eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Syndactyly: Treatment
Updated: Feb 5, 2009
Treatment
Medical Therapy
Syndactyly requires surgical intervention. Full-term infants can be scheduled for elective surgical procedures as early as 5 or 6 months of age. Surgery before this age can increase anesthetic risks. Prior to that time, there is generally no intervention necessary if there are no problems. If there is an associated paronychia (see image below), which can occur with complex syndactyly, the parents are given instructions to wash the child's hands thoroughly with soap and water and to apply a topical antibacterial solution or ointment. Oral antibiotics are given when indicated.
Paronychia in a patient with Apert syndrome. Despite the use of oral antibiotics and topical antibiotic solution, the paronychia did not fully resolve until the fingers were divided.
Surgical Therapy
The timing of surgery is variable. However, if more fingers are involved and the syndactyly is more complex, release should be performed earlier. Early release can prevent the malrotation and angulation that develops from differential growth rates of the involved fingers.
In persons with complex syndactyly, the author performs the first release of the border digits when the individual is approximately 6 months old. This approach is used because differential growth rates are observed, particularly between the small finger and ring finger or between the thumb and index finger. Prolonged syndactyly between these digits can cause permanent deformities. If more than one syndactyly is present in the same hand, simultaneous surgical release can be performed, provided only one side of the involved fingers is released. For example, in a 4-finger syndactyly involving the index, long, ring, and small fingers, the index finger can be released from the long finger, and the small finger can be released from the ring finger, leaving a central syndactyly involving the long and ring fingers (see images below). If both hands are involved, bilateral releases can be performed at one operative setting.
Left hand of a patient with Apert syndrome type II. The hand has already undergone a previous first-stage division. Bilateral releases were simultaneously performed to release the border digits along with deepening of the 1st webspaces using a 4-flap z-plasty.
Volar view of the left hand of a patient with Apert syndrome type II. The hand has already undergone first-stage division. Bilateral releases were simultaneously performed to release the border digits along with deepening of the 1st webspaces using a 4-flap z-plasty.
Perform bilateral releases whenever feasible to reduce the number of surgeries and the associated risks. Postoperative bilateral immobilization of the upper extremities is well tolerated in the child who is younger than 18 months. The increasingly active child who is older than 18 months has a difficult time with bilateral immobilization. Therefore, in children older than 18 months, any procedures must be staged unilaterally. The remaining syndactyly between the long finger and ring finger can be released approximately 6 months later (see images below). In an individual with isolated central syndactyly between the long finger and ring finger, the release need not be accomplished until the second year of life because of similar growth rates between the long finger and ring finger. It is preferable to complete all major reconstructions before a child is school age.
Left hand of a patient with Apert syndrome type II. This is a 6-month postoperative picture after second-stage release was performed for the central digits between the long finger and ring finger. Surgical release was performed with the standard zigzag incisions. Soft-tissue coverage for the phalanges was sufficient after the release; therefore, a pedicle groin flap was not needed. The long finger and ring finger shared a conjoint nail, which was also released successfully. This picture was taken during subsequent surgical revision of a tracheostomy.
Dorsal view of the left hand of a patient with Apert syndrome type II. This is a 6-month postoperative picture obtained after a second-stage release was performed for the central digits between the long finger and ring finger. Surgical release was performed with the standard zigzag incisions. Soft-tissue coverage for the phalanges was sufficient after the release; therefore, a pedicle groin flap was not needed. The long finger and ring finger shared a conjoint nail, which was also released successfully. This picture was taken during subsequent surgical revision of a tracheostomy.
However, even if the child is older than the ideal age (which is usually before school age for functional, developmental, and psychological reasons), it is not too late to release the central rays (long and ring fingers) at a later age, as they have similar growth rates. For example, a 5° flexion contracture could eventually improve once the fingers are released. In children, unlike in adults, persistent flexion contractures are rare. The technical details of syndactyly release are similar to the release performed in infants. In older patients, splints are still applied but can be removed earlier, at about 7-10 days, because the patients are more compliant with activity and with dressing changes after the splint is removed.13
Preoperative Details
The parents are instructed to bathe the patient on the morning of surgery, with particular instructions to wash the hands and the groin region where the skin graft will be harvested.
