SCIENTIFIC ARTICLE

Central Ray Deficiency: Subjective and Objective

Outcome of Cleft Reconstruction
Charles A. Goldfarb, MD, Ben Chia, MD, Paul R. Manske, MD

Purpose To assess the long-term subjective and objective outcome of cleft reconstruction in
patients with central ray deficiency.
Methods Twelve patients with 16 central ray deficiency hands were included. Each hand had
been treated with cleft reconstruction using soft tissue and/or bony procedures. A surgeon
and parent assessed the subjective outcome using a visual analog scale to compare preop-
erative and postoperative appearance. Objective outcome was assessed with a clinical
examination for digital range of motion and with a radiographic examination for preoperative
and postoperative divergence angles of the index finger and ring finger metacarpals and
phalanges.
Results The surgeon’s visual analog scale score significantly increased from 4 to 7. Nine
parents were very satisfied, 4 were satisfied, and 3 were somewhat satisfied with hand
appearance. A ring finger proximal interphalangeal joint flexion contracture averaging 31°
was the most notable clinical finding. The metacarpal divergence angle significantly im-
proved from 33° to 12°, and the phalangeal divergence angle significantly improved from 38°
to 12°.
Conclusions Cleft reconstruction improves hand appearance in patients with central deficiency. A
new technique of quantifying the radiographic divergence of the border rays of the cleft
demonstrates improved alignment at long-term follow-up. (J Hand Surg 2008;33A:1579–1588.
Copyright © 2008 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Appearance, central deficiency, cleft hand, reconstruction, transposition.

LEFT HAND, OR CENTRALlongitudinal deficiency, web space.4 Central longitudinal deficiency should be

C is a variable absence or an abnormal formation

of the central ray(s) of the hand.1–3 The classic
presentation includes a central V-shaped cleft and ab-
sence of 1 or more central digits, abnormalities or
syndactyly of bordering fingers, and a deficient first
From the Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes
Jewish Hospitals, St. Louis, MO.
This investigation was performed at the St. Louis Shriners Hospital for Children, St. Louis, MO.
Received for publication February 18, 2008; accepted in revised form May 6, 2008.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Correspondingauthor:CharlesA.Goldfarb,MD,DepartmentofOrthopaedicSurgery,660South
Euclid, Campus Box 8233, St. Louis, MO 63110; e-mail: goldfarbc@wudosis.wustl.edu.
0363-5023/08/33A09-0018$34.00/0
doi:10.1016/j.jhsa.2008.05.010
distinguished from the broad U-shaped cleft in sym-
brachydactyly, which affects a single extremity and
presents with finger nubbins as a notable clinical find-
ing.1
The absent central digits usually do not impact func-
tion; Flatt2 noted that “the cleft hand is a functional
triumph and a social disaster.” Function is affected
primarily by an insufficient first web space.3 However,
the absent central digits invariably negatively affect
hand appearance and may be socially prohibitive, and
surgical closure of the cleft is usually recommended.
Some variation of the procedure described by Snow
and Littler at the 4th International Congress of Plastic
Surgery in Rome in 1967 is commonly used4,5 to close
the central cleft and simultaneously widen the thumb–
index finger space by transposing a volar pedicle flap

