Central ray deficiency with extensive syndactyly: a dilemma for classification

Split Hand Foot Malformation (SHFM) (cleft hand/foot, central ray deficiency) is a complex, highly variable anomaly involving the hands and/or feet. A clinical epidemiologic study of split hand/foot (central ray deficiency) of the Manitoba population identified a subset of patients who did not present with either typical or atypical split hand. Clinically, some patients presented with "mitten hand" syndactyly; the deficiency was not recognized before imaging. In this paper, we identify additional similarly affected literature cases, review existing classifications of split hand and syndactyly and attempt to classify these patients. This group presents a challenge for classification and genetic counseling. General classifications permit inclusion of patients with diverse phenotypes; however, details are overlooked. Osseous fusions and disorganization of osseous components complicate classification. Many of these patients had findings that overlapped different subtypes within existing classifications. This cohort highlights the importance of imaging patients with distal limb anomalies. An effective classification scheme should include relevant clinical and radiographic findings in order to assist clinicians following these patients.

Elements of morphology: standard terminology for the hands and feet

An international group of clinicians working in the field of dysmorphology has initiated the standardization of terms used to describe human morphology. The goals are to standardize these terms and reach consensus regarding their definitions. In this way, we will increase the utility of descriptions of the human phenotype and facilitate reliable comparisons of findings among patients. Discussions with other workers in dysmorphology and related fields, such as developmental biology and molecular genetics, will become more precise. Here we introduce the anatomy of the hands and feet and define and illustrate the terms that describe the major characteristics of the hands and feet.

[Assessment of congenital foot deformities]

The assessment of congenital foot deformities is only relevant in the context of German legislation (SchwbG) defining disability and fitness for military service. All assessments of congenital foot deformities should be based on the twin concepts of function and capacity to withstand stress. However, assessments with regard to the degree of disability and fitness for military service will occasionally differ. This article discusses the various congenital foot deformities individually, allocating them to the respective degrees of disability [as laid down in German law]. The classification may serve as a guide for consultants within the context of disability legislation and for ascertaining fitness for military service in accordance with the "Central Standing Orders" of the Federal German armed forces.

Unique case of polydactyly and a new classification system

Polydactyly of the hands or feet is a common birth deformity. We recently encountered a female infant with a case of a crossed type 1 polydactyly with a mixed polydactyly of the feet. A mixed and crossed polydactyly is a rare finding with only one other reported case. This is the first report of crossed and mixed polydactyly of the feet presenting with 7 complete toes on each foot without syndactyly. In addition to a discussion of the treatment, this case has lead us to propose a more complete and less confusing classification system.

[Clinical signs and diagnosis of hallux valgus]

The hallux valgus deformity (fibular deviation of the big toe) is one of the most common deformities affecting lower limbs. If the hallux crosses over the second toe, the condition may be termed hallux valgus superductus, if it moves under the second toe, the term hallux valgus subductus applies. Mechanical pressure on the pseudoexostosis results in a bunion and possibly fistulization. Hallux valgus is often combined with a splay foot. Overloading of the second to fourth metatarsal heads may cause midfoot pain. As a result of the increased load, the second to fifth toes may deform into hammer or claw toes. Therefore hallux valgus should usually not be considered in its own. Apart from the anamnesis and clinical examination, X-ray diagnosis is very important for the treatment planning. A.p. and lateral X-rays should be obtained of the entire foot in the standing patient, as also an oblique view. While the latter permits evaluation of the extent of an arthrosis of the metatarsophalangeal joint of the big toe, the lateral films allow the longitudinal arch and the stability of the first tarsometatarsal articulation to be assessed. On the a.p. film the hallux valgus angle and the intermetatarsal (rays 1/2) angle can be determined.

The expanding panorama of split hand foot malformation

The split hand/foot malformation is a developmental defect of the extremities resulting from errors in the initiation and maintenance of the apical ectodermal ridge. The phenotype is genetically heterogeneous, and it can be identified either as an isolated phenotypic manifestation or as a constituent component of a malformation syndrome. This overview describes the clinical phenotype, related animal models, and the evolving genetic heterogeneity of the malformation.

Split hand foot malformation (SHFM)

The nomenclature describing the phenotype of missing central rays in the hand and/or foot in the genetics and surgical literature is heterogeneous and confusing. Split hand/foot malformation (SHFM) is the most common term for this phenotype in the genetics community; however, other names such as the offensive 'lobster-claw malformation' and the non-specific 'ectrodactyly' are still utilized to describe this malformation. In this article, we briefly review the nomenclature associated with SHFM and its classifications.

