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Ulnarization

What is ulnarization?

Ulnarization is a surgery used to treat radial club hand, (also known as radial dysplasia or radial aplasia), by correcting the deformity and achieving normal alignment of the wrist. In this surgery, the hand and carpus (wrist bones) are moved to the ulnar side (little finger side) of the ulna (one of the two long bones in the forearm, on the side opposite to where the thumb would normally be). The deforming forces around the hand and wrist are converted to stabilizing forces by using the distal ulna (weight-bearing part of the wrist joint) as a fulcrum (balancing point). Although some institutions use other procedures such as radialization and centralization, our center has had better results using ulnarization, with no recurrence of the deformity in our 14 years of performing the procedure. In this surgery, an external fixator  is used post-operatively to maintain the corrected position for three months.

At what age is ulnarization surgery performed?

Ulnarization is typically performed between twelve to eighteen months of age, but can be done on children as old as ages six to eight years. Families can have an initial evaluation for younger children whenever it is convenient for them. Many families feel more comfortable having an earlier evaluation so that they can meet Dr. Standard, better understand the process and can start planning ahead.

What happens at the initial evaluation and pre-surgical appointment?

New patient evaluations are typically done on Thursdays and take several hours. When the patient returns in the future for surgery, they will also generally need a pre-surgical appointment with Dr. Standard’s staff to review the plans, get final X-rays and photographs and sign consent forms. This generally is scheduled on the Monday of the week of the surgery. If the family is coming from a great distance, for example from overseas, these can usually be done in one trip. In this case, the new patient appointment is generally done on a Thursday with surgery taking place the following week. Note that some insurance companies may need more time between the evaluation and the surgery authorization.

When does surgery take place, and how long is the hospital stay?

Surgery usually takes place on a Tuesday or Wednesday. The patient stays in the hospital approximately two to three days.

How long does the patient need to stay in Baltimore post-surgery, and what occupational therapy is necessary?

Dr. Standard recommends that the patient stays in Baltimore for at least 2 weeks after the surgery, however some international patients choose to stay until the external fixator is removed to reduce travel costs. Depending on how the child is doing, some families may be able to return home sooner. The patient needs occupational therapy two times per week during the time that the fixator is on. Patients are responsible for paying for housing while they stay in Baltimore and we can direct you towards various priced options including the hospital’s Hackerman-Patz House and the Ronald McDonald House.

When is the external fixator removed?

The fixator is removed after approximately three months, and Dr. Standard prefers that this take place in Baltimore, since other surgeons who are not familiar with the ulnarization procedure may not understand what has been done and how to interpret any X-rays. This removal surgery is done in the operating room.

If a pollicization is needed, when and where is it performed?

If your child needs a pollicization, (creating a functional thumb by transferring another finger to the thumb position), this can usually be done at the time of the removal of the fixator. Pollicization is a much more common procedure than the ulnarization, so for financial reasons some international families choose to have that procedure done at home if it is covered by their health plan. It is important to find an experienced surgeon for the pollicization procedure.

What happens after the removal of the external fixator?

After the external fixator is removed, if a pollicization was not performed, the patient is placed in a cast which stays on for approximately 4 weeks. The cast removal is not a surgery; it is done in the clinic area. Dr. Standard may allow the cast to be removed by the patient’s home surgeon. An occupational therapist makes a custom resting splint for the child at a follow-up appointment in the clinic. This resting splint is only worn at night until the child outgrows the splint (anywhere between one and six months).

However, if a pollicization was performed, then the cast will need to stay on for approximately six weeks. The cast will need to be removed in the operating room at Sinai Hospital for detailed evaluation of the new thumb and removal of pins that are used in the pollicization procedure. After the cast is removed, an occupational therapist will make a custom resting splint for the child. It is worn day and night for one month, and then only at night until the child grows out of it, (anywhere between one and six months).