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| ORIGINAL ARTICLE |
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| Year : 2014 | Volume
: 28
| Issue : 3 | Page : 149-153 |
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The milk anesthesia management of neonatal accessory digits: The 6 year Coventry and Warwickshire experience
Zeeshan Ahmad, Alan J Park
Department of Plastic and Reconstructive Surgery, University Hospitals Coventry and Warwickshire, Coventry, Warwickshire, West Midlands, United Kingdom
| Date of Web Publication | 5-Jan-2015 |
Correspondence Address:
Zeeshan Ahmad
Department of Plastic and Reconstructive Surgery, University Hospitals Coventry and Warwickshire, Coventry, Warwickshire, West Midlands CV2 2DX
United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-4958.148496
The authors present their experience of the surgical management of accessory digits in neonates during a 6 year period (2006-2012). During this period a total of 135 cases were operated on using local anesthetic only when neonates were less than 8-10 weeks old. Through close relations with the local pediatricians, this pathway enables prompt and appropriate management, which is safe and obviates the need for general anesthesia. This paper highlights that managing this condition surgically can be performed in an appropriate pediatric setting safely solely under topical and local anesthesia with excellent cosmetic results as pediatric day-case procedures. Keywords: Milk anesthesia, Neuroma, Polydactyly
How to cite this article:
Ahmad Z, Park AJ. The milk anesthesia management of neonatal accessory digits: The 6 year Coventry and Warwickshire experience
. J Med Soc 2014;28:149-53 |
How to cite this URL:
Ahmad Z, Park AJ. The milk anesthesia management of neonatal accessory digits: The 6 year Coventry and Warwickshire experience
. J Med Soc [serial online] 2014 [cited 2022 May 21];28:149-53. Available from: https://www.jmedsoc.org/text.asp?2014/28/3/149/148496 |
| Introduction | |  |
Amongst the clinical problems presenting to plastic and reconstructive surgeons, congenital problems represent a significant portion of the clinical case-mix. Within the many subspecialties of plastic surgery congenital conditions such as hypospadias, cleft and craniofacial disorders, vascular malformations comprise the majority of cases presenting to pediatric plastic surgeons.
Congenital hand conditions are common and estimated to occur in at least 2.3 per 1000 of total births. [1] Many of these conditions are relatively minor and do not affect function. Polydactyly and syndactyly are the most common congenital hand conditions for which treatment is sought. However, they may be noticed by the parents and others who may seek advice about them. Some congenital anomalies are severe and affect function. In addition, the appearances of the deformities have significant psychological impact on both the parents and child. This paper portrays our 6 year experience of managing this condition surgically and demonstrates that this clinical problem can be safely managed under topical local anesthesia as pediatric day-cases with excellent cosmetic results.
Classification
Congenital hand anomalies can present in numerous ways; there can be failure of development, overgrowth and duplication amongst others. The Swanson Classification adopted by the American Society for Surgery of the Hand (ASSH) and the International Federation of Societies for Surgery of the Hand (IFSSH) addresses these variations [Figure 1]:
Nomenclature
Polydactyly, defined as an excess of digits or parts in the hand or foot, is the most common type of congenital anomaly in the upper limb. In this paper, the authors refer to post-axial polydactyly or ulnar duplication. Historically known as pedunculated postminimus duplication on the ulnar border of the hand is also called post-axial and fifth finger duplication. Purist hand surgeons tend to refer to the pre-axial and post-axial hand, which makes reference to true developmental origin of hand as it runs down the humerus through the ulna to the fifth ray of the hand. [2] The fifth ray is the only post-axial digit, and by definition the other three digits are pre-axial. Therefore ulnar duplication may represent a more appreciable term. Several classifications have tried to address the extent of the duplication with respect to presence of a neurovascular bundle or bony articulation as presentation can vary from a well-formed single phalanx to a skin tag. [6] Others however simply classify them into type A, a hypoplastic digit with well-formed parts and skeletal union with the fifth ray and type B, rudimentary nubbins jointed only by a soft tissue bridge [Figure 2]. [7] | Figure 2 : The temtamy (left) and stelling (right) classification of ulnar duplication [With permission from Elsevier, In: Mathes, Plastic Surgery 2nd Edition, Volume 8, Page 245]
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Genetics
Duplication deformities are the most common of all congenital differences of the upper limb and ulnar post-axial polydactyly is by far the most common duplication. In USA and UK, ulnar duplication are approximately seen ten times more frequently in black patients (1 in 300) compared to their white counterparts (1 in 3000). [4],[5] Ulnar duplication in whites is more likely to be associated with an underlying syndrome (40 syndromes including trisomy 13 and 18, achondroplasia, Cornelia de Lange and cleft lip have been identified by geneticists) compared with blacks who will rarely show any signs of an associated anomaly. Frequently inherited in an autosomal dominant pattern with variable penetrance, blacks typically exhibit bilateral duplications with strong penetrance affecting successive generations. This is not the case with the white population, where a generation may be skipped.
