Syndactyly Syndactyly and and

ClinodactylyClinodactyly

DescriptionDescription

Webbed fingers (or toes) usually Webbed fingers (or toes) usually detected at birthdetected at birth

Classification:Classification:SimpleSimple (skin only) versus (skin only) versus complex complex

(bony involvement/fusion)(bony involvement/fusion)CompleteComplete (entire length of digits (entire length of digits

involved) versus involved) versus incompleteincomplete (some part (some part of fingers joined)of fingers joined)

Simple syndactyly. Fingers are bridged only by skin and other soft tissues. Simple syndactyly. Fingers are bridged only by skin and other soft tissues. A,A, Palmar Palmar view. view. B,B, Dorsal view. Dorsal view. C,C, Radiograph. Note angular deformity of ring finger. Radiograph. Note angular deformity of ring finger.

Complex syndactyly. Common bony elements are shared by

involved fingers.

EpidemiologyEpidemiology More common in Caucasian.More common in Caucasian. Boys are more frequently affected than Boys are more frequently affected than

girls. girls.

IncidenceIncidence Syndactyly occurs per ~1 per 2,000 Syndactyly occurs per ~1 per 2,000

births.births.

It is seen bilaterally in 50% of cases.It is seen bilaterally in 50% of cases.

Syndactyly occurs between the long and ring fingers in Syndactyly occurs between the long and ring fingers in more than 50% of patients (Fig. 76-36); the fourth web, more than 50% of patients (Fig. 76-36); the fourth web, second web, and first web are affected in diminishing second web, and first web are affected in diminishing

frequenciesfrequencies Picture pf percentge. Picture pf percentge.

Risk FactorsRisk Factors The presence of other congenital The presence of other congenital

abnormalities. abnormalities.

GeneticsGenetics 10-40% of the cases are familial.10-40% of the cases are familial. 80% of cases are sporadic .80% of cases are sporadic . autosomal dominant trait for long-autosomal dominant trait for long-

ring ring

finger syndactyly, but penetrance finger syndactyly, but penetrance incomplete. incomplete.

EtiologyEtiology

The specific cause is unknown.The specific cause is unknown.

Syndactyly occurs secondary to a Syndactyly occurs secondary to a failure failure of separationof separation of the digits in the 6-8th of the digits in the 6-8th weeks of intrauterine life.weeks of intrauterine life.

Although syndactyly may be associated Although syndactyly may be associated in some cases with a positive family in some cases with a positive family history or with a syndrome, in most cases history or with a syndrome, in most cases it is an it is an isolated findingisolated finding..

Associated ConditionsAssociated Conditions Webbing of the toes, cleft feet.Webbing of the toes, cleft feet. Polydactyly .Polydactyly . Constriction rings(Cong. Const. band syndrome). Constriction rings(Cong. Const. band syndrome). Brachydactyly. Brachydactyly. Hemangioma, absence of muscles, spinal Hemangioma, absence of muscles, spinal

deformities, funnel chest, and heart disorders deformities, funnel chest, and heart disorders

Acrosyndactyly, fenestrated syndactyly (joined Acrosyndactyly, fenestrated syndactyly (joined tips)tips)

Proteus syndromeProteus syndrome

Apert syndromeApert syndrome: :

Acrocephalosyndactyly, characteristically Acrocephalosyndactyly, characteristically includes multiple syndactylies. includes multiple syndactylies.

Poland syndromePoland syndrome: :

Associated with chest wall anomalies and Associated with chest wall anomalies and cardiac anomalies,ipsilateral pectoralis cardiac anomalies,ipsilateral pectoralis major muscle is absent. The hand deformity major muscle is absent. The hand deformity includes unilateral shortening of the index, includes unilateral shortening of the index, long, and ring fingers; multiple simple long, and ring fingers; multiple simple incomplete syndactylies; and hypoplasia of incomplete syndactylies; and hypoplasia of the hand. the hand.

Poland syndrom picturePoland syndrom picture Poland syndrome in 18-month-old child. Poland syndrome in 18-month-old child. AA and and B,B, Brachysyndactyly. Brachysyndactyly. C,C, Hypoplasia of Hypoplasia of

pectoralis major muscle. pectoralis major muscle.

DiagnosisDiagnosis1. 1. Signs and SymptomsSigns and Symptoms No pain is associated with this condition.No pain is associated with this condition.

