The congenital triangular deformity of the tubular bones of hand and foot

Longitudinal Epiphyseal Bracket of the First Metatarsal Bone: Three Case Reports and a Review of the Literature

Longitudinal epiphyseal bracket (LEB) is a rare bone dysplasia of the tubular bones. Owing to an abnormal secondary ossification center, the affected bones can develop progressive shortening and angular deformity. The aim of our study was to provide an overview of the reported data regarding epidemiology and surgical procedures available for LEB of the first metatarsal bone in a pediatric population combined with a small case series. We report a retrospective case series of 3 nonsyndromic pediatric patients with different ages and with confirmed dysplasia of the first metatarsal bone. All patients presented with unilateral congenital hallux varus deformity and underwent surgical treatment. The radiographs and medical records were reviewed to evaluate the deformity characteristics, treatment, and clinical results. The mean patient age at initial surgery was 34 (range 12 to 63) months, and the median follow-up period was 46 (range 31 to 75) months. Almost all specific radiographic measurements showed correction of the deformity, and each foot demonstrated functional and cosmetic improvement. A standardized literature search was performed to obtain studies of LEB of the first metatarsal bone in the pediatric population. From on our results and the current data available, surgical treatment should be tailored to the patient's age and radiographic stage of LEB. However, monitoring until skeletal maturity of the feet is necessary to assess the final results.

Longitudinal epiphyseal bracket

Longitudinal epiphyseal bracket or bracket epiphysis is an uncommon disorder of growth. Alternatively known as a delta phalanx, it is due to an anomalous secondary ossification center that extends longitudinally along the diaphysis. Although rare, longitudinal epiphyseal bracket most commonly manifests in the hands as clinodactyly and in the feet as hallux varus. Previously, longitudinal epiphyseal bracket has been treated with angular osteotomy, but we recommend early surgical physiolysis. We describe this uncommon disorder, our current recommendation for treatment, and present three illustrative cases.

Free fat graft for congenital hand differences

BACKGROUND

Free fat graft has been used for the treatment of congenital hand differences. However, there have been a few reports about the outcome of that treatment. In this study, the outcome of free fat grafts for congenital hand and foot differences was investigated.

METHODS

Fourteen bones with longitudinal epiphyseal bracket, 3 wrists with Madelung deformity, and 5 cases of osseous syndactyly were treated with free fat graft with osteotomy, physiolysis, or separation of osseous syndactyly. Of the fourteen bones with longitudinal epiphyseal bracket, 9 were treated with open wedge osteotomy with free fat graft and 5 with physiolysis and free fat graft. The Madelung deformity was treated with physiolysis with free fat graft. For osseous syndactyly, syndactyly release with free fat graft was performed five times on four hands.

RESULTS

In the fourteen cases with longitudinal epiphyseal bracket, lateral deviation improved in all except two cases after surgery. The average lateral deviation angle changed from 32.5 degrees before surgery to 15.2 degrees after surgery. The average improvement of the lateral deviation angle was 12.2 degrees in the osteotomy group and 20.6 degrees in the physiolysis group. The mean ratio of improvement of the lateral deviation angle to the lateral deviation angle before surgery was 39.4% in the osteotomy group and 51.2% in the physiolysis group. The Madelung deformity improved after surgery in two cases but there was no improvement in one case. For these conditions, the results were not good enough when surgery was done after age 13 or at age four for severely hypoplastic brachymesophalangy. Of the 5 cases of osseous syndactyly, reunion of the separated bones occurred in one case. The grafted free fat should be deep enough to cover the osteotomy site of the bones to prevent reunion of the separated bones.

CONCLUSIONS

Physiolysis and free fat graft performed during the growth period can correct the deviation due to longitudinal epiphyseal bracket and Madelung deformity. Free fat graft is also useful to prevent reunion of the bones after separation of osseous syndcatyly, if the grafted fat is securely filled into the space between the separated bones.

