The treatment of cleft hand is usually invasive and can differ each time because of the heterogeneity of the condition. The function of a cleft hand is mostly not restricted, yet improving the function is one of the goals when the thumb or first webspace is absent. The social and stigmatising aspects of a cleft hand require more attention. The hand is a part of the body which is usually shown during communication. When this hand is obviously different and deformed, stigmatisation or rejection can occur. Sometimes, in families with cleft hand with good function, operations for cosmetic aspects are considered marginal and the families choose not to have surgery. Indications Surgical treatment of the cleft hand is based on several indications: * Improving function * Absent thumb * Deforming syndactyly (mostly between digits of unequal length like index and thumb) * Transverse bones (this will progress the deformity; growth of these bones will widen the cleft) * Narrowed first webspace * The feet Aesthetical aspects * Reducing deformity Timing of surgical interventions The timing of surgical interventions is debatable. Parents have to decide about their child in a very vulnerable time of their parenthood. Indications for early treatment are progressive deformities, such as syndactyly between index and thumb or transverse bones between the digital rays. Other surgical interventions are less urgent and can wait for 1 or 2 years. Classification and treatment When surgery is indicated, the choice of treatment is based on the classification. Table 4 shows the treatment of cleft hand divided into the classification of Manske and Halikis. Techniques described by Ueba, Miura and Komada and the procedure of Snow-Littler are guidelines; since clinical and anatomical presentation within the types differ, the actual treatment is based on the individual abnormality. Table 4: Treatment based on the classification of Manske and Halikis Type Treatment I/IIA Reconstruction of the transverse metacarpal ligament IIB/III Transposition of the index metacarpal with reconstruction of the thumb webspace IV Mobility and/or position of the thumb of ulnar digit to promote pinch and grasp V There is no cleft or web space and the thumb is very deficient. This hand requires consideration of creating a radial digit Snow-Littler The goal of this procedure is to create a wide first web space and to minimise the cleft in the hand. The index digit will be transferred to the ulnar side of the cleft. Simultaneously a correction of index malrotation and deviation is performed. To minimise the cleft, it is necessary to fix together the metacarpals which used to border the cleft. Through repositioning flaps, the wound can be closed. Ueba Ueba described a less complicated surgery. Transverse flaps are used to resurface the palm, the dorsal side of the transposed digit and the ulnar part of the first web space. A tendon graft is used to connect the common extensor tendons of the border digits of the cleft to prevent digital separation during extension. The closure is simpler, but has cosmetic disadvantage because of the switch between palmar and dorsal skin. Miura and Komada The release of the first webspace has the same principle as the Snow-Littler procedure. The difference is the closure of the first webspace; this is done by simple closure or closure with Z-plasties.
Ectrodactyly
Clinodactyly
Synpolydactyly
Sclerodactyly
Syndactyly
Camptodactyly
Oligodactyly
Pachydermodactyly