Management

Cleft hand patients typically have reasonable function but with a poor cosmetic appearance. Treatment is largely operative. Non-operative management largely consists of counselling the family and the identification and potential genetic testing for any associated syndromes.

Surgery can address cosmesis and function. Cosmesis is improved by closing the cleft. Function is entirely dependent on the degree of deformity, eg the degree of thumb hypoplasia, the width of the first web space and the number of remaining digits. Patients presenting late for surgery, eg in late childhood or early adulthood, may desire surgery for cosmetic reasons. However, there is a risk that function may be made worse by operating at this stage given the degree of adaptation. Normally the timing of surgery is dependent upon the clinical problem. Abnormalities which must be addressed in the first year of life include syndactyly of border digits, particularly the thumb and index finger, and the presence of a 'cross' or transverse bones. In these situations, early growth can produce a worsening deformity. Otherwise, surgery is carried out between one and two years of age

However, useful techniques might include:

• closure of the cleft hand
• division of syndactyly
• flaps to increase the width of the first web space
• release of 'cross bones' where, for example, metacarpals are fused
• pollicization in the absence of the thumb
• correction of digital deviation
• soft tissue releases
• reconstruction of the transverse metacarpal ligaments
• microvascular transfer of toes, foot rays or supernumerary digits from the hand; may be advantageous in the monodactylous hand