Pont épiphysaire longitudinal déformant du premier métatarsien ou « métatarse delta »

PURPOSE OF THE STUDY

The longitudinal epiphyseal bracket (LEB) or delta bone is a rare congenital ossification anomaly generally observed in finger or toe phalanges but occasionally in the metatarsus or metacarpus. LEB is initially composed of cartilage forming a bracket linking the proximal and distal epiphyses and causing defective growth of the primary ossification focus. Changes in bone growth secondary to the presence of a LEB would be the cause the angle malformations and length discrepancies observed in these subjects. This raises significant therapeutic problems and repeated surgical interventions when the diagnosis is not established early enough. The clinical presentation of LEB of the first metatarsus is similar to metatarsus adductus or hallux varus primus. The particular aspect on the plain x-ray enables the diagnosis.

MATERIAL AND METHODS

We operated five feet presenting LEB of the first metatarsus in three children aged on average 23 months (range 8 months to 3 years 10 months). The cartilage bracket was removed, followed by metatarso-phalangeal centromedullary pinning. We studied the course of the angle and length deformities and report outcome at mean follow-up of 4 years 11 months (range 2 years to 3 years 10 months).

RESULTS

Clinical improvement with correction of the angle deformities was observed in all feet. The length discrepancies did not resolve completely. The degree of correction depended on the age at the time of surgery.

DISCUSSION

In light of the results obtained in this series and considering the negative prognosis of late surgical management, it would be advisable to obtain a plain x-ray of the foot in all children presenting metatarsus adductus associated with a short first ray.

Pediatric longitudinal epiphyseal bracket: Review and case presentation

The longitudinal epiphyseal bracket is a rare deformity affecting the long and short bones of the hands and feet, creating an aberration in growth. The deformity is present in 2% to 14% of congenital hand and foot deformities, with 11% of all cases found in the great toe. Ultrasound may then be used to confirm the diagnosis. Radiographs usually show the presence of a bracket epiphysis once there is some ossification, but until then, the radiographs can appear normal. With the use of ultrasound, a suspected preossified bracket can be visualized and can establish the diagnosis. The purpose of this article is to present such a case with a preossified epiphyseal bracket of the great toe. The child presented initially with unremarkable x-rays, but the diagnosis was made with clinical suspicion and use of ultrasound. After surgical resection of the brackets, there was progressive improvement in the short-term follow-up. Long-term follow-up is essential until skeletal maturity, and, if the deformity persists, further surgical care may need to be implemented.

Correcting and lengthening of metatarsal deformity with circular fixator by distraction osteotomy: a case of longitudinal epiphyseal bracket

The condition known as longitudinal epiphyseal bracket or delta phalanx is a rare congenital anomaly that affects the tubular bones of hand or foot. Metatarsal epiphyseal bracket restrains longitudinal growth, causing progressive deformity and resulting in a short, broad metatarsal and a medially deviated metatarsophalangeal joint and hallux magnus. Although there are some case series describing metatarsal lengthening with the unilateral fixator in the literature, we could not find any case that combines both metatarsal lengthening and deformity correction with the circular external fixator. Gradual lengthening and deformity correction without bone grafting and soft-tissue modification were carried out in a case with bilateral longitudinal epiphyseal bracket of the first metatarsals of the foot. A literature review and treatment method for epiphyseal bracket in a 9-year-old boy is presented. Excellent clinical, and functional results were obtained with circular and semicircular fixators.

Two-stage reconstruction of apert acrosyndactyly

This report retrospectively reviews presenting radiographs and surgical treatment of 28 hands in 14 children with Apert acrosyndactyly with the purpose of developing a classification system to describe the decision-making process used to determine the type and staging of hand reconstruction. The average patient age at last follow-up evaluation was 7 years (range, 3-17 years). Type I deformities (7 hands) had little or no angular deformity at the metacarpophalangeal (MP) joint; two-stage reconstruction created a four-fingered hand. Type IIA deformities (11 hands) had mild MP joint angular deformity and a more proximal complex syndactyly of the middle three digits; two-stage reconstruction created a three-fingered hand with ray resection of the third digit. Type IIB deformities (7 hands) had pronation of digit 2 superimposed on the thumb and radial angulation at the MP joint of digit 2; two-stage reconstruction created a three-fingered hand with ray resection of the second digit. Type IIC deformities (3 hands) had supination of digit 4 superimposed on digit 5 with ulnar angulation at the MP joint of digits 4 and 5; two-stage reconstruction created a three-fingered hand with ray resection of the fourth digit. This report presents a classification system and four different treatment strategies based on presenting radiographs.

