Pediatric Upper Extremity Program

Children’s Arms in Strong Hands with Unique UMMC Program

When CJ was born, it soon became evident that one of his palms faced upward and he couldn't bend his elbow. But only after his parents brought the child to University of Maryland Children's Hospital — which boasts the only dedicated pediatric upper extremity program in the region — was the boy properly diagnosed and treated, undergoing two operations that now allow virtually normal use of his arm and hand.

About 10% to 15% of the infants, children and adolescents treated each year in the unique program are born with differences of their arms and hands that result in problems with bones, joints, muscles, tendons or ligaments anywhere from the shoulder to the fingertips. Some of these conditions, while congenital, aren't necessarily obvious at birth, according to Joshua M. Abzug, M.D., assistant professor of orthopaedics at the University of Maryland.

"Some differences aren't noticed until the child or adolescent attempts a specific task and has difficulty and it becomes apparent there's something different about the limb," Dr. Abzug explains. "Or they may have lived with it for a time without treatment. But a lot of differences are visual, meaning upon exam of the child, we can provide a diagnosis as well as observe the associated difficulties."

Interdisciplinary Approach for Hand and Upper Extremity Cases

Dr. Abzug is also director of the University of Maryland Brachial Plexus Practice, which focuses on brachial plexus birth palsy, a condition occurring in one to three of every 1,000 live births that results from the baby's head becoming stuck against the mother's pelvis during delivery. Because of the heads positioning, nerves in the baby's neck are stretched or torn, requiring surgery or other interventions for about 20% of these children.

There is a wide array of birth disorders of the arms and hands treated at UMMC's pediatric Hand and Upper Extremity Program.  Some examples include:

  • Syndactyly: Fingers are webbed or stuck together
  • Polydactyly: Extra fingers or thumbs are present
  • Hypoplastic digits: Fingers are missing or underdeveloped
  • Radial club hand: The radius bone in the forearm is missing or malformed
  • Ulnar club hand: The ulna forearm bone is malformed, leading to an abnormally bent wrist

Certain congenital hand and arm differences don't affect just the upper extremity, Dr. Abzug says, but are indicative of a systemic medical condition that may be dangerous. An example is TAR syndrome, where the absence of the arm's radius bone is also associated with a shortage of blood cells involved in clotting and possible malformations of the heart and kidneys. 

In these more complex cases, the program's interdisciplinary approach is crucial to the proper treatment of these patients.

"By looking at a child's hand, we can be on the lookout for other problems that are more systemic," he says. "We have a genetics team available to help counsel families, and we also have therapists in the clinic who can evaluate the child from a physical therapy standpoint and a functional standpoint, to see where they struggle. We can plan treatment, either surgical or non-surgical, that helps meet his or her needs."

If surgical intervention is needed for a more complex case, Dr. Abzug works closely with the team in the University of Maryland Children's Hospital's Pediatric Intensive Care Unit.  "In our PICU, we have private rooms designed to provide patient and family centered care.  Our PICU has pediatric intensive care attending physicians who are in house 24-7and not just on call. This assures the highest level of care for our most complex patient including those with complex orthopedic problems," says Dr. Adnan Bhutta, associate professor of pediatrics and division head, Pediatric Critical Care at the University of Maryland. 

Function Over Appearance

Dr. Abzug fosters a relaxed relationship with children and parents — ditching the white coat and tie — and watches how children play to get the best sense of how they use their hands and arms and determine what treatments may help. He also stresses that treatments that may make the hand or arm look more "normal" may not be optimal for how it functions.

"Feeding, dressing and bathing are vital self-care tasks that need to be prioritized above appearance," Dr. Abzug says. "We have excellent technologies available, for instance, to make fingers longer or move bones from the toe to the hand, but it's important to choose the right treatment for the right patient. People who focus on a limb and don't consider the child as a whole individual have the potential to harm the patient by taking away function."

Many children and their parents — like CJ's family — are extremely appreciative that surgery, physical therapy and/or other adaptive "tricks" provided by the pediatric Hand and Upper Extremity Program can help offer a more normal way of living.

"When we took off CJ's cast, after the operation that turned his forearm around, his mother was hugging and crying in the office. She couldn't express enough gratitude," Dr. Abzug says. "It made a huge difference in this child's life."

Dr. Abzug sees patients at 5 different practice locations.  To make an appointment, please call 410-448-6400.