Closing wedge osteotomy of abnormal middle phalanx for clinodactyly

A Complex Case of Clino-Syndactyly with Fourth Metacarpal Aplasia

Syndactyly is the most common congenital malformation of the hand, leading to the fusion of the digits and frequently affecting the ring and middle fingers. The incidence is 1 out of 2500 children, predominantly occurring in boys and Caucasians. Clinically, the malformation may present as a soft tissue or bony fusion, resulting in the union of the fingers characterised as complete or incomplete. This fusion may involve the phalanges but may also extend to the carpal/tarsal bones, even to the metacarpal or metatarsal level, rarely to the distal end of the forearm and lower leg. The malformation is mostly isolated but may occur together with other disorders or malformations such as synostosis, acro-syndactyly, cleft hand, clinodactyly, or polydactyly. Syndromic syndactyly can be observed in cases of Apert syndrome, Poland's syndrome, Pfeiffer syndrome, and many others. A girl born in June of 2019 was diagnosed with congenital malformation of the right hand at birth-affecting the right middle, ring, and little fingers, respectively. After X-ray imaging, the fusion of the third and fourth proximal phalanges to a common metacarpal was identified, forming a unique diagnosis of clino-syndactyly with metacarpal aplasia. Surgical intervention was advocated for, including a wedge osteotomy to correct the synchondrosis at the phalangeal base and a dorsal flap to close the interdigital space created during the correction of the III and IV. fingers. A trapezoid flap for the release of the syndactyly of the IV and V. fingers was applied. The paper aims to present this surgical correction and its results regarding an atypical case of syndactyly with clinodactyly and metacarpal aplasia.

Retalho bilobado na reconstrução das clinodactilias da mão: Descrição da técnica e avaliação do resultado

Objective  Clinodactyly is a congenital hand deformity that is characterized by coronal angular deviation and may occur in thumbs or fingers. Surgical treatment is indicated for severe angulations. Among the described techniques, one of the options consists of bone alignment by wedge-shaped addition osteotomy of the anomalous phalanx. Such alignment maneuver creates a problem in skin cover, along with soft-tissue tension at the concave aspect of the deformity. Hence, some sort of skin flap is required for the adequate operative wound closure. We aim to demonstrate the aforementioned technique and to assess the results of bilobed flap in the treatment of hand clinodactyly.

Methods  Retrospective study conducted between January 2008 and January 2015. Five patients were included in the study, including nine operated digits. Surgical indication consisted of angular deviations ˃ 30 ^o . Neither patients with thumb deformities nor those with deformities associated to syndromes were excluded from the study. We assessed the functional and cosmetic outcomes of the technique, as well as complications and the satisfaction rates of the family.

Results  All patients had satisfactory functional and cosmetic results, with a mean skin healing of 18.6 days. Among nine operated digits, only one of the patients presented vascular compromise at the distal portion of the first flap lobe, albeit without necrosis or the need for any additional procedure. Patients were followed up on a minimum of 12-month interval. No deformity recurred during the observation period.

Conclusion  Bilobed flap for the treatment of hand clinodactyly is a good option for skin cover after the osteotomy.

Closed wedge osteotomy for middle phalanx physeal injuries associated with angulation deformities in children

BACKGROUND

Middle phalanx physeal fractures in children are rare, and proper treatment gives good results. Despite treatment, these fractures may lead to physeal arrest and growth disturbances leading to severe angulation deformities. Closed wedge osteotomy with internal fixation efficiently corrects the angulation deformities in children.

METHODS

We did a retrospective study analyzing 11 children with middle phalanx physeal injuries and severe angulation. Closed wedge osteotomy and internal fixation with plate and screw were done. We interpreted the pre- and postoperative correction of angles, middle phalanx length discrepancy, technical aspects, range of movement, grip strength, pain, and functional outcomes.

RESULTS

The mean age of the patients was 10.5 years. The mean follow-up was 28 months (range 24-30 months). Ten of the 11 patients achieved good radiological union, range of motion, and good outcome. None of the patients had growth plate deformity in the follow-up. All patients had a significant correction of angulation/deformity, length, and improvement of grip strength in the postoperative period (p < 0.05). None had physeal disturbances/abnormalities in the follow-up.