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1579

1580 CENTRAL RAY DEFICIENCY
TABLE 1. Central Longitudinal Deficiency
Classification
Types*
Manske Ogino
I: Normal web space I: Cleft hand without
missing digit
IIA: Mildly narrowed first II: Defect of single finger
web space ray
IIB: Moderately narrowed III: Defect of two finger
first web space rays
III: Syndactylized first IV: Defect of 3 finger
web space rays
IV: Merged with cleft V: Defect of 4 finger rays
*The Manske classification3 is based on the quality of the first web
space. The Ogino classification10 is based on the bony central
deficiency.
from the cleft into the first web. Many variations, using
different skin incisions, such as transposition of a dorsal
pedicle flap from the cleft to the first web, have also
been reported.6 –9 The index ray is often transposed to
the base of the third metacarpal to facilitate cleft closure
and first web space widening.4,9 Clear indications for
index ray transposition versus a soft tissue cleft closure
alone have not been reported.
There have been few outcome reports on the opera-
tive treatment of central deficiency that provide objec-
tive outcome data5,6,10; nonetheless, the general results
from these reports have been satisfactory. The purpose
of this investigation was to assess the long-term out-
come of patients with central deficiency treated surgi-
cally with cleft closure and first web space reconstruc-
tion. Specifically, we evaluated hand appearance with
particular attention to the cleft, finger range of motion,
and radiographic measurements of divergence at the
cleft site.
MATERIALS AND METHODS
In this retrospective evaluation, we reviewed all patients
treated at our pediatric orthopedic hospital with cleft
hand to identify those with a central deficiency with
absence of only the long finger (phalanges with or
without absence of the metacarpal) (Tables 1, 2). Insti-
tutional review board approval for this investigation
was obtained, and all pertinent radiographs, clinical
photographs, and medical records were evaluated.
There were 17 patients with absence of the central digit
treated surgically with cleft closure between 1977 and
2001; 12 of these patients (16 central deficiency hands)
JHS 䉬 Vol A, November 
had sufficient preoperative and postoperative data and a
minimum 5-year follow-up to allow inclusion in this
investigation.
The long-finger phalanges were absent in all patients
except 2; one patient had a small remnant of proximal
phalanx and one had a transverse proximal phalanx.
The long-finger metacarpal was present in 12 of the 16
hands and absent in 4; two had a Y-shaped distal
long-finger metacarpal. Seven hands had a ring finger–
small finger syndactyly.
Operative techniques
Central cleft: Sixteen hands in 12 patients were treated
with cleft closure and reconstruction at a median age of
19 months (range, 12–39 months). Operative time av-
eraged 95 minutes (range, 63–120 minutes). The oper-
ative procedure was at the discretion of the operating
surgeon (P.R.M.) and was based on the specific features
of the cleft and the first web space. Generally, the
surgeon performed 1 of 2 types of cleft reconstruction
(Table 3): soft tissue only or soft tissue and bony
reconstruction.
A soft tissue– only correction was performed in 9
hands. In 5 hands, the long-finger metacarpal was com-
pletely excised, and a soft tissue closure of the cleft was
performed. In 3 hands (with an absent long-finger meta-
carpal), a soft tissue cleft closure was performed. The
final hand was reconstructed with a soft tissue closure
without resection of the metacarpal. A transverse meta-
carpal ligament reconstruction was performed in 8 of
the 9 hands to reapproximate and to maintain a close
proximity of the distal aspect of the ring finger and
index finger metacarpals. This was accomplished by
suturing together the A1 pulleys11 or by using tendon/
fascia grafts10 wrapped around the adjacent metacarpal
necks.
A soft tissue and bony reconstruction was performed
in 7 hands. In 5 hands, the majority of the long-finger
metacarpal was excised, retaining the base, and the
second ray was transposed3,5,9 to the base of the long-
finger metacarpal. In 2 hands without a long-finger
metacarpal, an oblique osteotomy of the index-finger
metacarpal was performed to place the index ray in a
more ulnar position.
First web space: There were 5 Manske3 type I hands, 7
type IIA hands, 1 type IIB hand, and 3 type III hands.
The web space was not addressed in the 5 type I
hands. Three of the patients with type IIA hands had
a z-plasty, 2 had a rotational flap from the cleft, and
2 were not treated at the time of the cleft reconstruc-
tion. The single patient with a type IIB hand was
 CENTRAL RAY DEFICIENCY 1581

TABLE 2. Basic Patient Information

Type*
Associated Musculoskeletal
Patient Side Affected Family History Anomalies Manske Ogino