Classification of postaxial polydactyly of the foot

BACKGROUND

The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options.

METHODS

We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head.

RESULTS

Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5th metatarsal medial deviation occurred.

CONCLUSIONS

Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.

The Newborn Foot

An assessment of the foot should be a part of every newborn physical examination. The newborn foot, although complex in structure, can be examined quickly in any office setting. Many foot deformities are diagnosed immediately after birth, allowing for earlier and often more successful treatment. A neonate with a foot deformity can be a source of anxiety to parents. Adequate knowledge of commonly encountered neonatal foot problems enables the nurse to give appropriate anticipatory guidance to the parents. Foot abnormalities usually occur as isolated findings in an otherwise healthy newborn. However, these deformities can also be seen in newborns with underlying neuromuscular disorders and syndromic conditions. Common newborn foot abnormalities include equinovarus deformity (clubfoot), metatarsus adductus, calcaneovalgus, congenital vertical talus, polydactyly (supernumerary digits), and syndactyly (webbed toes). These common foot disorders, their treatment, and their prognosis are discussed. This article also discusses fundamental nursing implications needed to care for these young patients and their families.

Analysis of anatomic variations in cleft hands

PURPOSE

This study presents an overview of the clinical and x-ray findings observed in 54 cleft hands of 31 patients. The emphasis was on a detailed analysis of typical malformation-associated x-ray patterns such as aplasia and synostosis, with findings arranged as a function of cleft location and of the Manske and Halikis classification.

METHODS

The charts and radiographs of 31 patients with 54 cleft hands were reviewed retrospectively and compared with data reported in the literature. Important clinical and x-ray findings as well as the typical morphology of cleft hands were analyzed. Cleft hands were differentiated according to their location and according to the Manske and Halikis classification. In the different locations the deformities were arranged in teratologic sequences.

RESULTS

In cleft hands syndactylies were seen in 30 of the 54 hands, most commonly between the ring and the small finger. In 3 hands polydactylies were noted. Analysis of the x-ray morphology showed 2 typical patterns: aplasia and synostoses. Location-specific teratologic sequences showed that radial cleft hands were bilateral more frequently and were associated significantly more frequently with cleft feet. Aplasias predominated in radial cleft hands, whereas synostoses were more common in central cleft hands. In terms of the Manske and Halikis classification the unilateral cleft hands often corresponded to type I whereas bilateral cleft hands with cleft feet mainly were type IV and type V deformities. Cleft hands with synostoses often were seen in types I to III whereas cleft hands with aplasias were classified most frequently as type V.

CONCLUSIONS

Analysis of the patients' clinical data and x-rays showed differences between radial and central cleft hands, as well as between the different Manske and Halikis types.

[Congenital quintus varus supraductus: surgical procedure]

Quintus varus supraductus is a congenital malformation that associates a hyperextension, a varus and an external rotation of the fifth toe coming over the fourth. The goal of this study is to explain an easy, reproducible and efficient surgical procedure to correct that malformation. Our procedure is only about soft tissues. It comprises a fifth toe extensor tenolysis, a circular capsulotomy and lateral ligament section of the fifth metacarpophalangeal articulation. The glenoid plaque is desinserted only if the peroperative reduction did not seem sufficient. The stabilization is achieved through a cutaneous plasty of modified BUTLER, with a cutaneous lengthening VY plasty. Exceptionally, an axial broaching of the articulation has been done. On about 20 children, aged 4-17 years, operated with this procedure, we have noticed a complete and definitive correction in 19 patients. Only one patient showed an incomplete resurgence, but without any functional disturbance. We did not notice any failure. This procedure seems efficient, and all the more interesting that it is technically easy to perform.

[The cleft hand. Proposal of a classification based on 279 cleft hands]

PURPOSE

We propose a new classification of cleft hand based on the analysis of our own cases and a literature search.

METHODS

We analysed clinical data and radiographs of 31 patients with 54 cleft hands in addition to 225 cleft hands from the literature, and classified them with the help of schematic drawings of radiographs in extension of the proposals of Blauth and Schneider-Sickert.

