Digital Transfer for Hand Reconstruction in Cleft Hand and Foot Differences

Background Digital transfer for hand reconstruction in children with cleft hand and foot differences present unique challenges with anomalous anatomy and rare opportunities to dramatically improve function of one- or two-digit hands. Methods Medical records were reviewed for patients with cleft hand and foot treated at two pediatric institutions between 1996 and 2018. Hospital records, clinical photographs, radiographs, and alginate molds were available on all patients. Patient characteristics, indications for transfer, associated syndromes, donor and recipient anatomy, and complications were examined. Results Twenty digital transfers were identified in 16 patients. The mean age at time of transfer was 6 years (range: 3–18 years). Associated syndromes in this study included ectrodactyly ectodermal dysplasia clefting (EEC) syndrome and Goltz's syndrome. Recipient sites included the thumb (n = 17) and index ray (n = 3) in 10 hands with monodactyly, 6 hands with a two-digit ulnar syndactyly, and 3 hands with central deficiency and associated polydactyly or other anomalies. Donor sites included the great toe (n = 7), fifth toe (n = 9), great toe polydactyly (n = 2), thumb polydactyly (n = 1), and second toe (n = 1). All transfers survived. Revisions included tenolysis (n = 2), repeat fixation for nonunion or malunion (n = 2), and fusion for instability (n = 3). Conclusion Digital transfer in cleft hand and foot patients is a functional endeavor. The transferred digits provide sensation, mobility, and stability for opposition. Technically challenging due to small structures and atypical anatomy, these rare cases represent unique opportunities to improve function and appearance in the pediatric hand. This is a therapeutic study and reflects level of evidence IV.

Pollicization of Middle Finger in a Cleft Hand Associated with Acrorenal Syndrome

Introduction Acrorenal syndrome is autosomal recessive inherited disorder commonly associated with congenital renal disorders and ipsilateral hand/foot anomalies. The hand and foot deformities corrections are challenging to achieve a good functional and cosmetic result. We described a case of acrorenal syndrome with suppressed radial elements and absent thumb in whom we were able to reconstruct the hand. Case Report A 5-year-old girl presented to us with right renal agenesis and right hand/foot deformity. The hand showed a cleft hand with central deficiency, index finger hypoplastic, and syndactylyzed to middle finger, absent thumb. The hand was nonfunctional because of absent thumb. To improve the functions, it was decided to proceed with thumb reconstruction. The middle finger was pollicized to regain tripod grip and thereby the functions was enhanced. Discussion The cleft hand belongs to “failure of finger ray induction group” in classification by “International Federation of Societies for Surgery of the Hand (IFSSH).” Absence of thumb and first web space makes it a strong indication for surgical reconstruction. In our case, thumb was addressed by pollicization of middle finger and we were able to provide a good tripod grip.

Morphological Variations of an Atypical Cleft Hand: A Cadaveric Case Report

Cleft hand is a group of hand deformities in which the central digits of the hand are congenitally absent. The soft tissue variations of cleft hand are rarely described. Hence, we report the anatomic variants of a unilateral atypical cleft hand with the absence of all of the phalanges of the middle finger. The 2nd and 3rd lumbricals showed a variation in their distal attachment. Both the superficial and deep flexor digital tendons of the missing middle finger were fused and inserted into the palmar surface of the head of the 3rd metacarpal bone. The extensor digitorum tendon of the missing finger was inserted on the dorsal surface of the head of the 3rd metacarpal bone. The palmar digital nerves of the median nerve of the middle finger formed 2 visible fibrotic masses; radial and ulnar, over the base of the 2nd web space. Of these, the radial mass was formed by the fusion of both palmar digital nerves and the common palmar digital artery. The knowledge of soft tissue abnormalities reported here is clinically important to plastic surgeons while restoring the good grasp and pinch of the cleft hand. The occurrence of fibrotic masses reported in the present case is unique, and these masses may cause diagnostic errors during an angiographic procedure.

Insights into the pathogenesis and treatment of split/hand foot malformation (cleft hand/foot)

Cleft hand or split hand foot malformation is a sequence of phenotypes, from a minor shortening of the central digit to a complete absence of the third ray and in the most severe cases, absence of two, three or four rays. It is a rare but spectacular presentation usually involving both hands and feet. Inheritance is mostly autosomal dominant but sporadic cases without family history are also reported, resulting from a de novo mutation/deletion/duplication. Intra-familial clinical variability is the rule, with incomplete penetrance. X-linked or autosomal recessive inheritance has also been described. To date, seven subgroups of split hand foot malformation have been identified and seven loci are currently known. Anatomical records have enhanced our knowledge of this group of disorders of the hands and feet and allowed us to improve surgical procedures and long-term outcome.