Seminar on syndactyly and management

1. Syndactyly
DR. RENU VERMA
M.Ch. Resident
PLASTIC AND RECONSTRUCTIVE SURGERY
DMCH, LUDHIANA

2. • The distal end of the normal web lies on the palmer side roughly at
the mid level of proximal phalanx. A more distal web is called
Syndactyly.
• Most common congenital malformation
• 1 in 2000 live births
• Familial 15-40%
• 50% have bilateral involvement
• M>>F

3. • Normally, digits form from condensations of mesoderm within the terminal
paddle of the embryonic upper limb. Between 5th and 6th week, Spaces form
between the fingers in a distal to proximal direction to the level of the normal
web space by a process of regulated apoptosis which is dependent on the apical
ectodermal ridge ( AER) and the molecular signaling.
• The normal web space slopes 45 degrees in a dorsal to palmar direction
• The second and fourth webs are wider than the third web, allowing greater
abduction of the index and small fingers.
• The first web space is a broader diamond-shaped expanse of skin composed of
the glabrous skin of the palm and thinner mobile skin dorsally

5. Syndromic associations
• Atleast 28 syndroms
• Poland Syndrome
• Apert Syndrome
• Constriction Ring

6. Ray involvement
• 50% long-ring finger
• 30% ring-small finger
• 15% index-long finger
• 5% thumb-index finger
• 3rd web space in hand and
2nd web space in foot are
most common

7. Types
A. Simple Incomplete
B. Simple Complete
C. Complex
D. Complicated

8. • Cutaneous/incomplete – only soft tissues attached
• Skin bridges can vary from supple to tight
• Attachement ends usually proximal to PIPJ
• Complete – nails can be separated with full pulps in between or can
be conjoined nails with ridges and insufficient pulp on attached sides
• Complex – distal bone fusion with tapered distal ends, ,fingers
rotated inward, abnormally ridged or confluent nails.
• Complicated – abnormal bone structure inside syndactyly with
fusions, rudimentary bones, missing bones, abnormal joints &
sometimes cross bones

9. Abnormal Anatomy
• Almost all permutations and combinations of abnormal soft tissue And skeletal anatomy
can be present
• Skin is invariably deficient specially in the region of normal commissure
• Although infrequently webbed, the first web space is usually deficient in the hypoplastic
hand where webbing of the digits is commonly present
• Broad or short fascial interconnections are present in all web digits, extend across the
inter digital space at the level of proximal and middle phalanges in the mid axial line .
• These bands Incorporate Cleland ligament Palmer to and Grayson ligament dorsal to the
neurovascular bundle on either digit.
• In first web space they appear to be above the adductor pollicis muscle connecting first
and second metacarpals .
• Adequate release of this fascia is often the single most important step in first web space
release

10. • Bones and joints may present bizzarre configurations
• On occasion alignment of skeletal elements into digital rays is
impossible
• Phalanges maybe crooked, broad, short, long or fused.
• In thumb, the proximal phalanx may present as delta or trapezoidal
placing the distal portion of the thumb in radial or ulnar deviation
• Missing or hypoplastic phalanges or metacarpals are often
accompanied by tendon, nerve and ligament deficiencies

11. • Digital nerves and arteries often have a wide variety of branching
patterns within a web space
• An arterial loop or a neural loop may be present
• Nerves can easily be teased apart microscopically but arterial loops
present a complex problem
• Extensor & Flexor tendons may have similar distal branching patterns
and interconnections within the web
• Digital insertions may be abnormal in complex and complicated
syndactyly

12. Treatment
Timing :
• Complicated and complex webbing involving adjacent digits with
different growth potential warrants early release by one year of age
• Upper age limit for correction is 24 months
• Complete webbing involving the important 1st and 4th web space –
best released by 6 – 12 months
• Elective syntactically releases may be postponed in the multiply
deformed child with cardiopulmonary, hematologic, neurologic or
severe muscular skeleton problems . It should be neglected until
other major malformations have been corrected .

13. Principles for the separation of all forms of
syndactyly
1. Use of full thickness tissue for commissure reconstruction
2. Placement of the commissioner at a dorsal to palmer 45 degree angle at the
level of mid portion of the proximal phalanx in a normal sized digit
3. Use of zig zag incisions on the palmer side
4. Equal distribution of full thickness skin graft to cover raw areas
5. Meticulous surgical technique
6. Operation on one side of digit at a time
7. Emphasis on construction of normal nails and nail folds
8. Earlier correction of skeletal deformities when there is no danger of injuring
the growth centers
9. Adequate post operative immobilization with a well padded long arm cast
10. Use of post operative stents at night to maintain web configuration

