Mary Claire Manske, MD, MAS, FAOA, is an attending physician with the Orthopedic Center and Hand and Arm Disorders Program at Children's Hospital of Philadelphia. In this Q&A, Dr. Manske discusses congenital hand and arm differences, as well as some of the surgical approaches she takes to help patients improve both physical and social function.
Q: What are some of the congenital hand and arm differences you see in your practice?
One of the great things about CHOP — and my congenital hand and arm practice — is that we truly see the full spectrum of congenital upper limb differences, from the common to the rare and from the simple to the complex.
Common conditions we encounter include:
- Syndactyly (webbed or joined fingers)
- Polydactyly (extra digits. most often on the pinky or thumb side but sometimes in between)
- Symbrachydactyly (short, sometimes webbed fingers)
- Amniotic band syndrome (bands around the limbs causing shortened fingers or webbing between non-adjacent digits)
Because we care for so many children with congenital upper limb differences at CHOP, we also routinely see less common conditions such as radial deficiency, hypoplastic thumb, ulnar deficiency, cleft hand and macrodactyly.
We also see many infants and children whose hand differences occur as part of a broader syndrome, such as Apert syndrome or arthrogryposis. Our experience with these syndromes helps us recognize associated conditions early. Working alongside world-class colleagues in other specialties — including pediatric anesthesiologists who are exceptional at caring for medically complex children — means we’re able to provide truly comprehensive care.
Q: What are some of the surgical approaches that can significantly help patients with function?
We have a wide range of reconstructive techniques that help improve hand function. We can separate webbed digits, reconstruct hands with extra fingers when they interfere with function and augment or stabilize underdeveloped fingers or thumbs.
Appearance matters too — hands are one of the most visible parts of the body — so we always talk with families about options that address both physical function and appearance — or what I call “social function.”
One of the things I love most about congenital hand difference is how unique each child and family is. I truly enjoy listening to what each family hopes to achieve and designing a surgical plan that aligns with those goals.
Q: Surgery is one tool to improve hand and arm function. What are other options you discuss with your patients and their families?
Surgery is just one tool in our toolbox. Two other important components of treatment are therapy and social support.
Therapy can be an alternative to surgery or a helpful adjunct before and after surgery. It teaches children how to use the hand they were born with, helps them learn new ways to accomplish daily tasks — like tying shoes, typing or participating in sports — and can even simulate the expected outcome of surgery, helping families decide whether a procedure is right for them. After surgery, therapy is essential for optimizing results — stretching, scar care and learning to use their “new” hand.
Social support is equally important. Many children tell me their hand works fine — even if it works differently — but they struggle with feeling different from their peers. At CHOP, we care for many families with hand differences, and many of those families are eager to talk with other parents and children. These connections can be incredibly powerful. There are also amazing programs like hand camps which bring kids with limb differences together in a fun, supportive environment. Our CHOP camp, Camp Rock, even offers rock climbing to help kids build confidence by trying an activity they may have been hesitant to try elsewhere.
Q: What is a “pediatric hand team?”
A pediatric hand team is a multidisciplinary group of providers dedicated to caring for children with hand differences. Surgery is only one aspect — the surgeon should never be the only person involved in treatment.
A comprehensive pediatric hand team typically includes:
- Surgeons
- Hand therapists
- Social workers
- Nurses
- Child life specialists
- Pediatric anesthesiologists
- Specialists from other medical fields who help evaluate associated conditions
- Psychologists or psychiatrists, when needed
A pediatric hand team is critical for comprehensive, developmentally appropriate care. The way we support an infant is different from how we support a toddler or a teenager.
The pediatric hand team cares for the whole family — supporting parents with education and guidance is a central part of what we do. A multidisciplinary team allows us to meet all those needs and provide holistic, family-centered care.
Q: Some hand and arm differences are now diagnosed prenatally. When this happens, what role can an orthopedic surgeon play?
Prenatal diagnosis of congenital hand or arm differences is still uncommon, but when it does occur, involving an orthopedic surgeon can be helpful. We often meet with families before delivery to explain the condition, discuss treatment options and outline the timing of possible interventions.
We can also help parents understand why the condition may have occurred and what to expect after birth. Knowledge is empowering, and early counseling helps families feel informed, supported and prepared to care for their baby.
Q: How did you become interested in congenital hand and arm differences as a focus area?
I have always found birth differences interesting. They are part of human variation. My father was a pediatric hand surgeon, so I grew up hearing about both these conditions and how much he loved caring for children. When I cared for children and families with upper extremity conditions during residency, I found the work deeply meaningful — through surgery or other treatments, I could make everyday tasks easier or improve the way a child used their hand.
