Updated: 7/9/2017

Syndactyly

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Questions
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https://upload.orthobullets.com/topic/6076/images/Syndactyly photo a_moved.jpg
https://upload.orthobullets.com/topic/6076/images/photo acrosyn.jpg
https://upload.orthobullets.com/topic/6076/images/illustration of types.jpg
https://upload.orthobullets.com/topic/6076/images/clincal photo incomplete syn.jpg
https://upload.orthobullets.com/topic/6076/images/photo of complex syn.jpg
Introduction
  • Most common congenital malformation of the limbs
  • Epidemiology
    • incidence
      • 1 in 2,000 - 2,500 live births
    • demographics
      • M > F
      • Caucasians > African Americans
    • ray involvement
      • 50% long-ring finger
      • 30% ring-small finger
      • 15% index-long finger
      • 5% thumb-index finger
  • Pathophysiology
    • failure of apoptosis to separate digits 
  • Genetics
    • autosomal dominant in cases of pure syndactyly
      • reduced penetrance  and variable expression
        • positive family history in 10-40% of cases 
  • Associated conditions 
    • acrosyndactyly 
      • digits fuse distally and proximal digit has fenestrations (e.g., constriction ring syndrome)
    • Poland Syndrome 
    • Apert Syndrome 
    • Carpenter syndrome
      • acrocephalopolysyndactyly
Classification
 
Syndactyly Classification
Simple Only soft tissue involvement, no bony connections  
Complex Side to side fusion of adjacent phalanges 
Complicated Accessory phalanges or abnormal bones involved in fusion 
Complete vs. Incomplete Complete syndactyly the skin extends to finger tips; with incomplete, skin does not extend to fingertips 
 
Treatment
  • Operative
    • digit release
      • indications
        • syndactyly 
          • perform at ~ 1 year of age
        • acrosyndactyly
          • perform in neonatal period
Technique
  • Digit Release
    • if multiple digits are involved perform procedure in two stages (do 1 side of a finger at a time) to avoid compromising vasculature
    • release digits with significant length differences first to avoid growth disturbances 
      • release border digits first (ring-little, and thumb-index) at <6mths because of differential growth rates between ring-little and between thumb-index digits
      • middle-ring syndactyly can be released later (2yr old) as because middle and ring digits have similar growth rates
      • thus if syndactyly involving index-middle-ring-small digits, releae index-middle and ring-small first, and leave the central syndactyly (middle-ring) for 6months later
      • do all releases before school age
    • bilateral hand releases 
      • perform simultaneously if child is <18mths (less active)
      • perform staged if child is >18mths (more active, hard to immobilize bilateral limbs simultaneously)
    • interdigitating zigzag flaps are created during release to avoid longitudinal scarring 
    • dorsal fasciocutaneous flaps to reconstruct the web
    • use only absorbable sutures (5-0 chromic catgut) which have less inflammation
Complications
  • Web creep
    • most common complication of surgical treatment (8-60%) 
    • causes
      • early creep is most commonly caused by necrosis of the tip of the dorsal quadrilateral flap and loss of full-thickness skin graft placed in the web
      • late creep (adolescence) is caused by discrepant growth between scar/skin graft and surrounding tissue during the growth spurt
    • treatment
      • reconstruct web space with local skin flaps
  • Nail deformities
 

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Questions (1)

(OBQ11.125) Figure A depicts a child with syndactyly. Following surgical treatment, the most common complication involves which of the following? Review Topic

QID: 3548
FIGURES:
1

Nail plate

2%

(63/3062)

2

Nail bed

3%

(81/3062)

3

Web commissure

76%

(2319/3062)

4

Radial digital nerve

14%

(422/3062)

5

Radial digital artery

5%

(150/3062)

ML 2

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