Intraoperative Details
Surgical technique
With any initial syndactyly release, operate on only 1 side of the finger at any particular time to prevent ischemic compromise to the finger should one of the digital vessels be absent or be injured. The surgical division is individually tailored based on complexity and location of the syndactyly. Generally, the release is accomplished by dividing the fingers and resurfacing the surgical wound with a well-vascularized dorsal trapezoidal-shaped flap, interdigitating fasciocutaneous flaps, and full-thickness skin grafts to resurface interdigital space (see images below). The web is reconstructed with a well-vascularized dorsal fasciocutaneous flap.14
Dorsal view of the hand of a 1-year-old patient with complete simple syndactyly between his long finger and ring finger. The typical zigzag incisions are marked on both the dorsal and volar surfaces. Note the length of the dorsal trapezoidal flap design. Because it needs to be inset at a 45° angle with the distal edge of the web at the midlevel of the proximal phalanges, the length of the flap needs to be long enough to achieve this goal.
Volar view of the hand of a 1-year-old patient with complete simple syndactyly between his long finger and ring finger. The typical zigzag incisions are marked on both the dorsal and volar surfaces. Note the length of the dorsal trapezoidal flap design. Because it needs to be inset at a 45° angle with the distal edge of the web at the midlevel of the proximal phalanges, the length of the flap needs to be long enough to achieve this goal. Note the incidental simian crease.
Hand of a 1-year-old patient with complete simple syndactyly between his long finger and ring finger. This picture was takenimmediately after the procedure. On the dorsal view, note the proximal skin graft on the ulnar and radial sides of the dorsal trapezoidal flap.
Hand of a 1-year-old patient with complete simple syndactyly between his long finger and ring finger. This picture was taken immediately after the procedure.
This flap is inset with a sloping inclination in the dorsal-to-volar orientation, with the distal edge ending at the midlength of the proximal phalanx. If the fingernail is involved, divide it longitudinally. Reduce the fingernails to normal size if they are broad. Osteotomize and cover any bony exposure with local fasciocutaneous flaps for stable coverage. Occasionally, when the area of exposed bone is small, a full thickness skin graft may suffice. It is important that the local interdigitating flaps be designed well to minimize the need for skin grafts. Apply the full-thickness skin grafts to areas that remain uncovered by the fasciocutaneous flaps.
Inform the parents that skin grafts are needed for all cases except for the most minor of incomplete simple syndactyly (eg, those that are located in the first web space between the thumb and the index finger). For incomplete simple syndactyly, various techniques, such as double-opposing Z-plasty or a 4-flap Z-plasty, may not require skin grafts (see images below). Many variations and techniques have been devised for syndactyly release, and Upton has reviewed their descriptions and their history.15
Dorsal view of left hand demonstrating a simple incomplete syndactyly between the long finger and ring finger. This incomplete simple syndactyly was released by using a V-to-M flap without the need for a skin graft. Note the markings.
Volar view of left hand demonstrates a simple incomplete syndactyly between the long finger and ring finger. Immediate postoperative results are shown. Note the markings.
Dorsal view of a left hand demonstrates a simple incomplete syndactyly between the long finger and ring finger. Immediate postoperative results are shown.
Immediate postoperative results are shown.
Immediate postoperative results are shown.
One month later, the hand has a sufficiently deepened web. However, hypertrophic and hyperpigmented scars are still present along the incision line.
One month later, the hand has a sufficiently deepened web. However, hypertrophic and hyperpigmented scars are still present along the incision line.
Regardless of the techniques used, the following general principles must be applied to achieve optimal results:
- Use loupe magnification (2.5X or greater).
- Use zigzag lines to distribute the lines of contraction; avoid straight lines.
- Use well-vascularized flaps to reconstruct the web space.
- Defatting of the interdigital space should be judicious; otherwise, the neurovascular pedicles may be injured.
