42: Cleft Hand Reconstruction

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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

image In children who have a central cleft with narrow thumb and index finger web, the skin over the dorsum of the cleft is raised as a palmar-based flap. This flap is used to resurface the narrow thumb and index finger web after it is released. Elevating this flap on the dorsum is easier because of a lack of adhering palmar fascia. Additionally, this allows access to the metacarpal heads that can be sutured together to close the cleft.

image A distally based rectangular flap is designed over the midproximal phalanx on one of the fingers adjoining the cleft. This flap will be used to create the web space formed after closure of the central cleft. An important consideration is to create a smooth slope in the web space.

image Figures 42-1 and 42-2 show a 2-year-old boy with a central cleft between the index and long fingers, a tight thumb and index finger web space, and complete complex syndactyly between the long and ring fingers. The syndactyly will need to be released in a second operation.

image

FIGURE 42-1

image

FIGURE 42-2

Procedure

Cleft Hand Reconstruction

Step 1: Elevation of Palmar-Based Cleft Flap

image A palmar-based flap is designed, extending to the dorsum of the hand by parallel incisions (Figs. 42-3 and 42-4).

image The parallel incisions are connected on the dorsum, and the dorsal flap is elevated superficial to the extensor tendons (Fig. 42-5).

image The neurovascular bundles are identified on the palmar aspect and protected, and the flap is mobilized by dividing any strands of palmar fascia (Fig. 42-6).

image

FIGURE 42-3

image

FIGURE 42-4

image

FIGURE 42-5

image

FIGURE 42-6

Step 1 Pearls

The flap should be mobilized sufficiently to allow easy transposition to the thumb and index finger web space.

The viability of this flap depends on preservation of the intrinsic blood supply, and dissection must maintain the subdermal plexus.

Step 2: Release of Thumb and Index Finger Web Space

image An opening incision is made between the thumb and index finger to release the web space contracture (Fig. 42-7).

image

FIGURE 42-7

Step 2 Pearls

Depending on the severity of the thumb and index finger web space narrowing, one may need to divide the fascia, the adductor pollicis, and the first dorsal interosseous, and rarely an osteotomy of the thumb metacarpal may be required to realign the thumb.

Step 3: Closure of Cleft

image The metacarpal heads adjoining the cleft are exposed as a result of elevating the flap (Fig. 42-8).

image Nonabsorbable sutures are placed into the metacarpal heads to bring the metacarpals together (Figs. 42-9 and 42-10).

image

FIGURE 42-8

image

FIGURE 42-9

image

FIGURE 42-10

Step 3 Pearls

It is rather easy to place sutures into the bones, which have not fully ossified. Tension is adjusted so that one does not create an overly tight closure, which can cause scissoring of the fingers.

Step 4: Transfer of Cleft Flap to Resurface Thumb and Index Finger Web

image The previously elevated flap is transposed into the defect created by release of the thumb and index finger web (Fig. 42-11).

image

FIGURE 42-11

Step 5: Creation of New Web Space in Cleft

image A distally based rectangular flap is designed over the ring finger, which will be sutured to the index finger on cleft closure to re-create the web space (Fig. 42-12).

image The flap is elevated and sutured to the opposite incision to create the gentle slope of the web space (Figs. 42-13 and 42-14).

image

FIGURE 42-12

image

FIGURE 42-13

image

FIGURE 42-14

Step 5 Pearls

It is better to elevate this flap (ring finger) after closing the cleft by suturing the metacarpal heads together. This allows for adjustments to the flap design based on final location of the web space.

Step 6

image All skin incisions are closed with absorbable sutures to avoid difficult suture removals in children. Chromic catgut is preferred because it dissolves earlier (Fig. 42-15).

image

FIGURE 42-15

Postoperative Care and Expected Outcomes

image The hand is splinted for 4 weeks to allow healing of the intermetacarpal closure.

image No therapy is necessary after splint removal. The child is followed yearly to evaluate the growth of the hand. Creeping of the web space is not uncommon with cleft surgery. Future web space releases may be needed to enhance the functional and aesthetic results for the hand. The outcome depends on the degree of preoperative deformity, and good function can be achieved in children with a preserved thumb.

Evidence

Rider MA, Grinder SI, Tomkin MA, Wood VE. An experience of the Snow-Littler procedure. J Hand Surg [Br]. 2000;25:376-381.

The authors reviewed 12 cases using the Snow-Littler procedure to close hand clefts. The procedure described is similar to the techniques illustrated in this chapter. They concluded that this technique improved the appearance and function for children with hand clefts. (Level IV evidence)

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