I also discovered how much I love talking with kids of all ages and meeting them at their developmental level. It’s incredibly rewarding to see a toddler beam as they master putting on their own clothes, or to see an older child feel confident joining a sports team or participating fully in another school program.
I also truly enjoy working with parents — they know their child better than anyone, and our conversations help me understand the family’s goals and values. I love educating families about their child’s condition and helping them make decisions that feel right for them.
Q: Could you share a story or anecdote that illustrates how profoundly these differences affect your patients’ lives?
I’ve been fortunate to be part of so many children’s lives that it’s difficult to choose just one story. What stays with me most are the long-term relationships — meeting a child as an infant or toddler, performing surgery early in life and watching them grow up.
Many of these children don’t even remember having surgery, but they do know they have a hand that lets them do the things they want to do. Knowing that something we did early in life continues to benefit them throughout childhood and beyond is one of the most meaningful parts of my work.
Q: What have you learned from your research?
My research focuses on two areas — epidemiology and the patient experience of living with a hand difference.
From an epidemiology standpoint, I study who develops these conditions and why — and whether some might be preventable. Many congenital upper limb differences are associated with other medical issues, so another aspect of this work is identifying when we should screen for additional conditions.
The second part of my research explores what it’s like to grow up with a hand difference. What clinicians consider important — such as strength, range of motion or sensation — doesn’t always match what matters most to patients. In a recent multi-center study, completed with other surgeon-researchers across North America, we found that children were often more concerned about the social impact of having a limb that looks or functions differently. That insight has challenged us to rethink our approach and consider not only functional outcomes but also social support, coping and appearance-related goals.
Q: Your philosophy is that the surgeon’s obligation to the patient doesn’t end in the operating room. Why is this important?
My goal is to help children achieve the lives they want to live. Surgery may be part of that, but my responsibility doesn’t end when the procedure is finished.
I follow children as they grow to ensure they can meet new developmental milestones and goals, whether those goals belong to a toddler, a grade schooler or a teenager. Any surgery performed in early childhood should support a child throughout all stages of development.
I also care about children and families as people — not just patients. Building relationships, supporting families and helping them navigate challenges — surgical or otherwise — is essential to caring for children and one of the best parts of being a pediatric hand surgeon. That connection is essential to the care I provide.
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Mary Claire Manske, MD, MAS, FAOA, is an attending physician with the Orthopedic Center and Hand and Arm Disorders Program at Children's Hospital of Philadelphia. In this Q&A, Dr. Manske discusses congenital hand and arm differences, as well as some of the surgical approaches she takes to help patients improve both physical and social function.
Q: What are some of the congenital hand and arm differences you see in your practice?
One of the great things about CHOP — and my congenital hand and arm practice — is that we truly see the full spectrum of congenital upper limb differences, from the common to the rare and from the simple to the complex.
Common conditions we encounter include:
- Syndactyly (webbed or joined fingers)
- Polydactyly (extra digits. most often on the pinky or thumb side but sometimes in between)
- Symbrachydactyly (short, sometimes webbed fingers)
- Amniotic band syndrome (bands around the limbs causing shortened fingers or webbing between non-adjacent digits)
Because we care for so many children with congenital upper limb differences at CHOP, we also routinely see less common conditions such as radial deficiency, hypoplastic thumb, ulnar deficiency, cleft hand and macrodactyly.
We also see many infants and children whose hand differences occur as part of a broader syndrome, such as Apert syndrome or arthrogryposis. Our experience with these syndromes helps us recognize associated conditions early. Working alongside world-class colleagues in other specialties — including pediatric anesthesiologists who are exceptional at caring for medically complex children — means we’re able to provide truly comprehensive care.
Q: What are some of the surgical approaches that can significantly help patients with function?
We have a wide range of reconstructive techniques that help improve hand function. We can separate webbed digits, reconstruct hands with extra fingers when they interfere with function and augment or stabilize underdeveloped fingers or thumbs.
Appearance matters too — hands are one of the most visible parts of the body — so we always talk with families about options that address both physical function and appearance — or what I call “social function.”
One of the things I love most about congenital hand difference is how unique each child and family is. I truly enjoy listening to what each family hopes to achieve and designing a surgical plan that aligns with those goals.
Q: Surgery is one tool to improve hand and arm function. What are other options you discuss with your patients and their families?
Surgery is just one tool in our toolbox. Two other important components of treatment are therapy and social support.
