Thursday, February 6, 2020

Cleft Hand: Beyond the Basics


I have posted numerous times on cleft hand. (See other posts.)  In my world, this is a still an unusual diagnosis and can be challenging as each child is somewhat different than the next.  The early and late treatment of cleft hand, therefore, has to be considered for each child.  

Late treatment in cleft hand is usually related to one of a few issues.  The first is muscle weakness, typically related to the lack of muscle development in the cleft.  Another issue that we see in cleft hand include instability of the MCP joints (the joints that connect the hand to the fingers), especially the index finger and the ring finger.  In addition, we often see challenges with straightening the PIP joints (main knuckle in the finger)- this is due to a lack of muscle in the hand which should straighten the finger.  Thankfully, despite these three issues, patients with cleft hand usually are highly functional and without pain.  This example shows another issue- finger alignment.

Here is an example of a great child and family who I have followed since birth.  Early surgery improved function and appearance for both hands.  As he has gotten older and more active, he has been frustrated around function and specifically that his left hand index finger (pointer finger) is pulled away from the rest of the fingers.  He can bring it back towards the next fingers but only by pushing with the thumb.  


Cleft hand with abnormal positioning of the index finger

Cleft hand with abnormal positioning of the index finger
The finger is able to be brought to the midline but only with thumb pressure.

Cleft hand with abnormal positioning of the index finger

Cleft hand with abnormal positioning of the index finger but excellent motion.


This video is really interesting and shows this nicely.  Watch how he uses the thumb.




After much discussion over a year, we decided to cut the bones and realign the index finger as well as tighten the ligaments to better support the finger.  This type of ‘touch’ up surgery in cleft hand can be highly successful, but we always think and talk a lot about it before actually proceeding with the surgery because we would never want worsen function or appearance.  In this case, I am happy to show, surgery has been very helpful and has increased activity, dexterity and appearance.

Surgery like this is an outpatient procedure, meaning the patient comes in for surgery and can then go home the same day.  The index finger proximal phalanx was cut and realigned and held in place to heal with pins.  

Bony reconstruction in cleft hand.

Cleft hand surgery.




The ligament on the midline side of the index finger (the ulnar collateral ligament of the MCP joint) is tightened (we also pinned this joint during the healing process).  After about 6 weeks, the pins were removed, therapy begun, and activities progressed.  These pictures and video are at 3 months.



The pictures after surgery are also helpful.
Cleft hand after reconstruction showing improved alignment. The patient can keep the index finger in the midline.

Cleft hand after reconstruction showing improved alignment. The patient can keep the index finger in the midline.
  
Cleft hand with surgery on both sides.
Charles A. Goldfarb, MD              

email: congenitalhand@wustl.edu

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