Dr Steve Carter


Congenital Hand Surgery

I have been doing congenital hand surgery for the past 11 years at the Red Cross Children's Hospital, as Head of the Congenital Hand Unit.

Congenital hand surgery is part science and part art, part plastic surgery and part orthopaedic surgery, and so requires a number of years to develop the necessary skills.

Each congenital case is unique and different and treatment has to be tailored to the individual.

Our aim is function before form so whatever surgery is required is individually designed to create the greatest functional impact.

These young children have a remarkable ability to adapt to their circumstances. Imagine being able to tie your shoelaces with no fingers on both hands!

Be it a simple polydactyly to more complex cleft or radial club hand. We will be able to assess and treat so that the child has the best possible function.

Swanson's Criteria for Congenital Hand Surgery

Swanson's criteria is probably the most commonly used system to differentiate the different types of Congenital conditions of the hand and wrist, and thereby create a usable classification sytem:

  1. Failure of formation
  2. Failure of differentiation (separation)
  3. Duplications
  4. Overgrowth
  5. Undergrowth
  6. Constriction band syndrome
  7. Generalized skeletal abnormalities

Although I am not going to give an exhaustive review of each condition, I would like to give you some examples of the conditions I have treated over the last ten years.

  1. Symbrachydactyly. A classic example of failure of formation whereby one or more of the fingers fails to form. There is often a useful thumb and perhaps little finger. The other fingers are not present and there is only a small soft tissue nubbin. A very useful surgical procedure to give some length to the fingers is to do a free toe phalangeal graft, whereby we take a bone out of the toe and place it in the finger, very often there is a flexor and extensor present in the hand which we are able to attached to the toe bone (phalanx) so that we get some movement out of the finger. The goal is to achieve a hand with improved length, stability and movement for prehension to occur. At the 2012 SASSH Congress I presented on 18 non vascularized free toe phalangeal grafts with very good outcomes. To date we have done a further 10 non vascularized toe phalangeal grafts. See ppt presentation.
  2. The Cleft Hand. The cleft hand is a rare condition which combines both failure of formation and failure of separation. It occurs in 0,14 to 1,4 per 10 000 live births. Inheritance is either sporadic or Autosomal dominant (runs in families, may often be an associated cleft foot deformity). The goals of surgery in the cleft hand are:
    • closure of the cleft
    • release of the thumb adduction deformity
    • release of Symdactylies
    • correction of deviation of joints
    I have used the Snow and Littler procedure with great success for this condition. In 2007 at the SASSH Congress I presented on 6 Snow and Littler procedure done on 20 cleft hands. Subsequent to this I have done a further 8 cleft hands. See ppt presentation.
  3. Duplicated Thumb (Radial Polydactyly). Accounts for 6-7% of all Congenital hand defects. The duplicated thumb was classified by Wassel in 1969 and it is based on at what level the extra thumb arises from. This obviously influences the type of surgery that is performed to remove the extra thumb. In terms of my surgical principles the goal is a functional thumb and for this I aim for:
    1. Adequate skeletal and soft tissue bulk
    2. Joint stability
    3. Joint motion
    4. Thumb alignment
    5. Tendon & muscle function
    6. Cosmesis
    In 2008 at the SASSH Congress I presented on our 5 year results in 29 patients with 35 duplicated thumbs showing overall very good functional results. See ppt presentation.
  4. The Windblown Hand. The Windblown hand also known a Congenital ulna drift, is an extremely rare condition. It can be classified under Swanson's criteria as a generalized skeletal abnormality. There are three essential features:
    1. Thumb adduction and flexion contracture
    2. Ulna drift of the fingers at the metacarpophalangeal joint
    3. Flexion contracture of the fingers
    We have one of the biggest series in the world. I presented on our results at the SASSH Congress in 2011 and won the Stratmed prize for the best research paper.
  5. Radial Club Hand. This is another example of failure of formation whereby the whole radius or part thereof fails to form, very often this is accompanied by failure of formation of the thumb. It is classified by Bayne and Klug into 4 different types depending on the length of radius that is present. Because the radius is missing the wrist is not supported so it sits at a right angle to the forearm. Treatment is a surgical correction whereby the wrist is centralized onto the remaining ulna bone, so that the wrist and forearm are now aligned. This gives vastly improved function of the wrist and fingers. The second stage of the procedure is 6 months later, where we make a new thumb for the patient. This procedure is called a Pollicization, whereby we use the index finger and convert it into a thumb. It is a very technical procedure, but our results have been good with pinch grip and mobility of the new "thumb". I have recently presented at the SASSH Congress 2014 on my results with the use of the Evans Bilobed flap in the management of radial club hand.