Delta phalanx

The authors present a case of congenital, bilateral, symmetrical, and purely transverse plane, abductus deformity of the second digit. The deformity appears to be familial in nature, although other possible etiologies remain including premature closure of the distal-lateral epiphysis of the middle phalanx, or a C-shaped epiphysis of the middle phalanx. The authors review a similar deformity described in orthopedic literature known as a delta phalanx.

Reduction osteotomy for triphalangeal thumb: an 11-year review

Since 1977 we have operated on 13 of 15 triphalangeal thumbs in nine children (five boys, four girls). Follow-up ranged from 22 to 134 months (mean, 65 months). Total active motion averaged 63 degrees at the interphalangeal joint and 79 degrees at the metacarpophalangeal joint. There was no evidence of instability or laxity of ligaments. Reduction osteotomy was insufficient to shorten grossly long thumbs of two patients, and it was necessary to shorten the metacarpal. Premature closure of the phalangeal physis occurred in two thumbs but did not result in inadequate length; one postoperative pin-tract infection resulted in nonunion that required reoperation. This long-term experience supports reduction osteotomy for triphalangeal thumbs because it addresses the deformities and preserves both motion and stability.

Longitudinal tibial epiphyseal bracket in Nievergelt syndrome

A patient is described with lower extremity mesomelic dwarfism associated with bilateral congenital elbow, hip, and knee dislocations. Rhomboid-shaped tibiae and delayed ossification of the primary fibular ossification centers were demonstrated at birth. Plain films and magnetic resonance imaging revealed that the tibial deformities were due to the presence of longitudinal epiphyseal brackets. These brackets were observed at surgery and confirmed histologically. Recognition of the longitudinal epiphyseal bracket and its relationship to the tibial deformities seen in this patient with Nievergelt syndrome is important for planning surgical treatment.

Delta formation in foot polydactyly

Congenital triangular deformity of the foot bones may occur in phalanges and metatarsals. As it resembles the Greek letter delta it is called "delta phalanx" and "delta metatarsal". We report on 19 delta formations in ten patients with foot polydactyly. Our long-term follow-up of these patients indicates four stages in the ossification process: no ossification of the epiphysis; appearance of single or multiple ossification centers; unification of the ossification centers with nonosseous tissue between the diaphysis and the epiphysis; and, finally, complete ossification. Pathogenetically, the delta formation may represent an intermediate stage in the bifurcation process of a polydactylic ray. Splitting longitudinally in a direction from distal to proximal, it is the root of the bifurcated toe ray.

Lethal and non-lethal diastrophic dysplasia. A study of 14 Swedish cases

A clinical study was performed on 14 patients with diastrophic dysplasia (DD), including three pairs of sibs. Six of these patients, including two pairs of sibs, died shortly after birth of respiratory and circulatory insufficiency. We consider these six patients to represent a special lethal variant of DD. In all infants with the lethal variant of DD the birth weight was lower than in those with the non-lethal variant. There were also roentgenological differences between these two groups. Overlapping in joints and dislocation of the cervical spine were seen in all the lethal cases. In addition, four of the six patients with lethal DD cases had a congenital heart defect, and none in the non-lethal group.