Etiological factors
The causes of ulnar duplication as with most of the congenital hand anomalies are very varied. Typically they occur either sporadically or as the result of various inherited genetic anomalies. Human limb malformations, like other congenital anomalies are frequently associated with defects in other organs. They are caused by mutations that affect important signaling pathways repetitively used during embryonic development at different times and different locations. [8] Environmental factors, diet, infections and other causes have been implicated but are much less common. The limb-bud develops at between four and 8 weeks of intrauterine life during embryogenesis and most anomalies have already developed by the time the pregnancy is diagnosed. [9]
Religious, ethnic and cultural significance
The significance of accessory digits in patients from different parts of the world should not be overlooked. Conditions including polydactyly, cleft lip and hypospadias are heavily stigmatized particularly in developing countries. Religious, cultural and racial practices vary and as a result such congenital abnormalities can be deemed to signify different things to different people. With reference to the Biblical era, Aramaic and Hebrew tradition, ''the Watchers'' were considered as the angels who came to Earth (Genesis 6:1-4), mated with female humans and sired a race of giants, regarded as the Biblical ''sons of God''. This race was known to be very tall and often had six digits. [10] In other parts of the world, such as areas of Western Africa, children born with polydactyly are thought be future Kings or those ''blessed'' with success and fortune. However, in some areas of Africa the opposite is true, where polydactyly is thought to have negative connotations relating to voodoo and bad spirits. Some argue such occurrences arise due to consanguineous relationships which are common in parts of South-East Asia, the Middle East, the Far East, Africa and South America. [11],[12],[13]
| Materials and Methods | | |
The authors included all patients who underwent a surgical procedure for excision of unilateral or bilateral hand accessory digits at University Hospitals Coventry and Warwickshire between 2006 and 2012. Accessory digits from feet were excluded from the study. The Department of Plastic Surgery prior to 2006 was located at George Eliot Hospital, Nuneaton, Warwickshire. At this facility, there was no provision for neonatal care (including anesthesia and intensive care) and hence procedures on children less than 3 years of age were not routinely performed; such patients had to visit Birmingham Children's Hospital or Leicester Royal Infirmary. Data was retrieved from retrospective case notes review.
Care pathway
Surgical steps
- Prep and drape.
- Local injection using 27G Sterican® needle with 2 ml 50:50 0.5% bupivicaine and 1% lignocaine with adrenaline (1in 200,000).
- Digit excised.
- Bipolar hemostasis using microforceps, setting on 6.
- Closure with 7/0 Vicryl rapide® (absorbable).
- Ό inch Steristrips® .
Post-operative care
- Home when well with Calpol as required.
- Wound check at GP PN.
| Results and Graphs | | |
Hand laterality
Ethnicity
Family history
Complications
| Discussion | | |
Between 2006 and2012, 86 patients (135 digits) were operated on. Of those 135 patients, there were a total of 3 minor complications, including 1 wound breakdown (due to digit sucking by patient), 1 lumpy scar (which resolved with massage) and 1 delayed wound treated with dressings. Overall, this technique has in our series shown to be reliable, reproducible and deliver excellent outcomes. From the results, interestingly 53% of patients had bilateral accessory digits. Further, serving an ethnically diverse region, approximately half of the patients were from black and Asian ethnicities. A significant proportion (13%) had a positive family history, with black and then Asian patients exhibiting higher rates of genetic penetrance. Consanguinity may also explain this amongst Asian patients in particular. No neuromas have been seen amongst this series to date.
