Cleft Hand - Clinical Case

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.
Cleft Hand - Clinical Case


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

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.

Section 2


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 
  2. Removal of transverse bones 
  3. First web space reconstruction 
  4. Pollicisation 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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