SYNDACTYLY Referat Pedi 2 - Reza Devianto

Consultant
Prof. Dr. dr. Yoyos Dias Ismiarto, SpOT(K)., M.Kes.,
CCD
dr. Fathurachman Sp.OT., M.Kes.

Pediatric Division
Orthopaedi and Traumaology department
Hasan Sadikin Hospital / Padjadjaran University
 Definition and embryology
• Its a variable fusion of the soft tissue or skeletal elements or both of
adjacent digits, and it occurs when the normal processes of digital
separation and web space formation fail to some degree
• Normally digits form as condensations of mesoderm within the
terminal paddle of the embryonic upper limb. Spaces form between the
fingers in a distal to proximal direction to the level of the normal we
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 from the metacarpal heads to the midproximal phalanx
• 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
 Etiology

• Are fairly common and often run in families

• Occur in about one out of every 2,500-3,000 newborns
• Affect boys more often than girls( 2:1)
• Affect whites more often than blacks or Asians
• Bilateral about 50 % of the time
• Can occur alone or as part of a genetic syndrome, such as Apert
syndrome
• Can sometimes be seen prior to birth by ultrasound
Ray involvement
• 50% long-ring finger
• 30% ring-small finger
• 15% index-long finger
• 5% thumb-index finger
Classification

Complete or incomplete

• In complete syndactyly, the skin is joined all the way to the tip of the
involved digits.

• In incomplete syndactyly, the skin is only joined part of the

distance to the tip of the involved digits.
Classification
 Management

• Syndactyly can have cosmetic, functional, or developmental impacts on the growing

child

• Syndactyly of the first web space hampers grasp and the development of pinch.
• Syndactyly of the second, third, and fourth web spaces inhibits independent digital motion,
particularly abduction, and therefore reduces the span of the hand.

• Syndactyly between digits of unequal length  tethering of the longer digit  deviates
toward the shorter digits & also cause a flexion contracture at PIP joint that progresses with
growth .
 Surgical contraindication
• include mild incomplete syndactyly without functional impairment

• medical conditions that preclude surgery, or complex syndactylies

that risk further functional impairment with attempted separation.

• In complicated complex – there are insufficient components in the

fused mass to produce independent, stable, and mobile digits

• This situation typically arises in central brachysyndactyly or

synpolydactyly, and separation risks reducing function.
 Timing of surgery

• Syndactyly release has been performed in the neonatal period or

during infancy, or it has been delayed until childhood.
• Longterm reviews by Flatt and Ger have shown better outcomes
with release after 18 months, although early surgery may be
dictated by progressive skeletal deviation or deformity.
• The goal  complete all the releases by school age
• In multiple staged release - the first procedure can be combined
with isolated release of the fingertips and distal phalangeal fusions
of all the digits to reduce the tethering effect between surgical
procedures
Surgical steps

(1) separation of the digits

(2) commissure reconstruction
(3) resurfacing of the intervening borders of the digits.
(4) Paronyhcial fold formation
 Seperation of digits
• Release of syndactyly requires
careful planning to optimize use of Cronin and Skoog
the available skin and to allow –dorsal and volar
surgical exposure for separation of
digits and structures. triangular flap
with matched zig
• Separation of the digits requires
division or excision of fascial zag incision
interconnections between the digits,
with care taken to identify and
preserve the individual neurovascular
bundles and the venous plexus on the
dorsum of the digits and of the
commissure flap
• Bifurcation of the common digital Somarlad open
nerve and artery may be distal to the finger technique
planned position of the web space.
• In this situation, the digital artery can
be ligated provided the other side of
the digit is unoperated or the
contralateral digital artery is known to
be intact
Different skin incision technique depicted below
Commissure reconstruction
• A basic tenet of syndactyly
release is reconstruction of the Butterfly flap for
interdigital commissure with a web deepening
local skin flap.
• Incision design must be placed
such that inevitable scar
contraction will avoid joint or
web space contracture
4 flap Z
• For 1st web space: Other plasty
options include a transposition for1stwe
flap from the index finger, a b space
combination of transposition flaps
from the radial and ulnar borders
of the index and thumb,
respectively, or a “V-to-Y”
advancement of the central web.
Resurfacing of the digit

• Resurfacing the digits is achieved with the palmar and dorsal

flaps raised from the conjoined digits supplemented with skin
grafts.

• Full-thickness skin grafts are preferred over split thickness

skin grafts to lessen secondary graft contracture

• Resurfacing the digits without skin graft may require some

reduction of digital diameter by excising the subcutaneous fat of
the digit while preserving the dorsal venous system
Graftless syndactyly release technique
Paronychial fold formation
• Release of a complete
syndactyly, particularly when
associated with distal
phalangeal fusion, requires the
formation of a paronychial fold.
• The distal phalangeal tufts
may be covered using the
technique described by
Buck-Gramcko.
• Laterally based long narrow
triangular flaps are raised from
the hyponychium of the
conjoined digital mass and
folded around to form the
lateral nail fold
 Post operative dressing
• The dressings  gentle compression : the skin graft sites & protect the separated digits.
• Nonadherent dressings and moist cotton  into the web spaces and reinforced with large
amounts of soft gauze.
• In young children  reinforced by above-the elbow plaster or a soft cast to
prevent inadvertent removal.

• The dressings are removed 3 weeks after surgery, and then gentle washing and wound
care are needed. The wounds are protected until they are dry and healed.
• Normal hand use is allowed after the dressing has been removed.
• Once healing has taken place, an elasticized compression glove may be fitted and worn
for up to 3 months for scar management.
• Scar massage by oil/gel , silicone gel sheets, or elastomere products can be used to
treat areas of hypertrophic scarring.
 Complication

• Early :vascular compromise, infection,

wound dehiscence, and graft loss.

• Late : web creep, Joint contractures, beaked

nail deformity
Complication
Management
Scar mobilization During the proliferative stage massage has a
beneficial role in collagen synthesis, as it prevents adhesions and helps
in collagen synthesis.
Splinting can be used at all stages of wound healing

Ultrasound therapy It stimulated the synthesis of growth factor

that in turn increase the strength and elasticity of the collagen fibers
formed

Laser: Laser inhibits collagen and improves keloid and

hypertrophic scarring
THANK YOU