Combined reduction osteotomy for triphalangeal thumb

Triphalangeal thumb is an uncommon congenital deformity. The thumb is long, awkward, frequently angulated, and may have a broad, unsightly nail. When the middle phalanx has an abnormal C-shaped ("delta") epiphysis, the deformity worsens if untreated. Three triphalangeal thumbs in two patients who were 2 1/2 and 8 1/2 years of age were treated with single-stage combined longitudinal and transverse reduction osteotomy, which included narrowing, shortening, and deangulation by ablating the extra joint and abnormal epiphysis. The patients were followed 48 to 59 months after surgery. Realignment, corrected relative length, and interphalangeal motion have been preserved in all thumbs. Neither patient has developed instability or angulation or had a recurrence after surgery.

Correlative roentgenography and morphology of the longitudinal epiphyseal bracket

Detailed examination of a complete chondro-osseous specimen from a patient with duplication of the first ray of the foot revealed the involved metatarsal had a trapezoid-shaped, diaphyseal-metaphyseal osseous unit that was longitudinally bracketed along the lateral side by a functioning physis, epiphysis, and secondary (epiphyseal) ossification center. The physis extended as an arc from the medial proximal side toward and along the lateral side and then back to the medial side distally. The medial side of the diaphysis had a normal periosteum. The longitudinal epiphyseal ossification bracket was a composite of initially separate proximal and distal secondary ossification centers that had progressively extended toward each other and finally coalesced along the laterally placed epiphyseal cartilage. We have termed this deformity the "longitudinal epiphyseal bracket" (LEB). The macroscopic and microscopic anatomy relevant to initial diagnosis and evaluation of sequential roentgenographic changes will be considered.

Clinodactyly. A review of a series of cases

A review of 50 patients with clinodactyly is presented in which six patients required surgery for a combination of functional and cosmetic problems. It is suggested that patients with a delta phalanx at the proximal phalangeal level should have a reversed wedge osteotomy early, while those with brachymesophalangism requiring surgery have a closing wedge osteotomy performed late. Delta phalanges in the triphalangeal thumb should be excised early and the joint reconstructed. An ulnar abduction deformity was noted in a minority of patients with clinodactyly. This deformity is relieved when the clinodactyly is corrected.

Polydactyly and the triphalangeal thumb

Polydactyly associated with triphalangeal thumb is not rare, as among the records of 1,269 patients with congenital deformation of the upper extremity at the University of Iowa there were 21 patients with 32 hands with such involvement. More detailed classification based on Wassel's work was made. Treatment should be early, with removal of the radial digit if equal in size, excision of all accessory parts including delta bone when present, reconstruction of joint ligaments or joint fusion and osteotomy for correction of deviations. Care should be taken to avoid leaving a narrow first web space.

Congenital triangular bones in the hand

From the literature we found reports of 105 patients whom we judged had a triangular deformity of one of the bones of the hand or foot. We found 49 patients of our own with 84 delta-shaped phalanges limited strictly to the hand. This represents an incidence of 3.5% of our congenital abnormalities of the upper extremity. The deformity is associated with many abnormalities: syndactyly, polydactyly, symphalangism, triphalangeal thumb, cleft hand, and hypoplastic hand are the most frequent Triangular deformity of the bone of the index finger usually is associated with Apert's syndrome. Triangular deformity of the proximal phalanx of the ring finger often is found with central polydactyly. Our average follow-up time on these 49 patients was 14 years, giving us a chance to establish some guidelines and general rules about the natural history and treatment of the delta bone.

Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis ("delta phalanx")

Clinodactyly in 10 fingers (9 patients) with longitudinally bracketed diaphysis (LBD) was treated surgically with various methods. In 4 cases with LBD in the middle phalanx of a triphalangeal thumb this phalanx was removed and the ligaments reconstructed. In the other 6 digits the LBD was in the base phalanx of a thumb or in the middle phalanx of some other digit. One of these was treated in infancy with transverse resection of the bracket. In 3 cases (4 digits) wedge osteotomy with reversal of the wedge was carried out. In the remaining case simple osteotomy was performed and a wedge-shaped bonegraft was interposed in the space created. Treatment in the last-mentioned case was unsuccessful because postoperatively the graft slipped out of position, but in all other cases the results achieved appear satisfactory.