The document discusses the use of the Snow and Littler procedure for managing cleft hand deformities. It provides background on classifications of cleft hands and discusses goals of surgical management, which include releasing syndactyly and thumb adduction deformities. The Red Cross Hospital experience from 2003-2007 is described, where 20 cleft hands were treated, including 6 with the Snow and Littler procedure. Complications included finger flexion contractures and rotation of the transferred index metacarpal bone, but patients reported high satisfaction overall.

1. The use of the Snow and Littler
prcedure in the management of
the Cleft Hand. The Red Cross
Hospital experience 2003-2007
Dr S. L. Carter
Head Congenital Hand Unit Red
Cross Hospital

2. Introduction
• Hartsinck 1700,s Dutch
Guiana
• Confusing , imprecise terms ,
Ectrodactyly, Lobster claw
hand , Forked hand
• Difficulty with classification
systems

3. Classification Sandzen 1985
Type 1
Type 2
Type 3
Typical
Atypical
Bilateral Unilateral 1,2,3, Rays absent
Foot invoved Foot not invoved Syndactyly
Familial Sporadic Polydactyly
Central ray absent Metacarpals
present
V shaped defect
into metacarpal
area
U shaped cleft

4. Classification IFFSH 1992
• Attempt to simplify classification.
• Sandzens Type 2 Atypical Cleft hand is now consigned to
Symbrachydactyly.
• Type 1 and type 3 same clefting process

5. Surgical Classification Manske
1995
Type Description Characteristics
1 Normal web Thumb web not narrowed
2A Mildly narrowed Thumb web mildly narrowed
2B Severely
narrowed
Thumb web severely
narrowed
3 Syndactylized
web
Thumb & index
syndactilized,no web space
4 Merged web Index suppressed thumb web
merged with cleft
5 Absent web Thumb suppressed ulna ray
remains

6. Atypical Cleft Type 2

7. Atypical Cleft Type 2

8. Typical Cleft Type 1

9. Typical Cleft Type 1

10. Typical Cleft Type 1

11. Typical Cleft Type 3

12. Typical Cleft Type 3

13. Cleft Hand
• Prevalence 0.14 to 0.4 per 10 000 live births
• Cheng 21 cases in 10 years
• Inheritance Sporadic or AD variable penetrance. Split hand /split
foot (SHFD) defect chromo 7
• Assoc anomalies / Syndromes
• Etiology central defect of apical ectodermal ridge

14. Surgical Management
• Flatt “ Functional triumph but a social disaster “
• Goals of surgery 1. Removal of transverse bone
2. Closure of cleft
3. Release of thumb adduction deformity
4. Release of syndactylies
5. Correction of deviation of digits
• Miura and Komada
• Snow and Littler

15. Surgical Management Snow and
Littler procedure

16. Snow and Littler procedure

17. Snow and Littler procedure

18. Snow and Littler procedure

19. Snow and Littler procedure

20. Results and Complications
• 20 Cleft hands in 4 years 11 Atypical 9 Typical
• 6 Snow and Littler procedures
• No neurovascular complications
• Tendency for FFD PIPJ
• Rotation of transferred index metacarpal
• Index Ring web space
• High satisfaction rate

21. Snow and Littler procedure