SYNDACTYLY

WHAT CAUSE SYNDACTYLY?

 Syndactyly comes from a failure of differentiation.
 During upper limb development, the hand segment forms
as a “paddle” at roughly the fifth week of gestation.
 Simple syndactyly occurs in approximately 1:3.000 live
births. Males are affected more commonly than females,
and Caucasians more than Blacks or Asians.
SYNDACTYLY CLASSIFICATION
 Syndactyly is classified according to the extent of digital
involvement and the character of the tissue involved.
 “Complete” syndactyly extends to the digital tips, whereas
“incomplete” syndactyly ends proximal to the fingertips.
 “Simple” syndactyly refers to digits connected only by skin and
soft tissue. The nail plates may or may not be fused.
 “Complex” syndactyly denotes bony fusions between adjacent
phalanges.
 “Complicated” syndactyly refers to the interposition of accessory
phalanges or abnormal bones between digits.
SURGICAL PROCEDURE
 In fact, the techniques of separation is vary, yet a number of general surgical
principles apply to almost all syndactylies.
 First, digits of differing lengths should be released early to prevent
deformity and growth disturbance of the affected digits.
 Second, both sides of a single digit should not be operated upon at the
same time to avoid vascular embarrassment.
 Third, local vascularized skin flaps should be used to re-create the
commissure to avoid scar contracture and “web creep.” Fourth,
interdigitating zigzag lateral flaps should be created to avoid longitudinal
scar contracture.
SURGICAL PROCEDURE
 Fifth,judicious defatting of the skin flaps should be
performed to facilitate skin closure, reduce tension
across the flaps, and improve the aesthetics of the
reconstructed fingers. And Last, full-thickness skin
grafts are typically utilized to cover “bare areas”
after syndactyly release.
 In cases of simple complete syndactyly, the combined
circumference of the separated digits is 22% greater than the
circumference of the syndactylized digits.7 While the need for
full-thickness skin grafting is accepted by most hand surgeons.

 Simple figures below may be performed to illustrate the need for

skin grafting.
SIMPLE INCOMPLETE SYNDACTYLY
RELEASE
 Simple skin rearrangement will provide adequate release with
minimal morbidity. Options in these cases include simple Z-
plasties, fourpart Z-plasties, double-opposing Z-plasties, or
variations thereof. Our preference is to utilize two or four-part
Z-plases for the first web space, and double opposing Z-
plasties for the second, third, and fourth web spaces.
SIMPLE INCOMPLETE SYNDACTYLY RELEASE

 After the skin incisions are created, with care

being made to ensure that all limbs are of equal
length, the tourniquet is infl ated and skin incised.
Care is made to preserve full-thickness flaps to
preserve vascularity.
SIMPLE COMPLETE SYNDACTYLY RELEASE

 Patients are placed supine with the affected upper limb supported on a
hand table. A nonsterile tourniquet is placed in the upper brachium,
taking care to maintain access to the antecubital fossa, if full-
thickness skin graft is to be taken from that site.
 If skin graft from the inguinal crease is to be harvested, the ipsilateral
groin is also prepped and draped sterilely into the surgical field.
 Skin graft from the inguinal region should be
taken well lateral to the palpated femoral pulse to
minimize harvest of hair-bearing skin, and a
surgical marking pen may be placed into the
inguinal crease with the hip flexed to identify the
most aesthetic axis from which to harvest skin;
this will allow for easy primary closure of the
harvest site with a scar that lies inconspicuously
in the skin folds.
GRAFTLESS SYNDACTYLY RELEASE
 Vascularized skin from the dorsum
of the hand is raised and advanced
to reconstitute the web commissure,
leaving the skin over the dorsal
aspects of the adjacent proximal
phalanges available to cover the
separated digits.
 The resulting donor defect is closed
primarily in the fashion of a V-Y
advancement fl ap. Areas of skin
eficiencies distal to the web
commissure are closed primarily
with interdigitating skin flaps after
aggressive defatting.
FIRST WEB SYNDACTYLY
 It is imperative that a wide, deep
first web space is reconstituted to
optimize hand function, and
reconstructed using a single,
scarless, vascularized flap of
native tissue.
 Ghani modification of the Buck-
Gramcko flap is currently used
and patients are positioned as
previously described. The
planned skin incisions are
marked on the dorsum of the
hand,
 Dorsally, the distal transverse extent of the flap
lies at the junction of the distal one-third and
proximal two-thirds of the thumb proximal
phalanx. The radial incision lies over the thumb
metacarpal. The ulnar incision is curvilinear—
almost bilobed—extending from the index to the
small metacarpal
APERT AND COMPLEX POLYSYNDACTYLY
 Apert syndrome, or acrocephalosyndactyly, refers to a constellation of
clinical manifestations including coronal craniosynostosis, midface
hypoplasia, and characteristic syndactylies of the hands and feet,
due to a mutation in the FGFR2 gene on chromosome 10q. Hand
involvement classified by Upton as well as Van Heest.
TYPE OF APERT AND COMPLEX
POLYSYNDACTYLY
 Type I hands (spade hand) have incomplete first web
syndactylies with a relative flat central mass and good
MCP joints with varying degrees of symphalangism and
IP stiffness.
 Type II hands (mitten or spoon hand) have complete
syndactylies of the first and fourth webs with fusion of
the digital tips and increasing concavity of the palm.
 Type III hands (hoof or rosebud hands) represent
complete complex syndactylies of all digits in which the
thumb is incorporated into the central, cupped hand
mass with a single synonychia.
POSTOPERATIVE
 Patients remain in casts for 3 to 4 weeks, after which casts are
removed and wounds examined.
 While not necessary, our preference is to have patients work with
our occupational therapists for scar mold (silicone or elastomere),
scar massage, and range-of-motion exercises to optimize healing.
COMPLICATION
 Digital necrosis is the most serious
potential complication, though it is
rare if the surgical principles are
followed.
 Skin graft failure may result from
hematoma formation beneath
and/or shear stresses imparted upon
the grafts in the postoperative
period. This risk may be greater in
younger patients, in whom
appropriate graft tensioning is more
difficult and in whom postoperative
immobilization is a greater
challenge.
 Nail plate deformity is common after complete
syndactyly release in the presence of a synonychia.
 “Web creep” refers to the distal migration of the
reconstructed interdigital commissure with continued
growth and is a common occurrence following
syndactyly release. Some evidence suggest that the
risk of web creep may be diminished if release is
performed after 18 months of age.
 Hypertrophic scar and true keloid formation may
lead to unsightly and dysfunctional digits following
syndactyly release