Hand Conditions & Brachial Plexus

Melanie Cole (Host): Hand disorders in children are more common than people realize and there are many new treatments to help children with various hand conditions such as syndactyly and polydactyly. Pediatric hand surgery is a growing field that takes extra precise skills plus the caring nature of working with children. My guest today is Dr. Felicity Fishman. She’s a hand and upper extremity surgeon at Shriners Hospital for Children – Chicago. Welcome to the show Dr. Fishman. What are some of the most common hand conditions that you see every day?

Dr. Felicity G. L. Fishman, M.D. (Guest): Well everything that we see at Shriners can range from traumatic conditions from kids who fell off their skateboard or the monkey bars all the way to congenital issues with which kids are born or things that can happen at the time of birth like brachial plexus birth palsy. So, some of the common congenital things that we see in kids are polydactyly which is too many or hypoplasia which would be too few or two small and sometimes we see things like syndactyly which is webbing of the fingers.

Melanie: If a parent comes to you, is this something that would be seen in utero; syndactyly or polydactyly? Would we know before the child is born?

Dr. Fishman: So, as technology advances, more and more families are finding out with prenatal ultrasounds but it’s not always something that you know in advance. But, a fair number of families now, have a heads up prior to the birth with one of the ultrasounds. It’s not a perfect science, so sometimes it’s hard to tell on such a small hand whether the fingers are linked or if there is the correct number. Because sometimes kids will hide their fingers and it will be different when the baby is born. But more and more people are having this knowledge before the child is born and sometimes we even do prenatal consultations to talk about what it might be like after birth.

Melanie: What are parents’ main concerns, Dr. Fishman?

Dr. Fishman: Well everybody wants their child to be “perfect” or normal. And so, I think their concerns are how the child will function with whatever hand difference or upper extremity difference they are born with and whether they will have pain, how many surgeries they might need to have and what the appearance will be.

Melanie: Is treatment always necessary?

Dr. Fishman: Treatment is not always necessary depending on the condition and I think our main goal is to work with both the parents as well as the child when the child is old enough to participate in their care; to make sure that we are doing things for the child and not to the child. So, we always want to make sure that we are helping to improve function or cosmesis if that’s something that the family desires to address.

Melanie: What type of treatments do you offer? What are available for these types of conditions?

Dr. Fishman: So, for syndactyly; we often suggest separating the fingers and the timing depends on which fingers are joined and our goal is to give each kid four fingers and a thumb if that is possible. So, if they have webbing between two fingers, we want to address that so that they have more mobility and a bigger hand spread. For kids who have polydactyly, meaning too many of either a thumb or something along the small finger side; then we want to reconstruct the hand to make it the most functional it will be and hopefully leave them again with four fingers and a thumb if possible.

Melanie: What’s the prognosis? If a child has this type of procedure; how early in their life do they have it and then what’s range of motion in their hands? Is anything else affected?

Dr. Fishman: So, it depends on the degree in which they have each congenital difference. So, for some kids having a polydactyly, it might just be a small extra digit that doesn’t have all the other parts involved in it and that may be a very simple reconstruction that leaves them with a small scar and essentially no sequelae as they grow older or they can have a very involved finger or thumb in which neither of duplicated parts really make up a full single part and for those kids they do have some functional deficit of that digit. But one of the best parts about working with children is that they are incredibly adaptable and that is the normal for them and so they typically do quite well because they are able to adapt and figure out ways in which to be successful with what they have.

Melanie: And how early in life do you do these procedures, generally?

Dr. Fishman: Usually between age one and three if we are able to do that. So, around two years of age is a pretty common time to be having any of these surgeries, but sometimes as young as one year of age.

Melanie: And now what is brachial plexus? People have heard this term. They are not sure what it is. Explain a little bit about what it is? Is it congenital or trauma-based?

