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

A comprehensive functional classification of cleft hand: The DAST concept

Context:

Phenotypic expressions of the congenital cleft hand are variable and might baffle even the experienced as to the choice of surgery. The morphological parameters defining the anomaly dictate not only the functional capacity of the anomalous hand but also the degree of possible surgical restoration. Despite a large number of classifying systems available, none encompass all the relevant issues.

Aims:

The purpose of this work is to present an all-inclusive and universally acceptable classification of the deformity which would graphically represent the entire gamut of possible presentations; principal and associated. Furthermore, based on such staging, the choice of surgical procedure and the stages of surgical intervention can be standardised to ensure the best results for the patient.

Patients and Methods:

This study is based on a series of 27 patients with a total of 38 cleft hands.

Results and Conclusions:

The necessity to include and to assess all determinants of function and complexity in these hands to standardise the choice of management, gave rise to the DAST system of classification; an acronym for all the morphological determinants of the anomaly (D = Digits missing, A = Associated anomalies in the hand, S = Site of cleft, T = Functional state of the Thumb). Numerical values were assigned to each component in increasing order of complexity. Score for each determinant as well as the aggregate score indicates the degree of complexity in a graphic manner. The DAST classification has a predictive value in choice of procedure and prognosticating surgical outcomes.

Insights into the pathogenesis and treatment of split/hand foot malformation (cleft hand/foot)

Cleft hand or split hand foot malformation is a sequence of phenotypes, from a minor shortening of the central digit to a complete absence of the third ray and in the most severe cases, absence of two, three or four rays. It is a rare but spectacular presentation usually involving both hands and feet. Inheritance is mostly autosomal dominant but sporadic cases without family history are also reported, resulting from a de novo mutation/deletion/duplication. Intra-familial clinical variability is the rule, with incomplete penetrance. X-linked or autosomal recessive inheritance has also been described. To date, seven subgroups of split hand foot malformation have been identified and seven loci are currently known. Anatomical records have enhanced our knowledge of this group of disorders of the hands and feet and allowed us to improve surgical procedures and long-term outcome.

Over 20-year follow-up of Miura reconstruction of cleft hand

Several techniques have been described for cleft hand closure and web space reconstruction in patients with central deficiency; however, long-term documentation of results is rare. We present a 23-year follow-up of a patient who underwent the Miura procedure for a Manske type IIb cleft hand exhibiting long-term aesthetic and functional success. In addition, early skin flap necrosis and late web space contracture, which have been seen after the Snow-Littler procedure, did not occur in this case.

[Cleft hand: a review of 33 cases and new ideas about classification]

Cleft hand is an uncommon congenital malformation, which is defined as a deficiency of the central part of the hand. It is the result of the absence or altered development of the central rays. The aim of treatment is to optimise the function of the hand at a young age and to improve its aesthetics. A retrospective review of 33 cases is presented and, with reference to their treatment, ideas about the classifications of cleft hand are discussed. The various anomalies seen and the management for each type of cleft hand are presented.

An experience of the Snow-Littler procedure

This paper reviews the results of the Snow-Littler procedure performed in twelve hands with classical central longitudinal deficiency and in one hand with symbrachydactyly, cleft type. There were no instances of major flap necrosis although two flaps showed tip ischaemia. The width of the first web was, in the main, satisfactory but four webspace revisions were performed. Supplementary skin grafting at the time of surgery was necessary in complete and/or complex thumb index syndactylies and in the patient with symbrachydactyly. In eight cases, a transverse metacarpal ligament was reconstructed. In the five other cases, no clinical instability or radiological divergence of the index and ring fingers occurred, in spite of no transverse metacarpal ligament reconstruction. Three de-rotational osteotomies of transposed index fingers were performed in patients who had a transverse metacarpal ligament reconstruction. These results indicated significantly improved appearance and improved function following the Snow-Littler procedure.