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Syndactyly

  • Overview

    -Donald S. Bae, MD, associate in Orthopedic Surgery, Boston Children's Hospital; Brian I. Labow, MD, principal investigator, Plastic Surgery, Boston Children's Hospital

    If your baby or child has been born with webbed or conjoined fingers (syndactyly), we share your concern. Please know that at Children’s Hospital Boston, we will approach your child’s treatment and care with sensitivity and support—for your child and your whole family.

    Please note: while syndactyly can affect a child’s toes as well as fingers, this section will focus mainly on syndactyly of the fingers, since the condition poses more complex challenges for hand-and-finger use than for foot-and-toe use.

    Here is some basic information about syndactyly:

    If your child has syndactyly, it means that his fingers and/or toes are webbed or joined, and that the condition was present at birth.

    • Syndactyly is a fairly common congenital defect that often runs in families. At Children’s, it’s one of the most common congenital hand problems that we treat.
    • The condition occurs in approximately one out of 2,500-3,000 newborns; affects boy babies more often than girls; and affects Caucasians more often than Blacks or Asians.
    • It affects both hands (bilateral) about 50 percent of the time.
    • Syndactyly most often occurs between the middle and ring fingers.
    • The condition can occur:
      • in isolation and sporadically—meaning by itself and for no identifiable reason
      • as an inherited trait (in about 10 to 40 percent of cases)
      • as part of a genetic syndrome, such as Apert syndrome, Holt-Oram syndrome or Poland syndrome
    • Syndactyly can sometimes be detected by prenatal ultrasound, and is apparent at birth; the underlying structure of the finger and the course for treatment are determined by physician exam and x-rays. See Tests.
    • Caucasian children are more likely to have syndactyly than African-American or Asian children.
    • All except the mildest forms of syndactyly are treated surgically. Surgery is usually done when the child is between 6 months 1 year old; surgery can range from fairly straightforward to very complex. See Treatment & Care.

    How Children’s Hospital Boston approaches syndactyly

    You can have peace of mind knowing that the skilled experts in our Orthopedic Center’s Hand and Orthopedic Upper Extremity Program and our Plastic Surgery Department’s Hand and Microsurgery Reconstructive Program have treated thousands of babies and children with hand problems, ranging from the simple to the highly complex. So we can provide your child with expert diagnosis, treatment and care—as well as the benefits of some of the most advanced clinical and scientific research in the world.

    Our Orthopedic Center is nationally known as the preeminent center for the care of children and young adults with a wide range of developmental, congenital, neuromuscular, sports related, traumatic and post-traumatic problems of the musculoskeletal system.

    As one of the largest pediatric plastic surgery centers in the United States, our Department of Pediatric Plastic Surgery provides comprehensive care and treatment for a wide variety of congenital and acquired conditions, including hand deformities.

    Syndactyly: Reviewed by Donald Bae, MD

    © Children’s Hospital Boston, 2012

    The Hand and Orthopedic Upper Extremity Program provides comprehensive care involving occupational and physical therapy, splinting, casting and reconstructive surgeries for infants, children and adolescents with complex congenital, neuromuscular, sports-related oncologic and traumatic upper limb conditions.
    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 2
    Boston MA 02115

     617-355-6021
     fax: 617-739-1093

    Boston Children's Hospital at Waltham
    9 Hope Avenue
    Waltham MA 02453

     617-355-6021

     
    Boston Children's North
    10 Centennial Drive
    Peabody MA 01960

     617-355-6021

     


    The specialists in the Hand and Reconstructive Microsurgery Program at Children's are experts in the management of congenital and acquired hand deformities. We recognize the social elements involved in pediatric hand surgery, so an essential part of these operations has been making the child's hand as symmetrical as possible with his unaffected hand.
    Children's Hospital Boston
    300 Longwood Avenue
    Hunnewell 1
    Boston MA 02115
     617-355-7252
  • In-Depth

    At Children’s Hospital Boston, our orthopedic and plastic surgery teams know that you’re concerned about your baby’s syndactyly. It might help put your mind at ease to know that we’ve developed innovative surgical treatments for children with all degrees of severity of this condition. Learning more about syndactyly can help you feel more confident and informed, as we treat your child to improve both the function and appearance of his hand.

    What is syndactyly?

    Syndactyly is a congenital (present at birth) condition in which the fingers and/or toes are webbed or joined.

     Are there different forms and different levels of severity with syndactyly?

    Yes. The classifications of syndactyly correspond to the condition’s different types and degrees of complexity. Syndactyly can be classified in the following ways:

    • incomplete: the webbing or joining doesn’t extend all the way to the fingertips
    • complete: the webbing or joining extends all the way to the fingertips
    • simple: the fingers are joined only by soft tissue
    • complex: the fingers are joined by bone or bony cartilage, as well as soft tissue, in a side-by-side fashion
    • complicated: the fingers are joined by bone or bony cartilage, as well as soft tissue, in a fashion other than side-by-side—such as with abnormally shaped, extra or missing bones

    Who is at risk for getting syndactyly?

