Cleft Hand

Introduction

Definition typical (central) cleft hand is characterized by absence of 1 or more central digits of the hand or foot also known as lobster-claw deformity Swanson type I failure of formation (longitudinal arrest) of central ray, leaving V-shaped cleft in the center of the hand types unilateral vs bilateral isolated vs syndromic Epidemiology incidence rare (1:10,000 to 1:90,000) demographics male:female ratio is 5:1 (more common in male) location hands, usually bilateral associated with absent metacarpals (helps differentiate from symbrachydactyly) missing middle finger on the ulnar side, small finger is always present often involves feet as well Pathogenesis  theory is wedge-shaped degeneration of central part of apical ectodermal ridge (AER) because of loss of function of certain genes expressed in that part of the AER Genetics inheritance pattern autosomal dominant with reduced penetrance (70%)  inherited forms become more severe with each generation mutations deletions, inversions, translocations of 7q split hand-split foot syndrome affected families should undergo genetic counseling Associated conditions Ectrodactyly-ectodermal dysplasia-cleft (EEC) syndrome sensorineural hearing loss syndactyly and polydactyly Prognosis functional limitation dependent on involvement of 1st webspace aesthetically displeasing, but not functionally limiting

Classification

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

Presentation

History may have family history  Symptoms aesthetic limitation functional limitation Physical exam absent or shortened central (third) ray may have absent radial digits may have syndactyly of ulnar digits may involve feet

Imaging

Radiographs recommended views AP, lateral, oblique views of bilateral hands foot radiographs if involved

Treatment

Nonoperative observation indications types I (normal web) and IV (merged web), no functional impairment Operative thumb web space, thumb, and central cleft reconstruction indications types IIA, IIB, III and V webs

Technique

Thumb, thumb web space reconstruction web space deepening, tendon transfer, rotational osteotomy, toe-hand transfer thumb web reconstruction has greater priority over correction of central cleft thumb reconstruction should not precede cleft closure as it might compromise skin flaps Central cleft reconstruction depends on characteristic of thumb web space close the cleft proper with local tissues from the cleft and stabilize and close intermetacarpal space

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