- Release only 1 side of a finger at a time during the initial syndactyly release, and whenever possible, perform bilateral syndactyly releases, particularly in children younger than 18 months, when bilateral surgeries are well tolerated.
- Harvest full-thickness skin grafts from a hairless region that has a reasonable color match.
- A tourniquet is crucial in the dissection to achieve a bloodless field to avoid damage to the neurovascular structures.
- Achieve hemostasis in the wound base to optimize survival of the skin graft.
- Use only absorbable sutures, such as 5-0 mild chromic catgut or synthetic rapidly absorbable sutures, which may cause less inflammation.
Skin grafts
Full-thickness skin grafts are preferable over split-thickness skin grafts because the former are less likely to contract over time and because they usually grow with the patient. The most common full-thickness skin-graft donor site is the lateral inguinal region close to the anterior superior iliac crest. This area is generally hairless, even in the hirsute adult. The skin is taken as an ellipse, and the donor site is closed primarily. Morbidity associated with this donor site, particularly the infection rate, is low. The incision heals nicely and is usually inconspicuous (see image below).
Skin-graft donor site. The donor site in the right inguinal region has healed well 10 months after the patient's syndactyly surgery. The graft harvested was able to resurface 2 web spaces during bilateral web-space releases. The incision is inconspicuous.
Because a large skin graft may need to be harvested from this area, the donor site can extend into the hair-bearing skin. It is important to thin the graft to decrease the chance of hair growth in the graft, which can occur during puberty. The parents should be advised that hair growth in the skin graft is a possibility, particularly in male patients.16
In complex syndactyly, such as Apert syndrome, in which a pedicled groin flap may be used later for resurfacing the interdigital space after the central syndactyly release, the surgeon may want to consider harvesting the full-thickness skin graft from the midline suprapubic region through a Pfannenstiel incision. Nonpigmented skin can also be harvested from the plantar surface of the foot or from the hypothenar region of the hand. In the nonambulating child, the plantar incision can be closed primarily and is well tolerated with minimal morbidity. Both the hypothenar and plantar donor sites for the skin graft are limited in quantity and can therefore be used to resurface only small wounds. Another source of skin, in an uncircumcised male, is the prepuce. This skin also tends to hyperpigment over time and may not be available if the patient has already been circumcised.
Postoperative Details
A well-molded bulky dressing is applied to the upper extremity. A generous amount of antibiotic ointment is directly applied to the skin graft, and the incisions are followed by a nonadherent dressing material such as Adaptik. (Petroleum-impregnated cotton gauze products tend to dry quickly and can become adherent to the skin grafts with the first dressing change, so the surgeon may want to avoid this.) This step is followed by gently laying cotton fluffs within the web space. The upper extremity is then placed into a well-padded, long-arm bulky dressing, which is reinforced with a long-arm fiberglass splint. The skin-graft donor site is closed with absorbable sutures and steristrips and covered with gauze and clear cellophane adhesive.17
The parents are instructed to remove the skin-graft donor site dressing on postoperative day 3. They may then start bathing the child and can get the donor site wet, with encouragement to wash this area with soap and water. The long arm splint is kept in place and is removed at 2 weeks. Utmost care should be taken when the dressing is removed. If there is any concern about the possibility of loss of the skin graft with an early dressing change at 2 weeks, the dressing is left in place for 3 weeks.
The dressing is removed intraoperatively if any concern exists about the child being unable to tolerate a dressing change in the office. After this, the parents are instructed to do daily wound care. Instruct the parents to gently wash their hands before changing each dressing and to change the dressing once a day for 2 weeks. During these changes, an antibiotic ointment should be applied with a cotton swab to gently agitate any dried blood or residual drainage that is adhering to the sutures. The web spaces are dressed with 2 × 2 cotton gauze, laid into the web space to prevent scar adhesions and synechiae. This dressing is then reinforced with 2-in gauze.
Stockinnettes are then applied over the arms and secured to the patient's shirt at the shoulder with safety pins to prevent the patient from chewing or taking the dressing off. If the bandages stick to the sutures or to the wound, the parents are instructed to pour warm water with peroxide as needed to lift the dressing off atraumatically. The parents are instructed about scar management starting 6 weeks after surgery.
