Sunteți pe pagina 1din 34

Clinodactyly

Christian Dumontier MD, PhD


Centre de la Main- Guadeloupe- FWI
• Clinodactyly is a physical sign, not a disease, and
may be found at birth, may gradually develop, or
may result from a variety of pathological processes.
Clinodactyly

• From the Latin -clīn(āre) (cognate with Greek klī́nein to cause


to lean) and the Greek daktylos = finger

• A bent finger: clinodactyly is defined as angulation of a digit in


the radio-ulnar plane

• Earliest report of clinodactyly is probably by Smith, in 1896,


who noted the association between mongolism and
clinodactyly
Incidence

• In the literature between 10,7-19.5%

• 1/1,000 in America (Hersch)

• 3-5% of Japanese children (geographical variations ? Fujita)

• Gender distribution in the USA to be 15% among boys and 8%


among girls for the little finger and 2% for index finger

Hersch, AH, De Marinus, F, Stecher R. On the inheritance and development of clinodaclyly. Am. J Human Gen., 1953;
5: 257-268.
Fujita H, Iio K, Yamamoto K. Brachymesophalangea and clinodac- tyly of the fifth finger in Japanese children. Acta
Paediatr Jpn 1964; 31:26 –30.

Classification
• 3 types

• Familial clinodactyly with a


dominant inheritance

• Clinodactyly in association with


other (> 60) syndromes; Marked
clinodactyly often indicates
mental retardation.

• Clinodactyly secondary to
epiphyseal injury (fracture,
frostbite…)
Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Poznanski AK et al. Clinodactyly, Camptodactyly, Kirner’s Deformity, and Other Crooked Fingers. Radiology 1969; 93:
573-582.
Clinodactyly in Apert Clinodactyly in a tri-
Syndrome phalangeal thumb

Norat F et al. Les clinodactylies : phalange delta et déformation de Kirner. Chirurgie de la main 27S (2008) S165–S173
« Familial » clinodactyly

• Minor angulation, particularly in the little finger, is a normal


finding and an angulation of 10° is commonly regarded as the
upper limit of normal.

• Inherited as an autosomal dominant trait with slight lack of


penetrance (Hersch, 1953)

Hersch, AH, De Marinus, F, Stecher R. On the inheritance and development of clinodaclyly. Am. J Human Gen., 1953;
5: 257-268.
Clinodactyly in art

François Ier, French king,


1494-1547 (painting from Jean Marguerite de Valois, « la reine Margot »,
Clouet, Musée du Louvre) 1553-1615 his grand daughter (painting from
François Clouet, Musée Condé-Chantilly)
Clinodactyly - Pathophysiology
• Skeletal basis is a delta-shaped
middle phalanx (in most cases)

• Characterized by an anomalous
epiphysis (C-shaped) that is
oriented longitudinally along the
short side of the affected bone
leading to progressive angulation
of the digit toward the convex side

• Blundell Jones suggested the term


“delta phalanx” to describe the
abnormal triangular bone, but it
could be a trapezoidal phalanx.

Blundell Jones G. Delta Phalanx. JBJS Br 1964, 46B(2): 226-228


Delta phalanx
Trapezoidal shape
Clinodactyly

• In young children without visible


epiphysis, the C-shape is not visible
Clinodactyly vs brachy-meso-
phalangism

• Studies have shown that the


ratio P2/P3 varies from 1.1 to
1.3 irrespective of age.

• Less than 1 are usually


regarded as abnormally short
and called brachymeso-
phalangism
Delta phalanx brachy-meso-phalangism

Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Rare cases

• « Kissing delta phalanx » in Cenani-Lenz and Carpenter


syndromes

Buck-Gramcko D, Ogino T. Congenital malformations of the hand: non- classificable cases. Hand Surg 1996;1:45–61
Rare cases

• Sporadic index clinodactyly


reported by Al Qattan

Al-Qattan MM. Congenital sporadic clinodactyly of the index finger. Ann Plast Surg 2007;59:682– 687.
Norat F et al. Les clinodactylies : phalange delta et déformation de Kirner. Chirurgie de la main 27S (2008) S165–S173
Flatt’s series of 50 cases
• 28 females, 22 males

• 32 had familial history

• 18 isolated (mostly familial


history), 30 had a syndrome

• 24 patients with P2 involvement,


4 P1 (2 thumb, 2 ring) had a
radiological appearance of delta
phalanx (17 too old without

cartilage left to conclude).

Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Clinical presentation

• Radial deviation of the DIP


of the little finger

• Most cases of true


clinodactyly are a cosmetic
rather than a functional
problem.

Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Poznanski AK et al. Clinodactyly, Camptodactyly, Kirner’s Deformity, and Other Crooked Fingers. Radiology 1969; 93:
573-582.
Indications for treatment

• « …The majority of patients with clinodactyly have little


in the way of functional problems and therefore require no
treatment. A minority will require surgical intervention,
either from a functional or a cosmetic point of view, usually
the latter… »( Flatt)

• It also depends of the phalanx involved


Abstention

• Minor deformity

• May reveal psychological


problems
Indications according to the
phalanx involved
• Middle Phalanx. Few of these merit surgery (according to Flatt) as
longitudinal growth of the affected middle phalanx is moderately reduced.

• Those with marked angulation of the small finger at the DIP joint can
accommodate by abduction of the metacarpophalangeal joint.

• It is advisable to allow the middle phalanx to achieve maximal length before


surgery is attempted ( await skeletal maturity before performing surgery)

• Proximal Phalanx. Angulation of a significant degree tends to occur early and


early intervention is indicated

• Congenital triangular bone in the tri-phalangeal thumb should be excise early


in life, for increasing instability and angulation will occur.
Surgical techniques
+/- Bone graft

• Closing wedge osteotomy (Wood)

• Opening wedge osteotomy (Jones)

• Reverse wedge osteotomy (Carstam)

Carstam N, Theander G. Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis (‘‘delta
phalanx’’). Scand J Plast Reconstr Surg 1975;9:199–202.
Jones GB. Delta phalanx. J Bone Joint Surg Br 1964;46:226–8.
Wood VE, Flatt AE. Congenital triangular bones in the hand. J Hand Surg Am 1977;2:179–93.
Closing wedge osteotomy

• 25 fingers (17 patients): small finger


(20 digits), index finger (4 digits), and
middle finger (1 digit)

• Age 1-15 years (mean, 9 years).

• Family history was positive for


clinodactyly only in 4 patients. Fifteen
patients had isolated clinodactyly.

Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
Closing wedge osteotomy
• Dorsolateral longitudinal incision over the
convex side of the finger.

• Remove a 2- to 3-mm bony wedge (or the kerf


of the blade)

• One or two K-wires (1.4 mm or 0.9 mm) from


the pulp, across the osteotomy, transfixing the
PIP joint.

• K-wires are removed after 4 or 6 weeks

Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
Closing wedge osteotomy
• Angular deformity improve
from 33° preop to 9° postop
(X-rays correction from 29°
to 5°)
6 years old boy, 6 months FU
• DIP joint arc of motion
decreased from 84° prior to
surgery to 81° after surgery,

• PIP joint arc of motion was


unchanged.
Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
Opening wedge osteotomy

• Dorsal V-shaped incision that


can be close in a VY fashion

Goldfarb CA, Wall LB. Osteotomy for clinodactyly. J Hand Surg Am. 2015;40(6):1220-1224
Opening wedge osteotomy
• A single 0.045-inch Kirschner
wire is placed retrograde in the
distal phalanx, slightly radial to
midline.