1 R No No I II
2 L No No I II
R III II
3 R Yes Right foot deficiency and IIA II
syndactyly, EEC
4 R Yes No IIA II
L IIA II
5 R No No I II
6 R Yes Left foot syndactyly, IIB II
duplicated great toe
7 R Yes No III II
8 R No No IIA II
9 R No No IIA II
10 R Yes Left index finger I II
clinodactyly
L I II
11 L No No III II
12 L Yes Right foot syndactyly IIA II
R IIA II

*The Manske classification3 is based on the quality of the first web space. The Ogino classification10 is based on the bony central deficiency.
EEC, ectrodactyly ectodermal dysplasia and cleft lip/palate syndrome.

treated with a rotational flap from the cleft. Finally,
the 3 patients with type III hands were treated with
rotational flaps and full-thickness skin grafts. Three
patients required a secondary procedure on the first
web space (2 had revision procedures to deepen the
first web space at an average of 18 months after the
initial surgery, and 1 type IIA patient who did not
have the first web addressed at the initial procedure
had a thumb–index finger z-plasty).
Ring finger–small finger syndactyly: Seven hands had ring
finger–small finger syndactyly. Three of these 7 hands
were reconstructed at the time of the initial cleft recon-
struction, and 2 were treated as secondary procedures.
In 2 patients, the syndactyly was not reconstructed per
the desires of the family.
Additional procedures: Additional bony procedures were
performed for 6 hands at an operative session separate
from that of the cleft reconstruction. Three hands (5
digits) required a rotational osteotomy of the index-
finger or ring-finger metacarpal or phalanges. Three
hands were treated for an extensor lag at the proximal
interphalangeal (PIP) joint of the ring finger; 2 had an
imbrication of the extensor mechanism, and 1 had an
extensor indicis proprius transfer.
Assessments
Subjective data:
● One of the authors (C.A.G.) not involved in the
initial surgical procedures evaluated clinical pho-
tographs before and after surgical intervention (at
last follow-up) for all 16 hands (Figs. 1, 2). Using
a visual analog scale (VAS), he rated the hand
appearance with particular attention paid to the
cleft. A score of 1 corresponded with a severely
abnormal hand, and a score of 10 corresponded
with a normal hand. Scores were averaged and
rounded to the closest whole number for reporting
and comparison.
● The primary caregiver, most commonly the pa-
tient’s mother, was queried by a research assistant
not involved in the care of the patient as to the
caregiver’s satisfaction with the surgical interven-
tion including appearance, function, and pain.
Choices included very satisfied, satisfied, some-

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1582 CENTRAL RAY DEFICIENCY

TABLE 3. Operative Details for Cleft Reconstruction and Additional Procedures

Age at Third Second to Third Transverse
Side Surgery Third Metacarpal Metacarpal Metacarpal Ligament
Patient Affected (Mo) Metacarpal Excision Transposition Reconstruction

1 R 12 Y-shaped Yes No No
2 L 14 Y-shaped No (bifid portion No No
excised)
2 R 21 Present Yes Yes No
3 R 13 Present Yes No No
4 R 19 Present Yes No Yes
4 L 21 Present Yes Yes Yes
5 R 19 Present Yes No Yes
6 R 12 Y-shaped No (bifid portion No Yes
excised)
7 R 13 Present Yes No Yes
8 R 38 Present Yes Yes No
9 R 39 Absent NA Yes, oblique osteotomy No
of second metacarpal
10 R 12 Present Yes Yes Yes
10 L 20 Absent NA No Yes
11 L 20 Present Yes Yes No
12 L 19 Absent NA No Yes
12 R 20 Absent NA Yes, oblique osteotomy No
of second metacarpal

NA, not applicable.

FIGURE 1: Clinical appearance of a typical cleft in a central deficiency hand prior to reconstruction: A dorsal view and B volar view.

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 CENTRAL RAY DEFICIENCY 1583

FIGURE 2: Clinical appearance of a typical cleft in a central deficiency hand after reconstruction: A dorsal view and B volar view.