Follow-up
At the time of the first dressing change, the skin graft has become adherent, and the child may start to use his or her fingers as tolerated, although the parents are instructed to place a stockinnette over the arm to prevent the child from inadvertently contaminating and injuring the site.
The author usually waits for 6 months before performing the next syndactyly release or revision.
Complications
Complications of syndactyly release include recurrence of syndactyly, finger ischemia, contracture, and various skin-graft complications.
Recurrence of syndactyly
Distal migration of the web (ie, web creep) can occur, even after successful release. The incidence is reported to be in the range of 7.5-60%.8,18,19
The causes are multifactorial. If recurrence appears early, it is usually the result of the presence of synechiae between the incision lines and, most likely, poor take of the skin graft. Because of this, making certain that the interdigital spaces remain separated is important in the early postoperative period. Also, it is important to create a dorsal flap that is well vascularized at the tip, where it will be sutured to the base of the web. The flap is important in providing tissue that has skin elasticity that with adapt with the growth of the finger. Skin-graft loss also can contribute to web creep by increasing the possibility of scar contracture.
However, the major reason why web creep occurs is the discrepant growth rates between the scar and the surrounding tissue, leading to the appearance of an incomplete simple syndactyly. Depending on the severity of the web creep (see image below), further release, as well as skin grafting, may be necessary. If left untreated, angulation and malrotation can occur.
Hand of a 23-year-old patient who underwent releases of simple complete syndactyly of both the left third and fourth web spaces as an infant. The patient noticed progressive shortening of the web space and found it hard to wear protective gloves, necessary for employment in the fishing industry. This resulted in a poor fit of the glove and chronic irritation of the web. Note the radial deviation of the small finger due to the contracture from the patient's first surgery. The web space was deepened with local flaps and full-thickness skin grafts from the left groin.
The most common causes of a web not being deep enough are tip necrosis of the dorsal flap and skin-graft loss. In such cases, re-release and more skin grafting are required. During adolescence, the web can migrate distally; this finding is referred to as creep, as the skin graft may not grow commensurate with the growth spurt of a patient. Release may be required if this complication interferes with function.
Finger ischemia
Although rare, finger ischemia can occur if a developmental anomaly with the digital vessels is present or if a digital vessel is damaged. This is why only 1 side of the finger should be operated on during initial syndactyly release.
Contracture
Occasionally, despite the best effort and well-planned flaps, a contracture develops along the length of the incision line. This can result in a scar contracture and angulation of the finger. To prevent further angulation, a Z-plasty or skin graft will be needed to release this contracture (see images below).
Hand of a 26-month-old patient who underwent release of a complete simple syndactyly between the left ring and long fingers with flaps and full-thickness skin grafts at 7 months of age. The patient developed hypertrophic scarring along the incisions. This persisted despite conservative treatment with topical steroid cream and scar massage. Contracture was present mostly along the ring finger, causing tethering of the distal ring finger with a mild radial deviation. The contracture was released with multiple Z-plasties and the web deepened with a small full-thickness skin graft.
Hand of a 26-month-old patient with syndactyly who underwent release of a complete simple syndactyly of the left ring finger and long finger with flaps and full-thickness skin graft at 7 months of age. The patient developed hypertrophic scarring along the incisions, which persisted despite conservative treatment with topical steroid cream and scar massage. This contracture was present mostly along the ring finger, causing tethering of the distal ring finger with a mild radial deviation.
Hand of a 26-month-old patient who underwent release of a complete simple syndactyly between the left ring and long fingers with flaps and full-thickness skin grafts at 7 months of age. The patient developed hypertrophic scarring along the incisions. This persisted despite conservative treatment with topical steroid cream and scar massage. Contracture was present mostly along the ring finger, causing tethering of the distal ring finger with a mild radial deviation. The contracture was released with multiple Z-plasties and the web deepened with a small full-thickness skin graft.