    Caucasians are more likely than African-Americans or Asians and to have syndactyly, and boys are more likely to have it than girls.

    How common is syndactyly?

    Syndactyly is a fairly common congenital hand defect, affecting about 1 out of every 2,500 babies. In 50 percent of cases, it affects only one hand.

    Will my child be OK?

    The good news is that after surgery, most of our young patients have adequate finger function and an improved appearance of their fingers and hands.

    If needed, your child’s care team will work with you and your child to learn home exercises that are important to his recovery. He may need to wear a cast in some circumstances. It is possible that in a severe case, your child may need additional reconstructive surgery(ies) to recover full function and improve the hand’s appearance.

    Causes

    During normal embryonic development (while the baby is still in the womb), the hand initially forms in the shape of a paddle; then—at about the sixth or seventh week of gestation—splits into separate fingers. Syndactyly results if there’s an irregularity in this process: The fingers fail to divide normally (failure of differentiation).

    Some cases of syndactyly occur in isolation and sporadically—meaning by themselves, for no identifiable genetic reason. In about 10 to 40 percent of cases, the condition occurs as an inherited trait. And in some cases, syndactyly is an accompanying defect in a genetic syndrome, such as Poland syndrome, Apert syndromeor Holt-Oram syndrome.

    Signs and symptoms

    Syndactyly is visible at birth. It may also be visible in utero by fetal ultrasound.

    When to see a specialist

    Your child’s doctor will know by sight that your baby’s fingers are webbed. The doctor will refer you to a hand specialist, who will guide you to a more detailed diagnosis and treatment plan.

    Questions to ask your doctor

    If your child is diagnosed with syndactyly, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed.

    • Some of the questions you may want to ask include:
    • What is happening to my child, and why?
    • What will x-rays reveal?
    • What actions might you take after you review my child’s x-rays?
    • Is surgery necessary? What will surgery entail?
    • Will my child be OK after surgery?
    • Will there be restrictions on his activities or capabilities?
    • What will be the long-term effects?
    • What can we do at home?

    Syndactyly glossary

    • The Center for Families at Children’s is dedicated to helping families find the information, services and resources they need to understand their child’s medical condition and take part in their care.
    • congenital: present at birth
    • embryonic development: development of the fetus in the womb
    • in utero:in the womb (uterus)
    • occupational and physical therapy: services offered by trained professionals to help restore function or (re)teach basic life skills, like walking or grasping objects
    • orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
    • orthopedic surgeon, orthopedist: a physician specializing in surgical and non-surgical treatment of the spine, skeletal system and associated muscles, joins and ligaments
    • prenatal (fetal) ultrasound: ultrasound performed at several stages of pregnancy; can detect syndactyly in the fetus
    • post-operative (post-op): occurring after surgery
    • pre-operative (pre-op): occurring before surgery
    • range of motion (ROM) exercises: physical therapy exercises designed to improve or restore flexion and extension of joints
    • reconstructive surgery: surgery performed to repair and/or restore a body part to normal or as near normal as possible
    • sporadic: occurring without apparent genetic cause
    • syndactyly: “webbed fingers” or “webbed hand;” one of the most common congenital hand differences
    • x-rays: a diagnostic test that uses invisible ionizing radiation to produce images of internal tissues, bones, and organs onto film
    • z-plasty: a surgical technique using zig-zag incisions

    See our extensive Glossary of Orthopedic Terms.

    Our plastic surgery programs and services include our Hand and Reconstructive Microsurgery Program

     

     

    Our complete orthopedic team

    Children’s is the primary pediatric teaching hospital of Harvard Medical School, where our physicians hold faculty appointments. We’re the largest pediatric orthopedic center in the nation, with 13 specialty clinics; an onsite brace shop; a plaster room; and a clinical team of orthopedic surgeons, orthopedic residents and fellows, certified physician assistants, nurse practitioners, registered nurses, physical/occupational therapists, brace technicians and cast technicians.


     

  • Tests

    At Children’s Hospital Boston, we understand that the first step to treating your child’s syndactyly is obtaining an accurate, timely and thorough diagnosis.

    Syndactyly may be seen by ultrasound prenatally, and is apparent at birth. Your doctor will use x-rays to assess the underlying structure of your baby’s fingers and determine a course of treatment. If the syndactyly is associated with a genetic syndrome, doctors will evaluate the baby’s entire upper extremity, chest feet and head/face to detect other abnormalities.

