| Barsky, 196411 Barsky AJ. Cleft Hand: Classification, incidence, and treatment. review of the literature and report of nineteen cases. J Bone Joint Surg Am. 1964;46:1707-20.
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Uses a retail place, pedicle foursquare, in diamond shape to recreate the commissure after the cleft is narrowed.
Indication: Cleft hand.
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Benefits: Aesthetic improvement.
Disadvantages: Insufficient functional concern; without reconstruction of the first commissure.
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| Snow and Littler, 19672626 Snow JW, Littler JW. Surgical treatment of cleft hand. In: Transactions of the International Society of Plastic and Reconstructive Surgery 4th Congress. Rome: Excerpta Medica Foundation; 1967.
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The cleft is elevated like a palmar flap, with a small radial flap preserved by recreating the commissure; the first commissure space is freed, which may require splitting the dorsal interosseous and surrounding fascia; the second metacarpal is transposed and attached to the remainder of the third metacarpal base; Fixation is obtained with axial and transverse wires, and the palmar flap is transferred, recreating the new commissure between the second and fourth ray.
Indication: Third metacarpal segment present.
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Benefits: Functional; Gain cosmetic.
Disadvantages: Risk of distal flap necrosis due to its high length-to-base ratio; Traction of the adductor and dorsal interosseous muscles may cause some radial angulation in the local translocation, incompletely correcting the central cleft.
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| Miura and Komada, 19792727 Miura T, Komada T. Simple method for reconstruction of the cleft hand with an adducted thumb. Plast Reconstr Surg. 1979;64(1):65-7.
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Index transposition in a central position and palmar and dorsal redesign as separate flaps to create the first commissure. Cleft incised from side to side. The index finger is raised in its neurovascular bundles and transposed by osteosynthesis with the third metacarpal or by angulation osteotomy.
Indication: Cleft hand with an adducted thumb.
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Advantage: Small flaps of random transposition of the dorsal and palmar skin.
Disadvantage: Incidence in necrosis distal and contracture secondary
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| Ueba, 19812828 Ueba Y. Plastic surgery for the cleft hand. J Hand Surg Am. 1981;6(6):557-60.
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Use of transverse flaps from any edge of the cleft and transposition of the index digit; Reconstruction of the intermetacarpal ligament by a free tendon.
Indication: Total absence of the third metacarpal.
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Advantage: Improved aesthetics without changing the function of the hand.
Disadvantage aesthetic of transferring the palmar to dorsal skin and dorsal to palmar skin.
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| Buck-Gramcko, 19852929 Buck-Gramcko D. Cleft hands: classification and treatment. Hand Clin. 1985;1(3):467-73.
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Cleft narrowing, syndactyly separation, crossbones removal, correction of joint flexion contractures, rotation or wedge osteotomies for axial deviations and ulnar translocation of the index digit.
Indication: Deep intermetacarpalpal ligament reconstruction.
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Advantages: Cosmetically acceptable without translocation.
Disadvantages: Inadequate correction of the central space.
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| Ogino, 19901111 Ogino T. Cleft hand. Hand Clin. 1990;6(4):661-71.
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The index and ring fingers reconstruct the deep metacarpaltransverse ligament using flexor sheaths (part of the A1 or A2 pulleys).
Indication: Total absence of the third metacarpal.
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Advantages: Possibility of spontaneous correction of the deformity in flexion of the ring finger.
Disadvantages: -
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| Upton, 20041212 Upton J. Simplicity and treatment of the typical cleft hand. Handchir Mikrochir Plast Chir. 2004;36(2-3):152-60.
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Wide incision that extends from the ulnar side of the cleft around the malpositioned index digit to the thumb; may include index transposition, metacarpal and/or phalangeal osteotomies, joint releases, phalangeal osteotomies, adductor pollicis muscle preservation, first dorsal interosseous muscle release, syndactyly separation(s), and thumb duplication correction.
Indication: Typical cleft hand.
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Advantage: Provides clear identification of all anatomical structures of the palm.
Disadvantage: Grasp and precision maneuvers remain poor despite considerable functionality.
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| Foucher, Loréa, Hovius, Pivato, Medina, 20063030 Foucher G, Loréa P, Hovius S, Pivato G, Medina J. Radial shift of the ulnar fingers: a new technique for special cases of longitudinal central deficiency. J Hand Surg Br. 2006;31(2):156-61.
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Translocation in the radial direction of the ulnar finger(s) by intracarpal osteotomy; When necessary, a synostosis metacarpal can be performed in the same procedure.
