Pediatric Hand and Upper Extremity Surgery Expertise

With a large patient population across the Rocky Mountain region and a culture of extreme mountain sports, expanding the comprehensive hand specialty program at Children’s Hospital Colorado is essential. Sarah Sibbel, MD, a pediatric orthopedic surgeon, built and leads the multidisciplinary Hand and Upper Extremity Program that serves hundreds of children each month.

Dr. Sibbel is one of only a few pediatric hand and upper extremity surgeons across the country and is the only physician in the region who treats brachial plexus injuries. She's an expert in the surgical treatment of epidermolysis bullosa, a family of rare, genetic mucocutaneous disorders that leads to debilitating mechanically-induced blistering — especially on the hands.

This year, the program makes a significant advancement with the addition of acclaimed pediatric plastic and reconstructive surgeon Timothy Irwin, MD, a peripheral nerve and microsurgery specialist.

Together, Drs. Sibbel and Irwin are expanding treatments and access to the multidisciplinary clinic across the region. “When it comes to treating brachial plexus and other complex upper extremity issues, these are complex challenges, and you can't have enough smart, trained brains looking at these problems from different angles,” says Dr. Sibbel.

Adding Dr. Irwin to the program substantially expands the hand and upper extremity treatment depth and breadth. “All our different multidisciplinary hats are essential for the best care of these kids because I learn something in almost every clinic,” says Dr. Sibbel.

Advancing hand and upper extremity care

Over 300 patients typically visit the Hand and Upper Extremity Program each month, seeking treatment for issues ranging from a straightforward broken finger to complex brachial plexus birth palsy. Dr. Sibbel estimates they perform some 500 surgeries a year.

The hand and upper extremity surgeons are experienced in handling particularly complex cases stemming from issues caused by birth, diseases or trauma. Every case varies, and the team continuously uses new techniques to solve pediatric problems. “We're trying to push, change and innovate,” says Dr. Sibbel.

Both surgeons work closely with hand therapists, who join them at preoperative and postoperative clinic appointments. In some cases, hand therapists provide direct care and help diagnose patients with conditions like brachial plexus. “I'm constantly communicating with them about what I was able to accomplish in surgery and how to best rehab that,” says Dr. Irwin.

Children’s Colorado’s hand therapy program is nationally renowned, offering one of only two hand therapy fellowships nationwide.

Complex hand and upper extremity cases require deep expertise and even creativity. Growing the team allows for even greater specialization and space to explore new ideas, opportunities and technologies.

3D surgical planning and modeling is one area where the team continues to innovate and use advanced techniques for fractures caused by trauma or hand and upper limb congenital differences. Before ever operating on a patient, surgeons can use a 3D model specific to their patient’s broken bone to perform a practice surgery on a computer.

In joining the team, Dr. Irwin brings his expertise in an advanced microsurgery called free flaps. In these surgeries, which involve eight years of training, the surgeon removes a piece of tissue or bone from one part of the body together with a tiny blood vessel. The transferred tissue remains linked to a major vein or artery to reconstruct another part of the body, restoring function for a patient with a debilitating disease or injury. Additionally, there are cases in which Dr. Irwin can restore function in patients with nerve injuries or spinal cord injuries by performing a nerve transfer, which is the transfer of a working nerve to a non-working one.

Another advancement Dr. Irwin brings to the team is a new surgical technique called hyperselective neurectomy for spasticity and cerebral palsy. For decades, physicians have performed tendon transfers or released joint contractures to treat spasticity in children with cerebral palsy or traumatic brain injuries. Neither approach addressed tone or spasticity itself.

Hyperselective neurectomy treats the spastic tone rather than its symptoms. The procedure helps manage patients’ tone and improves limb movement and positioning, negating the need for joint and muscle releases later. “When children with cerebral palsy or hemiplegic spasticity are young, we're able to perform surgery on the nerves that control those spastic muscles, decrease their spasticity overall and prevent joint contractures,” says Dr. Irwin.

The new technique was popularized in France by Caroline Leclercq, MD, and has been adopted by only a handful of surgeons in the U.S.

What’s next for the Hand and Upper Extremity Program

Although Dr. Irwin only recently joined Dr. Sibbel to expand the hand surgery program at Children’s Colorado, the team is already planning for future growth.

Dr. Irwin uses emerging nerve techniques to prevent and treat painful neuromas and plan for future myoelectric prostheses. These new nerve techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPN) prevent limb pain and phantom limb pain after amputations. These techniques are able to generate electrical signals to power a myoelectric prosthesis. The progression of technology can sometimes feel like the program is developing solutions that were once thought only possible in science fiction.

“We're pushing the envelope on many different fronts, and I think it's a really exciting time to be a hand surgeon,” says Dr. Irwin.