FIGURE 3: Radiograph before reconstruction with depiction of measurement technique for both A metacarpal and B phalangeal
divergence angles. The metacarpal divergence angle was 40°, and the phalangeal divergence angle was 60°.

what satisfied, and not satisfied. Older patients
provided input on these questions.
Objective data:
● Postoperative range of motion of the index, ring,
and small fingers was assessed. Particular attention
was paid to the presence of a flexion deformity at
the PIP joint and to finger alignment abnormalities.
Radiographic data:
● Preoperative, immediate postoperative, and final
postoperative radiographs were reviewed to assess

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1584 CENTRAL RAY DEFICIENCY

for alignment of the digits bordering the cleft. We suring the angle formed by lines drawn through the
determined the angle of divergence between the center of their longitudinal axis on a standard
index-finger and ring-finger metacarpals by mea- posteroanterior x-ray. Similarly, we measured the
angle of divergence between the index-finger and
ring-finger proximal phalanges—the phalangeal
divergence angle (Figs. 3 and 4).
Statistical analysis
A statistical analysis was performed to assess the data.
Paired t-tests were used to assess change in VAS scores
and the change in the divergence angle. Significance
was set at .05.

FIGURE 4: Radiograph after reconstruction in the patient of
Figure 3. The metacarpal divergence angle and the phalangeal
divergence angle were both 20°, one of the largest
postoperative deformities in this series.
RESULTS
Subjective data
The surgeon’s VAS score improved from 4 (range,
2–7) preoperatively to 7 (range, 5–9) postoperatively, a
significant improvement (p ⫽ .02). When subdivided
by severity (Manske3 type), the 5 type I hands had an
average VAS score of 5 preoperatively and 8 postop-
eratively (significant improvement, p ⫽ .007). The 8
type II hands (including type IIA and IIB) had an
average VAS score of 4 preoperatively and 7 postop-
eratively (significant improvement, p ⬍ .002). Finally,
the 3 type III patients had an average VAS score of 3

TABLE 4. Postoperative Finger Range of Motion

Index Finger (°)

MCP MCP PIP DIP

Joint Joint PIP Joint Joint DIP Joint Joint
Name Side Extension Flexion Extension Flexion Extension Flexion

1 R 10 80 Normal Normal Normal Normal

2 R Normal Normal Normal Normal Normal Normal
2 L Normal Normal Normal Normal Normal Normal
3 R Normal Normal Normal Normal Normal Normal
4 R Normal 65 Normal Normal Normal Normal
4 L Normal 65 Normal 85 Normal Normal
5 R Normal 55 Normal 60 Normal Normal
6 R Normal Normal Normal Normal
7 R Normal Normal 25 Normal Normal 20
8 R Normal Normal 10 Normal Normal 0
9 R Normal Normal Normal Normal Normal Normal
10 R 10 Normal 30 80 Normal 0
10 L 10 Normal Normal 85 Normal 15
11 L Normal Normal Normal Normal Normal Normal
12 R Normal Normal Normal Normal Normal Normal
12 L Normal Normal Normal Normal Normal Normal
Number of joints with normal 13 12 13 12 16 12
motion (n)
Average range of motion for those 10 66 22 78 NA 9
joints without full motion (°)

MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal; NA, not applicable.
(Continued)

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 CENTRAL RAY DEFICIENCY 1585

