Management

The management of transverse deficiencies of upper limb development should be carried out in specialised units. The key intervention is the provision of a prosthesis:

• initial fitting of a passive prosthesis in first year of life to facilitate psychosocial integration; typically carried out as soon as the child can sit independently
• by two years of age, child progresses to a body-powered prosthesis, secured to the stump by a socket with harness
• by five years, a myoelectric device may be introduced

The functional needs and physical fit of the prosthesis vary with time and the child needs regular reassessment. A key tenet of management is engagement with the family from an early age to encourage adaptation to the prosthesis.

Surgery for transverse deficiencies is rarely indicated. Rudimentary nubbin digits may be excised if non-functional and rarely, bone spicules at the distal end of the limb may warrant removal if painful or extruding. Other techniques that have been attempted include:

• The Krukenberg Procedure: converts the forearm to a pincer apparatus with separate radius and ulna movement; it is rarely indicated
• distraction lengthening
• free phalangeal transfer
• toe-to-hand free microvascular transfers