Keloid formation after surgery for release of polysyndactyly of the feet in a child

Keloid formation on the hands and the feet is very rare but should always be anticipated as a possible complication after surgery. Failure to recognise the potential for keloid may result in a severe deformity that is functionally and cosmetically undesirable. We report severe keloid formation after simple release of polysyndactyly of the feet of a 2-year-old child.

[Median clefts of the hand. Classification and therapeutic indications apropos of 29 cases]

Based on a series of 29 patients with median clefts of the hand (29 hands), the authors define the place of this malformation, its various clinical features and the therapeutic indications. The series consists of 13 boys and 7 girls, 9 bilateral cases and 11 unilateral cases. Involvement of the feet was observed in 9 cases. Several children also presented other malformations. 16 children were operated (22 hands). Two types of technique were used: simple closure of the cleft (Barsky's operation) and transposition of the index finger according to the Snow-Littler or Miura-Komada techniques. All operated patients were reviewed with a follow-up of more than one year and the results were assessed in terms of three criteria: overall use of the hand, thumb-index finger pinch grip, aesthetic appearance. The authors propose a new classification of median clefts of the hand based on examination of this series of 20 children: simple clefts with more or less complete absence of the middle finger, complex clefts with syndactyly (especially I and II), transverse bone polydactyly, extensive clefts with severe aplasia of the radial segment of the hand. Clinical and radiological examination confirm the experimental studies by Ogino. Barsky's operation gives satisfactory results in simple forms with parallel fingers. Translocation of the index finger to the base of the 3rd metacarpal is necessary in the presence of divergent fingers and syndactyly. Median clefts of the hand are very distinct from median aplasia, which is always unilateral, with no familial nature and no involvement of the feet and which can be classified together with brachysyndactyly. Each case must be studied before deciding treatment, as functional adaptation is always remarkable. The least favourable surgical results are observed in forms with abnormal position of the index finger (malrotation syndactyly). Lastly, the Snow-Littler operation is not devoid of complications.

Rehabilitation of a child with partial unilateral cryptophthalmos and multiple congenital anomalies

PURPOSE

This paper describes the surgical rehabilitation of a child with craniofacial anomalies, unilateral syndactyly, and partial unilateral cryptophthalmos associated with inferior colobomata of the iris and optic nerve and agenesis of the inferior rectus and inferior oblique muscles. The clinical presentation of cryptophthalmos is described.

METHODS

The medical literature since the original description of cryptophthalmos in 1872 was reviewed to define patterns of inheritance and the incidence of associated anomalies.

RESULTS

Including this patient, 149 case reports of cryptophthalmos were identified. In two families transmission from parent to child suggests dominant inheritance. None of the five dominant cases had any other anomalies, and all had bilateral complete cryptophthalmos. The incidence of cryptophthalmos in the remaining families is consistent with autosomal recessive inheritance. This group includes patients with bilateral, unilateral, and partial cryptophthalmos. Other anomalies are common, including those of the ear and nose, limbs, genitourinary system, and mouth and palate. Mortality in the perinatal period is associated with renal agenesis, laryngeal atresia, and pulmonary hypoplasia.

CONCLUSIONS

Cryptophthalmos is a rare congenital anomaly with two patterns of inheritance.

Surgical management of syndactyly in a dog

This report describes the treatment of simple syndactyly in a Golden Retriever. The left forepaw lacked cutaneous separation between the digits and had confluent metacarpal and digital pads. After vigorous exercise, the dog had intermittent non-weight-bearing lameness involving the affected forepaw. The lameness may have resulted from stretching of the thin skin on the dorsum of the paw as the digits attempted to spread during weight bearing. Surgical separation of digits 3 and 4 was performed by creating an interdigital web space with dorsal and palmar skin flaps and by covering the exposed axial surfaces with full-thickness skin grafts. At 11 weeks after surgery, the lameness had improved and the dog's level of activity had increased.

