Polydactyly: a review

Polydactyly of the hand is a difficult problem and poses a unique challenge for the hand surgeon. The embryology of limb development is complex, leading to a host of different phenotypes of polydactyly. Polydactyly can occur in any digit and is described as preaxial, postaxial, and central, based on location. Classification systems exist for each of these locations, which guide treatment options. Surgical treatment needs to address the aesthetic and functional aspect of hand reconstruction. Careful consideration and planning of surgical treatment individualized to each patient is required to obtain the best possible outcome.

[Use of the air-Q intubating laryngeal airway for tracheal intubation in predicted difficult airway management in a pediatric patient]

The intubating laryngeal airway, air-Q ILA, was recently introduced in Japan. It has been used in adult patients for difficult airway management; however, there are few reports available on its use in pediatric patients. We report the use of the air-Q ILA in predicted difficult airway management in a 16-month-old patient with Apert syndrome characterized by acrocephalosyndactyly undergoing a syndactyly operation. It was somewhat difficult to keep his airway with a facemask, and an air-Q ILA was inserted. Following the ventilation via air-Q ILA, tracheal intubation guided by a tracheal fiberscope was attempted through the air-Q ILA. Five months after this operation, the patient again underwent the same operation. We managed his airway in the same way as previously, and the tracheal was intubated. This case shows that the air-Q ILA can be an alternative device in pediatric difficult airway management.

A new skill for treating unclassified thumb polydactyly: ablation via a periosteal incision

BACKGROUND

Thumb polydactyly is a common congenital abnormality of the hand. Surgical treatment includes reduction and reconstruction. A new type of thumb polydactyly and the achieved treatment are reported.

METHODS

A 4-year-old boy with thumb polydactyly is reported. The duplicated two thumbs had one complete metacarpal and a separated triphalangeal phalanx. The ulna thumb was removed via periosteal incision, and a whole complex tissue sleeve was used to repair the ulna part of the joint capsule.

RESULTS

The postoperative aesthetic and functional results were satisfactory.

CONCLUSIONS

A new type of thumb polydactyly that cannot be matched with the classification of either Wassel or Wood is described. The thumb polydactyly was treated by ablation via periosteal incision and ulna metacarpophalangeal joint capsule reconstruction. Three-dimensional computed tomography could be a good way to examine the area preoperatively.

LEVEL OF EVIDENCE V

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[Transversal vaginal septum in two months old patient--case report]

The current publication describes a case of a two months old girl with a transverse vaginal septum presented. The clinical debut is with a large hydromucocolpos. It is concomitantly presented with a bilateral postaxial polydactyly of the upper limbs, typical for McKusick-Kaufmann syndrome.

A case of McKusick-Kaufman Syndrome

We are reporting a rare case of McKusick- Kaufman Syndrome in a ten-month old female infant from Addis Ababa with difficulty of urination often days duration. Clinical exam revealed supra-pubic mass with tenderness and had left hand postaxial polydactily. Ultrasound and CT scans showed the mass to be hydrometrocolpos posterior to the bladder. Intravenous urography revealed a lower abdomen-pelvic mass displacing and compressing the ureters with bilateral hydronephrosis. Further pelvic exam under anaesthesia revealed hydrometrocolpos with vaginal agenesis. This, to the best knowledge of the authors, is the first ever reported case of the syndrome in Ethiopia.

Outcome of reconstruction for duplication of the thumb in adults aged over 40

Congenital duplication of the thumb is usually reconstructed by 18 months of age. This paper reports satisfactory outcome following reconstruction of two Wassel Type IV duplicate thumbs in adults aged over 40. Both achieved a good outcome based on Tada's criteria and a subjective Visual analogue score 8.