preoperatively and 6 postoperatively (significant im-
provement, p ⫽ .02).
Subjectively, 9 parents were very satisfied about the
hand appearance, 4 were satisfied, and 3 were only
somewhat satisfied. All believed the hand appearance
was improved, and none were dissatisfied with the final
hand appearance. Four patients with bilateral involve-
ment were included in this investigation; 2 of the care-
givers were satisfied with both hands, and 2 were very
satisfied with 1 hand and only somewhat satisfied with
the other. Four patients had rare pain and the other 8
denied pain. Subjective functional improvements were
most commonly attributed to restoration of the first web
space. All patients were able to perform normal daily
activities with the affected hand(s).
Objective data
Postoperative range of motion was considered normal
for all 3 fingers in 7 hands (5 patients); the other 9 hands
had some loss of motion involving at least 1 joint (Table
4). The most notable abnormality was the limited active
and passive extension of the ring-finger PIP joint. Only
9 hands had full PIP joint extension of the ring finger,
and the other 7 hands had an average 31° loss of
extension (range, 20° to 55°). These postoperative
range of motion data were similar to the preoperative
data in each patient as documented in the medical
record. Three hands had a residual rotational abnormal-
ity of the ring finger at the time of final follow-up;
function was not affected in these patients.
Radiographic data
The divergence angles are noted in Table 5.
The metacarpal divergence angle between the index-
finger and ring-finger metacarpals averaged 33° (range,
10° to 60°) preoperatively, 15° (range, 5° to 40°) im-
mediately after surgery, and 12° (range, 0 to 40°) at
final follow-up. The improvement from before surgery
to final follow-up was significant (p ⫽ .0005) as was
the improvement from before surgery to immediately
after surgery (p ⫽ .002). There was no significant
difference in the metacarpal divergence angle immedi-
ately after surgery compared with that at final follow-up
(p ⫽ .16).
The phalangeal divergence angle between the index-
finger and ring-finger proximal phalanges averaged 38°
(range, 25° to 80°) before surgery, 15° (range, 0 to 45°)
immediately after surgery, and 12° (range, 10° conver-
gent to 50°) at final follow-up. The improvement from
before surgery to final follow-up was significant (p ⬍
.003) as was the improvement from before surgery to
immediate after surgery (p ⬍ .007). There was no

TABLE 4. Postoperative Finger Range of Motion (Continued)

Ring Finger (°) Small Finger (°)

MCP MCP PIP DIP MCP MCP PIP DIP

Joint Joint PIP Joint Joint DIP Joint Joint Joint Joint PIP Joint Joint DIP Joint Joint
Extension Flexion Extension Flexion Extension Flexion Extension Flexion Extension Flexion Extension Flexion

10 Normal 20 Normal Normal Normal 10 Normal Normal Normal Normal Normal

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal 50 Normal 85 Normal 35 Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal 45 Normal Normal 20 Normal Normal Normal Normal Normal Normal
Normal 60 80 0 Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal 55 Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal 35 65 Normal 10 Normal Normal 15 85 Normal Normal
10 65 30 Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal 60 35 75 Normal Normal Normal 60 15 Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
14 12 9 12 16 13 15 15 14 15 16 16

10 59 43 56 NA 22 10 60 15 85 NA NA

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1586 CENTRAL RAY DEFICIENCY

TABLE 5. Radiographic Measurements of the Metacarpal and Phalangeal Divergence Angles

Metacarpal Divergence Angle (°) Phalangeal Divergence Angle (°)

Immediately Final Immediately Final

Patient Side Preoperative Postoperative Postoperative Preoperative Postoperative Postoperative

1 R 30 5 0 25 0 5
2 R 60 40 45 45 45 50
2 L 60 10 10 50 5 5
3 R 40 0 20 65 15 20
4 R 25 15 15 55 15 5
4 L 45 35 25 30 10 10
5 R 7 0 0 82 5 25
6 R 45 25 25 60 30 10
7 R 25 15 0 40 5 0
8 R 25 20 0 30 20 25
9 R 60 20 20 40 20 0
10 R 25 0 0 15 10 10
10 L 15 15 15 0 15 15
11 L 15 10 10 30 15 15
12 R 30 15 0 25 20 0
12 L 15 20 0 10 10 0
Average 33 15 12 38 15 12

t-test: Metacarpal immediately postoperative:Metacarpal final, p ⫽ .164; Metacarpal preoperative:Metacarpal immediately postoperative, p ⬍ .023;
Metacarpal preoperative:Metacarpal final, p ⬍ .005.
Phalangeal immediately postoperative:Phalangeal final, p ⫽ .321; Phalangeal preoperative:Phalangeal immediately postoperative, p ⬍ .007;
Phalangeal preoperative:Phalangeal final, p ⬍ .003.