Hand of a 26-month-old patient who underwent release of a complete simple syndactyly between the left ring and long fingers with flaps and full-thickness skin grafts at 7 months of age. The patient developed hypertrophic scarring along the incisions. This persisted despite conservative treatment with topical steroid cream and scar massage. Contracture was present mostly along the ring finger, causing tethering of the distal ring finger with a mild radial deviation. The contracture was released with multiple Z-plasties and the web deepened with a small full-thickness skin graft.
Hand of a 26-month-old patient who underwent release of a complete simple syndactyly between the left ring and long fingers with flaps and full-thickness skin grafts at 7 months of age. The patient developed hypertrophic scarring along the incisions. This persisted despite conservative treatment with topical steroid cream and scar massage. Contracture was present mostly along the ring finger, causing tethering of the distal ring finger with a mild radial deviation. The contracture was released with multiple Z-plasties and the web deepened with a small full-thickness skin graft. At 3 months after surgery, he was doing well and had no evidence of recurrence.
Hand of a 26-month-old patient who underwent release of a complete simple syndactyly between the left ring and long fingers with flaps and full-thickness skin grafts at 7 months of age. The patient developed hypertrophic scarring along the incisions. This persisted despite conservative treatment with topical steroid cream and scar massage. Contracture was present mostly along the ring finger, causing tethering of the distal ring finger with a mild radial deviation. The contracture was released with multiple Z-plasties and the web deepened with a small full-thickness skin graft. At 3 months after surgery, he was doing well and had no evidence of recurrence.
Scar contractures often develop in the web space within the first 6 months, making the webs more shallow, even if no skin-graft loss has occurred and if the design of the flaps is correct. The author usually recommends that the parents massage the webs to help with scar remodeling. Parents are also encouraged to place elastic bandages (such as Coban bandages) in the webs to stretch them. The judicious use of steroid creams can also help with tight scars.
Skin-graft complications
Partial skin-graft loss results in an open wound that heals by secondary intention. As in any wound that heals by secondary intention, the contracture forces are great. The deforming forces can be so great that they produce angulation of the fingers, which requires further corrective surgery. Having complete hemostasis in the wound base prior to the application of the skin graft is extremely important, as is securely sewing the skin graft. Proper postoperative dressings are also important to the success of the skin graft.
Because of the zigzag incisions and the need for skin grafts, the finger has a patchwork appearance. In a light-colored individual, this difference is not noticeable. However, in a patient who has medium-to-dark pigmentation, spears or islands of pigmented skin in the usually nonpigmented palmar surface can be the result (see images below).20 To avoid this effect, nonpigmented skin grafts may be harvested from either the plantar surfaces of the feet or hypothenar regions of the hands.
Hand of an 18-year-old patient of Mediterranean heritage who had undergone multiple syndactyly releases with a full-thickness skin graft harvested from the groin as an infant. The skin graft can be observed as hyperpigmented patches within the web space. Some parts of the full-thickness skin graft also were noted to be hair bearing. Parents should be informed of the potential sequelae of the full-thickness skin grafts as the infant matures.
Hand of an 18-year-old woman of Middle Eastern heritage who had undergone multiple syndactyly releases with a full-thickness skin graft harvested from her groin when she was an infant. The skin graft can be observed as hyperpigmented patches within the web space. Some parts of the full-thickness skin graft were also noted to be hair bearing. Parents should be informed of the potential sequelae of the full-thickness skin grafts as the infant matures.
Usually, the lateral groin or inguinal region is hairless, particularly in females. Because the full-thickness skin is harvested at a young age, before the child has developed secondary hair growth, the skin grafts may start producing hair at puberty. This occurs more often in male patients. Inform the parents and patient of this possibility. If hair growth occurs, the hair may be trimmed, or the patient can undergo depilatory treatment. Occasionally, if the problematic skin graft is small and if laxity is present in the surrounding native skin, the skin graft can be excised directly, and the wound closed primarily. Alternatively, the patient may be offered a repeat skin-graft procedure with skin obtained from a part of the body that does not produce hair.
