A fundamental operation in the treatment of typical cleft hand is that of cleft closure. In practice, it is often combined with release of the first web space where there may be syndacytlyl between the index finger and thumb and an adduction contracture of the muscles. Most techniques rearrange skin from the cleft to widen the first web space. Muscle contractures of adductor pollicis or the first dorsal interosseous require releases of their origins or 'ladder'-type sectioning to lengthen.
The most widely utilised technique for closure of the cleft is that of Snow and Littler. A flap of skin with its base on the palmar surface is transposed to the first web space. Often, supplementation with a skin graft is required for complete resufacing of the first web space. At the same time, the index finger metacarpal is transposed onto the base of the residual middle finger metacarpal. To allow translocation, the first dorsal interosseous muscle needs to be released fully. To prevent subsequent digital divergence after translocation, reinforcement between the metacarpals may be achieved by transverse metacarpal ligament reconstruction with or without the creation of new junctions between the flexor or extensor tendons.
An alternative technique is that of Miura and Komada(1). Again, the index finger is translocated to the third ray but with incisions along the new first web and around the index finger extending dorsally to the metacarpal base. This produces both dorsal and palmar flaps which can be interdigitated to limit the tendency for single, longer cleft flaps to necrose at the tip.
For minor clefts, there may be little required other than removal of a hypoplastic middle metacarpal, creation of the web commissure with a local flap, and intermetacarpal ligament construction using spare tendon eg the extrinsic tendons to the middle ray. Ligament reconstruction is vital to prevent late splaying of digits that have been centralised around the cleft.
Ref: (1) Miura T, Komada T. (1979). Plast Reconstr Surg 64: 65-67.
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