Ulnar dimelia – a rare and neglected anomaly of upper extremity
0 likes40 views
This document describes a case report of a rare congenital anomaly called ulnar dimelia in a 1.5 year old male patient. Ulnar dimelia is characterized by double ulnae in the forearm, polydactyly, absence of the radius and thumb. The patient presented with restricted elbow and wrist movement and an unacceptable cosmetic appearance. Management would require multiple staged surgeries but the parents neglected further treatment after the initial visit. Ulnar dimelia results from imbalanced signals during embryonic development leading to abnormalities in the forearm, hand and digits. Surgical management aims to improve function and cosmesis but often requires several procedures and long-term follow up.
![Creative Commons 4.0
Ulnar Dimelia – a rare and neglected anomaly of upper extremity
Yasir Salam Siddiqui a, *
, Mazhar Abbas a
, Nusra Rahman b
, Julfiqar a
a Department of Orthopaedic Surgery, Faculty of Medicine, J. N. Medical College, A.M.U., Aligarh 202002, India.
b Department of Anatomy, Faculty of Medicine, J. N. Medical College, A.M.U., Aligarh 202002, India.
* Corresponding author: Yasir Salam Siddiqui
Mailing address: Department of Orthopaedic Surgery, Faculty of
Medicine, J. N. Medical College, A.M.U., Aligarh 202002, India.
E-mail: yassu98@gmail.com
Received: 11 December 2020 / Accepted: 12 January 2021
INTRODUCTION
Ulnar dimelia also referred to as mirror hand syn-
drome is a rare congenital anomaly of the upper ex-
tremity. The condition presents with double ulnae
forearm with complete absence of radius bone. There
is also polydactyly with absence of thumb [1, 2]
. Along
with musculoskeletal deformity, malformation of the
neurovascular structures in the form of doubling of
the ulnar nerve and artery with absence of the radial
artery has also been reported in the literature [1-3]
.
Clinically it presents not only as functional deformity
but also as cosmetic deformity. The broadened elbow,
short forearm, radially deviated wrist, polydactyly and
absent thumb gives a poor unacceptable cosmetic ap-
pearance. The functional deficit with ulnar dimelia is
restricted elbow range of motion, forearm rotations,
and oppositional grasp [4]
.
Most cases of mirror hand syndrome are sporadic,
while few case studies designated associated genetic
syndromes [5, 6]
. Ulnar dimelia results from the imbal-
Case Report
ance of the inductive signals across the radio-ulnar
plane during embryonic development [3, 7]
. Failure of
the morphogenesis signals on the radial side, while
the concentration of such signals on the ulnar side
produces ulnar dimelia. Diverse variants of the disease
depend upon the severity of the disproportion of the
signals across the radio ulnar plane [2, 8]
. In literature
case studies are reported, highlighting the various
aspects of deformity including anatomical variations,
clinical presentation, and management [1-4]
. We believe
that the case presented here deserves reporting not
only because of the rarity of the disease but also due
to its difficult and prolonged management requiring
multiple staged operations and henceforth consequent
neglect on the part of parents. An attempt is also made
to do a brief literature review.
CASE REPORT
A one-and-a-half-year-old male baby was brought to us
by his parents with complaints of restriction of move-
ments of the right elbow with polydactyly, giving an
unacceptable cosmetic appearance of the forearm and
hand. They further added that the child is also having
difficulty in holding the objects. The patient was their
third child with two female siblings without any such
complaints. There was no history of consanguinity.
The baby was full term, delivered through the vaginal
Yasir Salam Siddiqui et al 26
Clin Surg Res Commun 2020; 5(1): 26-29
DOI: 10.31491/CSRC.2021.03.071
Abstract
Ulnar dimelia is a rare congenital anomaly of the upper extremity. The condition presents with double ulnae
forearm and polydactyly with complete absence of radius bone and thumb. Clinically it presents not only as
functional deformity but also as cosmetic deformity. The case presented here is of a one-and-a-half-year-old
male baby, born with right side ulnar dimelia with no other musculoskeletal defect. We believe that the case
presented here deserves reporting not only because of the rarity of the disease but also due to its difficult man-
agement requiring multiple staged operations and henceforth consequent neglect on the part of parents. An
attempt is also made to do a brief literature review.
