Treatment Strategies

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At the Paley Institute, we can comprehensively address the upper extremity deformities, using a combination of techniques based on the specific manifestation of the deformity. Most patients present with radial club hand and absent thumb. We treat these patients with ulnarization of the hand to correct the radial club hand and with pollicization to correct the absent thumb. Before proceeding with upper extremity treatment, the heart needs to be evaluated and a decision involving surgical treatment made.


Ulnarization is a surgical procedure to correct radial club hand. Dr. Paley’s ulnarization technique is a modification of the Buck-Gramko radialization. They termed the technique a radialization because they made the ulna into a radius. Dr. Paley’s technique involves moving the carpus (wrist bones) to the ulnar side of the ulnar head.

Patients with radial club hand have poor grip strength due to the lack of a fulcrum; additionally, the shortening of the forearm results in shortened muscles. To easily understand this, try flexing your wrist downwards, palm side down, and then try and make a fist. You will find it much more difficult to make a fist then it is with your wrist in a neutral position.

In order to correct this, Dr. Paley transfers the flexor carpis ulnaris (FCU) tendon, which will give a stronger grip force. In the ulnarization technique, Dr. Paley converts the head of the ulna into the fulcrum. This makes recurrence impossible since the ulna physically blocks the wrist from reverting to the deformed position. The FCU is transferred from the palmer side to the dorsum (top) of the wrist. The FCU is a very strong tendon, and when it is transferred it becomes the new extensor for the wrist, allowing increased grip strength and finger range of motion.

For more information on the ulnarization procedure, please see Treatment Strategies for Radial Club Hand


Pollicization is a procedure that converts the index finger into a thumb. The metacarpal bone is shortened and the index finger with all of its nerves and vessels is transferred to the position of a normal thumb (135 degrees rotated and shortened relative to the other fingers). The 3 interosseous muscles are transferred to give the thumb movement like a thumb for pinch and opposition.

For more information on the pollicization procedure, please see Treatment Strategies for Absent Thumb

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