14. • Early indications for surgery are syndactylies between fingers of
unequal length and or distal bone fusions and in complex or
complicated acro syndactyly especially if the thumb is involved.
• Key points in syndactyly release:
• Creation of Web
• Treating the lateral soft tissue defects
• Separation of the fingertips

15. Surgical technique
• Creation of Web
• By a dorsal flap (clover leaf, dorsal metacarpal flap), a palmar flap or a
combination of both
• For 1st web space – different Z plasties (four flap, double opposing and five
flap), or Transposition flaps from the dorsum of the hand and index or thumb
are used depending on the width and deepness of the created defect
following release .
• As already described the release of the tight fascia on the first dorsal interosseous
muscle in combination with the fascia on the adductor muscle is essential to create a
web deeper. Sometimes even the insertion of adductor muscle is shifted more proximally
to open the web

18. • Treating the lateral soft tissue defects :
• Shortage of skin is very often underestimated – atleast 36% of the
circumference of the finger that is separated
• Zig zag skin separation distal to the flap for web reconstruction
• The triangular flaps created either fully or partially interdigitate depending on
the extent of skin shortage decreasing the areas for skin grafting
• FTSG are mostly used to cover the defects – harvested from groin, inner side of
upper arm, cubital fossa or thick STSG from non weight bearing part of sole of
foot

19. • Separation of the fingertips :
• If the nails are separately developed in complete syndactyly the pulp can be
separated and the skin advanced to the rim
• If the nails are partly fused with a deep furrow and indentation on the pulp side
then simple separation and primary closure
• If the nails are conjoined with hardly or no ridge, nail wall reconstruction with
flaps is necessary
• Buck-Gramcko – pedicled pulp flaps for nail wall reconstruction from
the adjacent finger pulp
• Disadvantage – thinner fingertips sometimes
• alternatives – thenar flap but finger needs to be supple to reach

20. • 1st Web Release – diamond shaped tetrahedron, needs a large tissue
• Mild – z plasties – preferably 4 flap Z plasty
• Moderate (webbed with simple syndactyly and palmar abduction) – V-Y flaps,
dorsal transposition, dorsal rotation with / without skin grafts
• Severe – as in syndromes (Apert), the entire diamond shaped tetrahedron must
be brought into the web – a combination of local rotation advancement flap
with or without skin graft (preferred), distally based radial forearm flap, free
flap
• 2nd, 3rd, 4th Web space release – needs a meticulous surgery, not to be
complicated
• No single method perfect
• The normal web space has an hourglass configuration and Palmer inclination of
40 to 45 degree

21. • Dorsal and Palmer levels of the cleft are marked and a large dorsal slightly
truncated rectangular flag outline
• 18mm x 9 mm in a 12 month old & Extends almost to the PIPJ extension
Crease
• The Palmer flap inset is marked – inset for the 3rd web space extends more
distal than that of the second and 4th web space
• Distal zigzag incisions are measured and marked so that mirror images are
formed on 2 sides of each finger – sharp acute angles are preferable

23. • Dissection – Web is released from distal to proximal.
• In case of conjoint nails with fuse bones underneath, a small osteotome or
oscillating saw may be used
• Palmer pulp can be defatted and advanced dorsally to form a new
paronychialfold
• With distal portion of digits in maximum abduction by hooks, dissection is
proceeded proximally towards the PIPJ
• The fascia interconnecting cleland and grayson’s is incised or excised
• Dorsal flap is raised
• Nerves can be teased proximally if distal bifurcation is found
• Arborization of the common digital artery to the adjacent sides of the web
space limits the depth of Commissure release

24. • Skeletal correction :
• The transverse metacarpal ligament identified and incised if metacarpal
mobility is desired
• Damage to growth centres and periosteum must be avoided – definitive
osteotomies can be delayed
• Duplicated parts should be excised
• Flap inset is done – dorsal flap is rotated into the depth of the release
and the palmer flap is inter digitated
• Distal digital triangular flaps are inter digitated
• The remnant raw area is covered with skin graft

25. • Finger tips and conjoined nails
A. Composite nail fold graft
B. Triangular pulp flaps

27. Post Op Care
• Dressings with fingers in abduction
• Long cast extending well above elbow – immobilisation for 6-8 weeks

29. Outcomes
• Release of 1st web space:
• most critical –. Investing intrinsic musculature & release of fascial bands (do
not expand with growth – reason for web creep)
• Release of 2nd through 4th web space
• Simple scar contracture
• Web creep – 3 – 40 %

30. Complications
• Early –
• skin slough
• Flap necrosis
• Infection
• Up to nearly complete adhesion of fingers
• Related to skin grafts
• Bony deviations , joint instabilities, insufficient functioning if
separated finger
• Nee for re do releases of residual syndactyly (complex 1st web space )

31. Apert Syndrome – Types of Apert Hand

32. Principles of Treatment

34. Thanks