significant difference in the phalangeal divergence an-
gle immediately after surgery compared with that at
final follow-up (p ⫽ .32).
There was no significant difference between the
metacarpal and phalangeal divergence angles at any
measurement point (p ⬎ .83).
The metacarpal divergence angles improved at the
immediate and final postoperative evaluation in 14 of
the 16 hands; 1 hand had an increased angle at the
immediate postoperative evaluation but improved at the
final evaluation, and 1 was unchanged. Similarly, 14 of
the 16 preoperative phalangeal divergence angles im-
proved at the immediate and final postoperative evalu-
ations; 1 was unchanged at the immediate postoperative
visit but improved at the final evaluation, and 1 had
increased proximal phalangeal divergence angle at both
postoperative evaluations.
Seven of the 16 hands (including the 2 hands with
increased divergence) had a final metacarpal or phalan-
geal divergence angle of more than 15°. The preoper-
ative metacarpal divergence angle averaged 34° in
those patients compared with 31° in the other patients;
this difference was not significant (p ⫽ .35), suggesting
that a larger preoperative divergence angle did not pre-
dispose to a larger, final divergence angle (Table 5). We
evaluated 3 variables that we believed may have con-
tributed to the failure to maintain a straighter alignment:
the presence/absence of a third metacarpal, the perfor-
mance of a second to third metacarpal transposition, (ie,
Snow-Littler procedure), and the performance of a
transverse metacarpal ligament reconstruction. We
were unable to demonstrate that any of these 3 surgical
factors decreased the risk of a persistent divergence
angle of more than 15°.
DISCUSSION
The subjective results of this investigation were very
good in that families were satisfied with the surgical
intervention and found the appearance of the hand to be
improved; this is similar to less vigorous outcome eval-
uations of previous reports.5,6,10,11 The VAS scores,
range of motion measurements, and the metacarpal and
phalangeal divergence angle measurements provide an
objective confirmation of the improved appearance.