    Our Orthopedic Clinical Effectiveness Research Center (CERC)

    Children’s Orthopedic Clinical Effectiveness Research Center (CERC) was established by our Orthopedic Center to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and is playing an instrumental role in establishing, for the first time, evidence-based standards of care for pediatric orthopedic patients throughout the world.

  • At Boston Children's Hospital, experts in our Orthopedic Center's Hand and Orthopedic Upper Extremity Program and our Plastic Surgery Department's Hand and Microsurgery Reconstructive Program provide comprehensive care for syndactyly—including evaluation, diagnosis, consultation, surgery and follow-up care.

    How is syndactyly treated?

    Our orthopedic surgeons and plastic surgeons usually treat children with syndactyly by surgically releasing the fingers from their webbing. This procedure is typically performed when the child is between 1 and 2 years old. At this age, the child is old enough to tolerate anesthesia and surgery but is not at risk for missing developmental milestones such as grasping (prehension).

    What happens during surgery?

    • In general, the skin is split evenly between the two fingers with zig-zag incisions (z-plasty).
    • Only one side of a finger is separated at a time in order to avoid complications related to the skin coverage and blood supply of the affected finger. For this reason, if your child has multiple fingers that are joined, more than one surgical procedure will be needed.

    Complications after surgery

    Complications right after surgery are uncommon and usually minor.But medium- to longer-term complications can include:

    • recurrence of the condition (web creep)
    • inadequate blood supply to the finger (finger ischemia)
    • shortening and hardening of scar tissue (scar contracture)
    • skin graft complications
    • nail plate deformity

    Caring for your child after surgery
    After surgery, your child is usually placed in an above-elbow cast for three weeks to help immobilize and protect the hand. Once the cast is removed, a splint that slides in between the fingers and keeps them apart is used for an additional six weeks. During this time, your child's doctor may recommend occupational or physical therapy to help reduce scarring, stiffness and swelling and improve function.

    What is the follow-up treatment plan?
    We will want to see your child for follow-up visits to ensure that healing has gone well and function has returned. In some cases, follow-up will continue for years to evaluate whether additional surgery is needed to improve the function or appearance of your child's hand.

    Long-term outlook

    Most of our young patients recover full hand function and an improved appearance of their hand. If needed, your child's team will work with you and your child to learn home exercises that are important to his recovery. He may need to wear a cast or splint in some circumstances. If your child's case is severe, he may need additional reconstructive surgery(ies) to recover full function and improve the hand's appearance.

    Your child may need to be followed for a number of months or years to:

    • ensure that the healing has gone well
    • check that function has returned to your child's hand
    • determine whether additional surgery is needed to improve the function or appearance of the hand as your child grows

    Coping and support

    At Boston Children's Hospital, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit The Center for Families for all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with syndactyly. Will this affect my child long term? Will he be able to play sports and do regular activities? Children's can connect you with extensive resources to help you and your family through this stressful time, including: 

    • patient education: From doctor's appointments to physical therapy and recovery, our nurses and physical therapists will be on hand to walk you through your child's treatment and help answer any questions you may have—Why will my child need surgery? How long will his recovery take? How should we manage home exercises and physical therapy? We'll help you coordinate and continue the care and support your child received while at Children's.
    • parent-to-parent: Want to talk with someone whose child has been treated for syndactyly? We can often put you in touch with other families who've been through the same process that you and your child are facing, and who will share their experiences.
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy— representing Protestant, Jewish, Muslim, Roman Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
    • social work: Our  social workers and mental health clinicians have helped many families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial difficulties.
  • Research & Innovation

    Improving outcomes for upper extremity disorders

    Children’s Hospital Boston’s Orthopedic Center's Hand and Orthopedic Upper Extremity Program is dedicated to the comprehensive care of all upper limb conditions in infants, children and adolescents. Under the direction of Peter M. Waters, MD and Donald S. Bae, MD, patients with congenital, neuromuscular, sports-related, oncologic and traumatic or post-traumatic conditions of the upper extremity receive multi-disciplinary care that includes occupational and physical therapy, splinting/casting and reconstructive surgery.

    In addition, our Hand and Orthopedic Upper Extremity Program is committed in its efforts to improve clinical care through continued clinical and basic science research. The program is studying the treatment of a wide variety of upper limb conditions, including:

    • reconstruction of the congenitally deficient hand
    • the use of microsurgical techniques in reconstructive surgery for congenital upper extremity differences
    • instability of the sternoclavicular and glenohumeral joints of the shoulder
    • post-traumatic stiffness and deformity of the elbow
    • surgical correction of forearm deformity following previous fracture
    • ligament and/or cartilage injuries of the wrist
    • the use of microsurgical techniques in reconstructive surgery following limb salvage for bone and soft-tissue tumors, as well as treatment of sports-related injuries to the upper limb

    Many of these investigations have resulted in national and international presentations or peer-reviewed medical publications—and all have increased our ability to provide the highest standard of patient care.

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