Keywords: Ulnar dimelia; polydactyly; ulna; radius; thumb](https://image.slidesharecdn.com/ulnardimeliaarareandneglectedanomalyofupperextremity-210819061750/85/Ulnar-dimelia-a-rare-and-neglected-anomaly-of-upper-extremity-1-320.jpg)
![as the genetic mechanisms of ulnar-dimelia [19, 20]
.
A classical ulnar dimelia has symmetrical distribution
around the midline axis. However, the non-classical
one lacks symmetrical distribution in morphogenesis
of the forearm bones and the fingers [8]
. In the non-
classical one, the forearm may contain an ulna and a
radius, or even three bones in different combinations
[9-11]
. Even though seven [9, 10]
or eight [2, 10-14]
digits are
typical, patients with six [15, 16]
or even five digits [17]
have been described in the literature. Taking into ac-
count the bony morphology of the forearm, Al-Qattan
et al published a descriptive classification for the ul-
nar dimelia [2]
. The goal of the management of such a
condition is to achieve a functional and cosmetically
acceptable upper extremity by executing single-stage
or more often multiple-stage operations. The literature
designates, depending upon the severity of the func-
tional and cosmetic deformity, the management of this
condition varies from physiotherapy alone to multiple-
stage operations [1, 2, 7, 8, 11, 18]
. The best age for the recon-
struction of hand is before the second year [11]
. Surgery
is preceded by passive range of motion exercises and
choosing the appropriate radial digit for pollicising.
Hand deformities can be corrected to give a satisfac-
tory outcome when they are not so severe. Either in-
dex or middle finger can be pollicised depending upon
the type of ulnar dimelia. When deformity correction
is not feasible the goal is to achieve the hold function
of the hand. Good functional and cosmetic results have
been reported in a few studies [3]
. The thenar recon-
struction by interosseous muscle transfers and further
improvements can be achieved by tendon transfer at a
later date has also been described in the literature [21]
.
The function of the wrist, forearm, and elbow may im-
prove with arthroplasty of the affected joints [22]
.
In the present case study, we discussed with the par-
ents about the future prospects and limitations of
activities due to deformity and planned for staged
surgeries with an objective to provide functional and
cosmetically acceptable upper extremity. However,
the parents never turned up again with the patient for
taking treatment, highlighting the neglect of the defor-
mity. The neglect was probably due to the low socio-
economic status and ignorance of parents. We believe
that in the patient described above, excision of the
proximal end of the laterally placed ulna with soft tis-
sue reconstruction along the medially placed ulna and
pollicization would have given a reasonable functional
and cosmetic enhancement of the upper extremity.
Yasir Salam Siddiqui et al 28
reconstruction of the thumb for oppositional grasp.
Meanwhile, the patient was put on stretching exercises
of elbow, wrist and fingers, especially to correct the ra-
dial deviation of the wrist along with night splinting of
the wrist in a neutral position. Parents were communi-
cated about the need for regular follow-up for proper
treatment and rehabilitation of the child, least as the
child would grow there will be limitations of activities
which require coordinated movement of the elbow,
forearm, and hand-like writing, buttoning, unbutton-
ing, tying shoelaces and others. However, the parents
never turned up again after their first visit, highlight-
ing the neglect of the deformity.
DISCUSSION
Our patient had double ulnae in the right forearm
with six digits with six corresponding metacarpals in
a single plane with two carpal bones supported by a
medially placed ulna. Laterally placed hypoplastic ulna
was not supporting any of the carpal bones. This might
be due to a delay in the development of the ossifica-
tion centers on the lateral side. Both thumb and radius
were absent. Although the laterally placed ulna was
hypoplastic in comparison to the medial one, both ul-
nae were well molded. Our case was classified as type
I ulnar dimelia, according to Al‑Qattan et al classifica-
tion [2]
.