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 CENTRAL RAY DEFICIENCY
There are few objective outcome data in the previous
studies of central deficiency reconstruction to allow
comparison.
The radiographic outcome of central deficiency re-
construction has not been previously reported. Use of
an index-finger and ring-finger metacarpal divergence
angle and/or proximal phalanx divergence angle allows
an objective assessment of cleft reconstruction to pro-
vide an improved understanding of alignment. The
metacarpal divergence angle measures the true “cleft”
angle and allows an accurate assessment of any recon-
struction. The phalangeal divergence angle is also help-
ful as it measures the clinical alignment of the digits
that, by definition, includes any compensatory angula-
tion (or convergence) of the metacarpophalangeal or
PIP joints. In this series, surgery provided a significant
improvement in both angles that was maintained at final
follow-up. Rider et al.5 measured divergence as the
distance in millimeters between the index-finger and
ring-finger metacarpal heads. Although this measure-
ment technique provides objective data, we believe use
of divergence angles is less dependent on patient size
and radiographic magnification and is, therefore, a more
useful measurement.
Seven of the 16 hands had a final metacarpal diver-
gence angle or phalangeal divergence angle greater than
15°. We evaluated 3 variables that we believed may
have contributed to the failure to maintain a straighter
alignment: the presence/absence of a third metacarpal,
the performance of a second to third metacarpal trans-
position (i.e., Snow-Littler procedure), and the perfor-
mance of a transverse metacarpal ligament reconstruc-
tion. We were unable to demonstrate that any of these
3 features affected the final angle of divergence.
Seven of the 16 hands in this investigation had a
notable flexion contracture of the ring-finger PIP
joint. Ogino11 previously noted that the ring-finger
flexion deformity was likely related to “dysfunction”
of the intrinsic muscles. He recommended flexor
digitorum superficialis transfer to the base of the
proximal phalanx of the ring finger or a split transfer,
in the case of index finger–ring finger divergence, to
the radial base of the ring finger and ulnar base of the
index finger. Tada10 also noted that there was re-
duced active extension of the PIP joint of the ring
finger due to hypoplasia of the third lumbrical. We
agree with these hypotheses, as the radial-sided in-
trinsic structures to the ring finger are likely to be
affected by the central ray deficiency. The presence
or absence of the third metacarpal did not contribute
to the flexed position, as the third metacarpal was
present in 5 hands and absent in 2 of these hands. We
JHS 䉬 Vol A, November 
1587
have not used the flexor digitorum superficialis trans-
fer10 to address this deficiency. The flexed posture of
the ring-finger PIP joint did not cause marked func-
tional difficulties but was primarily an appearance
issue.
One technical component of the reconstruction of
central ray deficiency that has received extra attention is
the reconstruction of the transverse metacarpal ligament
between the index-finger and ring-finger metacarpals.
Tada10 primarily used an autogenous tendon graft in a
circular fashion through both metacarpals and called it
“an essential part of closure of the cleft.” Ogino11
cautioned overtightening such tendon grafts and instead
used flaps from the adjacent flexor sheaths. This recon-
struction was in an anatomic position and was not
susceptible to overtightening. A simple, alternative
method is to cut the adjacent A1 pulleys and suture
them together.1 Rider et al.5 reported on the Snow-
Littler procedure in 13 hands with central deficiency.
They reconstructed the transverse metacarpal ligament
in 8 of the 13 hands. Notably, the 5 hands without
reconstruction had no evidence of instability or radio-
graphic divergence.
Our investigation did not find a difference in final
divergence angle in patients with or without reconstruc-
tion of the transverse metacarpal ligament. If good
balance and alignment are achieved at surgery by bony
transposition, a reconstruction of the transverse meta-
carpal ligament may not be necessary. In contrast, if
good balance and alignment are not achieved at the time
of surgery, it is unlikely the ligament reconstruction can
balance the hand to a satisfactory degree.
One weakness of this study is the small number of
patients included; however, this limitation is frequently
seen in patients with uncommon congenital abnormal-
ities. We believe the size of our patient group is accept-
able considering the narrow inclusion criteria and the
relatively structured approach to the cleft reconstruction
for these patients. Additionally, this study evaluated the
subjective and objective outcome of the cleft deformity
specifically. Although our objective measures could
accomplish this goal, the subjective outcome (both for
the surgeon and for the parent) is less easily isolated to
the cleft. The surgeon and the parents were instructed to
focus their assessment to the cleft (ideally avoiding
consideration of the first web space and the ring and
small fingers); in practicality, this may have been dif-
ficult to accomplish.
REFERENCES
1. Kantarincic J. Cleft hand. J Am Soc Surg Hand 2003;3:108 –116.
2. Flatt A. Cleft hand and central defects. St. Louis: Mosby, 1977.
1588 CENTRAL RAY DEFICIENCY

3. Manske PR, Halikis MN. Surgical classification of central deficiency
according to the thumb web. J Hand Surg 1995;20A:687– 697.
4. Hentz VR, Littler JW. Congenital anomalies of the upper extremity.
In: Converse JM ed. Reconstructive Plastic Surgery. 2nd ed. Phila-
delphia: WB Saunders and Company, 1977:3306 –3349.
5. Rider MA, Grindel SI, Tonkin MA, Wood VE. An experience of the
Snow-Littler procedure. J Hand Surg ) 2000;25B:376 –381.
6. Buck-Gramcko D. Cleft hands: Classification and treatment. Hand
Clin 1984;1:467– 473.
7. Ueba Y. Plastic surgery for the cleft hand. J Hand Surg 1981;6:557–
560.
8. Upton J. Simplicity and treatment of the typical cleft hand. Handchir
Mikrochir Plast Chir 2004;36:152–160.
9. Miura T, Komada T. Simple method for reconstruction of the cleft
hand with an adducted thumb. Plast Reconstr Surg 1979;64:65– 67.
10. Tada K. Central ray deficiency of the hand. Operative treatment and
results. Int Orthop 1984;8:229 –233.
11. Ogino T. Cleft hand. Hand Clin 1990;6:661– 671.

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