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Sindactyly

Andi Hakim
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Introduction
Syndactyly : webbing of the digits one of the most common congenital hand deficiencies Epidemiology :
Incidence : 1 per 2,000 to 2,500 live births Strong familial tendency : inherited in 10% to 40% cases result of a dominant gene with variable penetrance Males : females = 2 : 1
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Classified based on :
The extent of webbing The nature of the interconnected tissue

Most commonly involved : third web, fourth & second webs Common : asociation with Poland or Apert syndrome
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CLASSIFICATION Simple, complete Simple, incomplete

DESCRIPTION Soft tissue connection only, webbing extends to fingertips Soft tissue connection only, webbing terminates more proximally

Complex
Complicated

Either bony or cartilaginous connections Duplicated skeletal parts located in the interdigiti space

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Complete Simple Syndactyly

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Incomplete Simple Syndactyly

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Complex Syndactyly

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Apert Syndrome

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Poland Syndrome

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Timing of Surgery
Separation as early as 6 months, indication :
Involving digits of unequal length (i.e., the ring and little fingers) Complex syndactyly Cases of acrosyndactyly (digits distal tips fusion)

All other cases : remains controversial (before vs after 18 months) The principles of correction :
separation of the digits creation of a web space - skin coverage - immobilization
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Operation Technique
Separation carried out via dorsal and volar zigzag incisions creating interdigitating flaps The nail fusion can be corrected by opposing Zflaps After making the incisions, the neurovascular bundles are identified prior to completing the separation The web can be created using either a large dorsal flap or double opposing triangular flaps from dorsal and volar aspects
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The flaps are then interdigitated There will always be residual raw areas both proximally and on the sides of digits; these should be grafted with skin obtained from the groin crease To avoid vascular compromise to a single digit, it is critical that separation should not be performed simultaneously on adjacent webs Immobilizing the childs arm in an above-elbow cast until the grafts heal recommended
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Preoperative markings for Brunner incisions

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Radiograph showing complex complete syndactyly

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Postoperative result after release

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Intraoperative Considerations
Simple, incomplete syndactyly : treated with skin flaps only Correction of syndactylized digits : usually performed as a staged procedure simultaneous release of both the radial and ulnar side can compromise vascular supply to the digit procedure relies on meticulous, atraumatic technique Zigzag incisions : used on the palmar surface, the flaps divided equally between the two digits
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The volar flap base should be kept wider than the base of the dorsal flap Full-thickness skin grafts are commonly required, especially for commissure reconstruction The digits are closed from distal to proximal, preferably using absorbable sutures in young children In cases of complex syndactyly : the bone should be covered with soft tissue and burred down until it is smooth
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Postoperative Considerations
The web spaces must be packed with gauze dressings no undesirable healing of raw surfaces to one another In some centers : dressing changes under general anesthesia Postoperative immobilization is essential cast the childs entire arm with the elbow flexed at 90 Inadequate protection of the surgical site : lead to infection, skin graft loss and dehiscence
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Insufficient commissure release or closure under tension : scar contracture at the web space recurrence of the webbing

Surgical revision required especially for the first web space most important Overall revision rate of syndactyly repair : + 10%
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