Ulnar dimelia is probably due to the failure of differen-
tiation of a part of the ray rather than its pure duplica-
tion [18]
. During the embryogenesis, a disturbance of dif-
ferentiation of Zone of Polarizing Activity (ZPA) along
the axis of the limb may lead to post-axial duplication
and ulnar dimelia [3]
. Few authors have reported HOX
genes mutations or translocation breakpoint at 14q13
Figure 3. Radiograph of hand showing ulnar dimelia in right
hand compared with normal left hand.
Clin Surg Res Commun 2020; 5(1): 26-29
DOI: 10.31491/CSRC.2021.03.071](https://image.slidesharecdn.com/ulnardimeliaarareandneglectedanomalyofupperextremity-210819061750/85/Ulnar-dimelia-a-rare-and-neglected-anomaly-of-upper-extremity-3-320.jpg)
Ulnar dimelia – a rare and neglected anomaly of upper extremity
- 1. Creative Commons 4.0 Ulnar Dimelia – a rare and neglected anomaly of upper extremity Yasir Salam Siddiqui a, * , Mazhar Abbas a , Nusra Rahman b , Julfiqar a a Department of Orthopaedic Surgery, Faculty of Medicine, J. N. Medical College, A.M.U., Aligarh 202002, India. b Department of Anatomy, Faculty of Medicine, J. N. Medical College, A.M.U., Aligarh 202002, India. * Corresponding author: Yasir Salam Siddiqui Mailing address: Department of Orthopaedic Surgery, Faculty of Medicine, J. N. Medical College, A.M.U., Aligarh 202002, India. E-mail: [email protected] Received: 11 December 2020 / Accepted: 12 January 2021 INTRODUCTION Ulnar dimelia also referred to as mirror hand syn- drome is a rare congenital anomaly of the upper ex- tremity. The condition presents with double ulnae forearm with complete absence of radius bone. There is also polydactyly with absence of thumb [1, 2] . Along with musculoskeletal deformity, malformation of the neurovascular structures in the form of doubling of the ulnar nerve and artery with absence of the radial artery has also been reported in the literature [1-3] . Clinically it presents not only as functional deformity but also as cosmetic deformity. The broadened elbow, short forearm, radially deviated wrist, polydactyly and absent thumb gives a poor unacceptable cosmetic ap- pearance. The functional deficit with ulnar dimelia is restricted elbow range of motion, forearm rotations, and oppositional grasp [4] . Most cases of mirror hand syndrome are sporadic, while few case studies designated associated genetic syndromes [5, 6] . Ulnar dimelia results from the imbal- Case Report ance of the inductive signals across the radio-ulnar plane during embryonic development [3, 7] . Failure of the morphogenesis signals on the radial side, while the concentration of such signals on the ulnar side produces ulnar dimelia. Diverse variants of the disease depend upon the severity of the disproportion of the signals across the radio ulnar plane [2, 8] . In literature case studies are reported, highlighting the various aspects of deformity including anatomical variations, clinical presentation, and management [1-4] . We believe that the case presented here deserves reporting not only because of the rarity of the disease but also due to its difficult and prolonged management requiring multiple staged operations and henceforth consequent neglect on the part of parents. An attempt is also made to do a brief literature review. CASE REPORT A one-and-a-half-year-old male baby was brought to us by his parents with complaints of restriction of move- ments of the right elbow with polydactyly, giving an unacceptable cosmetic appearance of the forearm and hand. They further added that the child is also having difficulty in holding the objects. The patient was their third child with two female siblings without any such complaints. There was no history of consanguinity. The baby was full term, delivered through the vaginal Yasir Salam Siddiqui et al 26 Clin Surg Res Commun 2020; 5(1): 26-29 DOI: 10.31491/CSRC.2021.03.071 Abstract Ulnar dimelia is a rare congenital anomaly of the upper extremity. The condition presents with double ulnae forearm and polydactyly with complete absence of radius bone and thumb. Clinically it presents not only as functional deformity but also as cosmetic deformity. The case presented here is of a one-and-a-half-year-old male baby, born with right side ulnar dimelia with no other musculoskeletal defect. We believe that the case presented here deserves reporting not only because of the rarity of the disease but also due to its difficult man- agement requiring multiple staged operations and henceforth consequent neglect on the part of parents. An attempt is also made to do a brief literature review. Keywords: Ulnar dimelia; polydactyly; ulna; radius; thumb
