42: Cleft Hand Reconstruction

Procedure 42 Cleft Hand Reconstruction



Sandeep J. Sebastin, Kevin C. Chung


A central cleft associated with a tight thumb and index finger web space in a child is probably the strongest indication for cleft hand closure. An isolated central cleft should not create a functional problem, and most pediatric hand surgeons will agree that closure of the cleft is primarily an aesthetic consideration to decrease the stigma associated with a prominent deformity. The indications for the cleft closure procedure must be discussed fully with the parents.



Indications




image Presence of a transverse bone in which growth leads to a progressive deformity


image Syndactyly affecting border rays with progressive deviation of the longer ray


image Constricted first web space


image Closure of the cleft for aesthetic reasons



Examination/Imaging



Clinical Examination




image A cleft hand is considered a longitudinal deficiency affecting the central digits. It is commonly inherited as an autosomal dominant trait with variable penetrance. The condition may be bilateral and may involve the feet. Manske and Halikis have proposed a classification based on the status of the first web space that is useful in planning treatment (Table 42-1).


image Patients with a typical cleft hand present with a V-shaped cleft in the center of the hand. This is occasionally associated with absence, polydactyly, and/or syndactyly of one or more digits. The cleft may be minor or major with absence of one or more digits. The absence progresses from the radial to the ulnar side. Polydactyly/syndactyly involves the digits adjacent to the cleft. Proximal muscle tendon units and nerves may be variably absent.


image There is a strong genetic component associated with hand clefts, and genetic counseling is helpful.


Table 42-1 Classification of Cleft Hand (Manske and Halikis)































Type Description Characteristics
I Normal web Thumb web space is not narrow
IIA Mildly narrowed web Thumb web space is mildly narrow
IIB Severely narrowed web Thumb web space is severely narrowed
III Syndactylized web Thumb and index rays syndactylized, web space obliterated
IV Merged web Index ray suppressed, thumb web space merged with the cleft
V Absent web Thumb elements suppressed, ulnar rays remain, thumb web space no longer present


Imaging




image Radiographs of the hand and upper limb are necessary for all congenital hand problems to identify other areas of concern.


image Metacarpal anomalies are frequently noticed. These include absence of metacarpals within the cleft, transverse tubular bones that widen the cleft with growth, bifid metacarpals supporting one finger, and duplication. Phalangeal anomalies include longitudinally bracketed epiphyses or double phalanges.



Positioning




image The procedure is performed under tourniquet control with the patient in the supine position.



Exposures


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28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 85: Wrist Denervation 38: Reconstruction for Congenital Thumb Hypoplasia 65: Arthroscopic Treatment for Septic Arthritis 89: Total Wrist Fusion

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 42: Cleft Hand Reconstruction

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