2.2. Physical ExamPhysical Exam Observe joined fingers, which can be Observe joined fingers, which can be

associated with many anomalies.associated with many anomalies. Examine the joints for active and passive Examine the joints for active and passive

ROM.ROM. If the fingers are of relatively similar length, If the fingers are of relatively similar length,

flexion and extension usually are normal flexion and extension usually are normal

Test the 2 joined digits at each level for Test the 2 joined digits at each level for independent movement.independent movement. Ability to move separately indicates no bony or Ability to move separately indicates no bony or

complex syndactylycomplex syndactyly.. Insufficient amount of skin between the digits Insufficient amount of skin between the digits

is a sign of the difficulty of reconstruction.is a sign of the difficulty of reconstruction.

Abnormally tight fascial bands minimize any Abnormally tight fascial bands minimize any lateral movement between the involved digits lateral movement between the involved digits

Inspect the nails.Inspect the nails. If they are joined, it is likely that the If they are joined, it is likely that the

underlying bones are joined also.underlying bones are joined also. Completely separated,or the digits may Completely separated,or the digits may

share common nail share common nail

Pathological FindingsPathological Findings

Insufficient amount of skin presentInsufficient amount of skin present Abnormal fascial interconnections, tight fascial Abnormal fascial interconnections, tight fascial

bands bands Abnormal interconnection between flexor and Abnormal interconnection between flexor and

extensor tendonsextensor tendons Various anomalies of joints and bonesVarious anomalies of joints and bones

various interosseous connections(Complex form) duplication various interosseous connections(Complex form) duplication patterns, to branching patterns, to shared patterns.patterns, to branching patterns, to shared patterns.

Frequently, there are anomalous sharings of Frequently, there are anomalous sharings of musculotendinous units, nerves, and vessels musculotendinous units, nerves, and vessels between joined digitsbetween joined digits

Angular Deformity Angular Deformity

Rarely at birth, unless a delta phalanx is present. Rarely at birth, unless a delta phalanx is present.

Central syndactyly angular deformities develop Central syndactyly angular deformities develop slowly. slowly.

Syndactyly involving border fingers, however,a gradual Syndactyly involving border fingers, however,a gradual flexion contracture, lateral deviation, and rotation flexion contracture, lateral deviation, and rotation deformity usually develop in the longer of the two digits deformity usually develop in the longer of the two digits within the first year within the first year

3. 3. ImagingImaging

Plain radiography is indicated to Plain radiography is indicated to differentiate simple from complex differentiate simple from complex syndactyly.syndactyly.

Angiography or MRA may be needed in Angiography or MRA may be needed in difficult cases of syndactyly to assess the difficult cases of syndactyly to assess the structure of the underlying vascular structure of the underlying vascular supply of the 2 digits.supply of the 2 digits.

Vasculature branching distally instead of Vasculature branching distally instead of proximally may limit the extent of possible proximally may limit the extent of possible separation.separation.

TreatmentTreatment

Massage the web in an attempt to stretch the Massage the web in an attempt to stretch the intervening skin to facilitate later surgery intervening skin to facilitate later surgery

Release of webbing:Release of webbing:

Can improve cosmesis and functionCan improve cosmesis and function Webs less than a few millimeters distally, or Webs less than a few millimeters distally, or

those causing minimum ROM-inhibition, dont those causing minimum ROM-inhibition, dont need surgical intervention.need surgical intervention.

Complex syndactyly, especially with only 1 Complex syndactyly, especially with only 1 branching neurovascular bundle, can be difficult to branching neurovascular bundle, can be difficult to correct surgically.correct surgically.

The timing of surgery is controversial, The timing of surgery is controversial, but usual recommendations:but usual recommendations:

best done before the child is of school age best done before the child is of school age 6-12 months of age for border digits .6-12 months of age for border digits . >18 months for central digits>18 months for central digits

Physical TherapyPhysical Therapy Postoperative scar management, web Postoperative scar management, web

space splinting, and/or motion.space splinting, and/or motion.

The surgical procedure includes three The surgical procedure includes three technical steps:technical steps:

Separation of the digits. Separation of the digits.

Commissure reconstruction, Commissure reconstruction,

Resurfacing of the intervening borders of Resurfacing of the intervening borders of the digits the digits

Zigzag incision to prevent linear contracture Zigzag incision to prevent linear contracture

Shared digital nerves are carefully split longitudinally Shared digital nerves are carefully split longitudinally

Common digital arteries may extend into the web and Common digital arteries may extend into the web and require ligation of one or more branches. Care should require ligation of one or more branches. Care should be taken to avoid devascularizing the digit. be taken to avoid devascularizing the digit.

