Upper Limb Abnormalities
Background
Traumatic
These may include birth trauma such as injuries to the nerve plexus of the arm (brachial plexus palsy), in which the baby is often big, and may present shoulder first causing a traction injury to the nerves to the arm. Typically patterns of injury are recognised (Erb's palsy or Klumpke's palsy). Most babies recover within three months, but some may develop a weak arm that is small. In such cases, where surgery to the brachial plexus may be warranted, expert advice is necessary
Congenital
Whole limb
- The whole limb may fail to grow. The cause for this may be multifactorial as in congenital amputation, or may be due to a specific environmental factor such as in many cases of Phocomelia (caused by maternal ingestion of Thalidomide). Treatment includes prostheses from a young age, and very occasionally surgery. Many individuals function well even without a prosthesis.
Elbow
- The outer bone in the forearm (thumb side) is the radius. At the elbow the radial head forms a joint with the humerus bone of the upper arm. Radial head dislocation causes mild loss of forearm rotation and a cosmetic bulge over the outer elbow. It is sometimes associated with other skeletal anomalies such as Nail-Patella syndrome, Hereditary Multiple Exostoses or Ollier disease and may be secondary to a short ulna. Surgical treatment is reserved for the painful or dysfunctional elbow.
- A bony bridge between the two bones of the forearm (Radioulnar synostosis) is usually a pain-free condition, but results in a stiff forearm. Surgery is indicated if both arms are affected to improve the functional position of the forearm.
Hand
Congenital hand abnormalities occur in about 1 in 1,000 live births and the following are the commonest manifestations:
- Failure of the fingers to separate from each other (Syndactyly) in the womb. Twenty per cent are inherited. Severity ranges from mild skin webbing to complete bony fusion of the fingers. Surgery is most successful in the milder forms, but is necessary early in severe cases to avoid progressive deformity.
- Polydactyly (extra fingers) may sometimes be inherited. Surgery is performed to remove extra digits at an early age.
- Camptodactyly (bent finger towards the palm) commonly affects the little finger at the proximal joint. This condition is often inherited. Treatment is rarely necessary, but if progressive may respond to splinting, or surgery.
- Clinodactyly (bent finger in the plane of the palm) is common, and surgery is only warranted if there is an underlying bony abnormality with progressive severe deformity. Again there is likely to be a strong family history.
- Failure of formation of the radius bone (radial club hand) occurs in 1 in 30,000 live births, and has many possible causes. Sometimes other body systems are involved (cardiac, haematological, spine, gastro-intestinal, renal) in various named syndromes (Holt-Oram syndrome, VACTERL Association or TAR syndrome).Treatment depends on functional needs, and may include early splinting, surgery to centralise the wrist on the forearm and prevention of radial drift of the hand. Secondary thumb reconstructive surgery may also be necessary.
There are also further specific syndromes which include arm defects amongst their characteristic features:
What are the causes? 
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