Analysis of anatomic variations in cleft hands

Digital Transfer for Hand Reconstruction in Cleft Hand and Foot Differences

BACKGROUND

 Digital transfer for hand reconstruction in children with cleft hand and foot differences present unique challenges with anomalous anatomy and rare opportunities to dramatically improve function of one- or two-digit hands.

METHODS

 Medical records were reviewed for patients with cleft hand and foot treated at two pediatric institutions between 1996 and 2018. Hospital records, clinical photographs, radiographs, and alginate molds were available on all patients. Patient characteristics, indications for transfer, associated syndromes, donor and recipient anatomy, and complications were examined.

RESULTS

 Twenty digital transfers were identified in 16 patients. The mean age at time of transfer was 6 years (range: 3-18 years). Associated syndromes in this study included ectrodactyly ectodermal dysplasia clefting (EEC) syndrome and Goltz's syndrome. Recipient sites included the thumb (n = 17) and index ray (n = 3) in 10 hands with monodactyly, 6 hands with a two-digit ulnar syndactyly, and 3 hands with central deficiency and associated polydactyly or other anomalies. Donor sites included the great toe (n = 7), fifth toe (n = 9), great toe polydactyly (n = 2), thumb polydactyly (n = 1), and second toe (n = 1). All transfers survived. Revisions included tenolysis (n = 2), repeat fixation for nonunion or malunion (n = 2), and fusion for instability (n = 3).

CONCLUSION

 Digital transfer in cleft hand and foot patients is a functional endeavor. The transferred digits provide sensation, mobility, and stability for opposition. Technically challenging due to small structures and atypical anatomy, these rare cases represent unique opportunities to improve function and appearance in the pediatric hand. This is a therapeutic study and reflects level of evidence IV.

Epidemiological and Clinical Aspects of Cleft Hand: Case Series From a Tertiary Public Hospital in São Paulo, Brazil

Background: Cleft hand is a rare and congenital deformity that affects hands and feet and can be associated with other malformations. The objective was to evaluate the epidemiological and clinical aspects of cleft hand patient in a case series. Methods: Baseline characteristics associated with this deformity, such as sociodemographic characteristics, affected upper limb side, family history, clinical manifestations, and the degree of deficiency according to Barsky, Manske and Halikis, and Valenti classifications, were analyzed in 38 patients treated in the Department of Orthopedic Surgery of the Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil. Results: A predominance of typical hands as classified by Barsky, types II and IV by Manske and Halikis, and type IV by Valenti was found. A high frequency of typical cases (55.3%), as defined by Barsky, had a positive family history (P = .031) and were associated with other clinical manifestations (44.7%), when compared with atypical cleft hand patients (P < .001). Conclusion: In our study, there were more typical cleft hands than atypical, and they were more commonly associated with family history and other clinical manifestations.

Concurrent dorsal dimelia in 160 consecutive patients with congenital anomalies of the hands and feet

This study was designed to investigate the prevalence of dorsal dimelia in a series of 160 consecutive patients with congenital anomalies of the hands and feet, and to investigate the distribution of dorsal dimelia and the concurrent anomalies. Five cases (3.1%) showed evidence of dorsal dimelia and the distribution of dorsal dimelia was similar to the distribution of concurrent anomalies in all five cases. Another 11 cases of concurrent dorsal dimelia with other congenital anomalies have been reported previously with a positive match in the distributions in all cases. This similarity in the distribution in all 16 reported cases (including the five cases in the current study) is statistically significant. It is concluded that dorsal dimelia in humans is not as rare as it is generally thought to be, and that it may be viewed as an error of dorso-ventral patterning, which occurs in the same distribution as other concurrent anomalies.

Central and ulnar cleft hands: a review of concurrent deformities in a series of 47 patients and their pathogenesis

Two main types of cleft hands have been described. The ulnar cleft hand deformity is very rare and is characterized by two constant features: a deep cleft radial to the little finger and hypoplasia of the ulnar digits. The pathogenesis of ulnar clefts is unknown. The second type is the central cleft hand deformity, which is characterized by a soft tissue/bone defect in the hand centrally. Patients with central clefts also have several concurrent deformities in the remaining digits. This paper reviews the clinical features of three cases with ulnar cleft hands and 44 cases of central cleft hands, with special emphasis on concurrent deformities. The author's hypothesis of pathogenesis for both types of clefts and their concurrent deformities is then offered.

Digitalization of the second finger in type 2 central longitudinal deficiencies (clefting) of the hand

In central longitudinal deficiency of the hand type 2 (Manske and Halikis), the second finger presents itself anatomically and functionally as a second thumb. It is therefore necessary to undertake digitalization of the index, performed exactly as a reverse pollicization technique, with the same principles: minimum volar scarring and reconstruction of a large first web space without scars at the fold of the commissure. The incision surrounds the second digit at the level of the midproximal phalanx, extends over the dorsal edge of the cleft, and finishes on the radial side of the third finger where the second web space is to be created. Through this approach, the index metacarpal is freed (extraperiosteally), preserving the dorsal venous network, and translocated into the space of the missing third ray. After internal bone fixation, the flap, with its wide and safe volar cutaneous pedicle, is easily transposed to reconstruct the first web space, avoiding the need for skin grafting. This technique is easier and safer and does not impair the normal thumb musculature compared with the classic Snow-Littler procedure.

Anatomic variations in a cleft hand of an elder cadaveric specimen

Cleft hand is a rare and complex malformation in which the central part of the hand is missing. Since the nineteenth century, a very small number of dissections in cleft hand have been reported and very few reports describe the soft-tissue abnormalities. We report a case of an elderly cadaveric specimen with bilateral cleft hand. X-ray, CT-scan with 3D reconstruction and dissection were performed on the right hand and forearm. On both the sides, we noted the absence of the index, middle and ring finger. Malformation and degenerative arthrosis at the carpal bones level have been identified. The flexor and extensor tendons of the absent fingers fuse with one another over the end of the remaining carpal bones, forming a radial and an ulnar tendinous plexus and two tendon loops. Data concerning intrinsic muscles, vessels and nerves are entirely recorded. Soft-tissue abnormal distribution is due to the abnormal bony configuration. Correction of the bone abnormalities does not resume the surgical treatment of a cleft hand. Hand surgeons need to be aware of the soft-tissue disorders and their surgical implications.