Type IV-D thumb duplication: A new reconstruction method

INTRODUCTION

In the Wassel type IV classification category, the thumb is duplicated from the metacarpophalangeal joint; this abnormality accounts for approximately 50% of the cases of thumb duplication. Type IV is divided into four subtypes in which the IV-D type, or convergent (9% of cases), is the most complex form because both thumbs are hypoplastic with a divergent metacarpophalangeal joint and a convergent interphalangeal joint. Reconstruction is prone to axis deformity and ligament laxity, whereas the Bilhaut-Cloquet technique's main pitfall is nail dystrophy. We propose a modified Bilhaut-Cloquet procedure to avoid these complications.

MATERIAL AND METHOD

Four males (mean age: 11 months; range: 10-12 months) with IV-D thumb duplication were operated on using a modified Bilhaut-Cloquet procedure.

SURGICAL TECHNIQUE

The skin is preliminarily marked, taking into account the excision of the central skin and the more hypoplastic nail of the two (most often the radial nail). Both proximal phalanges are split longitudinally and the central halves discarded. An oblique osteotomy is performed at the base of the distal phalanx of the ulnar thumb duplicate (the less hypoplastic) and the radial wedge is excised. The same osteotomy is applied to the distal phalanx of the radial thumb duplicate, but the radial wedge is preserved. The proximal phalanx and the bases of the distal phalanx are joined by bone suture. Axis correction and ligament stability are thus achieved without nail surgery.

RESULTS

The patients were examined with a mean 24 months of follow-up (range: 12-36 months). The result was good in all four cases according to the Horii score.

DISCUSSION AND CONCLUSION

This procedure combines an excision of the central part of the proximal phalanx and partial excision of the base of the distal phalanx. It provides axis correction and stabilization of the interphalangeal joint while avoiding subsequent nail dystrophy because a single nail is preserved. Preliminary results are encouraging: no axis deformity, instability or nail dystrophy has been noted. Nonetheless, the long-term results need to be evaluated.

LEVEL OF EVIDENCE

IV retrospective study.

Duplication

Congenital limb duplications include pre- and post-axial polydactyly, central polydactyly, and the mirror-hand spectrum. Treatment of these duplications constitutes a significant functional and aesthetic challenge for the reconstructive hand surgeon. This article provides an inclusive review of the embryologic and molecular mechanisms underlying these deformities and focuses on their clinical treatment. The anatomic variation, classification, surgical treatment, and outcomes of surgical intervention are reviewed for each of the disorders of duplication.

Postaxial polydactyly

We present a case of postaxial polydactyly with well formed six digits on left hand and seven digits on right hand. Both conditions are rare and combination of these two conditions even rarer. The patient also had supernumerary sixth right toe and cleft lip. Very few cases of postaxial polydactyly are reported previously.

A 10-year experience with the surgical treatment of radial polydactyly

PURPOSE

Authors' clinical and surgical experience in correction of the radial polydactyly in its various degrees of severity is presented.

MATERIAL AND METHODS

Nineteen patients were operated due to thumb duplication in a 10-year period from 1996 to 2006. The cases were classified according to Wassel 7-type classification. The surgical techniques adopted were the Bilhaut-Cloquet and the method of exclusion of the more hypoplasic thumb with preservation of the more functional and aesthetic one.

RESULTS

In 95% of the cases, the performed procedures meant to sacrifice the finger that was more hypoplastic and to preserve the more functional and aesthetic finger. The Bilhaut-Cloquet procedure was utilized only in one case.

DISCUSSION

A correct preoperative evaluation has to be performed in order to assess the osseo-muscular, articular and neurovascular properties of the duplicated fingers. The type of the deformity, type of the selected treatment procedure, and the surgical experience of the surgeon are factors contributing to the high satisfaction rate after surgery.