When the nail is shared, an additional longitudinal When the nail is shared, an additional longitudinal strip of nail and underlying matrix usually must be strip of nail and underlying matrix usually must be removed to match the normal nail width. removed to match the normal nail width.

Osseous structures usually are divided longitudinalOsseous structures usually are divided longitudinal . .

The normal commissure has a sloping configurationThe normal commissure has a sloping configuration

Distally, the commissure forms a rectangle Distally, the commissure forms a rectangle

In recreating a commissure a properly designed local flap In recreating a commissure a properly designed local flap generally is preferable to a skin graft to minimize generally is preferable to a skin graft to minimize commissure contracture commissure contracture

Most commonly used are:Most commonly used are:

the the dorsal “pantaloon” flapdorsal “pantaloon” flap described by Bauer, Tondra, described by Bauer, Tondra, and Trusler; and Trusler;

the the matching volar and dorsal proximally based V-matching volar and dorsal proximally based V-shaped flapsshaped flaps popularized by Cronin and by Skoog; popularized by Cronin and by Skoog;

and the “and the “butterfly” flapbutterfly” flap devised by Shaw et al. devised by Shaw et al.

Woolf and Broadbent described the butterfly Woolf and Broadbent described the butterfly flap as useful for partial simple syndactyly that flap as useful for partial simple syndactyly that

ends proximal to the PIP jointends proximal to the PIP joint

Butterfly flap technique for release of syndactyly. Flaps are designed in web space Butterfly flap technique for release of syndactyly. Flaps are designed in web space to form to form

dorsal rectangledorsal rectangle, then flaps are , then flaps are rotated to deepen webrotated to deepen web. .

There usually is not enough skin for primary closure of There usually is not enough skin for primary closure of each digit. each digit.

Occasionally redundant skin may make primary Occasionally redundant skin may make primary closure possible. closure possible.

Greuse et al. suggested that sufficient defatting allows Greuse et al. suggested that sufficient defatting allows for primary closure without grafting; for primary closure without grafting;

The zigzag incision is designed to create The zigzag incision is designed to create interdigitating volar and dorsal flaps for one finger; the interdigitating volar and dorsal flaps for one finger; the other finger requires either full-thickness or split-other finger requires either full-thickness or split-thickness thickness

Open technique of syndactyly release Open technique of syndactyly release (Withey et al.)(Withey et al.) . . A,A, Dorsal incisions. Dorsal incisions. B,B, Palmar incisions. Palmar incisions.

Open Finger Syndactyly Release Open Finger Syndactyly Release

(Withey et al.)(Withey et al.) Mark the flaps as shown, using the Mark the flaps as shown, using the rectangular flaprectangular flap to recreate the to recreate the

web and web and seven or eight flaps to interdigitateseven or eight flaps to interdigitate around the fingers around the fingers

Raise each flap to the midaxial line. Because of the number of flaps, Raise each flap to the midaxial line. Because of the number of flaps, each has a narrow base.each has a narrow base.    

Do not defat the digital flaps to avoid compromising their vascularityDo not defat the digital flaps to avoid compromising their vascularity

Tack the flaps in place with a single apical stitch, leaving the raw Tack the flaps in place with a single apical stitch, leaving the raw areas between them to heal by secondary intention.areas between them to heal by secondary intention.

If necessary, use a split-thickness skin graft to resurface the defect If necessary, use a split-thickness skin graft to resurface the defect at the commissure.at the commissure.

Apply a bulky dressing.Apply a bulky dressing.

     

AFTERTREATMENTAFTERTREATMENT

The dressing is left in place for 1 week and then The dressing is left in place for 1 week and then changed. changed.

The second dressing is removed at 2 weeks after The second dressing is removed at 2 weeks after surgery, at which time the incisions should be surgery, at which time the incisions should be healed.healed.

The patient's parents should be informed that The patient's parents should be informed that scar deformity , revision(30-60%) ,recurrence, scar deformity , revision(30-60%) ,recurrence, angular deformity and web Distal migration are angular deformity and web Distal migration are possible.possible.