• It crosses the DIP joint to


stabilize it during the osteotomy

• A second, temporary 0.035-inch


Kirschner wire is placed across
the PIP joint to avoid deviation
through the joint when “opening”
the osteotomy

Goldfarb CA, Wall LB. Osteotomy for clinodactyly. J Hand Surg Am. 2015;40(6):1220-1224
Opening wedge osteotomy
• 13 fingers in 9 patients treated Preop Postop
between 2003 and 2011.
Clinical 34°
• Average age at surgery was 7° (0-35°)
angle (20-45°)
nine years. FU was 25 months

• 2 complications (non-unions X-rays 35°


7° (0-30°)
angle (27-45°)
with recurrent deformity)-
they now use bone grafts from
259,3° 234,5°
the radius TAM
(225-270) (110-270°)

Piper SL, Goldfarb CA, Wall LB. Outcomes of Opening Wedge Osteotomy to Correct Angular Deformity in little finger
Clinodactyly J Hand Surg Am. 2015;40(5):908-913
Others

• Realignement

• Reverse wedge osteotomy


(Carstam)

Carstam N, Theander G. Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis (‘‘delta
phalanx’’). Scand J Plast Reconstr Surg 1975;9:199–202.
Surgical techniques
The limiting factor is tightness of all the soft tissues, and Z-
plasty of the skin does little to help (Jones, 1964).
The extensor mechanism and the neurovascular structures
are at risk

• Physiolysis (Vickers)

Vickers D. Clinodactyly of the little finger: a simple operative technique for reversal of the growth abnormality. J Hand
Surg Br 1987;12:335–42.
Physiolysis

• Vickers removes the proximal


bone metaphysis up to the
growth plate and add a fat
graft
Radiographic evolution over a 5 years period
• He reported (progressive)
improvement in 12 patients

Vickers D. Clinodactyly of the little finger. A simple operative technique for reversal of the growth abnormality. J Hand
Surg Br 1987; 12B(3):335-342
Vickers’s Physiolysis
• 22 patients (27 fingers) over a 13 years period with 7,4 years FU

• 14 boys, 8 girls Mean age 3,9

• 1 index, 1 middle, 24 little fingers

• Fat graft from the hypothenar

• No K-wire, only the skin is sutured. 2 weeks immobilisation.

• No immediate correction of the clinodactyly; the response to surgery is seen


only with the child’s growth +++

• No complications, normal finger motion

• Final angulation was 8° (79% correction) obtained in most cases within 1 year

Medina J, Lorea P, Elliot D,Foucher G. Correction of Clinodactyly by Early Physiolysis: 6-Year Results. J Hand Surg
Am. 2016;41(6):123-127
Vickers’s Physiolysis
• 14 patients (24 fingers) over a 6
years period with 54 months FU

• Mean age 4,3 years at surgery

• Correction rate was 49% at 1 year


and 70% at 2 years

• 2 premature growth plate closure

• No difference if performed after 6


years of age

El Sayed L, Salon A, Glorion C, Guéro S. Physiolysis for correction of clinodactyly with delta phalanx: Early
improvement. Hand Surgery and Rehabilitation 38 (2019) 125–128
Other series
• Al Qattan, in 10 index fingers using closing wedge osteotomy recommended that
Vickers physiolysis should be used early and that closing or open wedge
osteotomy should be followed later. He obtained a mean correction from 44° to
13°.

• Gillis compared 21 patients (30 digits) with Vickers’s technique and 6 patients
(11 digits)with osteotomy

• Angulation improved from 43.0° to 23.9° (46.2% correction) in the Vickers


group. The osteotomy decrease from 39.2° to 22.4° angulation (55.3%
correction).

• The use of osteotomy may lead to more revision cases, while the Vickers
procedure has minimal complications and need for revision. The Vickers
physiolysis procedure is more effective in those with angulation less than 55°

Al-Qattan MM. Congenital sporadic clinodactyly of the index finger. Ann Plast Surg 2007;59:682– 687.
Gillis JA. Comparison of Vickers Physiolysis Versus Osteotomy for Primary Correction of Clinodactyly. Abstract ASSH
2018
Conclusion

• Rarely a functional impairment

• Vicker’s physiolysis is safe, effective if performed in


the early ages (but complete removal of the
abnormal epiphysis is required)

• Ostotomies can be performed later when sufficient


bone is available