Indication: Type IIA of the Manske & Halikis classification77 Manske PR, Halikis MN. Surgical classification of central deficiency according to the thumb web. J Hand Surg Am. 1995;20(4):687-97..
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Advantage: No functional loss; Good alignment of the second metacarpal with the radius.
Disadvantage: Mobility between hamate and capitate is physiologically limited in all biomechanical studies.
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| Oberlin, Korchi, Belkheyar, Touam, MacQuillan, 20093131 Oberlin C, Korchi A, Belkheyar Z, Touam C, Macquillan A. Digitalization of the second finger in type 2 central longitudinal deficiencies (clefting) of the hand. Tech Hand Up Extrem Surg. 2009;13(2):110-2.
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Reverse policing: The incision wraps around the second digit in the middle, extends over the dorsal edge of the cleft, and ends on the radial side of the third digit, where the second commissure space should be created. The index metacarpal is released (extraperiosteally) and translocated into the space of the absent third ray. After internal bone fixation, the flap, with its volar cutaneous pedicle, is transposed to reconstruct the first space of the mesh.
Indication: Type II of the Manske & Halikis classification77 Manske PR, Halikis MN. Surgical classification of central deficiency according to the thumb web. J Hand Surg Am. 1995;20(4):687-97.
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Advantages: Preservation of the dorsal venous network; no need for grafting; It does not harm the normal musculature of the thumb.
Disadvantages: Possibility of ectopic bone deformation; Index finger misalignment; Divergence of the metacarpals if reconstruction of the transverse metacarpal ligament is insufficient.
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| Upton, Taghinia, 201099 Upton J, Taghinia AH. Correction of the Typical Cleft Hand. J Hand Surg Am. 2010;35(3):480-5.
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Simple circumferential incision around the index radius; straightline incisions inside the cleft; and thumb extensions; Elevation of the dorsal and palmar flaps to provide exposure of the metacarpal portion of the hand; Reconstruction of the intermetacarpal ligament employing simple sutures, circumferential sutures around adjacent metacarpals, or by joining adjacent A1 pulleys. The new space of the first commissure is closed by a small flap based on the radial side of the radius of the annulus with a dorsal-palmar slope of 45°.
Indication: Type II and Type III of the Manske & Halikis77 Manske PR, Halikis MN. Surgical classification of central deficiency according to the thumb web. J Hand Surg Am. 1995;20(4):687-97. classification.
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Advantages: Preservation of the adductor pollicis muscle for a functional pinch.
Disadvantages: Instability of the thumb in the joint metacarpophalangeal; Progressive camptodactyly of fingers adjacent to central cleft; Narrowing of the first commissure; Excessive length and radial deviation of the transposed index radius; Risk of recurrence of commissure narrowing due to scarring along the edge.
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| Christen, Dautel, 20131010 Christen T, Dautel G. Metacarpophalangeal ligamentoplasty in typical cleft hand. Tech Hand Up Extrem Surg. 2013;17(2):120-2.
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Dorsal skin incision; Autologous tendon graft (preferably the palmar longus, otherwise the plantaris or a toe extensor); Positioning the tendon in a figure of eight around the base of the proximal phalanx and corresponding metacarpal neck.
Indication: Hyperlaxity of the joint(s) metacarpophalangeal adjacent to the cleft.
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Advantages: Prevents the occurrence of excessive progressive narrowing;
Disadvantages: Over-tightening of the graft will result in a limited range of motion in flexion and extension, whereas under-tensioning will lead to persistent laxity.
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| Yasin, Amin, Mahmoud, Abdel-Ghani, 20203232 Yasin E, Amin H, Mahmoud M, Abdel-Ghani H. Using Skin of the Cleft as Bipedicle flap for Release of the First Web Space in Congenital Central Deficiency. J Hand Surg Am. 2020;45(7):665. e1-665.e7.
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Use cleft skin as a bipedicled flap for reconstruction and widening of the first commissure’s narrow space of the first commissure. The skin of the cleft maintains its fixations on the dorsal and palmar surfaces of the hand, and the index digit is passed (tunneled) under it so that the skin of the cleft will occupy the space of the U commissure.
Indication: Type IIB and Type III of the Manske & Halikis classification77 Manske PR, Halikis MN. Surgical classification of central deficiency according to the thumb web. J Hand Surg Am. 1995;20(4):687-97..
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Advantages: Ensures the maintenance of a good blood supply to the skin of the cleft; a rounded edge of the U commissure without scars.
Disadvantages: In a deep fissure, the skin retains its shape after reconstructing the first commissure.
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(*) Two studies met the inclusion criteria in two groups of concomitant analyses, therefore they were counted as single inclusions. (Flowchart prepared by the authors).