Skoog technique for syndactyly.Skoog technique for syndactyly. A and B, Dorsal and volar skin incisions. C, Web space A and B, Dorsal and volar skin incisions. C, Web space

reconstruction; closure of ring finger. D and E, Dorsal and volar reconstruction; closure of ring finger. D and E, Dorsal and volar

views: skin graft in place on little finger and graft in web space.views: skin graft in place on little finger and graft in web space.

Syndactyly Release with Matching Volar and Dorsal Syndactyly Release with Matching Volar and Dorsal

Proximally Based V-Shaped FlapsProximally Based V-Shaped Flaps( Skoog)( Skoog) Outline the incisions on fingers. Outline the incisions on fingers.

Design dorsal and volar flaps so that they cover most of the Design dorsal and volar flaps so that they cover most of the denuded side of one fingerdenuded side of one finger

Designing small triangular points at the level of the Designing small triangular points at the level of the interphalangeal joints.interphalangeal joints.           

Flaps shoud fit each other, first outline the incision on one side Flaps shoud fit each other, first outline the incision on one side and then establish the key points for the incision on the opposite and then establish the key points for the incision on the opposite side by pushing straight needles vertically through the web.side by pushing straight needles vertically through the web.         

Raising the flaps, preserving all subcutaneous tissue, and take Raising the flaps, preserving all subcutaneous tissue, and take care not to sever digital nerves and arteries.care not to sever digital nerves and arteries.    ••    Release the tourniquet, and control all bleeding.    Release the tourniquet, and control all bleeding.           

Using the triangular flaps, reconstruct the web space Using the triangular flaps, reconstruct the web space       

On one finger, close the flaps as planned, small remaining On one finger, close the flaps as planned, small remaining defect (dorsomedial aspect/ base)by a full-thickness skin defect (dorsomedial aspect/ base)by a full-thickness skin graft..graft..           

Matching full-thickness graft for denuded area on the Matching full-thickness graft for denuded area on the adjacent finger and on the new web.   adjacent finger and on the new web.   

Carefully suture the graft in place Carefully suture the graft in place

            Pressure dressing with Xeroform gauze over the grafts and Pressure dressing with Xeroform gauze over the grafts and

suture lines, spread the fingers widely and place between suture lines, spread the fingers widely and place between them wet cotton pressed them wet cotton pressed

Plaster splint; if necessary A/E.Plaster splint; if necessary A/E.         

AFTERTREATMENTAFTERTREATMENT

Hand elevation for at least 3 days after Hand elevation for at least 3 days after surgery. surgery.

10-14 days, dressing( if necessary under 10-14 days, dressing( if necessary under GA).GA).

Sutures can be removed at this time. Sutures can be removed at this time.

Another bandage is maintained for an Another bandage is maintained for an additional 10 to 14 days, and gradual additional 10 to 14 days, and gradual resumption of normal activities is allowed.resumption of normal activities is allowed.

Apert SyndromeApert Syndrome

Reconstructive surgery usually improves Reconstructive surgery usually improves hand function in these patients by hand function in these patients by creating a three-fingered hand with an creating a three-fingered hand with an opposable thumb. opposable thumb.

The surgical management should follow The surgical management should follow the protocol outlined by Flatt. the protocol outlined by Flatt.

Flatt-ProtocolFlatt-Protocol STAGE ISTAGE I      Release of the border digits as described by Bauer et al before 1 year.Release of the border digits as described by Bauer et al before 1 year.

         If the thumb is not included, deepen the web with a four-part Z-plasty.If the thumb is not included, deepen the web with a four-part Z-plasty.

          Close the skin flaps, and cover the remaining defects with a full-thickness Close the skin flaps, and cover the remaining defects with a full-thickness

skin graft.skin graft.

STAGE IISTAGE II   6 to 9 months later to allow for revascularization and softening of the 6 to 9 months later to allow for revascularization and softening of the

tissues.tissues.    

Incisions and flaps as described by Bauer et al. using all the skin overlying Incisions and flaps as described by Bauer et al. using all the skin overlying the middle digit.the middle digit.         

After the flaps are elevated, amputate the long digit MCP.After the flaps are elevated, amputate the long digit MCP.    

Use the overlying skin to reconstruct the remaining commissure between Use the overlying skin to reconstruct the remaining commissure between the index and ring fingers and to cover the fingersthe index and ring fingers and to cover the fingers

Close the flaps, cover the remaining defects full-thickness skin graft.Close the flaps, cover the remaining defects full-thickness skin graft.         