Overall, the parents of the patients were very pleased by the overall service, swiftness of treatment and outcome. Indeed the father of one of the patients 'wished' he could have had his accessory digit formally excised rather than 'tied-off' as he now has an exquisitely painful leading edge of the ulnar hand [Figure 6]. | Figure 6 : Residual nubbin and painful neuroma of the ulnar aspect of the left little finger
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The authors feel passionate about this technique due to its simplicity, safety and excellent outcomes. In the authors' opinion managing this condition by string or suture ligation is unacceptable. Undertaking techniques such as this leads to complications including infections, painful and debilitating neuromas, which may affect hand function development as well as aesthetic disfigurement and the psycho-social sequelae thereof. Patillo and Rayan report some severe complications of suture ligation techniques leading to cellulitis and gangrene. [11]
Mullick and Borschel analyzed 13 hands where suture ligation techniques had been used leading to painful neuromas. [12] Their patients underwent surgical procedures under general neonatal anesthesia to correct the residual deformity, subjecting neonates to general anesthesia unnecessarily. This could be avoided if the authors' approach were to have been employed in the first instance. Leber and Gosain compared primary suture ligation to surgical excision in 9 patients. They found that those who underwent surgical excision had excellent cosmesis post-operatively and no neuromas. [13] When suture ligation is employed as a technique, the digital nerves of the rudimentary digit are severed at the level of the skin and cannot retract into the soft tissues. This may lead to a sensitive scar and subsequent neuroma formation. Long-term follow-up from studies employing the suture ligation method reveal high morbidity rates with signs and symptoms of neuroma formation at the ligation site. [12],[14],[15]
A recent paper by Katz and Linder approaches the clinical issue using topical anesthesia in the nursery. [16] The authors feel this practice is unsafe and unacceptable. Such procedures should be performed in a controlled pediatric surgical environment with the benefit of optimal lighting, high-grade surgical equipment and instruments as well as surgical expertise. These procedures should be undertaken by appropriately trained surgeons who have expertise in pediatric and hand surgery working in a center with pediatric set-up and support.
| References | | |
| 1. | Lamb DW, Wynne-Davies R. Incidence and genetics. In: Buck-Gramcko D, editor. Congenital Malformations of the Hand and Forearm. London: Churchill Livingstone; 1998. p. 21-7.  |
| 2. | Ezaki M. Radial polydactyly. Hand Clin 1990;6:577-88. |
| 3. | Kozin SH. Upper-extremity congenital anomalies. J Bone Joint Surg Am 2003;85-A:1564-76. |
| 4. | Upton J 3 rd . Disorders of duplication. In: Mathes SJ, editor. Plastic Surgery. Saunders/ Elsevier; 2006. p. 245-60. |
| 5. | Temtamy SA, McKusick VA. The Genetics of Hand Malformations. New York: Alan R Liss Inc.; 1978. |
| 6. | Stelling F. The upper extremity. In: Ferguson AB, editor. Orthopaedic Surgery in Infancy and Childhood. Baltimore: Williams & Wilkins; 1963. p. 304-9. |
| 7. | Grzeschik KH. Human limb malformations; an approach to the molecular basis of development. Int J Dev Biol 2002;46:983-91. |
| 8. | Mathes SJ, Hentz VR. Plastic Surgery. 2 nd ed. Philadelphia: Saunders; 2006. |
| 9. | Chung J, Nam IW, Ahn SK, Lee SH, Kim JG, Sung YO. Rudimentary polydactyly. J Dermatol 1994;21:54-5. |
| 10. | Al-Qattan MM, Al-Shanawani B, Al-Thunayan A, Al-Namla A. The clinical features of ulnar polydactyly in a middle eastern population. J Hand Surg Eur Vol 2008;33:47-52. |
| 11. | Patillo D, Rayan GM. Complications of suture ligation ablation for ulnar polydactyly: A report of two cases. Hand (N Y) 2011;6: 102-5. |
| 12. | Mullick S, Borschel GH. A selective approach to treatment of ulnar polydactyly: Preventing painful neuroma and incomplete excision. Pediatr Dermatol 2010;27:39-42. |
| 13. | Leber GE, Gosain AK. Surgical excision of pedunculated supernumerary digits prevents traumatic amputation neuromas. Pediatr Dermatol 2003;20:108-12. |
| 14. | Heras L, Barco J, Cohen A. Unusual complication of ligation of rudimentary ulnar digit. J Hand Surg Br 1999;24:750-1. |
| 15. | Suzuki H, Matsuoka S. Rudimentary polydactyly (cutaneous neuroma) case report with ultrastructural study. J Cutan Pathol 1981;8:299-307. [ PUBMED] |
| 16. | Katz K, Linder N. Postaxial type B polydactyly treated by excision in the neonatal nursery. J Paediatr Orthop 2011;31:448-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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