Webbed finger or toe repair

Definition

Webbed finger or toe repair refers to corrective or reconstructive surgery performed to repair webbed fingers or toes, also called syndactyly. The long and ring fingers or the second and third toes are most often affected. Generally, syndactyly repairs are done between the ages of six months and two years.

Purpose

Webbing, or syndactyly, is a condition characterized by the incomplete separation or union of two or more fingers or toes, and usually only involves a skin connection between the two (simple syndactyly), but may—rarely—also include fusion of bones, nerves, blood vessels, and tendons in the affected digits (complex syndactyly). Webbing may extend partially up between the digits, frequently just to the first joint, or may extend the entire length of the digits. Polysyndactyly describes both webbing and the presence of an extra number of fingers or toes. The condition usually develops within six weeks after birth. Syndactyly can also occur in victims of fires, as the intense heat can melt the skin and fuse the epidermis and dermis of the phalanges, fingers, or toes. Burn victim syndactyly is always less invasive because bone fusion is not present in these cases. The purpose of repair surgery is to improve the appearance of the hand or foot and to prevent progressive deformity from developing as the child grows.

Demographics

In the United States, approximately one infant in every 2,000 births is born with webbed fingers or toes. Both hands are involved in 50% of cases; the middle finger and ring finger in 41%; the ring finger and little finger in 27%; the index finger and middle finger in 23%; and the thumb and index finger in 9%.

Description

Polydactyly can be corrected by surgical removal of the extra digit or partial digit. Syndactyly can also be corrected surgically. This is usually accomplished with the addition of a skin graft from the groin.

There are several ways to perform this type of surgery; the design of the operation depends both on the features of the hand or foot and the surgeon's experience. The surgery is usually performed with zigzag cuts that cross back and forth across the fingers or toes so that the scars do not interfere with growth of the digits.

The procedure is performed under general anesthesia. The skin areas to be repaired are marked and the surgeon then proceeds to incise the skin, lifting small flaps at the sides of the fingers or toes and in the web. These flaps are sutured into position, leaving absent areas of skin. These areas may be filled in with full thickness skin grafts, usually taken from the skin in the groin area.

This webbed finger shows a simple, complete syndactyly, meaning the bones for two fingers are complete, and only the soft tissues form the webbed section (A). To repair this, an incision is made in the skin of the webbing (B). Tissues and muscles are severed (C), and the two separated fingers are stitched (D). (

Illustration by GGS Inc.

)

Diagnosis/Preparation

Syndactyly may be diagnosed during an examination of an infant or child, with the aid of x rays. In its most common form, it is seen as webbing between the second and third toes. This form is often inherited. Syndactyly can also occur as part of a pattern of other congenital defects involving the skull, face, and bones.

An infant with webbed fingers or toes may have other symptoms that, when observed together, define a specific syndrome or medical condition. For example, syndactyly is a characteristic of Apert syndrome, Poland syndrome, Jarcho-Levin syndrome, oral-facial-digital syndrome, Pfeiffer syndrome, and Edwards syndrome. Diagnosis of a syndrome is made on family history, medical history, and thorough physical evaluation. The medical history questions documenting the condition in detail usually include:

• Which fingers (toes) are involved?
• Are any other family members affected by the same condition?
• What other symptoms or abnormalities are also present?

To prepare for surgery, seven to 10 days before surgery, the child visits the family physician or pediatrician for a general physical examination and blood tests. The child cannot have solid food after midnight before surgery. Breast milk, formula, or milk (no pablum or other cereal may be added) up to six hours before the scheduled start of surgery is allowed, and then only clear fluids up to three hours before surgery. Thereafter, the child may not have anything else to eat or drink.

Aftercare

Hospital stays of one or two days are common for webbed finger or toe repair surgery. There is usually some swelling and bruising. Pain medications are given to alleviate any discomfort. The bandages must be kept clean and dry and must remain for two to three weeks for proper healing and protection. Skin grafts and the hand or foot may become very dry, so it is encouraged to dampen them with a good moisturizer such as Lubriderm or Nivea. Small children with hand syndactylies may have a cast put on that extends above the flexed elbow. Sometimes, the cast extends beyond the fingers or toes. This protects the repaired areas from trauma.