Apply sterile dressings of moistened cotton batting between the webs, and Apply sterile dressings of moistened cotton batting between the webs, and apply a plaster splint..apply a plaster splint..

Syndactyly release(bauer et al). Syndactyly release(bauer et al). A,A, Dorsal skin incisions. Rectangular Dorsal skin incisions. Rectangular dorsal flap (A) is designed for web; alternating flaps (C, D, and E) are dorsal flap (A) is designed for web; alternating flaps (C, D, and E) are arranged to interdigitate with volar flaps. arranged to interdigitate with volar flaps. B,B, Palmar skin incisions. Palmar skin incisions. Rectangular flap (B) is arranged to cover radial side of ring finger; Rectangular flap (B) is arranged to cover radial side of ring finger; remaining flaps (C′, D′, and E′) are arranged to interdigitate with remaining flaps (C′, D′, and E′) are arranged to interdigitate with dorsal flaps. dorsal flaps. C,C, Separation is completed; flaps have been sutured into Separation is completed; flaps have been sutured into place, covering radial side of ring finger and web. Skin graft is place, covering radial side of ring finger and web. Skin graft is required for ulnar side of long finger. required for ulnar side of long finger.

Syndactyly Release with Dorsal Flap Syndactyly Release with Dorsal Flap (Bauer et al.)(Bauer et al.)

Incise the dorsal flaps, and defat the proximal flap Incise the dorsal flaps, and defat the proximal flap Incise the palmar flaps Incise the palmar flaps

dorsal flap “A” first to restore the commissur. dorsal flap “A” first to restore the commissur. Flap “B” to resurface the radial and proximal border of the Flap “B” to resurface the radial and proximal border of the

ring finger.ring finger.

Triangular flaps to resurface intersurface of the digits.Triangular flaps to resurface intersurface of the digits.

Release the tourniquet, controlle perfusion to the Release the tourniquet, controlle perfusion to the triangular flapstriangular flaps

Remaining defects with a full-thickness skin graft. Remaining defects with a full-thickness skin graft.

Xeroform gauze over the grafts, a wet contour dressing Xeroform gauze over the grafts, a wet contour dressing between the fingers held in wide abduction and extension. between the fingers held in wide abduction and extension.

Apply a dry dressing and a plaster splint for 4 weeks.Apply a dry dressing and a plaster splint for 4 weeks.

PrognosisPrognosis The prognosis is good, although minor differences The prognosis is good, although minor differences

in width and appearance of the reconstructed in width and appearance of the reconstructed digit are common.digit are common.

ComplicationsComplications StiffnessStiffness Wound dehiscenceWound dehiscence Scar contractureScar contracture Partial web recurrencePartial web recurrence Circulatory deficit, resulting in loss of digit:Circulatory deficit, resulting in loss of digit:

RareRare Can be minimized by operating on only 1 side of the Can be minimized by operating on only 1 side of the

digit at a time, so that a collateral vessel is preserved.digit at a time, so that a collateral vessel is preserved.

Patient MonitoringPatient Monitoring As children grow, they should be monitored for As children grow, they should be monitored for

partial recurrence of the web or scar contracture.partial recurrence of the web or scar contracture.

ClinodactylyClinodactyly DescriptionDescription Clinodactyly presents as a painless bent Clinodactyly presents as a painless bent

finger with angulation in a radial or ulnar finger with angulation in a radial or ulnar directiondirection

most common little finger in a radial most common little finger in a radial direction.direction.

Most often, the finger has a short, delta-Most often, the finger has a short, delta-shaped middle phalanx.shaped middle phalanx.

Association with mental retardation, Association with mental retardation, especially when clinodactyly is severe.especially when clinodactyly is severe.

EpidemiologyEpidemiology

Detected at birthDetected at birth More common in More common in malesmales, in whom it is usually , in whom it is usually bilateralbilateral

IncidenceIncidence 1-19.5%1-19.5% in otherwise normal children; least common in in otherwise normal children; least common in

Caucasians .Caucasians .

Risk FactorsRisk Factors In children with Down syndrome, the incidence of In children with Down syndrome, the incidence of

clinodactyly is clinodactyly is 35-70% .35-70% . It also is seen in children with many other syndromes, It also is seen in children with many other syndromes,

especially Kline-Felter and trisomy 18.especially Kline-Felter and trisomy 18.