- 2. route. There was no history suggestive of any mater- nal infection or any exposure to teratogenic agents throughout the antenatal period. There was no family history of the congenital elbow and hand anomalies in first degree lineages. There was no developmental de- lay. No history of any other joint involvement or other systemic illness. Clinical examination revealed short- ening of the right forearm with fixed flexion deformity of 20 degrees at the elbow, with a further 50 degrees of free flexion possible (range of motion = 20 to 70 degrees). Forearm rotations were grossly restricted. The wrist was deviated radially with the hand having six well-formed fingers in a single plane (Figure 1). Contour and the movements of the right shoulder were comparable to the left shoulder. The child was able to hold the objects in between fingers (crude grasp). However fine grasp requiring opposition function was not conceivable. The left upper extremity was abso- lutely normal. There were no other skeletal abnormali- ties. Furthermore, no definite syndromic features were noted. Systemic examination was unremarkable. Ul- trasonography of the abdomen and echocardiography were normal. The radiographic anatomical features of our patient as seen in Figure 2 and 3 could be summa- rized as follows： (1) A normal humerus with an ossification center in the post-axial part of the distal epiphysis; (2) Thumb and radius was absent; (3) Two ulnae facing each other: post-axial ulna had a proper morphology and pre-axial ulna was shorter with less defined proximal anatomical features; (4) Wrist shows duplication of ossification centers cor- responding to lunate; (5) Normal morphology of metacarpals and phalanges of three post-axial fingers; (6) Hypoplasia of all pre-axial metacarpals; (7) Shortening of all phalanges of the pre-axial index finger; (8) Normal pre-axial middle (M) and ring (R) fingers; (9) Hypoplasia of pre-axial little (L) finger. The wrist and hand showed two carpal bones and six metacarpals all lying in the same plane compared to the normal left hand (Figure 2 and 3). The two carpal bones were centered over the medially placed ulna. In the present circumstance, we planned for staged surgeries, with an objective to provide a functional range of motion at the elbow, forearm rotations, and Yasir Salam Siddiqui et al 27 Figure 1. Clinical photograph of patient showing radial deviation of the right wrist (arrow) with the hand having six well-formed fingers in single plane. Also note the absence of thumb. Figure 2. Radiograph of the right upper extremity including elbow revealed double ulnae facing each other with complete absence of radius and thumb. The laterally placed ulna is hypoplastic with a broad distal end (thin arrow). The wrist and hand showed two carpal bones and six metacarpals all lying in the same plane. The two carpal bones were centered over the medially placed ulna (thick arrow). ANT PUBLISHING CORPORATION Published online: 29 March 2021
- 3. as the genetic mechanisms of ulnar-dimelia [19, 20] . A classical ulnar dimelia has symmetrical distribution around the midline axis. However, the non-classical one lacks symmetrical distribution in morphogenesis of the forearm bones and the fingers [8] . In the non- classical one, the forearm may contain an ulna and a radius, or even three bones in different combinations [9-11] . Even though seven [9, 10] or eight [2, 10-14] digits are typical, patients with six [15, 16] or even five digits [17] have been described in the literature. Taking into ac- count the bony morphology of the forearm, Al-Qattan et al published a descriptive classification for the ul- nar dimelia [2] . The goal of the management of such a condition is to achieve a functional and cosmetically acceptable upper extremity by executing single-stage or more often multiple-stage operations. The