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# Cleft Hand - Clinical Case
- URL: https://www.theplasticsfella.com/cleft-hand-clinical-case/
- Published: 2023-01-14T12:23:49.000Z
- Updated: 2024-09-04T19:12:51.000Z
- Description: This assesses your clinical expertise, decision-making, and management skills through an oral "viva" structure, using real-world scenarios representative of clinical practice and exams.
- Author: PlasticsFella
- Tags: Clinical Cases, Upper Limb Scenario, Paediatric Scenario, Paediatrics, Upper Limb

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Hand---Clinical-Case-1.png)

#### ****Objectives**

  
****1\.** Clinical diagnosis of a central longitudinal deficiency  
****2\.** Classify and stage the congenital malformation  
****3.** Describe the aetiology of this condition  
****5.** Order and report on relevant investigations  
****6\.** Develop a treatment timeline  
****7.** Describe soft tissue and bony reconstruction options  
  
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## Section 1

### Clinical Assessment 

#### Describe what you see in this clinical photograph. 
  
  
This patient has clinical features consistent with a left cleft hand. Examining this hand from radial to ulnar

- Thumb is present; it does not appear hypoplastic
- 1st webspace is mildly narrowed
- Central cleft result in divergence of the index and ring finger
- The little finger is unremarkable on inspection
- There is no secondary malformation, such as syndactyly.

To conclude the exam

- Compared to the right hand
- Examine the wrist, elbows, shoulders
- Assess for secondary associations (e.g. EEC - ectrodactyly, ectodermal dysplasia, facial clefts).
- Formal hand assessment to assess movement, prehension and grip.
- Take a detailed history.

So, in summary, this 3-month-old baby has a left-side cleft hand. I would support these clinical findings by following up with relevant investigations.

#### How do you classify the degree of first webspace narrowing? 

This patient has a mildly narrow first webspace. Therefore, it is an IIA as per the Manske and Haliki classification. The grades of this classification are as follows:

- ****Type I:** normal first webspace
- ****Type II:**  narrowed (A: mildly, B: severely)
- ****Type III**: thumb-index syndactyly
- ****Type IV:** Index ray suppressed, first web space merged with cleft
- ****Type V:** thumb suppressed, absent first webspace.

#### What is the classfication of cleft hand?

This patient has a central longitudinal deficiency. The Swanson classification describes this as a failure of formation, and OMT classifies this condition as a malformation. 

#### Explain the core concepts of upper limb embryology

  
The upper limb develops during weeks 4-8 from 3 axes with specific signalling centres and proteins.

More specifically:

- ****AP axis** "ulnarises" the limb via zone of polarising activity, and sonic hedgehog protein
- ****PA axes** "distalises" the limb via apical ectodermal ridge, and FGFR proteins
- ****DV axes** "dorsalises" the limb via dorsal ectoderm and WNT7A.

You can read more about [embryology](https://www.theplasticsfella.com/upper-limb-embryology/).

## Section 2

### Investigations

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Hand---Clinical-Case-xray-1.png)

#### Report the X-Ray above. 

This is a PA x-ray of the 3-month-old baby's left hand. It supports the clinical diagnosis of a cleft hand. 

Important features to note include:

- The thumb is well formed and not syndactylised to the index
- Transverse bone in the central cleft area. This will only increase the width of the cleft over time.
- The ring and little finger are radiologically normal.

## Section 4

### Management of Cleft Hand

#### What are your treatment principles for achieving a cleft hand? 

  
The goals are guided by the patient's clinical and radiological findings. These can include: 

1. [Syndactyly release](https://www.theplasticsfella.com/syndactyly/#management-of-syndactyly)
2. Removal of transverse bones
3. First web space [reconstruction](https://www.theplasticsfella.com/syndactyly/#management-of-syndactyly)
4. [Pollicisation](https://www.theplasticsfella.com/thumb-hypoplasia/#index-pollicisation-for-thumb-hypoplasia) if an absent thumb or free toe transfer
5. Correct feet deformity
6. Closure of the cleft using the Snow-Littler technique

#### Would you operate on all patients?
  
  
It's important to individualise patient care. During my initial assessment, there are some specific markers I look out for. These include:

- Prehension
- Dexterity
- Impact of QOL/ADLs
- Delayed presentation

If the patient is coping well and has minimal psychosocial issues or impact on quality of life, I would be unlikely to operate.

#### What is your technique for cleft closure?

  
I use the Snow-Littler technique for soft tissue and a 2nd-3rd metacarpal transfer for bone reconstruction. 

In terms of the ****Snow-Littler Technique**

- Palmar-based flap transposed to the first webspace
- Random-pattern flap that can be axial if volar vessel identified
- The donor site closed primarily with a Barksy flap for the commissure

In terms of ****bony** reconstruction: 

- Transfer 2nd metacarpal to the 3rd metacarpal base
- Secured with K-wire.

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