More on Syndactyly |
| Overview: Syndactyly |
| Workup: Syndactyly |
 Treatment: Syndactyly |
| Follow-up: Syndactyly |
| Multimedia: Syndactyly |
| References |
| « Previous Page | Next Page » |
References
Schwabe GC, Mundlos S. Genetics of congenital hand anomalies. Handchir Mikrochir Plast Chir. 2004;36:85-97. [Medline].
Mandal K, Phadke SR, Kalita J. Congenital swan neck deformity of fingers with syndactyly. Clin Dysmorphol. Apr 2008;17(2):109-11. [Medline].
Flatt AE. The Care of Congenital Hand Anomalies. St Louis, Mo: Quality Medical Publishing; 1977.
Poland, Alfred. Deficiency of the pectoral muscles. Guy's Hospital Reports. 1841;VI:191-193.
Upton J. Apert syndrome. Classification and pathologic anatomy of limb anomalies. Clin Plast Surg. Apr 1991;18(2):321-55. [Medline].
De D, Narang T, Kanwar AJ, Dogra S. Brachycephaly and syndactyly: Apert's syndrome. Indian J Dermatol Venereol Leprol. Jul-Aug 2008;74(4):395-6. [Medline].
Patterson TJ. Congenital ring constriction. Br J Plast Surg. 1961;14:1–31. [Medline].
Percival NJ, Sykes PJ. Syndactyly: a review of the factors which influence surgical treatment. J Hand Surg [Br]. May 1989;14(2):196-200. [Medline].
Eaton CJ, Lister GD. Syndactyly. Hand Clin. Nov 1990;6(4):555-75. [Medline].
Lamb DW, Wynne-Davies R, Soto L. An estimate of the population frequency of congenital malformations of the upper limb. J Hand Surg [Am]. Nov 1982;7(6):557-62. [Medline].
Light TR. Congenital anomalies: syndactyly, polydactyly, and cleft hand. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill: 1996: 2111-44.
Man LX, Chang B. Maternal cigarette smoking during pregnancy increases the risk of having a child with a congenital digital anomaly. Plast Reconstr Surg. Jan 2006;117(1):301-8. [Medline].
Agarwal A. Comment on Shevtsov and Danilkin: Application of external fixation for management of hand syndactyly. Int Orthop. Jul 16 2008;[Medline].
Frick L, Fraisse B, Wavreille G, Fron D, Martinot V. [Results of surgical treatment in simple syndactily using a commissural dorsal flap. About 54 procedures]. Chir Main. Apr-Jun 2008;27(2-3):76-82. [Medline].
Upton J. Congenital anomalies of the hand and forearm: syndactyly. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co: 1990: 5279.
Sharma RK, Tuli P, Makkar SS, Parashar A. End-of-Skin Grafts in Syndactyly Release: Description of a New Flap for Web Space Resurfacing and Primary Closure of Finger Defects. Hand (N Y). Sep 19 2008;[Medline].
Dillon CK, Iwuagwu F. Cavi-care dressings following syndactyly correction. J Plast Reconstr Aesthet Surg. Sep 24 2008;[Medline].
Barot LR, Caplan HS. Early surgical intervention in Apert's syndactyly. Plast Reconstr Surg. Feb 1986;77(2):282-7. [Medline].
Colville J. Syndactyly correction. Br J Plast Surg. Jan 1989;42(1):12-6. [Medline].
Wu JC, Cunningham BB. Ectopic acanthosis nigricans occurring in a child after syndactyly repair. Cutis. Jan 2008;81(1):22-4. [Medline].
Further Reading
Keywords
syndactyly, simple syndactyly, incomplete simple syndactyly, complete simple syndactyly, complex syndactyly, complicated syndactyly, type I acrocephalosyndactyly, acrocephalosyndactyly, Apert syndrome, type I Apert syndrome, type II Apert syndrome, type III Apert syndrome, Apert's syndrome, Apert syndactyly, Poland syndrome, constriction band syndrome, polydactyly, cleft hands, ring constrictions, brachysyndactyly, symbrachyphalangisms, spade hands, mitten hands, spoon hands, rosebud hands, hoof hands, Holt-Oram syndrome, congenital hand deformity, congenital syndromes