Release of acquired syndactylies in Kindler syndrome

Kindler syndrome is a rare, blistering skin disease characterized by acral bullae, poikiloderma, and diffuse cutaneous atrophy. Kindler syndrome has been established as a separate entity from epidermolysis bullosa; however, controversy still remains as to whether Kindler syndrome can be differentiated from Weary's hereditary acrokeratotic poikiloderma. Fusion of the digits secondary to blistering and scarring, "pseudosyndactyly," has been reported in several patients with Kindler syndrome; however, surgical correction of the syndactylies in these patients has not been described. In this report, a patient with Kindler syndrome underwent surgical treatment of acquired syndactylies. Treatment included a tailored approach to preparation of the patient for surgery, surgical separation of fused tissues, selection of donor site for skin-graft harvest, postoperative dressings, splinting, and therapy. Results in our patient 2 years after correction demonstrate that syndactyly release in Kindler syndrome can be accomplished effectively, with improvement in both function and appearance.

Dividing the fingers in congenital syndactyly release: a review of more than 200 years of surgical treatment

In three specific eras the approach to the dividing of the fingers in syndactyly release has changed. In the 19th century "straight cutting" or local flaps were used; then in the beginning of the 20th century skin grafts were introduced. After Cronin published work on zigzag incisions, combinations of zigzag incisions, flaps, and grafts came into use. Here, we present a review of the most important technique, given in a historical perspective.

Recurrent trismus: twenty-year follow-up result

The authors encountered an unusual case of recurrent trismus in a patient who had oral synechia, cleft lip and palate, digital anomalies, and external genital anomaly. Mandibular movement was severely restricted by congenital soft-tissue adhesion in the retromolar region. Despite aggressive surgical efforts and postoperative manipulations, limitation of mouth opening recurred soon after each operation. Furthermore, congenital and postoperative soft-tissue adhesion resulted in severe subsequent jaw deformities, which needed combined maxillary and mandibular advancement.

[Anesthetic management of a patient with a cryptophthalmos syndactyly syndrome and subglottic stenosis]

We experienced five episodes of anesthesia for a girl with dryptophthalmos syndactyly syndrome and congenital subglottic stenosis from the age of 1.3 year to 4 years. A girl was born at 34 weeks of gestation. The birth weight was 1360 g. The Apgar score was 8 at one minute and there was a hoarseness. She had right cryptophthalmos, syndactyly of hands and left foot, left polydactyly, anomalies of ear and nose, and agenesis of right kidney. The operation was scheduled for syndactyly under general anesthesia when she was 17 days and 5 months. As intubation was unsuccessful in both occasions, the operation was cancelled and subglottic stenosis was pointed out. We decided to postpone the operation until she could cry fully without cyanosis. We evaluated her respiratory ability from the time she became able to cry fully without cyanosis. As a result, we could manage her without any complications such as hypoxia or hypercapnea except mild wheezing.

Syndactyly of the ring and small finger

Five new cases of isolated syndactyly of the small and ring finger are described. Autosomal dominant inheritance is obvious. Brachymesophalangia of the fifth finger is a frequent association. Surgery is required at a young age.

Bilateral syndactyly. A unique case with surgical correction

Cases must be treated on an individual basis, appreciating the complexity of the syndactyly, considering the patient compliance, and understanding the goals of the surgical correction. Extensive discussion with the patient and parents must occur to clarify the goals of the surgery, the expectations, and possible complications. Careful preoperative planning and incision design is paramount in obtaining satisfactory results. Skin grafting may be required, either full-thickness from a variety of donor sites or split-thickness grafting as in one case study reported. Adjunctively, manipulation and stretching of the web space for 2 to 3 months preoperatively may be helpful to achieve more laxity of the soft tissues. The choice of suture material is of particular concern when dealing with a small child. It is usually wise to use an absorbable suture material for skin closure in a small child to prevent undue emotional stress to the child or even further anesthesia upon suture removal. Vascular compromise caused by soft tissue tension in not an infrequent occurrence. As with any surgery that addresses largely cosmetic deformities, there is no substitute for exact prior planning, meticulous technique, and surgeon experience to optimize results.

Acrosyndactyly with epidermoid inclusion cysts: evidence for the extrinsic theory

A case of acrosyndactyly was treated with routine syndactyly release and full-thickness skin grafts. Two epidermoid inclusion cysts were found within the syndactylyzed index and middle fingers. This association is discussed along with the mechanism that best explains this unusual occurrence.