Long-term results of nail fusion plasty of the duplicated thumb

SUMMARY

We report the long-term results of nail fusion plasty in eight duplicated thumbs. These eight cases were hypoplastic, with nails less than 80% the size of that on the normal side. We operated on these duplicated thumbs using a technique that we developed. We evaluated postoperative nail shape in our series using both our and Tada's scoring systems. The average follow-up period was 12 years. Excellent results were obtained in six cases, with natural-looking nails and even curvature. One case showed acceptable results. Only one case had uneven curvature and a gap in the nail. To reconstruct a natural-looking nail, it is important to correctly design and suture together two nails under no tension. To obtain one nail with even curvature, bones are left floating so that the nail can grow with a natural transverse curve without interference. This technique yielded promising results on long-term follow-up.

Correction of polydactyly in patients with Ellis-van Creveld syndrome: a report of two cases

Ellis-van Creveld syndrome (EVC) is a rare chondroectodermal dysplasia presenting several skeletal manifestations and congenital heart malformations. Polydactyly is the most frequent skeletal anomaly. The authors report two cases of EVC syndrome with different manifestations, which underwent surgical treatment for polydactyly.

[Polydactyly and syndactyly as the most common congenital disorders of the limbs]

Polydactyly is a common hereditary disorder in which extra or vestigial digits are present on the one or both sides of the extremities. It is ten times more frequent in Blacks than in Whites. Polydactyly occurs both in a sporadic form and in a hereditary form. In polydactyly type A, the extra digits contains phalanges, in polydactyly type B, there is no skeletal structure. The extra digit is made by skin only. Syndactyly type I exists when the connection is at the level of skin, in type II the phalanges of the fingers are connected. For syndactyly correction, combined use of "Z"-method incision and full-thickness free skin grafts are the most common method of treatment. A new method is based on a straight incision and free skin grafts. The scars after the serial excision are placed on the midlateral lines. The final scars are minimal, and good functional and cosmetic result is obtained.

Bilateral Polydactyly in a foal

The following case report describes the diagnosis and surgery of bilateral polydactyly of unknown origin in a colt. A 7-month-old Berber colt was referred for cosmetic and curative excision of supernumerary digits. Radiographic examination revealed bilateral polydactyly and welldeveloped first carpal bones. Surgery consisted of an osteotomy of both second metacarpal bones combined with an amputation of the supernumerary digits. The follow-up at 18 months after surgery revealed a sound horse with an excellent cosmetic outcome.

Triplicated thumbs: a rarity?

SUMMARY

Triplication of the thumb is supposed to be a rare condition and a complex form of radial polydactyly. However, we encountered an unusually high number of triplicated thumbs at our unit. Is triplication of the thumb indeed a rare condition? In our study, 121 patients with radial polydactyly were recorded between 1933 and 2005. In nine patients of this group, triplicated thumbs, either unilateral or bilateral, were identified. This complex type of radial polydactyly occurs in various forms. A total of 11 triplicated thumbs were found, and all cases were combined with triphalangeal components. Only one of these 11 triplicated thumbs could be classified according to currently used classifications. In all cases, aberrant rays were excised, thumb length and alignment restored by osteotomies, joints were stabilised, tendons reinserted and nails and nail walls corrected if necessary. Also, in all cases, a correction of triphalangeal components was carried out. Triplications are a rarity, and have only been presented in single case reports. We found that triplicated thumbs are not so rare. The likely explanation for this is the identification of a genetic isolate (a deformity located at chromosome 7q36) with radial polydactyly and triphalangeal thumbs in the southwest region of the Netherlands. Treatment for the presented triplicated thumbs was based on the same general principles as for less complex forms of radial polydactyly (i.e. to assemble useful elements of the separate [partial] thumbs to reconstruct one functioning, stable thumb).

Unique case of polydactyly and a new classification system

Polydactyly of the hands or feet is a common birth deformity. We recently encountered a female infant with a case of a crossed type 1 polydactyly with a mixed polydactyly of the feet. A mixed and crossed polydactyly is a rare finding with only one other reported case. This is the first report of crossed and mixed polydactyly of the feet presenting with 7 complete toes on each foot without syndactyly. In addition to a discussion of the treatment, this case has lead us to propose a more complete and less confusing classification system.