CONCLUSIONS

Though middle phalanx physeal fractures are rare and innocuous, adequate treatment is essential to prevent angulation and growth disturbances. Close wedge corrective osteotomy and internal fixation with plates and screws provide stable and rigid fixation. Greater attention is needed to follow-up them until skeletal maturity.

LEVEL OF EVIDENCE

IV.

Phalangeal Intra-Articular Osteochondroma Caused a Rare Clinodactyly Deformity in Children: Case Series and Literature Review

BACKGROUND

Various factors are discovered in the development of clinodactyly. The purpose of this retrospective study was to present a group of children with a rare clinodactyly deformity caused by phalangeal intra-articular osteochondroma and evaluate the efficacy of various treatment methods.

METHODS

All child patients that were treated for finger problems in our center between Jan 2017 and Dec 2020 were reviewed. A detailed analysis was made of the diagnosis and treatment methods in eight rare cases. X-rays and histopathology were applied.

RESULTS

A preliminary analysis of 405 patients in total was performed, and we included eight cases in our final analysis. This cohort consisted of 2 girls and 6 boys, with a mean age of 5.74 ± 3.22 years (range: 2y5m to 11y). Overall, four patients had their right hand affected and four patients had their left hand affected. One patient was diagnosed as having hereditary multiple osteochondroma (HMO) while the other seven patients were all grouped into solitary osteochondroma. Osteochondroma was proven in all of them by histopathology examination. Preoperative X-rays were used to allow identification and surgery planning in all cases. All osteochondromas were intra-articular and in the distal end of the phalanges, which is located opposite the epiphyseal growth area. All of the osteochondromas developed in half side of the phalanges. The angulation in the finger long axis was measured, and resulted in a mean angulation of 34.63 ± 24.93 degree (range: 10.16-88.91 degree). All of them received surgery, resulting in good appearance and fingers straightening. No recurrence was recorded.

CONCLUSIONS

This retrospective analysis indicates that 10 degrees can be selected as the angulation level for diagnosis of clinodactyly deformities. What's more important, the abnormal mass proven by X-rays should be included as the classical direct sign for diagnosis. The first choice of treatment is surgery in symptomatic osteochondromas.

Comparison of Vickers' Physiolysis With Osteotomy for Primary Correction of Clinodactyly

Background: The purpose of this study was to compare the Vickers physiolysis procedure with osteotomy for correction of digital clinodactyly and determine which method provides better correction at final follow-up or whether the patient's age, preoperative angulation, or presence of syndactyly affects final outcomes. Methods: All patients of skeletal immaturity who underwent surgical correction of clinodactyly were evaluated with clinical examination and radiographs to determine the percentage and absolute change in the degree of clinodactyly pre- versus postoperatively, in addition to stratification based on the degree of deformity, age, and presence of syndactyly. Results: Vickers' physiolysis and osteotomy were undertaken in 30 and 11 digits, respectively. The angulation significantly improved from 43.0° to 23.9°, with a 46.2% correction of deformity in the Vickers group at 46.3 months. The angulation decreased from 39.2° to 22.4° in the osteotomy group, with a 55.3% correction of deformity at 55.3 months. There was better correction in those with isolated clinodactyly compared with those with concomitant syndactyly and better percentage of correction in patients with lesser deformity in the Vickers group. There were more reoperations in the osteotomy group. Conclusions: The use of osteotomy may lead to more revision cases, whereas the Vickers procedure has minimal complications and need for revision. The Vickers physiolysis procedure is more effective in those with angulation <55°.

Patient-Reported Outcomes and Complications After Surgical Fixation of 143 Proximal Phalanx Fractures

PURPOSE

Multiple methods exist to surgically fix unstable phalangeal fractures. Whereas these methods have different rates of complications or reoperation, it is not known whether these differences lead to changes in patient reported outcome. We compared patient-reported outcomes measures and complications of Kirschner wire (K-wire), lag-screw and plate fixation of proximal phalanx fractures (excluding the thumb).

METHODS

From 2010 to 2015, 159 patients with 159 proximal phalanx fractures were identified in 2 level 2 trauma centers and fixed with K-wires (44% of patients), lag-screws (26%), or plates (30%). Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) and complications were assessed. In addition, subjective outcomes were assessed. Follow-up was achieved for 143 fractures (90%) and average time to follow-up was 3.4 years.