The anaesthetic management of patients with dystrophic epidermolysis bullosa. A review of 44 patients over a 10 year period

The case notes and anaesthetic charts of 44 patients with dystrophic epidermolysis bullosa were reviewed retrospectively. A total of 390 general anaesthetics were performed for 469 surgical procedures over a 10-year period. Procedures included repair of syndactyly, dilatation of oesophageal strictures, extraction of teeth, excision of skin tumours and other procedures related to dystrophic epidermolysis bullosa. Anaemia, thrombocytosis and hypoalbuminaemia was found in many patients pre-operatively. Damage to skin or mucosa occurred peri-operatively. Four patients developed bullae around the head and neck, two patients developed oral or pharyngeal bullae and three patients developed conjunctival abrasions including one with a new corneal ulcer. There were no reports of laryngeal bullae and no bullae associated with intramuscular injections or the use of limb tourniquets. Thirty-one patients (70%) had evidence of oesophageal strictures and six regurgitated peri-operatively. In all cases there was a history of oesophageal disease. In 10 patients (23%) intubation of the trachea was difficult. It was carried out by various methods including blind nasal and fibreoptic intubation or by using the laryngeal mask airway. One patient requiring a series of general anaesthetics had a tracheostomy formed after fibreoptic intubation. Previous reports have suggested problems with the use of suxamethonium, nondepolarising muscle relaxants and thiopentone. These agents were all used in many of our patients without any adverse effects. There was one intra-operative death in a 35-year-old woman having an oesophageal dilatation which was complicated by oesophageal rupture.

The treatment of metacarpal synostosis

One hundred nine patients with metacarpal synostosis were examined to determine the best treatment for this condition. The fourth and fifth metacarpals are most frequently affected, and bilateral involvement occurs often. Many anomalies are associated with synostosis, as well as many syndromes such as Apert's syndrome, central polydactyly, syndactyly, and partial absence of the hand. An osteotomy to split and separate the synostosis, a bone graft to lengthen the fifth metacarpal, collateral ligament reconstruction, and tendon transposition of the extensor digiti minimi quinti all appear to be valuable for the treatment of this rare congenital anomaly.

Surgical treatment of contracture and syndactyly of children with epidermolysis bullosa

A new approach to the operative treatment of syndactyly and contracture of the hands of children with recessive dystrophic epidermolysis bullosa is described. It is based upon the principle of surgical release of fingers allowing spontaneous epithelialisation of skin wounds without using skin grafts. Nineteen children had operations using this method, with an incidence of recurrence of 53%. This method has the advantage of a short operating time, simple technique and limited trauma.

Reverse W-M plasty in the repair of congenital syndactyly: a new method

A W-M plasty is described as a means of establishing an interdigital web in the repair of congenital syndactyly. 25 cases of congenital syndactyly were operated using this method. The web created did not advance distally, nor cause a transverse scar-band.

Somatosensory cortical plasticity in adult humans revealed by magnetoencephalography

Microelectrode recordings in adult mammals have clearly demonstrated that somatosensory cortical maps reorganize following peripheral nerve injuries and functional modifications; however, such reorganization has never been directly demonstrated in humans. Using magnetoencephalography, we have been able to demonstrate the somatotopic organization of the hand area in normal humans with high spatial precision. Somatosensory cortical plasticity was detected in two adults who were studied before and after surgical separation of webbed fingers (syndactyly). The presurgical maps displayed shrunken and nonsomatotopic hand representations. Within weeks following surgery, cortical reorganization occurring over distances of 3-9 mm was evident, correlating with the new functional status of their separated digits. In contrast, no modification of the somatosensory map was observed months following transfer of a neurovascular skin island flap for sensory reconstruction of the thumb in two subjects in whom sensory transfer failed to occur.

Hand splintage following surgery for dystrophic epidermolysis bullosa

Patients with Epidermolysis Bullosa, a rare hereditary blistering skin disorder, pose many problems in view of the extreme fragility of their skin. Following surgical division of syndactylised digits hard acrylic splints have traditionally been provided. This paper presents a splint design which is quicker and safer to manufacture, is readily altered and better tolerated by the patient, and has led to improvement in the maintenance of surgical correction.

[Forum on tissue expansion. Expansion of the upper limb]

The authors report their experience of skin expansion of the upper limb based on a series of 42 operated patients: shoulder (8 cases), arm (19 cases), forearm (5 cases) and hand (8 cases). The operative protocol must be rigorous in terms of the choice of prosthesis (shape and size) and the type of valve (internal or external) and in terms of the technique of insertion of the expansion prosthesis (short incision in healthy skin) and harvesting of the expanded flap (sliding-draping flap rather than rotation flap). The indications are varied: unsightly scars and sequelae of burns, congenital naevi, syndactyly, resurfacing and preparation for a secondary surgical procedure (implant of a prosthesis, neurolysis, tenolysis). There were few complications with only 2 major complications resulting in failure of this technique.

