Bilateral delta phalanx of the proximal phalanges of the great toes. A report on an affected family

Unusual Presentation of Familial Unilateral Postaxial Polydactyly With Metacarpal Delta Phalanx: A Report of a Rare Case

The term "delta phalanx" is proposed to characterize an uncommon deformity that typically affects the middle phalanx of a finger. It has the appearance of the Greek capital letter delta, meaning it is shaped like a triangle. Because the faulty epiphysis occurs proximally to distally instead of along its usual horizontal course, the bone has a semilunar shape. Functional impairment or significant finger shortening are indications for surgery. A variety of congenital hand anomalies are linked to the delta phalanx. Few cases of middle delta phalanx in the ulnar polydactyly finger have been documented. This case study investigates an extremely uncommon occurrence of metacarpal delta phalanx in an ulnar polydactyly finger.

The Developmental Phenotype of the Great Toe in Fibrodysplasia Ossificans Progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder in which extensive heterotopic ossification (HO) begins to form during early childhood and progresses throughout life. Although HO does not occur during embryonic development, children who carry the ACVR1^R206H mutation that causes most cases of FOP characteristically exhibit malformation of their great toes at birth, indicating that the mutation acts during embryonic development to alter skeletal formation. Despite the high prevalence of the great toe malformation in the FOP population, it has received relatively little attention due to its clinically benign nature. In this study, we examined radiographs from a cohort of 41 FOP patients ranging from 2 months to 48 years of age to provide a detailed analysis of the developmental features, progression, and variability of the great toe malformation of FOP, which include absent skeletal structures, malformed epiphyses, ectopic ossification centers, malformed first metatarsals and phalangeal fusion.

Minimally Invasive Hallux Interphalangeal Joint Arthrodesis for Hallux Varus in Pfeiffer Syndrome: A Case Report

Pfeiffer syndrome is a rare hereditary condition with an autosomal dominant transmission caused by a mutation that affects fibroblast growth factor receptors. It is one of the acrocephalosyndactyly diseases causing cranial malformations owing to early suture fusion. In the foot, it is typically associated with hallux varus, first ray hyperplasia, and partial lesser digit syndactyly. We report a clinical case of a 10-year-old patient with Pfeiffer type I syndrome with bilateral severe hallux varus due to a hypoplastic trapezoidal shaped proximal phalanx, a distal, medial-facing articular surface, and interphalangeal instability. This deformity was addressed by minimally invasive hallux interphalangeal joint arthrodesis with internal and external fixation. We report the results at the 2-year follow-up point.

Longitudinal bracketed epiphysis of proximal phalanx of the great toe with congenital hallux varus managed simultaneously with monorail external fixator: a case report

Longitudinal bracketed epiphysis (delta phalanx) is a rare congenital anomaly that affects phalanges in the hand more commonly than toes. We present a rare case of congenital hallux varus with longitudinal bracketed epiphysis of proximal phalanx with bifid distal phalanx of the great toe, which was managed with monorail type of external fixator. To the best of our knowledge, this is the first report of its successful implementation in simultaneous treatment of longitudinal bracketed epiphysis of the proximal phalanx of the great toe and hallux varus. Apart from adding to the literature a case of rare subtype of delta phalanx with hallux varus, the present study highlights the role of a reliable alternative in its management.

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.

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.

Treatment of first metatarsal longitudinal epiphyseal bracket by excision before closure

The longitudinal metatarsal epiphyseal bracket is a rare ossification abnormality of tubular bones in which an abnormal epiphysis brackets the diaphysis of a phalanx, metacarpal, or metatarsal. This leads to progressive shortening and angular deformity of the involved bone. When it affects the first metatarsal, the longitudinal metatarsal epiphyseal bracket leads to a short, trapezoidal metatarsal. We present the case of a 6-year-old patient with an ossified longitudinal epiphyseal bracket along the medial side of the first metatarsal. The abnormality was surgically treated by bracket excision before physeal closure. At 6 years' follow-up, the patient displayed a normally aligned hallux of appropriate size in proportion to the other toes. Surgical correction resulted in alteration of the first metatarsophalangeal angle, which went from a preoperative value of 13 degrees of hallux varus to a postoperative value of 9 degrees of hallux valgus; the first metatarsal intraosseous angulation went from a preoperative value of 30 degrees to a postoperative value of 5 degrees , and the metadiaphyseal length index went from a preoperative value of 0.39 to a postoperative value of 0.92. This case study demonstrates that early resection of an ossified abnormal bracket before physeal closure, a relatively simple procedure, can restore longitudinal growth and correct angular deformity.

Radiographic evaluation and unusual bone formations in different genetic patterns in synpolydactyly

OBJECTIVE

To compare the radiological findings of heterozygous and homozygous subjects with synpolydactyly (SPD) and to discuss their unusual bone formations.

DESIGN AND PATIENTS

Families with hand and foot SPD were examined. Genetic analysis was performed with blood samples and the pedigree was constructed. The affected individuals, especially those with distinctive phenotypic features, were invited to our orthopaedics clinic for further diagnostic studies. All participants underwent detailed clinical and X-ray examinations.

RESULTS

Of the invited patients, 16 (five female and 11 male; age range 4-37 years, mean age 10.75 years) were included in our study, and hand and foot radiographs were obtained. All subjects had bilateral hand radiographs (32 hands), and 14 had bilateral foot radiographs (28 feet). Genetic analysis revealed 12 heterozygote (75%) and four (25%) homozygote phenotypes. Among patients enrolled into the study nine (three homozygotes, six heterozygotes) had SPD of both hands and feet bilaterally (tetrasynpolydactyly). Six unusual bone formations were observed in the hands and feet: delta phalanx, delta metacarpal/metatarsal, kissing delta phalanx, true double epiphysis, pseudoepiphysis and cone-shaped epiphysis. There were major differences in radiological and clinical manifestations of homozygote and heterozygote phenotypes. The homozygous SPD presented with very distinctive unusual bone formations.

CONCLUSION

The existence and variety of unusual bones may indicate the severity of penetrance and expressivity of SPD.

Brachydactylic multiple delta phalanges plus syndrome

Delta phalanges are unusual, shortened bones of the hands and feet with abnormal epiphyses and diaphyses. Here, we report on a patient with a unique multiple congenital anomaly syndrome that includes brachydactyly consisting of multiple delta phalanges in several digits of the hands and feet. The patient, who was born to consanguineous parents, had several other congenital anomalies, including butterfly vertebrae, craniofacial dysmorphism, and coarctation of the aorta. We have called this distinctive condition "brachydactylic multiple delta phalanges plus syndrome." Although no other member of the family had obvious hand or foot anomalies, several siblings had other malformations. Possible modes of inheritance in this family include variable expression of a recessive or de novo dominant condition.

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.

Triphalangeal thumb with delta phalanx in a case of Klinefelter's syndrome

We report a case of Klinefelter's syndrome owing to maternal meiotic error associated with triphalangeal thumb and delta phalanx bilaterally. There are no previous reports of similar cases and triphalangism with delta phalanx abnormalities of both thumbs might therefore be considered a further, but rare, manifestation of this aneuploidy.