline].
Saunders JW Jr. The proximo-distal sequence of origin of the parts of the chick wing and the role of the ectoderm. 1948. J Exp Zool. Dec 15 1998;282(6):628-68. [Medline].
Kozin SH. Congenital anomalies. In: Trumble TE, ed. Hand Surgery Update. Rosemont, Ill: American Society for Surgery of the Hand; 2003:599-624.
James MA, McCarroll HR Jr, Manske PR. The spectrum of radial longitudinal deficiency: a modified classification. J Hand Surg [Am]. Nov 1999;24(6):1145-55. [Medline].
Kozin SH. Upper-extremity congenital anomalies. J Bone Joint Surg Am. Aug 2003;85-A(8):1564-76. [Medline].
Manske PR, McCarroll HR Jr, James M. Type III-A hypoplastic thumb. J Hand Surg [Am]. Mar 1995;20(2):246-53. [Medline].
Kozin SH, Weiss AA, Webber JB, et al. Index finger pollicization for congenital aplasia or hypoplasia of the thumb. J Hand Surg [Am]. Sep 1992;17(5):880-4. [Medline].
Damore E, Kozin SH, Thoder JJ, et al. The recurrence of deformity after surgical centralization for radial clubhand. J Hand Surg [Am]. Jul 2000;25(4):745-51. [Medline].
Goldfarb CA, Wall L, Manske PR. Radial longitudinal deficiency: the incidence of associated medical and musculoskeletal conditions. J Hand Surg [Am]. Sep 2006;31(7):1176-82. [Medline].
Vilkki SK. Distraction and microvascular epiphysis transfer for radial club hand. J Hand Surg [Br]. Aug 1998;23(4):445-52. [Medline].
Goldfarb CA, Murtha YM, Gordon JE, et al. Soft-tissue distraction with a ring external fixator before centralization for radial longitudinal deficiency. J Hand Surg [Am]. Jul-Aug 2006;31(6):952-9. [Medline].
Kanojia RK, Sharma N, Kapoor SK. Preliminary soft tissue distraction using external fixator in radial club hand. J Hand Surg Eur Vol. Oct 2008;33(5):622-7. [Medline].
McCarroll HR. Congenital anomalies: a 25-year overview. J Hand Surg [Am]. Nov 2000;25(6):1007-37. [Medline].
Sestero AM, Van Heest A, Agel J. Ulnar growth patterns in radial longitudinal deficiency. J Hand Surg [Am]. Jul-Aug 2006;31(6):960-7. [Medline].
Launay F, Glard Y, Jacopin S, Jouve JL, Bollini G. [Progressive correction of the hand in the congenital radial clubhand.]. Chir Main. Aug 21 2008;[Medline].
Thirkannad SM, Burgess RC. A technique for using the Ilizarov fixator for primary centralization in radial clubhand. Tech Hand Up Extrem Surg. Jun 2008;12(2):71-8. [Medline].
Sabharwal S. Treatment of traumatic radial clubhand deformity with bone loss using the Ilizarov apparatus. Clin Orthop Relat Res. Jul 2004;143-8. [Medline].
Heikel HV. Aplasia and hypoplasia of the radius: studies on 64 cases and on epiphyseal transplantation in rabbits with the imitated defect. Acta Orthop Scand Suppl. 1959;39:1-155. [Medline].
Manske PR, McCarroll HR Jr, Swanson K. Centralization of the radial club hand: an ulnar surgical approach. J Hand Surg [Am]. Sep 1981;6(5):423-33. [Medline].
Bayne LG, Klug MS. Long-term review of the surgical treatment of radial deficiencies. J Hand Surg [Am]. Mar 1987;12(2):169-79. [Medline].
Bora FW Jr, Nicholson JT, Cheema HM. Radial meromelia. The deformity and its treatment. J Bone Joint Surg Am. Jul 1970;52(5):966-79. [Medline].
Bora FW Jr, Osterman AL, Kaneda RR, et al. Radial club-hand deformity. Long-term follow-up. J Bone Joint Surg Am. Jun 1981;63(5):741-5. [Medline].
Lamb DW. Radial club hand. A continuing study of sixty-eight patients with one hundred and seventeen club hands. J Bone Joint Surg Am. Jan 1977;59(1):1-13. [Medline].
Watson HK, Beebe RD, Cruz NI. A centralization procedure for radial clubhand. J Hand Surg [Am]. Jul 1984;9(4):541-7. [Medline].
Goldfarb CA, Klepps SJ, Dailey LA, et al. Functional outcome after centralization for radius dysplasia. J Hand Surg [Am]. Jan 2002;27(1):118-24. [Medline].
Catagni MA, Szabo RM, Cattaneo R. Preliminary experience with Ilizarov method in late reconstruction of radial hemimelia. J Hand Surg [Am]. Mar 1993;18(2):316-21. [Medline].
Raimondo RA, Skaggs DL, Rosenwasser MP, et al. Lengthening of pediatric forearm deformities using the Ilizarov technique: functional and cosmetic results. J Hand Surg [Am]. Mar 1999;24(2):331-8. [Medline].
Ponde V, Athani B, Thruppal S. Infraclavicular coracoid approach brachial plexus block for radial club hand repair. Paediatr Anaesth. Sep 2007;17(9):863-6. [Medline].
Keywords
radial clubhand, radial deficiency, pre-axial deficiency, preaxial deficiency, forearm deformity, hand deformity, congenital hand deformity, thumb hypoplasia, Holt-Oram syndrome, cardiac septal defects, thrombocytopenia with absent radius, TAR, Fanconi anemia, aplastic anemia, VACTERL syndrome, cleft palate, clubfoot, kyphosis, scoliosis, torticollis, rib deformities, congenital spinal deformity
