Microsurgery is undoubtedly the pinnacle of hand surgery. Significant advancement in recent years has stretched the indications for toe-to-hand transfer in both acquired and congenital hand defects to restore function, esthetics, and motion, with minimal morbidity to the donor site. There is no one fixed microsurgical transfer technique but a surgeon\'s versatility and innovation in using what one could spare because each case is unique. Esthetic refinements and reducing donor site morbidities have taken a front seat in recent years. We present a few cases to put forward the senior author\'s preferred techniques with this objective in mind.

OBJECTIVE: We attempted a technique for patients with congenital ring-little finger metacarpal synostosis involving simultaneous interpositional allograft bone after split osteotomy of the synostosis site and distraction lengthening of the fifth metacarpal along with correction of the metacarpal joint abduction contracture. The purpose of this study was to describe the surgical technique and its outcomes.
METHODS: We reviewed the medical records of children with congenital ring-little finger metacarpal synostosis treated surgically at our institute. Eight hands of six children with an average age of 5.0 (range, 1.7-9.3) years were treated by simultaneous interpositional allograft bone after split osteotomy, distraction lengthening, and tenotomy of abductor digiti minimi. We measured the metacarpal head-to-capitate area ratios from serial radiographs and analyzed them according to age. We also measured the change in the intermetacarpal angle (IMA) and metacarpal length ratio during an average of 8.1 (range, 1.4-16.8) years of follow-up. These changes were compared with changes in seven hands of five children with an average age of 8.1 (range, 1.5-15.6) years treated by the same method, but without a distraction lengthening of the fifth metacarpal and followed up for an of average 12.1 (range, 4.1-19.8) years, as a control group.
RESULTS: Abnormal metacarpal head-to-capitate area ratio before surgery was normalized in all patients within the first 2 years after surgery. The IMA change averaged 39.8°, and the metacarpal length ratio changed by 17%. The control group showed an average IMA change of 36.6° and metacarpal length ratio change of 6%.
CONCLUSIONS: Simultaneous interpositional allograft bone after split osteotomy of the synostosis site and distraction lengthening of the fifth metacarpal with correction of metacarpal joint abduction contracture can restore the radiographic parameters in congenital ring-little finger metacarpal synostosis. The normalized ossification of the fifth metacarpal head indicates that the surgical procedure is probably safe.
METHODS: Therapeutic V.

This study describes mental health and psychosocial screening processes, access to care and interventions provided to children with upper limb musculoskeletal conditions. A cross-sectional e-survey study was conducted of 107 healthcare professionals who work with children with congenital hand and upper limb differences and brachial plexus birth injuries. Of them, 41 (38%) reported that they routinely screen for mental health and psychosocial concerns. Few (12%) reported the use of standardized outcome measures. In total, 51 (48%) healthcare professionals reported that there was a waiting list for mental health services at their institution. Collectively, healthcare professionals were unsatisfied with the staffing, access to care and types of interventions available. Reported barriers to care included the growing need for mental health support, lack of resources and poor continuity of care after referrals. Future research should focus on identifying and validating a mental health screening tool and investigating the processes affecting access to mental health care.Level of evidence: IV.

UNASSIGNED: The aim of the study is to assess the readability of online patient education materials (PEMs) for congenital hand differences.
UNASSIGNED: The top 10 online, English-language PEMs for 10 conditions (polydactyly, syndactyly, trigger finger/thumb, clinodactyly, camptodactyly, symbrachydactyly, thumb hypoplasia, radial dysplasia, reduction defect, and amniotic band syndrome) were compiled and categorized by source and country. Readability was assessed using 5 tools: Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman-Liau Index (CLI), and Simple Measure of Gobbledygook Index (SMOG). To account for the potential effect of each condition\'s name in the aforementioned formulas, the analysis was repeated after replacing the name with a monosyllabic word/s.
UNASSIGNED: The mean readability scores of the 100 PEMs were FRES 56.3, where the target was ≥80, FKGL 8.8, GFI 11.5, CLI 10.9, and SMOG 8.6, and the median grade score was 9.8, where the target grade was ≤6.9. Following adjustment, all readability scores improved significantly (P < .001). Postadjustment scores were FRES 63.8, FKGL 7.8, GFI 10.7, CLI 9.1, and SMOG 8.0, and the median grade score was 8.6. Only 1 webpage met the target level using all tools. Two-sample t test for country of publication (the United States and the United Kingdom) demonstrated that PEMs originating from the United Kingdom were easier to read using the preadjustment CLI (P = .009) and median grade metrics (P = .048). A 1-way analysis of variance revealed no influence of condition or source on readability.
UNASSIGNED: Most online PEMs for congenital hand differences are written above the recommended reading level of sixth grade, even when adjusted for the effect of the condition\'s name.

OBJECTIVE: Syndactyly surgical release is one of the most common congenital hand surgeries performed by pediatric hand surgeons. The purpose of our study was to evaluate the complications associated with syndactyly release and determine factors that correlate with higher complication rates within the 2-year postoperative period.
METHODS: A retrospective chart review was completed for patients who underwent syndactyly release at a single pediatric center between 2005 and 2018. Patients were included if they had a diagnosis of syndactyly and underwent surgical release, and excluded for a diagnosis of cleft hand, incomplete surgical documentation, surgery performed at an outside institution, or follow-up care that did not extend beyond the first postoperative visit. Complications were classified using the Clavien-Dindo (CD) system.
RESULTS: Fifty-nine patients met the inclusion criteria, which included 143 webs released in 85 surgeries. A total of 27 complications occurred for the 85 surgeries performed. The severity of complications was CD grade I or II in 23% of surgeries, most commonly unplanned cast changes, and CD grade III in 8% of surgeries. No CD grade IV or V complications occurred. The CD grade III complications included 6 reoperations. The complication rate was higher when performing >1 syndactyly release per surgery. It also was higher for patients undergoing >1 surgical event. Rates of complication per surgery were similar between patients with multiple surgeries compared with those with a single surgery. Concomitant diagnoses and complexity of syndactyly was not associated with a higher complication rate.
CONCLUSIONS: Syndactyly release was associated with a complication rate of 31% per surgical event with 44% of these complications related to unplanned cast changes and 8% of complications that required admission or reoperation. Risk factors for complications following syndactyly release include >1web operated on per surgery and undergoing >1 surgical event.
METHODS: Prognosis IV.

