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Preaxial

Polydactyly
Preaxial Polydactyly
Thumb duplication may be a Preaxial Polydactyly is a
misnomer because it implies
that there are two normal rare occurrence with an
thumbs whereas, in fact, both incidence estimated at 0.08
thumbs are hypoplastic. in 100.000 live births.

There are many different Classification by the Wassel


system is dependent of the number
classification systems, of bifid or duplicated phalanges
including the universal, Marks or metacarpals, starting distally
and Bayne, and Wassel systems. and progressing proximally.

Surgical reconstruction
is the treatment of
choice to improve
functions and aesthetics.
Wassel Classification

I Bifid VI
distal
phalanx IV Duplicated
proximal Duplicated
phalanx metacarpal

II
Duplicated
40%
distal
phalanx VII
20%
V Triphalangism

III
Bifid
proximal
Bifid
metacarpal
20%
phalanx
Wassel
Type I & II
Thumbs

the distal phalanx is bifid, but a common joint is shared. when one thumb is much
smaller, it can simply be ablated. when the duplication resulted in two markedly
smaller thumbs of equal size, excision of one entire duplicated thumb leaves a small
thumb with an unnatural appearance. The Billhaut-Cloquet procedure or modifications of
it have been used effectively to resect the central portion and join the two.
Wassel
Type III
Thumbs

when one thumb is smaller, it is best deleted, but when the condition
represents a truly bifid thumb, the Bilhaut-Cloquet operation maybe
possible. However, IP joint motion is usually limited
Wassel reconstruction of the radial
Type IV collateral ligament is compromised
and instability of the joint result.
Thumbs
is by far the most common of the
duplicated thumbs. correct

unless the condyle of the


metacarpal is reduced, an
unsightly bump rather than a
more natural taper is left incorrect
behind.
Correct technique to help surgeon avoid the
problems of instability and achieve the best
possible appearance and function of the thumb.

The resulting
closure after
reconstruction and
removal of the
duplicated thumb
follows the hand
surgery principles
for incision
design and avoids
the problem of
hypetrophy of the
surgical incision
scars.

flexor surfaces so that the tendon bifurcations and


digital neurovascular structures can be well seen.
Exposure usually entails a racwuet-shaped incision of some
type with extension proximally and distally.
ulnar thumb
capsule radial thumb

radial facet of
periosteum metacarpal
collateral ligament

sharp dissection of the radial joint tissues is begun distal the metacarpal head can usually be noted to
to the metacarpophalangeal joint of the thumb to be sacrificed hace two facets, one for the excised thumb and
(the ulnar thumb in most cases). The collateral ligament is one for the remaining thumb. using a no. 15
carefully detached as far distally as possible. Working
distally to proximally, the operator preserves the origin of
blade as an osteotome, the surgeon removes the
the ligament off the broad metacarpal head. now sharp mostly contaginous radial facet along with a
dissection of a cuff of radial periosteum confluent with the triangular distal portion of the radial shaft
collateral ligament is done carefully. of the metacarpal.
extensor
tendons

radial collateral
ligament
abductor policis
brevis muscle

Supracondylar osteotomy of the metacarpal is rarely


the extensor hood is reconstructed by
required--only with marked angulation of the remaining
articular facet. with these small bone osteotomies it is
attaching a portion of the abductor policis
useful to remember that when the osteotomy of each side of brevis tendon to the proximal phalanx over the
the wedge is made at a right angle to the long axis of the radial collateral ligament repair and extensor
metacarpal shaft proximally and the long axis of the distal tendon.
thumb distally, a straight thumb results from wedge removal
and closure. special care must be taken to protect the
origin and the entire ulnar collateral ligament. the bone
fragments are stabilized with a substantial Kieschner wire
positioned longitudinally, and the reconstruction is
protected with a safety cast.
Excision of
Duplicate Thumb neurovascular
bundle
The incision is planned so that a straight scar is avoided. the
incision illustrated has committed the surgeon to removal of the
thenar muscle
radial thumb. this incision permits exposure of all the structures to
attachments
both thumbs. if the surgeon is uncertain at the beginning of the case
about which thumb is to be retained, a different incision should be
planned. this situation might arise if both digits are small or there
is a question of the blood suplly to the digit that has to be
retained.

after the flaps are developed, the neurovascular


bundles are identified and-traced to their
respective digits. this is to ensure that they are
protected and the digit to be retained is
innervated and vascularized. at this point, the
thenar muscles are detached from the base of the
radial digit. these will attach to the radial side
of the radial digit by a broad tendon. sufficient
tendon and, if necessary, periosteum should be
retained with the muscles to provide strong
attachment to the retained digit.
periosteal and
ligament flap

with the thenar muscles detached and retracted out of the way, a flap of periosteum and ligament from the
radial digit is raised. this flap is then dissected proximally off the metacarpal and sutured into the radial
side of the retained digit to reconstruct the radial collateral ligament. this step is important to avoid
ulnar deviation, which is one of the most common complication of this procedure. The radial digit is now
removed and the remaining ulnar digit sublucated to demonstrate the condyle of metacarpophalangeal joint. this
condyle is broader than normal and must be narrowed to provide good cosmesis as well as good stability for the
retained digit. there is usually a small ridge on the articular surface of the condyle that identifies that
portion of the condyle on which each of the thumbs articulated, in addition, there is frequently an ulnar
deviation of the metacarpal head. in keeping with the principles outlined, it is necessary to correct this
deviation at this time.
the excess radial portion of the condyle is removed with a small osteotome, a
small closing wedge osteotomy is made just behind the condyle of the
metacarpal. this is designed to correct the ulnar deviation. any rotational
malalignment can also be corrected. this osteotomy usually is fixed with one
small Kirschner wire passed from the tip of the distal phalanx.
when the osteotomy is fixed, the periosteal
and ligamentous flap that was raised from the
discarded digit and radial side of the
metacarpal is sutured to the radial side of
the retained digut. care should be taken in
adjusting the tension of this repair.
subsequently, the thenar muscles are sutured
over this to the base of the retained digit.

the skin is closed. there is no


problem with a shortage of skin.
there is often excess skin that
may be trimmed. the resulting
suture line should not be linear.
a rigid dressing and a long arm
cast are applied.
Triphalangeal
Thumbs
Wassel The extra phalanx
is in the middle
The latter
situation may

Type V & VI
phalanx. indicate an
index finger
It may be wedge- duplication
Thumbs shaped or
rectangular.
with an
absent thumb.

These rare and complex The thumb may be in


duplications require reattachment a position of
opposition or in
of the abductor tendons and the plane of motion
reconstruction of the basal joint of the other
of the thumb. fingers.

Triphalangeal thumbs may be associated with musculoskeletel


malformations, such as cleft feet and preaxial polydactyly,
congenital heart disease, including Holt-Oram syndrome,
hematopoietic abnormalities such as Fanconi and Blackfan-
Diamond syndromes and imperforate anus.
Complication

unstable joints and


deformity.

careful reconstruction of
Nail deformities
tendon insertions and joint
after the two distal
collateral ligaments
duplications are
reduces the incidence of
joined occur
complications.
frequently and are
sometimes a problem
Joint reconstruction by
for the patient.
fusion or ligament
reconstruction may
occasionally be necessary
later.
etc.
• Central Polydactyly
• Ulnar Polydactyly
• Mirror Hand

complication.
• Central Polydactily
• stiff digit is left behind
after reconstruction.
• Ulnar Polydactyly
• cicatrix and keloid scars.