literature designates, depending upon the severity of the func- tional and cosmetic deformity, the management of this condition varies from physiotherapy alone to multiple- stage operations [1, 2, 7, 8, 11, 18] . The best age for the recon- struction of hand is before the second year [11] . Surgery is preceded by passive range of motion exercises and choosing the appropriate radial digit for pollicising. Hand deformities can be corrected to give a satisfac- tory outcome when they are not so severe. Either in- dex or middle finger can be pollicised depending upon the type of ulnar dimelia. When deformity correction is not feasible the goal is to achieve the hold function of the hand. Good functional and cosmetic results have been reported in a few studies [3] . The thenar recon- struction by interosseous muscle transfers and further improvements can be achieved by tendon transfer at a later date has also been described in the literature [21] . The function of the wrist, forearm, and elbow may im- prove with arthroplasty of the affected joints [22] . In the present case study, we discussed with the par- ents about the future prospects and limitations of activities due to deformity and planned for staged surgeries with an objective to provide functional and cosmetically acceptable upper extremity. However, the parents never turned up again with the patient for taking treatment, highlighting the neglect of the defor- mity. The neglect was probably due to the low socio- economic status and ignorance of parents. We believe that in the patient described above, excision of the proximal end of the laterally placed ulna with soft tis- sue reconstruction along the medially placed ulna and pollicization would have given a reasonable functional and cosmetic enhancement of the upper extremity. Yasir Salam Siddiqui et al 28 reconstruction of the thumb for oppositional grasp. Meanwhile, the patient was put on stretching exercises of elbow, wrist and fingers, especially to correct the ra- dial deviation of the wrist along with night splinting of the wrist in a neutral position. Parents were communi- cated about the need for regular follow-up for proper treatment and rehabilitation of the child, least as the child would grow there will be limitations of activities which require coordinated movement of the elbow, forearm, and hand-like writing, buttoning, unbutton- ing, tying shoelaces and others. However, the parents never turned up again after their first visit, highlight- ing the neglect of the deformity. DISCUSSION Our patient had double ulnae in the right forearm with six digits with six corresponding metacarpals in a single plane with two carpal bones supported by a medially placed ulna. Laterally placed hypoplastic ulna was not supporting any of the carpal bones. This might be due to a delay in the development of the ossifica- tion centers on the lateral side. Both thumb and radius were absent. Although the laterally placed ulna was hypoplastic in comparison to the medial one, both ul- nae were well molded. Our case was classified as type I ulnar dimelia, according to Al‑Qattan et al classifica- tion [2] . Ulnar dimelia is probably due to the failure of differen- tiation of a part of the ray rather than its pure duplica- tion [18] . During the embryogenesis, a disturbance of dif- ferentiation of Zone of Polarizing Activity (ZPA) along the axis of the limb may lead to post-axial duplication and ulnar dimelia [3] . Few authors have reported HOX genes mutations or translocation breakpoint at 14q13 Figure 3. Radiograph of hand showing ulnar dimelia in right hand compared with normal left hand. Clin Surg Res Commun 2020; 5(1): 26-29 DOI: 10.31491/CSRC.2021.03.071
