Sunday, July 12, 2015

Pollicization- concerns immediately after surgery

Pollicization, or the creation of a thumb, is a fantastic procedure that creates a hand that is more functional and looks better.  It is certainly a specialized procedure in that most hand surgeons don't perform this surgery.  I do believe that this is a surgery that is best performed by surgeons that do at least several of these each year.  If this is the case, the surgeon is familiar with the procedure, the specific tricks and tips in performing the surgery, and understands what to worry about.  That is, the problems that can happen around the time of surgery and the problems that can appear months or years later.  I have blogged several times about pollicization- read here. 

Here is a recent surgery on pollicization.  This case is interesting to me because the child has a thumb- but it is a really small thumb that is completely unstable (i.e., floppy) and a thumb that she does not use.  In the US, most of congenital hand surgeons agree that this thumb is best treated with a pollicization (in Asia, some surgeons will stabilize this thumb).  However, this is a tough conversation for the family (it is easier to discuss a pollicization when there is no thumb).

Hypoplastic thumb Type 3B

Second view of a hypoplastic thumb, type 3B

Successful pollicization

Second view of successful pollicization
So this child did well in surgery and just after surgery.  The color of the thumb was good.  We carefully watch kids in the recovery room and also typically overnight in the hospital.  We want to make sure the thumb does not turn white (which means not enough blood flow in) or purple (which means that there is not enough blood flow out).  In this case, all looked good.

Mom called 3 days later to say that she was concerned about the color of the thumb and we asked her to bring the patient in to be seen.  The thumb did look slightly darker but not dramatically so.  We loosened the dressing and it looked somewhat better.  

Pollicization position and color of the thumb.

Slightly dark thumb after pollicization.

We elected to continue to carefully watch the patient.  Rarely, in the situation when thumb clearly does not look healthy, a return trip to the operating room is required.  In my experience, that has only very, very rarely been necessary and it has been immediately after pollicization.

Charles A. Goldfarb, MD
My Bio at Washington University

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