Central deficiency (cleft hand) is classically as I have shown in previous blogs. http://congenitalhand.wustl.edu/2012/05/cleft-hand-surgery.html We have previously published our experience with the classic central deficiency, that is the hand with a limited thumb- index web space, 3 fingers (index, ring, and small finger), and a large cleft http://www.ncbi.nlm.nih.gov/pubmed/18984341
However, there are many different varieties of cleft hand, as previously classified by Dr Ogino in Japan and Dr. Manske here in St. Louis. Dr Ogino’s classification is based on how many digits are missing and Dr Manske’s classification, http://www.ncbi.nlm.nih.gov/pubmed/7594304 is based on the thumb web space- which is important for function. If the thumb- index web space is limited, the overall hand function will be markedly limited. The child will struggle to grab large objects but also will find it difficult to manipulate smaller ones.
With less common types of central deficiency, surgery is sometimes completely avoided or may be minimized. Consider these 2 examples.
|A conjoined thumb with pinky finger in cleft hand. Note the small web space.
|Cleft hand with difficulty grasping large objects. The thumb is not positioned to best grasp or pinched (i.e., not opposed to fingers)
|Cleft hand xray.
We will likely help this child’s function with 2 procedures, one to slightly deepen the web space to allow larger object grasp and a second to rotate and reposition the thumb in a position to better pinch and grasp against the pinky finger.
2) Consider the next child with a very similar hand. A merged thumb and a single other digit. However, the difference is that the cleft
is deeper allowing the child to grasp larger objects and the thumb is opposed. Look how the child can grasp with the thumb against the finger with a pen and with cheerios. Surgery is unlikely to help. Additionally, one might consider narrowing the thumb but I would argue against that procedure as I think it would hurt function and would be unlikely to help appearance.
|A second child with similar cleft hand.
|Cleft hand with a well- opposed thumb easily manipulating a pen.
|Also able to easily manipulate a cheerio. Note the position of the thumb against small finger.