Dr. Fishman: Sure, I’m not sure it actually fits in either one of those categories, truly. The brachial plexus is a collection of nerves that come out of your spinal cord in your neck area and then helps to innervate your entire arm. So, basically, it provides all of the sensation and all of the motor power for all of the muscles of your arm. And when a baby is born, these nerves can get stretched depending on the birth itself as well as multiple other factors depending on the size of the baby and other things. And what happens when the nerve is stretched is that it doesn’t work very well, and we are not able to see at the time of birth how severe the injury is to the nerve; we can only see that the arm isn’t working because of some sort of injury to the brachial plexus. So, it is not necessarily trauma per se, because about 50% of these kids don’t have any risk factors or any issue with labor or birth that we can actually identify. But it is also not congenital, other than the fact that the child is born with it.

Melanie: So, what do you want parents to know? Are there – you mentioned their arm may not be working. At what age should those red flags be something they call their pediatrician about?

Dr. Fishman: So, this is typically diagnosed at birth because they have great checklists for when babies are born to make sure that everything is moving symmetrically with the child. So, it is typically something that is discovered at the time of birth and although the pediatrician is usually happy to follow along for a month or two; I would really love to see these kids as early as possible so that we can compare their exam over the first six months. So, ideally, I would see these babies within the first one to two months if possible. But about 80% of the kids will get better on their own without having any intervention.

Melanie: That was going to be my next question in the less severe injuries will babies regain their function? Nerves take a long time to heal. So, what do you look at as the prognosis for these babies and when is intervention necessary?

Dr. Fishman: Sure so, within the first six months of age we are examining the babies on a monthly basis if they still have a deficit after birth. And again, 80% of them are going to get almost all the way better on their own or better enough so that I don’t need to help them with surgery, which is great. And so, we are literally just performing a physical exam every month and the parents are observing and stretching and helping to tell us what they are doing with the arm and what they are not. If by about six months of age, they haven’t regained certain functions of the arm; then that’s when we would talk about considering microsurgery. If there is no motion at all of the arm from the time of birth up to about three months; we might consider even earlier performing microsurgery which is an exploration of the nerves themselves with potential grafting from other nerves in the body versus potentially taking nerves that are working and helping to make the nerves that aren’t working to work better.

Melanie: Is this something that can happen to older children as a result of contact sports or some sort of traumatic injury?

Dr. Fishman: Sure. Brachial plexus birth palsy which is what we are talking about or obstetrical birth brachial plexus palsy is what happened at the time of birth but certainly you can have a traumatic brachial plexus injury from a car accident, or any other trauma really which certainly could include a contact sport, but is a lot more frequently seen in something like a car accident in an older child.

Melanie: So, is it something that you deal with as well in older children?

Dr. Fishman: Yes, older children and adults, absolutely.

Melanie: So, their treatment would be different because they can speak about it, they can tell you what’s going on or what they are feeling or any tingling or numbing or so then what’s the course of action depending on how severe it is? Is occupational, physical therapy intervention required? What do you do for them?

Dr. Fishman: So, for older folks who have a traumatic injury such as a teenager who might have had a brachial plexus injury because of a car accident, we would certainly have therapy work with them to make sure that the arm stays nice and subtle so that it can be moved passively. And then our options would consist of exploration of the area of injury with possible repair of nerves, possible grafting of nerves and then later we would consider doing tendon transfers or nerve transfers to try and improve the function of the arm if it doesn’t improve on its own with therapy and time.

Melanie: And so, wrap it up for us Dr. Fishman, with your best advice or information that you want parents to know about the field that you are in as a wrist and hand surgeon and being able to do these kinds of precise procedures and work with children and what parents should know about it.

Dr. Fishman: So, I think the services that we offer at Shriners are wonderful in that it’s a kid-friendly environment, clearly being a children’s hospital and that being able to offer such a high level of specialty care means that if you have unique problems or basic trauma that we can provide all of that in one place which is great, since we have therapy there. We have specialists pretty much for any part of the care that they would need, all the way from the operating room to therapy to our clinic staff. So, it’s a wonderful privilege to be able to treat kids with these differences and to help to make them better or more functional.

Melanie: Thank you so much Dr. Fishman, for being with us today. This is Pediatric Specialty Care Spotlight with Shriners Hospital for Children – Chicago. For more information, please visit www.shrinerschicago.org that’s www.shrinerschicago.org . This is Melanie Cole. Thanks so much for listening.