K011iker observed in a few cases abnormal growth of the radius when resected out of its natural position.
Congenital ankylosis of the and complete or partial defects of the forearm bones constitute arrests of development which are rather rare. These deformities are usually associated with club hand (mantis vara). This deviation of the hand, forming an angle with the forearm, has been called club-hand by general consent, and this of course includes fixation in this position. It signifies the rest position which must be assumed before certain restricted movements can be executed. The most frequent fixation is in palmar and ulnar flexion. Any of the other forms occur less frequently.
Club-hand without simultaneous malformation of the forearm is a very rare deformity, its occurrence in conjunction with missing radius or ulna being more frequent. The radius is absent more frequently than the ulna, and in this deformity the hand is radially deflected as if broken off, standing at a right angle to the ulna. Its termination is easily pal pable under the skin. The thumb and its metacarpus, in fact the entire radius, are likewise missing.
The ulna is less often absent, a more frequent combination being club-hand with ankylosis of the elbow-joint.
Stoffel's investigations have shed more light on the pathogenesis of this deformity. In his opinion there has been a pathological course in the process of development, caused by increased uterine pressure, or an atavistic deviation, as indeed appears probable from the frequent coin cidence with other deformities, strangulations and occlusions, pointing to the same causative factor.
:Fig. 42 illustrates a club-hand caused by twisting the umbilical cord around the forearm, the child having been brought to the clinic with the visible pressure necrosis of the forearm.
In these latter cases the treatment is facilitated, because these positional changes which occur at a much later period are, as it were, of secondary origin and may be corrected by adequate orthopedic treat ment with felt-covered steel springs, elastic traction or splints (Lange's orthopedic glove). In germinal errors, which occur at a much earlier
period, the entire motor apparatus is involved, and the mechanical as well as the operative treatment is much more complicated, having to reckon with the small size and tender infantile tissues and the very susceptible infantile skin.
Bardenhener has achieved good results in cases of absent radius by cleaving the ulna and inserting the carpus into the bifurcation. The style of the operation—elongation or shortening of the tendons, etc.— would course vary with the pathological picture.
The fact of accompanying ankylosis of the elbow-joint points to very inhibition of development ; and if mechanical correction is impossible, linear resection is indicated, the shortened triceps tendon being plastically elongate 1.
Congenital Deformities of the Fingers.—The pictures resulting from structural disturbances of the end radiations of the extremities may vary exceedingly. Incomplete development or diminished numbers dactylism), atavistic retrogression to supernumerary radiations dactylism), absence of separation, presence of adhesions (syndactylism), secondary fissures, etc., may give rise to the most varied pictures. The biological factor is common to all that they owe their origin to an normal course of development, in which heredity plays an important part. Polydactylism gives the most frequent occasion for surgical ference, not only for the reason that parents dislike having "marked" children of this description, but also because the supernumerary fingers are but rarely capable of useful function.
It stands to reason that all the rules of cosmetics should be oloerved in operative removal. The relations of the supernumerary fingers to the metacarpal radiations should be established by means of the X-ray (Fig. .14c), as this frequently furnishes information as to which finger is really supernumerary or which is the duplex radiation.
The plastic treatment of the thumb requires special care on account of its great functional value.