Sunday, January 3, 2016

Cleft Hand Reconstruction


I have posted a number of times on cleft hand, or central deficiency as can be found HERE.  To me, cleft hand is one of the most interesting diagnoses as kids with it may look and function very differently from each other despite have the same diagnosis.  Some of my other posts highlight these differences between kids with cleft hand.  This highlights the importance in understanding both the functional and the appearance differences for each child.

This case is that of a child who is a bit older- at 12 years- with less dramatic complaints compared to some kids but with clear functional difficulties.  There is a syndactyly involving the ring and small finger which limits his ability to wear gloves and maximally spread the fingers and the ring finger has limited flexion (bending) and some angulation.
Cleft hand with limited ring finger motion and syndactyly

Cleft hand palm view with limited ring finger motion and syndactyly

x-ray of cleft hand
This cleft hand is very interesting to me.  The pictures of the hand and the x-ray are informative.
  1. The cleft itself (ie, the gap between the index finger and the ring finger) is not a problem for this child.  Sometimes this gap is much larger and, therefore, more of an issue whether for appearance or function.  
  2. The thumb- index webspace is not an issue in the patient.  It is often the single biggest problem in cleft hand as it limits function if it is narrow.
  3. The xray clearly shows the extra bone from the missing long finger is joined to the ring finger.  This is the proximal phalanx of the long finger (middle finger).  In this child, that bone is causing some difficulties with ring finger motion and also deviation.  
  4. Finally, it is not uncommon to find syndactyly between the ring and small finger.  However, patients and families do not always find this to be a problem (in this case, it was).
As mentioned above, the primary issue for this child was the ring finger, tethered on the thumb side by the extra bone and on the pinky side by the syndactyly.  The family requested reconstruction.  

We removed a portion of the extra bone and deepened the web space between the ring and small finger.  Certainly, we could have done a more extensive surgery but, as for most cases, we focus on accomplishing our surgical goals in an appropriately limited way.  Early results are promising.  

Cleft hand after reconstruction.

Cleft hand after reconstruction.
Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu




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