Principles of Reconstructions of Pediatric Hand.pptx
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This document discusses principles of reconstructing a child's hand. It begins by covering hand physiology and architecture, emphasizing the importance of restoring sensibility, motion, and strength. Nerve function and regeneration is discussed next, noting better outcomes in children. The architecture of the hand is then described as having fixed and mobile components. Planning reconstruction involves addressing the fixed unit's stability first before mobile structures. Evaluation of the child considers cooperation, anesthesia risks, tissue healing, and establishing reasonable goals and timelines.
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Principles of Reconstructions of Pediatric Hand.pptx
- 1. Principles of Reconstruction Dr. Mohammad Taqi Ehsani PGY1 of Orthopedics, FMIC
- 2. Contents: • Architecture and Hand Physiology • Nerve Function: Sensibility and Power • Architecture of the Hand • Planning Reconstruction • Evaluation of the Child for Reconstruction
- 3. Architecture and Hand Physiology • Successful reconstruction of a child’s hand relies on the well established principles of hand surgery developed for adults, with some special considerations for children • reconstruction is based on understanding the architecture and physiology of the hand as an organ of motion, strength, and sensibility • A short discussion of mechanics and function of this unique element of the musculoskeletal system is appropriate • any surgeon’s reconstructive plan must, as much as possible, restore sensibility, motion, and strength
- 4. Nerve Function: Sensibility and Power • The primary consideration in any hand reconstructive procedure is the ability of the hand to feel • Wilder Penfield’s homunculus illustrates the great importance given to the hand by the sensory cortex of the brain • operations designed to improve the appearance of a crippled upper limb are an important part of reconstruction, the child’s ability to feel with and protect the hand is essential for improving hand use
- 5. Nerve Function: Sensibility and Power • the child’s ability to feel with and protect the hand is the fundamental reason for failure of long-term use of upper limb prostheses • the results of all peripheral nerve reconstructions are considerably better in children than in adults, due to: • central reintegration of the defective signal from the periphery • less to faster or better growth of axons • the shorten distances of axonal growth needed in a child’s shorter limb • the nerve injury must be recognized, repaired, and held in contact long enough for the child to realize these advantages • the aftermath of nerve injury is not always more favorable in children than in adults • in very young and rapidly growing children, nerve injuries can affect the length of growing bones, as well as the shape of joints
- 6. Architecture of the Hand • Reconstruction of the complex function of the hand can be facilitated by dividing its mechanics into two components, a fixed portion surrounded by a collection of mobile units • The fixed component is made up of the index and long finger metacarpals and the distal row of carpal bones. These six rigid bones form two arches at right angles to one another
- 7. Architecture of the Hand • The transverse arch formed by the distal carpal row is a semicircular arch. • The fixed unit of the hand is the foundation of all hand motion and power for practical purposes, no movement occurs between these bony elements • The stability and alignment of this combined “foundation” are controlled in space by the strong flexor and extensor muscles of the wrist
- 8. Architecture of the Hand • The mobile components include three groups of movable parts • The first part is the highly mobile thumb ray radiating off the radial volar side of the fixed unit. Its complex conical motion and great strength are the result of a collection of the three joints empowered by the intrinsic and extrinsic muscles of the thumb • The second mobile component consists of the two minimally mobile ulnar metacarpals, which in conjunction with the thumb, allow flattening and cupping of the palm • The third and highly mobile component is made up of the 12 bones of the four fingers
- 9. Architecture of the Hand • The interaxial lengths of these bones make it possible for the sensate fingertip to move in a motion commonly found in nature—the equiangular spiral • This spiral motion of the fingers accounts for the adaptability of the hand to objects of any size and is a consequence of the fact that the distance between the axes of the joints of the bones of the finger precisely follows the Fibonacci sequence. (A) It is the consequence of an arrangement of the distances between the joint axes in a sequence described by the Italian mathematician Fibonacci: 0, 1, 1, 2, 3, 5, and so forth (B) Because the equiangular spiral is a circle with a continuously increasing radius, it provides an infinite variability in the size (radius) of objects that the digit can surround
- 11. Planning Reconstruction • First: address restoration of the fixed unit’s stability in reconstruction of any complex hand injury or anomaly • Fusions and osteotomies are used to restore the two arches and their stability • Wrist fusion: When adequate power in the wrist motors is absent and transfers are not available, wrist fusion is required to allow the fingers and digits to experience the motion provided by the muscles originating above the wrist • In general, operations to restore the fixed unit or other elements of the skeleton require prolonged immobilization. • As soon as skin coverage is achieved, bone reconstruction takes priority. • Bone reconstruction must not be combined with operations that require early movement such as tenolysis, tendon repair, or tendon transfer.
