KidsMD Health Topics

Ulnar Club Hand

  • A diagnosis of ulnar club hand means that your child’s wrist is in a fixed and bent position toward the side of the hand with the little finger.

    • It’s caused by an ulna (the bone that connects the elbow to the forearm) that wasn’t formed correctly in the womb.
    • Your child’s thumb may also be deformed or absent.

    What is radial and what is ulnar?

    When describing a particular side of the arm, you may hear your child's doctor refer to the "radial side," which indicates the side of the arm on which the thumb lies, or the "ulnar side," which describes the side on which the little finger lies.

    These terms are used rather than "inner" or "outer" arm because the palm of the hand can face either forward or backward.

    Hand and Orthopedic Upper Extremity Program

    The Hand and Orthopedic Upper Extremity Program provides comprehensive care involving occupational and physical therapy, splinting, casting and reconstructive surgeries for infants, children and adolescents with complex congenital, neuromuscular, sports-related oncologic and traumatic upper limb conditions.

    Hand and Reconstructive Microsurgery Program

    The specialists in the Hand and Reconstructive Microsurgery Program at Boston Children's are experts in the management of congenital and acquired hand deformities. We recognize the social elements involved in pediatric hand surgery, so an essential part of these operations has been making the child's hand as symmetrical as possible with his unaffected hand.

  • What causes ulnar club hand?

    Ulnar club hand is a birth defect. As with the majority of birth defects, researchers do not know why it occurs, but information that is known about ulnar club hand indicates that it doesn’t result from anything the mother did (or didn’t do) during her pregnancy.

    Ulnar club hand develops early in pregnancy — sometime between the 28th and 56th day of gestation — when the bones of the hand and forearm are being formed.

    It is sometimes, but not always, picked up on a prenatal ultrasound.

    Even if it is detected prenatally, the condition cannot be treated until after your baby is born.

    How common is ulnar club hand?

    It’s less common than radial club hand. It’s present in about 1 in 100,000 babies.

    How is this going to affect my child?

    It really depends on the severity of the problem.

    Type I

    In the mildest cases, the ulna is merely slightly smaller than normal and there is minimal deviation at the wrist. This won’t cause many problems in your child’s development.

    Type II

    This is the most common form of ulnar club hand. It involves a partial absence of the ulna and the hand appears deviated toward the ulnar side. Bowing of the radius may also occur.

    Type III

    Your child’s ulna is completely absent, leading to limited range of motion at the wrist.

    • The elbow joint may also be disturbed or even fused with no motion.
    • There may also be underdevelopment or absence of the thumb, which interferes with hand function.

    Type IV

    Here, there’s an abnormal connection between your child’s radius and humerus, resulting in bowing of the radius and hand deformations.

    A tethered wrist?

    The severity of ulnar club hand is also affected by the presence of an abnormal bar of fibrous tissue that may appear when the part of the ulna near the hand is absent. This fibrous tissue has a very limited ability to grow. It is attached to the ulnar side of the hand and wrist.

    As the radius grows in the mothers' womb, the lack of growth in the ulnar side draws the hand into a deviated "club" position.

    What other symptoms might my child have?

    The most severe cases lead to significant problems in the function of the hand, fingers and elbow.

    • Your child’s entire arm will be shorter, with curving of her forearm and stiffness of her elbow and fingers.
    • Your child’s thumb will either be very small or missing.

    The arrangement of muscles and nerves may be unbalanced and some muscles and nerves may even be absent.

  • Ulnar club hand is diagnosed after inspection of the forearm and an x-ray. Your child's doctor will want to check for other congenital deformities or syndromes that are associated with radial club hand.

    Further tests may depend on whether the doctor suspects any associated problems, including problems with heart, kidneys, vertebral column, blood cells and digestive system.

    In diagnosing the condition, the doctor will want to note the severity and will likely classify it as one of the previously described four types.

  • Treatment for ulnar club hand can be complex.

    Exercises and splinting

    During infancy, the first goal of treatment is to allow your child's wrist to extend and the elbow to move into a normal position. Your child's doctor will guide you in performing gentle but firm and frequently repeated passive stretching exercises for the wrist and elbow to help accomplish this goal.

    • More severe cases may require casting or splinting to gradually stretch the contracted soft tissues.

    Once passive motion is achieved, your baby will likely need to wear a splint during the night throughout infancy and during periods of rapid growth.

    • Even if your child needs surgery, keep in mind that the range of motion exercises are extremely important.

    Any improvement in range of motion achieved through exercise will make subsequent surgery more
    effective and perhaps less complex.

    Surgical treatment

    Surgical treatment is usually required to correct deviation of the wrist that persists after stretching and splinting. However, the decision to perform surgery is weighed against any other problems that your child may be experiencing due to associated medical conditions.

    Sometimes, if your child cannot flex his elbow, a bent wrist and short forearm can be an advantage, enabling your child to do things like feed himself.

    Surgery is divided into phases. Each problem is treated in separate surgical procedures that may take place over the course of months or years, depending on the problem.

    The following is a general description of how the different parts of the arm and hand affected by radial club hand are surgically treated:

    The wrist

    There are a number of procedures your child's doctor may recommend:

    • Lengthening - This procedure is used prior to surgery to gently stretch your child's hand into a straighter position. Lengthening is recommended in infancy if it's difficult to stretch out the tight wrist. It is also used in adolescence when there is recurrent deformity or marked shortening of the forearm.
    • Centralization - This procedure involves removing bones from your child's wrist so that the hand sits straight on the end of the radius, which is sometimes placed in a slot within the wrist.
    • Radialization - This procedure involves moving your child's hand slightly closer to the radial border of the forearm and reorganizing the tight muscles of the wrist so that the hand is balanced on the end of the radius.
    • Splinting - This is usually necessary following centralization or radialization procedures. At the time of surgery, surgeons will likely create an internal splint — a pin that is placed through your child's wrist and radius. This splint may remain in place for a year or even more after surgery, until the ulna gradually broadens and becomes a more stable platform on which the wrist may balance.

    The forearm bones

    • Osteotomy — Your child's surgeon may want to straighten her forearm bones by cutting them into wedges, then rearranging them into a straighter position. These will be held in place by the same pin that holds the wrist.
    • Underdeveloped or absent thumb – Reconstructive surgery, either through a procedure known as pollicization or by tendon transfers, is usually performed after other procedures described above are completed.
    • Elbow – Surgery on the elbow is uncommon in ulnar club hand. However, in some cases, your child's doctor may want to perform an operation to release the tight soft tissue structures at the back of the elbow that are causing the elbow to stiffen.

    What's my child's long-term outlook?

    It depends on the severity of the deformity.

    • In mild cases, intermittent therapy throughout growth is required to maintain alignment and strength.
      • These children will have minor limitations of motion, function and strength.
    • In the more severe cases, there will be marked limitation of motion, strength and function.

      • In these situations, growth will also be limited in that forearm.
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