RESULTS

Classification of cleft hand: 1. Median cleft hands without involvement of thumb and small finger. 2. Medioradial cleft hands with thumb affected but with detectable residuals preserved. 3. Radial cleft hands with thumb aplasia. Medioulnar cleft hands with small finger affected but detectable residuals preserved. 5. Ulnar cleft hands with small finger aplasia. Median cleft hands more frequently appear unilateral and are more seldom combined with cleft feet as medioradial and radial cleft hands. In radiographs, aplasia predominate in radial cleft hands while synostoses often appear in median cleft hands.

CONCLUSIONS

The new classification enables us to arrange the great diversity of this malformation and takes medioulnar and ulnar cleft hands into account.

[Identification of a recurrent mutation in the ROR2 gene in a Chinese family with brachydactyly type B]

OBJECTIVE

To identify the disease-causing mutation in a Chinese family with brachydactyly type B (BDB).

METHODS

Genomic DNA was extracted from peripheral blood samples of family members. Exons 8 and 9 of the ROR2 gene were amplified by polymerase chain reaction (PCR) and sequenced directly. Furthermore, the PCR products showing mutation were cloned into pMD18T vector and the insert fragments were sequenced.

RESULTS

A 1398-1399 insA heterozygous mutation was detected in the patient. This mutation had been found in German families with BDB.

CONCLUSION

To the authors' knowledge, it is the first report on identification of the ROR2 pathogenic mutation in Chinese patients with BDB.

Fibular hemimelia: a new classification system

A new classification system for fibular hemimelia is proposed based on the authors' experience with 32 patients with 33 involved limbs representing a spectrum of involvement. The data demonstrate the broad and unpredictable relationships among the fibula, ankle, and foot in this disorder. The classification system, based on fibular and ankle morphology, hindfoot coalition, and foot ray deficits, is designed to improve communication about the condition. Because of the variability and unpredictability of the multiple relationships, limb salvage criteria should also include the nature of the foot and ankle and not merely depend on the length discrepancy or the presence or absence of the fibula.

Review of the effect of early amniocentesis on foot deformity in the neonate

A recent publication by the Canadian Early and Mid-Trimester Amniocentesis Trial Group reported an increase in orthopaedic foot deformities in infants whose mothers underwent an amniocentesis from 11 to 12 + 6 gestational weeks versus a group sampled between 15 to 16 + 6 gestational weeks. Because the sampling of the former group was at the time of maximum foot growth and maximum acquisition of amniotic fluid, the authors hypothesize that the foot deformities are secondary to decreased fetal movement during a key phase in foot and ankle development.

[Abnormalities of the foot]

A few selected++ metric and numeric malformations of the foot (Fibular deficiency, vertical talus, coalition, syndactylism, macrodactylism, metatarsal malformation, cleft foot, overriding fifth toe) are discussed to demonstrate, that concepts for their treatment should be developed as early as possible in order to allow for bringing those structures that are developed in optimum use. Besides function cosmetic aspects of the foot also deserve being respected.

Accessory bone or unusual congenital anomaly

This case study presents a congenital anomaly, diagnosed in a 23-year-old male, not found previously described in the medical literature. It also reviews the current classification systems used to describe congenital anomalies.

Clinical study of symbrachydactyly of the foot

Seventeen patients with symbrachydactyly of the foot are described. Patient characteristics including sex, the side of the affected foot, age at first medical examination, and condition of the nails were recorded. Compared with the unaffected side, the lengths of the proximal phalangeal and metatarsal bones were significantly shorter. The abnormalities of the feet were classified into four types: typical axial, atypical axial, medial ray, and rudimentary. The anomaly progresses from hypoplasia of the central rays to a deformity of the great toe, but rarely involves the fifth toe. The fact that this differs from symbrachydactyly of the hand is of considerable interest.

[Median clefts of the hand. Classification and therapeutic indications apropos of 29 cases]

Based on a series of 29 patients with median clefts of the hand (29 hands), the authors define the place of this malformation, its various clinical features and the therapeutic indications. The series consists of 13 boys and 7 girls, 9 bilateral cases and 11 unilateral cases. Involvement of the feet was observed in 9 cases. Several children also presented other malformations. 16 children were operated (22 hands). Two types of technique were used: simple closure of the cleft (Barsky's operation) and transposition of the index finger according to the Snow-Littler or Miura-Komada techniques. All operated patients were reviewed with a follow-up of more than one year and the results were assessed in terms of three criteria: overall use of the hand, thumb-index finger pinch grip, aesthetic appearance. The authors propose a new classification of median clefts of the hand based on examination of this series of 20 children: simple clefts with more or less complete absence of the middle finger, complex clefts with syndactyly (especially I and II), transverse bone polydactyly, extensive clefts with severe aplasia of the radial segment of the hand. Clinical and radiological examination confirm the experimental studies by Ogino. Barsky's operation gives satisfactory results in simple forms with parallel fingers. Translocation of the index finger to the base of the 3rd metacarpal is necessary in the presence of divergent fingers and syndactyly. Median clefts of the hand are very distinct from median aplasia, which is always unilateral, with no familial nature and no involvement of the feet and which can be classified together with brachysyndactyly. Each case must be studied before deciding treatment, as functional adaptation is always remarkable. The least favourable surgical results are observed in forms with abnormal position of the index finger (malrotation syndactyly). Lastly, the Snow-Littler operation is not devoid of complications.