The treating physician should be informed of any post-operative swelling, severe pain, fever, or fingers that tingle, are numb, or have a bluish discoloration.

Risks

Webbed finger or toe repair surgery carries the risks associated with any anesthesia, such as adverse reactions to medications, breathing problems, and sore throat from intubation. Risks associated with any surgery are excessive bleeding and infection.

Specific risks associated with the repair surgery include possible loss of skin graft and circulation damage from the cast or bandages.

Normal results

The results of webbed finger or toe repair depend on the degree of fusion of the digits and the repair is usually successful. When joined fingers share a single fingernail, the creation of two normal-looking nails is rarely possible. One nail will look more normal than the other. Some children may require a second surgery, depending on the type of syndactyly. If polydactyly or syndactyly are just cosmetic and not symptomatic of a condition or disorder, the outcome of surgery is usually very good. If it is symptomatic, the outcome will rely heavily on the management of the disorder.

Alternatives

Syndactyly does not generally pose any health risk, so that it is not mandatory that the repair be performed. However, if the thumb is joined, or if the fingers are joined out toward their tips, they will grow in a progressively worsening bend over time.

See also Cleft lip repair ; Club foot repair .

Resources

books

Jones, Kenneth Lyons. Smith's Recognizable Patterns of Human Malformation. 5th ed. Philadelphia: W.B. Saunders, 1997.

Moore, K. L., and T. V. N. Persaud. Before We Are Born: Essentials of Embryology and Birth Defects. New York: Elsevier Science, 2003.

periodicals

Ad-El, D. D., Neuman, A., and A. Eldad. "Syndactyly repair in kindler syndrome." Plastic and Reconstructive Surgery 111 (January 2003): 504-505.

Benatar, N. "The open finger technique for release of syndactyly." The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand 26 (October 2001): 500-501.

Deunk, J., Nicolai, J. P., and S. M. Hamburg. "Long-term results of syndactyly correction: Full-thickness versus split-thickness skin grafts." The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand 28 (April 2003): 125-130.

Greuse, M., and B. C. Coessens. "Congenital syndactyly: defatting facilitates closure without skin graft." Journal of Hand Surgery (American) 26 (July 2001): 589-594.

Takagi, S., Hosokawa, K., Haramoto, U., and T. Kubo T. "A new technique for the treatment of syndactyly with osseous fusion of the distal phalanges." Annals of Plastic Surgery 44 (June 2000): 660-663.

organizations

The American Academy of Orthopaedic Surgeons. 6300 North River Road, Rosemont, Illinois 60018-4262. (847) 823-7186; (800) 346-AAOS. http://www.aaos.org .

The American Society for Surgery of the Hand. 6300 North River Road, Suite 600, Rosemont, Illinois 60018-4256. (847) 384-8300. http://www.assh.org .

Office of Rare Diseases (NIH). 6100 Executive Boulevard, Room 3A07, MSC 7518 Bethesda, Maryland 20892-7518. (301) 402-4336. http://rarediseases.info.nih.gov/infodiseases.html .

other

"Before and after webbed finger repair." Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/imagepages/10034.htm .

"Repair of webbed fingers or toes." PennHealth. http://www.pennhealth.com/ency/article/002969.htm

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Webbed finger or toe repair surgery is usually performed in a children's hospital by a pediatric surgeon or orthopedic surgeon specializing in syndactyly surgery.

If prenatal screening indicates syndactyly in the fetus, arrangements are usually made so that the baby is delivered at a hospital with a pediatric surgeon on staff.

QUESTIONS TO ASK THE DOCTOR

• What will happen during the surgery?
• Does my baby have any other birth defect?
• How long will it take to recover from surgery?
• Will my baby have normal fingers/toes?
• How many webbed finger/toe repair surgeries do you perform each year?
• Will the syndactyly return?