- 4. hands and feet with a distinct nasal defect, an autosomal dominant condition. American journal of medical genet- ics, 46(2), 129-131. 7. Gaba, S., John, N., Bhogesha, S., Singh, O., & Vemula, G. K. (2017). Mirror Hand: An Uncommon Neglected Case Managed with Pollicisation. World journal of plastic sur- gery, 6(2), 263. 8. Afshar, A. (2010). Ulnar dimelia without duplicated arte- rial anatomy. The Journal of Bone and Joint Surgery. Brit- ish volume, 92(2), 293-296. 9. Barton, N. J., Buck-Gramcko, D., & Evans, D. M. (1986). Soft-tissue anatomy of mirror hand. Journal of Hand Sur- gery, 11(3), 307-319. 10. Bhaskaranand, K., Bhaskaranand, N., & Bhat, A. K. (2003). A variant of mirror hand: a case report. The Journal of hand surgery, 28(4), 678-680. 11. Jafari, D., & Sharifi, B. (2005). A variant of mirror hand: a case report. The Journal of Bone and Joint Surgery. Brit- ish volume, 87(1), 108-110. 12. King, R. J., & Hoyes, A. D. (1982). The mirror hand abnor- mality. The Hand, 14(2), 188-193. 13. Pintilie, D., Hatmanu, D., Olaru, I., & Panoza, G. (1964). Double ulna with symmetrical polydactyly. The Journal of bone and joint surgery. British volume, 46(1), 89-93. 14. Yang, S. S., Jackson, L., Green, D. W., & Weiland, A. J. (1996). A rare variant of mirror hand: a case report. The Journal of hand surgery, 21(6), 1048-1051. 15. De Smet, L. (1999). Ulnar dimelia. Acta orthopaedica bel- gica, 65(3), 382. 16. Gorriz, G. (1982). Ulnar dimelia—a limb without antero- posterior differentiation. The Journal of Hand Surgery, 7(5), 466-469. 17. Chinegwundoh, J. O. M., Gupta, M., & Scott, W. A. (1997). Ulnar Dimelia: Is it a true duplication of the ulna?. Journal of Hand Surgery, 22(1), 77-79. 18. Muradian, A. A. (2007). Ulnar dimelia, a case report. Bas- rah Journal of Surgery, 13(2), 73-74. 19. Apiou, F., Flagiello, D., Cillo, C., Malfoy, B., Poupon, M. F., & Dutrillaux, B. (1996). Fine mapping of human HOX gene clusters. Cytogenetic and Genome Research, 73(1-2), 114-115. 20. Matsumoto, N., Ohashi, H., Kato, R., Fujimoto, M., Tsujita, T., Sasaki, T., ... & Niikawa, N. (1997). Molecular mapping of a translocation breakpoint at 14q13 in a patient with mirror-image polydactyly of hands and feet. Human ge- netics, 99(4), 450-453. 21. Hussl, C. H. H. (1999). A case of mirror hand deformity with a 17-year postoperative follow up: case report. Scandinavian journal of plastic and reconstructive sur- gery and hand surgery, 33(3), 329-333. 22. Tsuyuguchi, Y., Tada, K., & Yonenobu, K. (1982). Mir- ror hand anomaly: reconstruction of the thumb, wrist, forearm, and elbow. Plastic and Reconstructive Surgery, 70(3), 384-387. CONCLUSION Ulnar dimelia is a rare congenital anomaly presenting as functional as well as cosmetic deformity. If untreat- ed, renders the patient with poor function and cos- metic appearance of the extremity. The condition not only has the difficult management requiring multiple staged operations is a therapeutic challenge for treat- ing orthopaedic surgeon but also neglect on the part of caregivers. Hence, awareness among the masses is to be developed regarding the condition and educating them that an acceptable outcome can be achieved with proper treatment. DECLARATIONS Authors’ contributions Siddiqui YS and Abbas M: substantial contribution to conception and designing and supervision of the study. Nusra Rahman and Julfiqar: provided material & tech- nical support for the study. Conflict of interest All authors declared that there are no conflicts of inter- est. Ethics approval and consent to participate Informed consent was obtained from the parents of the patient to participate in the study. Consent for publication Written informed consent for publication was obtained. REFERENCES 1. Alosaimi, M. N., Samman, A. T., Alswat, M. M., & Alsaggaf, K. W. (2020). A rare developmental anomaly of the upper limb: Case of ulnar dimelia. Journal of Musculoskeletal Surgery and Research, 4(3), 160. 2. Al-Qattan, M. M., Al-Thunayan, A., De Cordier, M., Nan- dagopal, N., & Pitkanen, J. (1998). Classification of the mirror hand-multiple hand spectrum. Journal of Hand Surgery, 23(4), 534-536. 3. Tomaszewski, R., & Bulandra, A. (2015). Ulnar dimelia-di- agnosis and management of a rare congenital anomaly of the upper limb. journal of orthopaedics, 12, S121-S124. 4. Kay, S. P., McCombe, D., & Kozin, S. H. (2005). Deformities of the hand and fingers. Green’s Operative Hand Surgery (7th Edition)(Eds. Wolfe, Hotchkiss, Pederson, Kozin, Co- hen.)(Elsevier, 2016). 5. Sandrow, R. E., Sullivan, P. D., & Steel, H. H. (1970). He- reditary ulnar and fibular dimelia with peculiar facies: a case report. JBJS, 52(2), 367-370. 6. Martin, R. A., Jones, M. C., & Jones, K. L. (1993). Mirror Yasir Salam Siddiqui et al 29 ANT PUBLISHING CORPORATION Published online: 29 March 2021