The position of symbrachydactyly in the classification of congenital hand anomalies

The clinical features of 53 cases of intercalated hypoplasia and 113 cases of distal aplasia are reviewed and compared with each other and with 129 cases of syndactyly. Tri-, di- and mono-phalangeal symbrachydactyly, and adactyly with nubbin digits are consecutive anomalies. Transverse deficiency may result if the mesenchyme is damaged severely, and if damage is mild and formation has continued, intercalated transverse deficiency may occur. Webbing in symbrachydactyly may result from failure of the apical ectodermal ridge under the influence of damaged mesenchyme.

Congenital longitudinal deficiency of the fibula (fibular hemimelia). Parental refusal of amputation

Fibular hemimelia with significant limb-length inequality is usually best treated with foot ablation and prosthetic fitting. Parents tend to be reluctant to agree to allow their child's foot to be amputated at an early age, especially when the foot is near normal and the limb length is not grossly abnormal. Experience with some families of children with fibular hemimelia who initially refused amputation of the affected limb prompted a retrospective review of the treatment experience with these children. Twenty-four children with 36 affected limbs were treated during the last three decades. Amputation of the foot was performed for 16 limbs in 12 of the 24 patients. The 12 patients whose limbs were not amputated were reviewed in detail. Six of these children were advised to have an amputation, but their families refused to consent. These children were managed by specially designed prostheses to incorporate their foot deformity and limb-length inequality. Four patients required subsequent corrective surgical procedures in an attempt to stabilize the feet or lengthen the limb. To facilitate treatment decisions for both the clinic team as well as the involved families, the authors propose a more practical classification of fibular hemimelia.

Polydactyly of the foot: an analysis of 265 cases and a morphological classification

Three hundred and thirty feet in 265 patients with polydactyly of the foot were classified on the basis of ray involvement and the level of duplication. Anatomic differences in bony structures according to x-ray and operative findings, external appearance of involved digits, associated anomalies, and familial incidence were studied. In medial-ray polydactyly, bilateral occurrence was common, and a higher frequency of associated anomalies was detected. Each involved foot with even the same level of duplication usually had a different morphologic pattern. In central-ray polydactyly, all patients except one had duplications of the second toe, commonly with unilateral involvement. Both components were underdeveloped, with delay in appearance of ossification areas. In two patients, each member of duplication had syndactyly with the neighboring toe, resembling the pattern of polysyndactyly-cleft hand complex. Lateral-ray polydactyl was classified into two new major groups based on ossification pattern and bony alignment: (1) fifty-ray duplication, referring to the medially duplicated supernumerary fifth toe, and (2) sixth-ray duplication, referring to the laterally duplicated supernumerary sixth toe. Fifth-ray duplication was much more frequent than sixth-ray duplication in the Japanese population. Many differences were noted between the two groups of lateral polydactyly. Syndactyly between the fourth and fifth toes was associated only with fifty-ray duplication. Ulnar polydactyly was associated only with sixth-ray duplication. In lateral polydactyly, every patient with bilaterally involved feet had similar groups of polydactyly bilaterally. All the patients in the same family also had similar groups of anomalies. These facts suggest independent etiologic mechanisms for each.

Foot deformities in diastrophic dysplasia. An analysis of 102 patients

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition.

Postaxial polydactyly. A case report

Polydactyly is a fairly common congenital foot deformity. Treatment may include simple shoe modification or surgical intervention. Careful preoperative planning must be undertaken with each patient because of the uniqueness of each individual case. A case of type A postaxial polydactyly was presented with a brief review of classification, etiology, and treatment.

