42: Cleft Hand Reconstruction

Published on 19/04/2015 by admin

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Last modified 19/04/2015

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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

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