GeneticsGenetics Autosomal dominant, with variable expressivity.Autosomal dominant, with variable expressivity. Some cases are sporadic.Some cases are sporadic.

EtiologyEtiology Abnormal shape of the underlying phalanx Abnormal shape of the underlying phalanx

develops as a result of asymmetrical longitudinal develops as a result of asymmetrical longitudinal growth.growth.

Associated ConditionsAssociated Conditions Symphalangism(IPJ fusion)Symphalangism(IPJ fusion) Brachydactyly (short fingers)Brachydactyly (short fingers) TrisomiesTrisomies Treacher Collins syndrome(Treacher Collins syndrome(mandibulofacial mandibulofacial

dysostosis )dysostosis ) Silver syndrome (Silver syndrome (poor growth) poor growth)

Prader-Willi syndromePrader-Willi syndrome

DiagnosisDiagnosis

Signs and SymptomsSigns and Symptoms Finger (usually the little finger)curved in a Finger (usually the little finger)curved in a

radial or ulnar direction.radial or ulnar direction.

Deviation can occur at the PIP joint, middle Deviation can occur at the PIP joint, middle phalanx, or DIP joint.phalanx, or DIP joint.

It is most common in the DIP joint.It is most common in the DIP joint.

This condition is painless.This condition is painless.

Physical ExamPhysical Exam

The angle of deviation of a finger at the PIP joint, The angle of deviation of a finger at the PIP joint, the middle phalanx, or the DIP joint should be the middle phalanx, or the DIP joint should be measured.measured.

Active and passive motion at each joint should be Active and passive motion at each joint should be recorded.recorded.

The remainder of the skeleton also should be The remainder of the skeleton also should be inspected.inspected.

Tests ,LabTests ,Lab Chromosome analysis should be undertaken if an Chromosome analysis should be undertaken if an

underlying syndrome is suspected.underlying syndrome is suspected.

ImagingImaging

Plain radiography of the affected finger Plain radiography of the affected finger is recommended, especially when is recommended, especially when considering surgical correction.considering surgical correction.

<10 degree of angulation is within <10 degree of angulation is within normal limits.normal limits.

Pathological FindingsPathological Findings

Maldevelopment of 1 of the phalanges causes Maldevelopment of 1 of the phalanges causes an angulation of the joint surface.an angulation of the joint surface.

Differential DiagnosisDifferential Diagnosis

Delta phalanx (a wedge-shaped phalanx with a Delta phalanx (a wedge-shaped phalanx with a sloped joint surface)sloped joint surface)

Malunion after fracturesMalunion after fractures

TreatmentTreatment

Most cases are cosmetic problems.Most cases are cosmetic problems.

Slight deformity does not need surgical Slight deformity does not need surgical correction.correction.

Because nonoperative treatment, including Because nonoperative treatment, including manipulation and castingmanipulation and casting, usually is futile, , usually is futile, and patients find such modalities difficult to and patients find such modalities difficult to tolerate, treatment choices are no intervention tolerate, treatment choices are no intervention or surgery.or surgery.

Surgical correction can be considered for Surgical correction can be considered for substantial deformity persisting after the substantial deformity persisting after the age of 6 years.age of 6 years.

Surgical procedures are elective because Surgical procedures are elective because the problem is mainly cosmetic.the problem is mainly cosmetic.

Physical TherapyPhysical Therapy Therapy may be helpful for regaining Therapy may be helpful for regaining

motion after surgery.motion after surgery.

SurgerySurgery

Includes osteotomy and growth plate Includes osteotomy and growth plate reconstruction with a free-fat graft.reconstruction with a free-fat graft.

For a child <6 years old, a fat-graft placement For a child <6 years old, a fat-graft placement should be performed after resection of the should be performed after resection of the midportion of the continuous epiphysis and midportion of the continuous epiphysis and underlying physis (growth plate).underlying physis (growth plate).

After age 6, a simple closing osteotomy can be After age 6, a simple closing osteotomy can be done easily and with few complications.done easily and with few complications.

PrognosisPrognosis

The prognosis is good, with no evidence The prognosis is good, with no evidence of degenerative joint disease.of degenerative joint disease.

Patient MonitoringPatient Monitoring

Patients may monitor the angulation of Patients may monitor the angulation of the finger and return for surgical the finger and return for surgical treatment if it becomes unacceptable.treatment if it becomes unacceptable.

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