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Polydactyly
Arnold David Pardamean
Pembimbing:
Dr. dr. Yoyos Dias Ismiarto, SpOT(K), M.Kes, CCD
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.
Surgical reconstruction
is the treatment of
choice to improve
functions and
aesthetics.
Epidemiology
Incidence Demographics
1 per 1,000 to 10,000 live
Male > Female
births
caucasian > African Americans
Type IV most common (43%)
Type II second most common (15%)
Associated
Genetics
Conditions
Inheritance pattern pollex abductus
usually unilateral and sporadic abnormal connection between EPL and FPL
tendons, seen in approximately 20% of
except for Type VII which is hypoplastic and duplicated thumbs
associated with several syndrome
including: suggested by abduction of affected digit +
absence of IP joint crease
Holt-Oram syndrome
Fanconi's anemia
Blackfan-Diamond anemia
imperforate anus
cleft palate
tibial defects
Wassel Classification
I Bifid VI
distal
phalanx IV Duplicated
proximal Duplicated
phalanx metacarpal
II
Duplicated
43%
distal
phalanx VII
15%
Triphalangism
V
Bifid Bifid
III proximal metacarpal
phalanx
Treatment
operative
goals of treatment
to construct a thumb that is 80% of the size of the
contralateral thumb
resect smaller thumb (usually radial component)
preserve / reconstruct medial collateral structures in
order to preserve pinch function
reconstruction of all components typically done in one
type 1 combination procedure procedure
(Bilhaut-Cloquet)
indications: type I, II, or III type 3 combination procedure
type 2 combination procedure indications: when one digit has
technique: involves removing central superior proximal component and one
tissue and combining both digits indications: usually favored
approach for type III and IV. type V digit has superior distal fragment
into one (type V, VI, and VII)
and VI usually require more complex
outcomes: approximately 20% have transfer of intrinsics and technique: a segmental distal
late deformity. problems include collateral ligaments transfer (on-top plasty)
stiffness, angular and size
deformity, growth arrest, and nail technique: preserve skeleton and
deformities nail of one component and augment
with soft tissue from other digit
and ablation of lesser digit (radial
digit most commonly)
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
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.
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
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.
Type V & VI
indicate an
index finger
It may be wedge- duplication
Thumbs shaped or
rectangular.
with an
absent thumb.
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.