Therapy can be an alternative to surgery or a helpful adjunct before and after surgery. It teaches children how to use the hand they were born with, helps them learn new ways to accomplish daily tasks — like tying shoes, typing or participating in sports — and can even simulate the expected outcome of surgery, helping families decide whether a procedure is right for them. After surgery, therapy is essential for optimizing results — stretching, scar care and learning to use their “new” hand.
Social support is equally important. Many children tell me their hand works fine — even if it works differently — but they struggle with feeling different from their peers. At CHOP, we care for many families with hand differences, and many of those families are eager to talk with other parents and children. These connections can be incredibly powerful. There are also amazing programs like hand camps which bring kids with limb differences together in a fun, supportive environment. Our CHOP camp, Camp Rock, even offers rock climbing to help kids build confidence by trying an activity they may have been hesitant to try elsewhere.
Q: What is a “pediatric hand team?”
A pediatric hand team is a multidisciplinary group of providers dedicated to caring for children with hand differences. Surgery is only one aspect — the surgeon should never be the only person involved in treatment.
A comprehensive pediatric hand team typically includes:
- Surgeons
- Hand therapists
- Social workers
- Nurses
- Child life specialists
- Pediatric anesthesiologists
- Specialists from other medical fields who help evaluate associated conditions
- Psychologists or psychiatrists, when needed
A pediatric hand team is critical for comprehensive, developmentally appropriate care. The way we support an infant is different from how we support a toddler or a teenager.
The pediatric hand team cares for the whole family — supporting parents with education and guidance is a central part of what we do. A multidisciplinary team allows us to meet all those needs and provide holistic, family-centered care.
Q: Some hand and arm differences are now diagnosed prenatally. When this happens, what role can an orthopedic surgeon play?
Prenatal diagnosis of congenital hand or arm differences is still uncommon, but when it does occur, involving an orthopedic surgeon can be helpful. We often meet with families before delivery to explain the condition, discuss treatment options and outline the timing of possible interventions.
We can also help parents understand why the condition may have occurred and what to expect after birth. Knowledge is empowering, and early counseling helps families feel informed, supported and prepared to care for their baby.
Q: How did you become interested in congenital hand and arm differences as a focus area?
I have always found birth differences interesting. They are part of human variation. My father was a pediatric hand surgeon, so I grew up hearing about both these conditions and how much he loved caring for children. When I cared for children and families with upper extremity conditions during residency, I found the work deeply meaningful — through surgery or other treatments, I could make everyday tasks easier or improve the way a child used their hand.
I also discovered how much I love talking with kids of all ages and meeting them at their developmental level. It’s incredibly rewarding to see a toddler beam as they master putting on their own clothes, or to see an older child feel confident joining a sports team or participating fully in another school program.
I also truly enjoy working with parents — they know their child better than anyone, and our conversations help me understand the family’s goals and values. I love educating families about their child’s condition and helping them make decisions that feel right for them.
Q: Could you share a story or anecdote that illustrates how profoundly these differences affect your patients’ lives?
I’ve been fortunate to be part of so many children’s lives that it’s difficult to choose just one story. What stays with me most are the long-term relationships — meeting a child as an infant or toddler, performing surgery early in life and watching them grow up.
Many of these children don’t even remember having surgery, but they do know they have a hand that lets them do the things they want to do. Knowing that something we did early in life continues to benefit them throughout childhood and beyond is one of the most meaningful parts of my work.
Q: What have you learned from your research?
My research focuses on two areas — epidemiology and the patient experience of living with a hand difference.
From an epidemiology standpoint, I study who develops these conditions and why — and whether some might be preventable. Many congenital upper limb differences are associated with other medical issues, so another aspect of this work is identifying when we should screen for additional conditions.
The second part of my research explores what it’s like to grow up with a hand difference. What clinicians consider important — such as strength, range of motion or sensation — doesn’t always match what matters most to patients. In a recent multi-center study, completed with other surgeon-researchers across North America, we found that children were often more concerned about the social impact of having a limb that looks or functions differently. That insight has challenged us to rethink our approach and consider not only functional outcomes but also social support, coping and appearance-related goals.
Q: Your philosophy is that the surgeon’s obligation to the patient doesn’t end in the operating room. Why is this important?
My goal is to help children achieve the lives they want to live. Surgery may be part of that, but my responsibility doesn’t end when the procedure is finished.
I follow children as they grow to ensure they can meet new developmental milestones and goals, whether those goals belong to a toddler, a grade schooler or a teenager. Any surgery performed in early childhood should support a child throughout all stages of development.
I also care about children and families as people — not just patients. Building relationships, supporting families and helping them navigate challenges — surgical or otherwise — is essential to caring for children and one of the best parts of being a pediatric hand surgeon. That connection is essential to the care I provide.
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