Pediatric wide-awake local anesthesia no-tourniquet technique (WALANT) hand surgery is feasible for the treatment of the spectrum of pediatric hand surgeries, which can include traumatic injuries and congenital hand differences. The key component for success is identifying the appropriate patient for this technique, with the typical patient frequently being >10 years of age. The discussion with the patient and adequate preparation for maximum efficiency become key for patient and surgeon comfort. Here we describe a practical approach for successfully performing this valuable technique for the pediatric population.

Background: In resource challenged nations, the true magnitude of the congenital hand differences (CHD) remain unknown due to a lack of nation-wide surveillance system. We created a hospital-based registry system with the aim to determine the prevalence and distribution of CHD and compare the Swanson/IFSSH (SI) and Oberg, Manske and Tonkin (OMT) classifications. Methods: Data of children aged 0 to 18 years with CHD was entered into the online registry and classified based on the SI and OMT classifications from January 2018 to December 2021. The prevalence and distribution of CHD and risk factors like family history were summarised using descriptive analysis. Syndromic and heredity associations were further analysed using Fischer exact test and odds ratio. Clustered columns were used to compare the two classification systems. Results: A total of 307 patients with CHD presented during the study with a prevalence of 2.4/1,000 patients. Among them, 164 were unilateral, 21 were born of consanguineous marriages (7.6%) and 10 (3.6%) had a family history of CHD. Although not statistically significant, bilateral involvement was twice as likely to be hereditary compared to unilateral involvement. A total of 10 different syndromes were identified among 27 patients of which Holt-Oram syndrome was most common. The most common CHD was Radial longitudinal defificiency (111). A total of 82 (27%) children had other associated anomalies that could not be grouped as a syndrome. Two patients could not be classified using either SI or OMT classifications. Conclusions: The online registry established an efficient way to store and analyse data related to CHD. It provides new information on its prevalence in South India, which is similar to the existing literature. Most of the CHD can be grouped in both the SI and OMT classifications. However, there still remains some conditions that are unclassifiable. There is a need for a national registry of CDH for effective management, funding and research. Level of Evidence: Level IV (Epidemiological).

Background: Children with congenital differences who require prosthesis, have special needs due to their growth and psychosocial factors. Cosmetic or body-powered prosthesis provides basic functional needs but poses a financial burden on the family. Prostheses with advanced functions need to be deferred until adulthood. 3D printed prosthesis is a novel alternative being cost-effective for children. Since limited literature is available on the functionality of 3D printed prosthesis and none in the South Asian population, this study was done to assess its utility in congenital hand amputations. Methods: Fourteen children with congenital hand amputations were selected for a prospective observational study. Unilateral below Elbow test (UBET), Box and Block test and ABILHAND questionnaire were used for assessment with and without prosthesis after six months. Results: Eleven patients completed the follow-up. Box and Block test improved from a mean score of 24 to 35 with the prosthesis implying an improvement in manual gross dexterity (p -0.049). UBET (p -0.002) and ABILHAND questionnaire (p < 0.001) showed a decrease in score with the use of a prosthesis which suggested a lack of lateral and tripod pinch in the current design of a prosthesis. Patients with below elbow prosthesis performed better. Conclusions: 3D printed prostheses are an excellent option for use as a transitional prosthesis as they are inexpensive, serves to improve needs with respect to grasping activities at both wrist and elbow level amputation and customizable according to patients\' need and limb deficiency and replaceable as the child grows with age. Current designs are useful with respect to grasping activities.

The purpose of this article is to provide information about the changing landscapes in research, treatment, civil rights\' protection, disability awareness, and accepted terminology in the care of children with congenital upper limb differences. This knowledge can guide clinical and nonclinical conversations between patients and their families.

BACKGROUND: Prenatal ultrasonography for the detection of fetal structural anomaly is an important component of antenatal care. During the assessment, proximal limb deformities are readily diagnosed. Distal limb, especially digit, abnormalities, however, may be difficult to detect, particularly if the ultrasonography is performed in the third trimester, and the deformity is unilateral and isolated.
METHODS: A 24-year-old primigravida booked for antenatal care with a general practitioner had threatened miscarriage at 12 weeks of gestation, and at 34 weeks was referred to an obstetrician for further care and delivery. The growth ultrasonographic examination was normal but at 40 weeks of gestation she developed antepartum haemorrhage of unknown origin. She had a caesarean delivery and a female baby with \"rudimentary\" left fingers (\"isolated symbrachydactyly\") was delivered. The parents were counselled and they declined further assessment of the baby by a hand surgeon and a clinical geneticist. At 3 years of age, the baby had normal development and \"is using her hand even without fingers,\" according to the mother.
CONCLUSIONS: Collaborative goal-directed antenatal care that involves different categories of healthcare professionals, but particularly a certified sonologist who performs fetal anomaly ultrasonography, is essential for the detection of congenital hand defects. Adequate counselling is essential for the satisfaction of the baby\'s family.