Plastic Surgery>>>>>Hand surgery
Question 2#

The parents of a 2-week old boy bring the child to your clinic because he was born with a unilateral complete syndactyly of the thumb and the index finger. He has no other congenital abnormality. You examine the patient and order an X-ray that shows it to be a complex complete syndactyly of the first web space. You decide to:

a. Wait until the child is 2 years of age or older to release the syndactyly without the need of a skin graft
b. Wait until the child is 4 years old and release the syndactyly using a split thickness skin graft
c. Wait for over 6 months and release the syndactyly under regional block to reduce the risk of anaesthesia and utilize a split thickness skin graft
d. Wait until the child is 3-6 months old and release the syndactyly using a full thickness skin graft from the groin
e. Wait until the child is 1-year-old and release the syndactyly with an open technique

Correct Answer is D

Comment:

Wait until the child is 3-6 months old and release the syndactyly using a full thickness skin graft from the groin. Release of syndactyly of unequal length digits should be performed as early as possible; between 3 and 6 months is a good time as the child is old enough to withstand the procedure without undue anaesthetic risk, whilst the chances of damage to the joints are reduced, especially the PIP joint of the longer digit. If the procedure is delayed the child will develop permanent changes to the PIP joint. Syndactyly is more common in males, is present bilaterally in 50% of affected patients, and often is associated with other musculoskeletal malformations or systemic syndromes. The goal of syndactyly release is to create a functional hand with the fewest surgical procedures while minimising complications. For simple syndactyly, surgical reconstruction can begin at approximately 6 months, although many surgeons prefer to wait until the infant is 18 months old. Special situations, such as complex syndactyly and involvement of border digits, may warrant surgical intervention earlier than 6 months. Reconstruction of the web commissure is the most technically challenging part of the operation, followed by separation of the remaining digits. Full thickness skin grafting is almost always required for soft-tissue coverage. Complex syndactyly and syndactyly associated with other hand anomalies warrant special consideration. After reconstruction, patients should be examined periodically until they have achieved skeletal maturity because late complications such as web creep can occur.

References:
1. Dao KD, Shin AY, Billings A, Oberg KC, Wood VE. Surgical treatment of congenital syndactyly of the hand. J Am Acad Orthop Surg 2004; 12(1): 39-48.