Updated: 5/22/2021

Syndactyly

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Images
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
  • summary
    • Syndactyly is the most common congenital malformation of the limbs and is characterized by abnormal connections of digits of the hand. 
    • Diagnosis is made clinically. 
    • Treatment is usually digit release performed at ~ 1 year of age.
  • 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
  • Etiology 
    • 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?

QID: 3548
FIGURES:

Nail plate

2%

(79/4103)

Nail bed

2%

(101/4103)

Web commissure

76%

(3119/4103)

Radial digital nerve

14%

(574/4103)

Radial digital artery

5%

(194/4103)

L 2 C

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