Observer variability in the radiographic measurement and classification of metatarsus adductus

The classification system of Berg was evaluated using four observers and the radiographs of 42 feet from patients with metatarsus adductus. Interobserver disagreement in diagnosis was 36%. Intraobserver inconsistency averaged 26%. The error range for the lateral and anteroposterior talocalcaneal angle measurement was 13.6 and 15.1 degrees intraobserver and 19.8 and 25.2 degrees interobserver, respectively. There was no correlation between classification and the length of time required for cast correction. The irregularity of hindfoot ossification centers makes measurements inconsistent and seriously reduces the usefulness of classification based on such measurements.

[Split hand/foot abnormalities: classification, pathogenesis, epidemiology]

Authors report on the genetic epidemiologic investigation of one of the sentinel anomalies made on purpose to define the birth prevalence of the different types of it, to calculate the mutation rate of autosomal dominant forms as well as to recognize the clinical features of Hungarian cases. 58% of all cases registered in the Hungarian Congenital Abnormality Registry in 1975-1984 proved to be atypical. The birth prevalence of autosomal dominant forms was 1.33/100.000 total birth. 71% of dominant forms was sporadic since 29% was familial. Thus the mutation rate was estimated 4.7 x 10(-6) +/- 1.22 x 10(-6).

An apparently new mental retardation syndrome in three elderly sisters

Three elderly sisters with profound mental retardation in association with the clinical features of microcephaly, short stature, brachydactyly type D, flattened occiput, down-slanting palpebral fissures, low-set large ears, broad prominent nose and kyphoscoliosis have been investigated. Each was more than 60 years of age and their clinical features were strikingly similar. The disorder has several manifestations in common with Rubenstein-Taybi syndrome and appears to be inherited as an autosomal recessive in this family.

Pedal polydactyly. A case report

Polydactyly is a common pedal deformity with great variation in clinical presentation. There is a tendency toward a higher incidence in previously affected families, but the actual occurrence rate of the different forms of polydactyly has not been agreed upon in the literature to date. Most authors agree that the isolated deformity is an expression of an autosomal dominant gene with varied penetrance. Syndromatically associated polydactyly is inherited as an autosomal recessive trait. Surgical intervention should be attempted as early as possible. Correction should be undertaken only after a thorough clinical and radiographic evaluation has been performed. The patient's postoperative goals should always be considered. It is not necessary to remove the supernumerary digit if it does not interfere with the foot's function and comfort. Cosmesis should not be the chief consideration. The surgeon should strive to return the foot to a more normal contour while maintaining or improving foot function.

[Classification of polydactyly of the hand and foot]

The authors present a classification for polydactyly of the upper and lower limb based on a follow-up examination of 177 patients with 336 polydactylies. The malformations are described in longitudinal and transverse directions. In the transverse axis the affected rays are designated with Roman numbers from I to V. The longitudinal axis from distal to proximal is used to differentiate the rays into ten types according to their duplication assessed both anatomically and radiologically. Triphalangism, rudimentary forms, and trifid rays can also be described by this system, so they can be correlated. Evaluation of the patient group according to this classification shows that the marginal rays of hand and feet are most affected. In the longitudinal axis the metacarpo- metatarsal joint type predominates in the upper and lower limb. Using this classification it seems possible to relate different forms of polydactyly to each other and to compare therapeutic procedures and their results.

Classification of polydactyly of the hands and feet

The authors present a new classification of polydactyly based on radiomorphological alterations. The malformations are defined in two directions, as in a system of coordinates. The longitudinal arrangement is based on the pathogenetic principle of bifurcation of a finger or a toe ray from distal to proximal. We accordingly divided polydactylies into five types: distal phalanx, middle phalanx, proximal phalanx, metacarpal or metatarsal, carpal or tarsal. The transverse arrangement indicates which rays are involved. All polydactylies, including the special forms such as rudimentary manifestations, triphalangism, and multiple duplications, can be incorporated into this simple basic scheme. Depending on their characteristics, the special forms are further subdivided, e.g., into a distal or proximal phalanx type with simple or double triphalangism, or a tarsal type with third-degree duplication and first-degree aplasia. Numerous radiological examples and schematic drawings illustrate the classification. The advantage of the classification is that it depends exclusively upon the skeletal finding and all manifestations are registered according to a simple scheme longitudinally and transversely. This makes them codifiable for the computer and suitable for multicenter studies. The special forms, the rudiment, triphalangism, and multiple duplication, can easily be further subclassified. Moreover, the nomenclature is simple and is oriented to anatomical terminology.