[The treatment of syndactylia and results in 31 children]

In recent years there have been some changes in the treatment of congenital syndactyly. Nowadays treatment is started in the first year of life, before the child uses his hands purposefully. In the University Hospital of the Free University of Amsterdam 31 patients with 61 congenital syndactylies in 45 hands were treated between 1971 and 1991. The results were good in 40, fair in 15, moderate in 4 and poor in 2 corrections. Surgery was performed under general anaesthesia and whenever possible on an out-patient basis. To split the fingers zig-zag incisions are used. For web reconstruction two triangular flaps or one rectangular flap are used. Complex syndactyly is treated in two sessions: first two double opposing palmar flaps to cover the tips and to form the nail walls are raised and after two weeks the rest of the syndactyly is corrected. Postoperative treatment consists of a compression bandage for two weeks, followed by bathing and training in warm water until all wounds have healed.

Congenital constriction band syndrome. Pathophysiology and treatment

The clinical manifestations of 88 children with congenital constriction band syndrome involvement of the hand were reviewed. Seventy-five of these children had evidence of digital or limb amputations, with 235 upper limb amputations and 138 lower limb amputations. In the hand, digital amputations were most common in the index, middle, and ring fingers, whereas in the foot, amputations of the hallux were most often noted. Band indentation was often present at multiple levels. Proximal bands may be associated with neural compression. Syndactyly was invariably associated with a proximal interdigital sinus or cleft and was frequently associated with distal amputation. Examination of a 27-week gestation stillborn specimen having manifestations of congenital constriction band syndrome demonstrated the intrauterine biologic response to band constriction. The variable clinical manifestations of congenital constriction band syndrome can best be explained as the response of the growing, embryologically defined limb to intrauterine deformation or band-induced compression and ischemia.

[Clinical aspects, morphology and therapy of an unusual case of bilateral macrodactyly]

Macrodactyly, originally described by von Klein in 1824, is one of the rarest congenital anomalies of the hand. It displays a wide variety of manifestations, and its association with other congenital defects and syndromes has been discussed by many authors. A rare case involving an adult with bilateral, hyperostotic macrodactyly of the hands is presented. The hands were not treated in childhood. Clinical findings, pathology, and treatment are discussed.

The double opposing palmar flaps in complex syndactyly

Double opposing flaps on the palmar surface were designed to create nail folds and to cover bony defects of the distal phalanges in the treatment of complex syndactyly. This is a two-stage procedure, and the flaps were used on 10 hands in 8 patients. There were no failures, and the results were satisfactory after a mean follow-up time of 2 1/2 years. The two stages were performed 2 weeks apart, and the surgery can be done as an outpatient procedure.

Operation for polysyndactyly of the fifth toe using Z-plasty

A new operative procedure was devised to treat polysyndactyly of the fifth toe. This procedure, which consists of removal of the fifth toe, correction of the alignment of the preserved sixth toe by arthroplasty and construction of an interdigital space by Z-plasty, is technically simple and produces good results, both functionally and aesthetically.

Experience in the surgical management of the hand in dystrophic epidermolysis bullosa

Between 1981 and 1990, 45 patients (80 hands) underwent 122 hand operations, involving extensive release of contractures and pseudosyndactyly, with split skin grafting of secondary defects. Other procedures included the use of Kirschner wires, tendon release and arthroplasty. A postoperative programme of long term night splintage was employed. Finger extension was significantly improved for up to 5 years postoperatively, with a mean extension deficit preoperatively of 139 degrees, at 1 year postoperatively 60 degrees (p < 0.0001) and 4 years 84 degrees (p < 0.05). Preoperatively, pseudosyndactyly was present in 64.3% of web spaces, in comparison to 13.3% at 1 year, 37% at 4 years (p < 0.01) and 66.6% at 5 years (N.S.) postoperatively. Adduction contracture of the thumb was significantly improved for 2 years postoperatively. Functional assessment of 18 hands showed significant improvement postoperatively.