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Michelle A. James, MD

AAOS Now

Published 3/1/2014
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Sharon Johnson

Pilot Study Focuses on Hand Function

OREF grant recipient leads effort to advance treatment for children with hand anomalies

If Michelle A. James, MD, and her research team are successful, pediatric orthopaedic surgeons who treat children with hand anomalies will soon have a better way to help them understand how the thumb interacts with the fingers and inform clinical decision-making.

The team’s work is supported by a 2012 research grant provided by the Orthopaedic Research and Education Foundation (OREF) in partnership with the Pediatric Orthopaedic Society of North America (POSNA).

“The OREF/POSNA grant is huge for us,” Dr. James said. “This is a study that could fall between the cracks with other funding sources. It’s not a large multicenter outcome study. It’s a pilot that we hope will eventually yield a highly useful tool that will help kids.”

The research is underway at the Motion Analysis Laboratory of Shriners Hospitals for Children—Northern California, in Sacramento, where Dr. James is chief of orthopaedics. She is also chief, division of pediatric orthopaedics at the University of California Davis School of Medicine in Sacramento, and deputy editor of The Journal of Bone and Joint Surgery.

Hands = connection + expression
“Our hands connect us to the world,” Dr. James said. “We use our hands to open doors, tie our shoes, comb our hair, and perform a multitude of basic tasks that get us through each day. They are also instruments of expression because we use our hands to design, create, repair, and touch.”

Today, Dr. James said, it’s difficult to perform a comprehensive clinical evaluation of children with abnormal or impaired thumbs. Better testing would help pediatric orthopaedic surgeons evaluate patients for invasive procedures, such as index pollicization, in which the index finger is shortened and rotated to act as a thumb for children who don’t have thumbs.

“Currently, no validated clinical test can quantify the volume of motion—how the thumb interacts with the fingers to enable a child to perform activities,” Dr. James explained. That’s what her research aims to provide.

Such a tool would do more than just enable better decision-making for treating patients with congenital thumb deficiency. Dr. James also believes it would help orthopaedists more precisely assess surgical and nonsurgical treatment options for children with impairments and malformations affecting prehension, including those stemming from cerebral palsy, consistent joint contracture (arthrogryposis), and thumb polydactyly.

Michelle A. James, MD
Grip strength test will help determine dominant hand.
Courtesy of Michelle A. James, MD
Hand markers being placed as part of a study on the kinematics of thumb motion.
Courtesy of Michelle A. James, MD

Three patient groups
Three study groups (10 males and 10 females in each) ages 5 to 18 years will help the team establish a continuum of thumb opposition volume. The control group consists of children with no history of surgery or injury to the hand. The second group includes children with previously diagnosed congenital thumb deficiency who have undergone surgical thumb reconstruction, and the third group includes children with previously diagnosed congenital thumb deficiency who have undergone an index pollicization procedure.

All participants will perform a series of trials to measure maximal range of motion and will be monitored while picking up different-sized objects, buttoning a shirt, and grasping a measuring tape. Six standardized clinical tests, modified for the third group to account for one less digit, will assess dominant and nondominant hands. Results for all three groups will be compared to build the continuum of thumb opposition volume.

There’s an app for that
In addition to the OREF/POSNA-funded study, the team will use funding from other sources to apply the design of the kinematic model to mobile technology and create an inexpensive and reliable tool for testing thumb/finger function in children. The study will yield at least a first-generation smart phone app.

“We envision little balloons that the kids pop or something like that,” Dr. James said. “We’ll translate the data back and make sure the results compare with those that would be captured through our kinematic analysis.”

The app also offers promise for lowering the age at which pediatric orthopaedists are able to test function in children.

“Today, below roughly age 5, it’s hard to get consistent performance,” Dr. James said. “My goal is to have a valid test for a 2-year-old or, even better, a 1½-year-old because that’s the age at which we want to intervene—the age at which we start thinking about doing surgery but can’t, as of yet, measure results either pre- or postprocedure.”

Bigger steps for better patient care
Research is necessary for counseling parents on the most appropriate treatment, according to Dr. James. “Research helps us determine which assessment and treatment works best so we can tell parents the best alternative when we’re talking about doing surgery on their child,” she said. “But doing research in little bits and pieces in our free time doesn’t get us very far. OREF and other funding organizations help by giving us time. We can take a bigger step.”

Sharon Johnson is a contributing writer for OREF and can be reached at communications@oref.org