Soft tissue reconstruction for type IV-D duplicated thumb: a new surgical technique

Type IV-D duplicated thumb has the most complex anomalies and difficulties for treatment among polydatyly. Double osteotomy is usually recommended to gain the best cosmetic and functional outcome. However, 4 cases of type IV-D duplicated thumb were treated only by soft tissue procedure in this study. At operation, a conjoined A2 pulley was routinely identified, and the flexor pollicis longus (FPL) was found bifurcated distal to the conjoined pulley in every of these cases. Instead of double osteotomy, a soft tissue procedure that included centralization of FPL and A2 pulley reconstruction was pursued to correct these special anomalies. The overall clinical results were evaluated by a modification of the Tada scoring system based on the range of motion, joint stability, alignment of the remaining thumb, and subjective opinion regarding the reconstructed thumb after an average follow-up of 3.3 years (range, 2.5-4.7 years). According to the scoring system, the results were rated as good in 3 cases and fair in 1 case. From the results, the A2 pulley reconstruction and FPL centralization could prove to be an effective method for the treatment of type IV-D duplicated thumb and could efficiently avoid the residual angular deformities. Therefore, we recommend this soft tissue procedure as an alternative surgical technique to the double-osteotomy procedure for treating a type IV-D duplicated thumb in a very young child, whose bone is still not mature enough for holding the fixing pins.

Reconstruction of syndactyly and polysyndactyly of the toes with a dorsal pentagonal island flap: a technique that allows primary skin closure without the use of skin grafting

Syndactyly and polysyndactyly are common congenital conditions involving the foot, and surgery to reconstruct the toes may be indicated for cosmetic, psychological, and practical reasons. A dorsal flap is traditionally used for web space reconstruction, with skin grafts for the bases of the toes. Skin grafting has associated morbidity and can result in pigmentation mismatch. Single-stage direct closure with a specially designed flap has advantages including a reduction of morbidity from avoidance of skin grafting and shorter surgery. Four patients (6 feet) were included in the study. There were 2 cases of syndactyly and 2 cases of polysyndactyly. Bilateral involvement occurred in 2 patients. The average age was 18 months at time of first surgery. Direct closure was achieved with a dorsal pentagonal island flap with dorsal and plantar triangular flaps. The average duration of follow-up was 19.8 months. At final follow-up, all patients had acceptable web depth and pulp contour. The distance between the proximal interphalangeal joints of adjacent toes and the web slope of the reconstructed web space were acceptable. Complications included partial synechiae, cellulitis, and keloid formation. The dorsal pentagonal island flap is an acceptable technique in providing another means for single-stage reconstruction of the web space in syndactyly and polysyndactyly. Good functional and cosmetic outcomes can be expected. However, the potential complication of keloid formation can affect cosmesis and overall outcome, and must be understood by patients and parents.

Modified Bilhaut-Cloquet procedure for Wassel type-II and III polydactyly of the thumb

BACKGROUND

The Bilhaut-Cloquet operation is a combined surgical procedure for the treatment of a symmetric bifid thumb. Although this procedure can obtain a normal-sized thumb with a stable interphalangeal joint, it has limitations, such as the technical difficulty of combining all segments of a duplicated thumb, possible later physeal growth arrest, joint stiffness, and nail-plate deformity. We reviewed the results of our modification of this procedure for the treatment of Wassel type-II and III polydactyly of the thumb.

METHODS

Seven patients, two with type-II and five with type-III polydactyly of the thumb, underwent the modified Bilhaut-Cloquet procedure and were followed for an average of fifty-two months. Cosmetic and functional assessments were made.

RESULTS

All patients and their parents were satisfied with the cosmetic and functional results. Compared with the preoperative motion, the postoperative range of motion of the interphalangeal joint was preserved in thumbs with type-III deformity and was increased in those with type-II deformity. No nail deformity or growth arrest occurred, and remodeling and hypertrophy of the distal phalanx occurred with time.