RESULTS

Mean DASH and PRWHE scores were 5.0 and 8.2, respectively. No differences in functional outcomes were found between fixation methods, although unplanned reoperation was more common in the plate fixation group (9 patients; 21%) than in the K-wire and lag-screw fixation groups (3 patients and 1 patient; 4.8 and 2.7%, respectively). We also found that K-wire fixation was associated with better aesthetic outcome than open reduction internal fixation.

CONCLUSIONS

Overall patient-reported outcomes measure scores were similar across fixation methods, and unplanned reoperation was more prevalent after plate fixation. In addition, we found that regardless of fracture pattern, percutaneous fixation with K-wires was often sufficient and associated with better aesthetic outcome than open reduction and internal fixation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Physiolysis for correction of clinodactyly with delta phalanx: Early improvement

Congenital clinodactyly known as "delta phalanx" is a congenital finger deviation caused by a middle phalanx abnormality. Progressive realignment can be achieved with normal growth through physiolysis according to Vickers. The purpose of this investigation was to identify the rate of correction in congenital clinodactyly following epiphyseal bar resection.We studied retrospectively 24 fingers in 14 patients aged from 14 months to 11 years old (y/o), operated on by two surgeons performing epiphyseal bar resection using a modified Vickers' method. Angle measurements were compared pre-operatively, at 1 year and at the final follow-up. The rate of correction was evaluated at each time point. The cohort was divided into two groups: surgery < 6 y/o and ≥ 6 y/o. Statistical analyses were conducted to compare the patient groups.The mean deviation decreased from 33° pre-operatively (20°-80°) to 17.2° (0°-40°) at 1 year after surgery. The deviation at the last follow-up decreased to 10.6° (0°-40°). Seventy percent of the operated fingers were completely corrected (angle ≤ 10°) at the latest follow-up visit. No difference was found regarding the age at surgery. There were two cases of premature fusion of the epiphyseal plates. Regardless of the patient's age, Vickers' procedure is a simple and effective solution for treating delta phalanx with early correction. Our data suggest that physiolysis is a successful surgery in patients up to 11 years old. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Untethering physiolysis for delta phalanx (longitudinally bracketed diaphysis) combined with free fat interposition graft

We report the results of physiolysis of the epiphyseal bracket combined with free fat grafting for the treatment of delta phalanx. Thirteen cases (five patients) were included. Mean patient age was 6.6years (range, 4-9). The patients underwent physiolysis in which the epiphyseal bracket was cut and replaced with a free fat graft. The angle between the long axis of the proximal and distal phalanges and the ratio between the width and length of the affected middle phalanx were evaluated on plain radiographs. The range of motion in the fingers was also evaluated. The mean follow-up period was 42.2months (range, 25-61). The mean correction angle was 17.1° (range; 13-23). The mean width-to-length ratio of the affected phalanx was improved from 0.6 to 0.47. The range of motion was maintained at the previous level. Physiolysis by untethering the bracketing epiphysis and free fat grafting can alleviate the angulation of clinodactyly, especially in growing children. It also allows catch-up growth in the middle phalanx.

NOSOLOGY OF HAND DISEASES IN CHILDREN AND ADOLESCENTS OPERATED IN PROVISIONAL FACILITIES IN A MODEL HOSPITAL - PERNAMBUCO STATE, BRAZIL

To report the frequencies of congenital hand diseases in patients who underwent surgery on a collective mobilization basis at SOS Hand, Recife, Pernambuco, between 2005 and 2009. Methods: Information was collected from 833 children and adolescents who were examined in eight missions. Results: Among the patients, 306 (36.7%) underwent surgery: 240 (78.4%) because of congenital malformation and 66 (21.6%) because of acquired lesions. The most frequent congenital malformations were: syndactyly, 72 cases (30.0%); polydactyly, 30 cases (12.5%); bifid thumb, 19 cases (7.9%); complex hand malformation, 14 cases (5.8%); cleft hand, 13 cases (5.4%); trigger finger, 12 cases (5.0%); camptodactyly, 11 cases (4.6%); and brachysyndactyly, 9 cases (3.7%). The most frequently acquired injuries were: obstetric traumatic lesions, 26 cases (39.4%); hand trauma sequelae, 18 cases (27.3%); cerebral paralysis sequelae, 7 cases (10.6%); electric shock sequelae, 5 cases (7.6%); and burn sequelae, 4 cases (6.1%). Conclusion: The nosology of hand diseases is similar to that of large series of elective surgery, especially regarding congenital deformities. The frequency of acquired hand lesions seems to be higher than the frequency in international series. The collective mobilization system for hand surgery is important for decreasing the need for this activity in public institutions, and it has been shown to be very efficient. The success of the project may provide support for the Brazilian National Health System to enroll hand surgeons in the on-call system, in emergency units.