- 12. Planning Reconstruction • Reconstruction of the mobile portion of the hand requires wrist stability, flexible digital joints, gliding tendons, and the combined power of the extrinsic and intrinsic muscles. • Without the balanced function of these four components, the long cantilever of the wrist and multiarticulated finger falls into the familiar claw deformity • Although children maintain joint mobility and tendon gliding better than adults do, the surgeon must be certain that passive motion of joints has developed before adding active muscle power. • If the surgeon cannot move the child’s joints easily with his or her own hands, it is not possible that the child’s diminutive muscle that the surgeon transfers to the area can move them.
- 13. Planning Reconstruction • Synergy of wrist and finger motion: • Active finger extension cannot be restored without wrist flexion power that is at least equal to the power of the extrinsic finger extensor muscles. Conversely, finger flexion requires active, strong, simultaneous contraction of the wrist extensor • The inability of a patient with radial nerve palsy to make a fist is convincing evidence of this critical synergism • When the synergistic wrist motor is not available, wrist arthrodesis is required.
- 14. Evaluation of the Child for Reconstruction • Guidelines from adult surgery are important, but some additional factors need to be considered before embarking on reconstruction in children. • Such factors: • the child’s variable and often limited ability to cooperate in the postoperative period • the risk associated with anesthesia in early life • the size of the structures • absence of critical parts • the need for growth • occasionally the reduced life span of some patients with particular congenital syndromes. • The goal is to get the best result with the least insult to the limb. This is important because the healing capacity of the tissues is compromised by repeated operations.
- 15. Evaluation of the Child for Reconstruction • Useful guidelines for decision making in complex reconstruction problems: 1. What is the patient’s problem? This question must be answered after the diagnosis has been made. Sometimes it can be difficult to get children or parents to verbalize how their problem really affects their daily lives. The surgeon must observe and listen carefully to both the parent and child to discover the child’s exact needs. 2. Goals of treatment, short and long term. • Treatment of the patient’s short-term goal requires the surgeon to remain focused on the patient’s problem, as noted previously, and to detect losses that are critical to the patient’s daily life. Reduced to its basic elements, the hand needs the power of pinch and grasp with durable, sensate coverage. • The long-term goal of treatment is to make the patient as independent as possible.
- 16. Evaluation of the Child for Reconstruction 3. Reasonable methods to achieve these goals. The key here is reasonableness. Surgeons must carefully consider the probable responses of the child, the parent, and the tissues of the child’s hand to the planned operation. In addition, surgeons must realistically evaluate what they can actually deliver in the operating room and postoperative period. 4. Reasonable time schedule. Both the surgeon and the family find comfort when a realistic time schedule is agreed on at the beginning. This schedule may need revision later, but the child’s exit from the medical environment should not be delayed more than necessary. Although follow-up to the treatment is important, the final goal of all surgery is maximal independent life for the patient. When a treatment plan is open ended, the child and parent tend to delay taking responsibility for this ultimate goal.
- 17. Evaluation of the Child for Reconstruction 5. Outcome evaluation method. All too often, failure to take preoperative photographs, to measure and record joint angles and grip strength, and to perform functional tests before treatment renders an honest, accurate assessment of the result at the end of treatment impossible. This is as important as establishing the type of treatment.