Saturday, May 18, 2013

Cleft Hand Long Term Follow- up

Cleft hand, central deficiency, is an uncommon birth anomaly of the hand.  I have previously posted a few times on this interesting difference including one about surgery http://congenitalhand.wustl.edu/2012/05/cleft-hand-surgery.html
and another about cleft hand in general http://congenitalhand.wustl.edu/2012/01/central-deficiency.html and a few others as well.  I thought a long- term follow- up sequence of pictures might be interesting to share.

We are learning more about all of the birth anomalies of the hand and upper extremity.  There is good evidence to suggest that cleft hand (also called central deficiency) is a hand difference which is part of a spectrum with central syndactyly and synpolodactyly.  We will continue to learn more about the origin of this hand difference and with this knowledge will come different treatment options.  I do not see a lot of changes in our basic treatment plan for many years but I am excited about our continuing progress and understanding.

Currently, it is our goal to make the cleft hand function better and look better.  The thumb- index web space often needs to be expanded and the cleft needs to be narrowed.  Those are the clear goals.  Additionally if there is a syndactyly between the ring and small fingers, that is corrected as well.  Finally, there can be laxity or instability of the index finger MCP joint (see picture below) and sometimes the PIP joint of the ring finger can be limited in motion (not in this patient).

The case below is an excellent example of a severe cleft hand and an outstanding clinical and functional outcome.  As the patient said to me (12 year old), "no one notices my hand."  I must admit that not all cleft hand reconstructions look as good as this hand.  However, if we apply the basic principles of reconstruction, generally good outcomes (both function and appearance) can be achieved.

Pre surgery for cleft hand.  Notice the cleft, missing long finger and abnormal hand appearance.

Another pre surgery view of cleft hand with a direct view of  cleft and finger rotation.

More than 10 years after surgery for cleft hand.  Notice how well the fingers are aligned.
Palm side view of cleft hand after surgery.

In cleft hand the index finger MCP joint (connecting finger to palm) can be lax.  This demonstrates that I can move his finger a great deal but this is not a regular problem for him.
The patient making a fist in cleft hand.  See that the fingers are not perfect but motion is generally excellent.  Interestingly, strength is also very good, almost as good as the other side.

The thumb- index web space is key to outcome in cleft hand. In this case we took skin from the central cleft and rotated it into the area that needed skin providing a great outcome.


Syndactyly reconstruction which looks very good in cleft hand.
X-ray showing good outcome with well- aligned fingers in cleft hand.





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