Osteotomy for clinodactyly

Clinodactyly, finger deviation in the coronal plane, affects the little finger most commonly. Patients typically tolerate clinodactyly without functional limitation, but with increasing deformity, they may have difficulties with specific tasks such as playing musical instruments. In those who do not tolerate the deformity, surgical options include physiolysis for young patients and osteotomy for older patients. An opening wedge osteotomy increases finger length while correcting the coronal deformity. Surgical results of the opening wedge osteotomy are satisfying and complications are rare, with stiffness of the distal interphalangeal joint noted in some patients.

Outcomes of opening wedge osteotomy to correct angular deformity in little finger clinodactyly

PURPOSE

To evaluate the outcomes and complications in a series of children with clinodactyly treated with opening wedge osteotomy of the abnormal phalanx.

METHODS

We performed a retrospective review of all children with clinodactyly treated at our institution with opening wedge osteotomy of the abnormal middle phalanx between 2003 and 2013. Patients with concomitant pathology or prior surgery in the affected finger were excluded. Preoperative and postoperative clinical angle, radiographic angle, digital range of motion, and pain were compared and complications were recorded.

RESULTS

We included 13 digits in 9 patients. All had greater than 20° of preoperative clinical angulation (mean, 36°). Mean age at time of surgery was 11 years; mean duration of follow-up was 25 months (range, 12-43 mo). All digits had significant improvement (mean, 32°) in clinical and radiographic angles after surgery. This improvement was maintained at final follow-up in 12 digits. Six patients had pain preoperatively and no patient had pain postoperatively. One digit had a recurrent deformity at final follow-up and 3 digits developed stiffness at the distal interphalangeal joint.

CONCLUSIONS

Opening wedge osteotomy is an effective treatment for angulation in children with clinodactyly. We counsel families regarding the risk of distal interphalangeal joint stiffness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Bilateral proximal delta phalanges: an unusual presentation of familial congenital clinodactyly

We report a unique case of bilateral proximal delta phalanges with secondary distal accessory ossification centers of the long fingers in a 16-month-old boy. The bony anomalies presented as severe ulnar deviation at the proximal interphalangeal joints bilaterally. This is a unique occurrence of congenital clinodactyly which has not been previously reported. Several family members show similar deformity, although to lesser degrees, suggesting an autosomal dominant mode of inheritance with incomplete penetrance and variable expressivity.

Surgical correction of clinodactyly: two straightforward techniques

Clinodactyly, a deviation of the thumb or finger in the coronal plane, is rarely functionally limiting and in most cases is treated nonoperatively. Those with functional limitations, typically associated with angulation greater than 25 degrees, may benefit from surgical correction. We have used 2 different surgical procedures, a physiolysis in younger children and an opening-wedge osteotomy in older children, to manage this deformity in selected children with a functional limitation.

Epiphyseal bar resection and fat interposition for clinodactyly

Clinodactyly, the angulation of a digit in the anteroposterior plane, is often due to a longitudinal epiphyseal bracket on the radial side of the middle phalanx of the little finger. Treatment options include observation, osteotomy, and epiphyseal bar resection. Epiphyseal bar resection is a simple surgery that requires neither postoperative pin fixation nor immobilization. The most appropriate indications are in children 3 to 6 years old with radial deviation of at least 25 degrees. The procedure reliably diminishes the extent of deformity.

Congenital hand differences

This article explores recent developments for 6 common congenital hand differences, including polydactyly, syndactyly, camptodactyly, clinodactyly, trigger thumb, and cleft hand. These differences are challenging because the surgeon must understand the potential for both functional and social (ie, appearance) issues in order to provide ideal treatment for each child and family. Therapy or surgical correction plays a role for most of these children. Recent investigations have provided additional data on the expected outcomes following intervention.