syndactyly

One of the common birth defects is syndactyly, in which two or more fingers are fused together. Surgical correction involves cutting the tissue that connects the fingers, then grafting skin from another part of the body. (The procedure is more complicated if bones are also fused.) Surgery can usually provide a full range of motion and a fairly normal appearance, although the color of the grafted skin may be slightly different from the rest of the hand. Other common congenital defects include short, missing, or deformed fingers, immobile tendons, and abnormal nerves or blood vessels. In most cases, these defects can be treated surgically and significant improvement can be expected.

Medical therapy

Syndactyly requires surgical intervention. Full-term infants can be scheduled for elective surgical procedures as early as 5 or 6 months of age. Surgery before this age can increase anesthetic risks. Prior to that time, there is generally no intervention necessary if there are no problems. If there is an associated paronychia which can occur with complex syndactyly, the parents are given instructions to wash the child's hands thoroughly with soap and water and toa apply a topical antibacterial solution or ointment. Oral antibiotics are given when indicated.

Surgical therapy

The timing of surgery is variable. However, if more fingers are involved and the syndactyly is more complex, release should be performed earlier. Early release can prevent the malrotation and angulation that develops from differential growth rates of the involved fingers.

In persons with complex syndactyly, the author performs the first release of the border digits when the individual is approximately 6 months old. This approach is used because differential growth rates are observed, particularly between the small finger and ring finger or between the thumb and index finger. Prolonged syndactyly between these digits can cause permanent deformities. If more than one syndactyly is present in the same hand, simultaneous surgical release can be performed, provided only one side of the involved fingers is released. For example, in a 4-finger syndactyly involving the index, long, ring, and small fingers, the index finger can be released from the long finger, and the small finger can be released from the ring finger, leaving a central syndactyly involving the long and ring fingers (see Images 27-28). If both hands are involved, bilateral releases can be performed at one operative setting.

Perform bilateral releases whenever feasible to reduce the number of surgeries and the associated risks. Postoperative bilateral immobilization of the upper extremities is well tolerated in the child who is younger than 18 months. The increasingly active child who is older than 18 months has a difficult time with bilateral immobilization. Therefore, in children older than 18 months, any procedures must be staged unilaterally. The remaining syndactyly between the long finger and ring finger can be released approximately 6 months later (see Images 29-30). In an individual with isolated central syndactyly between the long finger and ring finger, the release need not be accomplished until the second year of life because of similar growth rates between the long finger and ring finger. It is preferable to complete all major reconstructions before a child is school age.

However, even if the child is older than the ideal age (which is usually before school age for functional, developmental, and psychological reasons), it is not too late to release the central rays (long and ring fingers) at a later age, as they have similar growth rates. For example, a 5° flexion contracture could eventually improve once the fingers are released. In children, unlike in adults, persistent flexion contractures are rare. The technical details of syndactyly release are similar to the release performed in infants. In older patients, splints are still applied but can be removed earlier, at about 7-10 days, because the patients are more compliant with activity and with dressing changes after the splint is removed