CONCLUSIONS

Our modification of the Bilhaut-Cloquet procedure for the treatment of type-II and III thumb polydactyly is effective in preserving interphalangeal joint motion, minimizing nail deformity, and preventing growth arrest.

A nonclassified and unusual polydactyly of the foot

A rare polydactyly of the foot, mixed central and pre-axial type, is described; no other dysmorphic features were present. Early surgery was performed with good results.

Synpolydactyly of the foot in homozygotes

In 2002, we reinvestigated a large synpolydactyly kindred first described in 1995. It was found to have expanded with an increase in number of homozygous offspring. These homozygotes had severe hypoplasia, with synpolydactyly of their hands and feet. We present the clinical, genetic, and surgical findings of this deformity and the histologic findings of the removed bones of the heterozygous and homozygous members. There were 125 affected individuals (113 heterozygotes and 12 homozygotes) of 245 members of the past five generations. We identified seven marriages in which both spouses were affected. Twelve offspring from these marriages had homozygote genetic patterns, hypoplastic synpolydactyly of the hands, and a distinctive foot deformity, with a prominent great toe and syndactylized hypoplastic minor toes. From clinical and surgical perspectives, their hand and foot deformities were different from those of their parents. We surgically treated both feet of four individuals with this deformity, which we called "homozygote foot synpolydactyly." Clinically, the deformity consisted of a supinated prominent great toe, hypoplastic and severely synpolydactylized minor toes, and secondary problems. Radiographically, the bones were underdeveloped, unshaped, and largely fused. Abundant cartilage covering the bones was observed surgically and histologically. Genetically, analysis of HOXD13 identified a 27-base pair duplication with a homozygote pattern. The foot deformity of the homozygotes was so distinctive and complicated that it should be considered a separate foot synpolydactyly type--homozygote foot synpolydactyly.

Thumb polydactyly: clinical outcome after reconstruction

PURPOSE

To evaluate clinical and cosmetic outcomes of reconstruction in thumb polydactyly and prognostic value of the Wassel classification.

METHODS

Between 1993 and 2000 inclusive, out of the patients with thumb polydactyly (involving 80 thumbs) operated on, 34 patients (36 thumbs) were available for review and underwent clinical and radiological assessment. Outcomes in terms of the Tada score and complications were recorded.

RESULTS

The mean age of patients at the time of operation was 2.8 (range, 0.6-47) years. The mean follow-up period was 5 (range, 2.4-10) years. According to the Wassel classification, 12 were type-II thumb polydactyly, 3 type-III, 11 type-IV, 6 type-V, one type-VI, and 3 type-VII. There was no perioperative mortality or wound infection. More than 88% of the patients were satisfied or very satisfied with functional and cosmetic outcomes. Postoperative complications such as scar hypertrophy, pulp atrophy, joint deformity, and instability were common but minor. Ridge nail deformity after the Bilhaut Cloquet procedure was amenable to secondary corrective procedures. All types of operated thumb polydactyly achieved similar mean Tada scores (14.7- 16.6 out of 20). The Wassel classification category, age, and surgical procedures were found to have no prognostic value with regard to the Tada score and presence of complications.

CONCLUSION

Surgery on thumb polydactyly is rewarding. The Wassel classification category can be used as a guide for treatment, although it fails to predict the occurrence of postoperative complications or Tada scores. Our patients' results can serve as guidelines of expected outcomes after reconstructive procedures in different sub-types of thumb polydactyly.

Reconstruction of radial polydactyly

The spectrum that encompasses radial polydactyly can be categorized by the Wassel classification. Reconstruction of radial polydactyly depends on the size and quality of each of the thumbs. Most commonly, the ulnar thumb is larger and is maintained, whereas the smaller radial thumb is excised. In a Wassel type 4, after the redundant thumb is excised, the remaining thumb is centralized and aligned, and the radial collateral ligament of the maintained thumb is reconstructed. Other types of radial polydactyly are more complicated and require more complex reconstructions.