European Journal of Cardiovascular Medicine

syndactyly is most common.1 Syndactyly word derived from 2 Greek word “Syn” means together and “Dactylos” means digit. Syndactyly is described as fusion of soft tissue, skeletal elements or both elements in variable degree of adjacent digits. Syndactyly occurs when digital separation and websspace creation is failed to occur during 4-8 weeks of development of hand.

Incidence of syndactyly is 1 in 2000 to 1 in 3000 life birth approximately2. Males are 2 times more common than female. Isolated syndactyly is most common in 3rd webspace between ring and middle finger (50%), followed by 4th webspace between ring and little finger (30%), followed by 2nd webspace (10%) between index and middle finger and least common is 1st webspace between thumb and index finger (5%)3. In Syndromic, case 1st web space involvement is more common than 2nd web space & other web spaces. In foots, involvement 2nd web space between 2nd and 3rd toe is most common than other web space. Majority of syndactyly are isolated. But familial in 10-40% of cases4.Most common genetic inheritance is autosomal dominant with incomplete penetrance.5

Syndactyly may be congenital present since birth by developmental abnormality or acquired after birth by burn or trauma.

Main aim of Surgery is to separate fingers, creation of webspace, cover joint with flap, cutaneous cover of both finger with a functional hand with few complications.

Study has been conducted in different part of world and India about syndactyly. But in Odisha no such study has been conducted. So we have conducted our study to assess clinico-epidemiological profile of syndactyly patients in a tertiary care centre in Western Odisha.

It was a prospective study conducted in department of plastic surgery VIMSAR Burla, a tertiary centre in Western Odisha between 1stJuly 2022 to 31st December 2023 a period of one and half years. 20 syndactyly patients were included in the study.

Inclusion criteria-

All patients of syndactyly admitted to indoor were included in the study.

Exclusion criteria-

Cases with other severe congenital malformations were excluded from study.

All patients of syndactyly admitted in indoor detailed history was taken. Patients information like age, sex, family history, whether congenital or acquired were collected. In case of acquired case cause of syndactyly whether following burn or trauma history was collected. A thorough clinical examination was done. Type of syndactyly was found out, complete or incomplete, unilateral or bilateral, involvement of only hand or foot orboth was found out. X-ray done to know syndactyly was simple or complex. Other congenital anomaly ruled out. Cardiology done to exclude congenital heart diseases. Counselling about detailed surgical procedure, complications during surgery and after surgery was done. After patients were fit for surgery, operation was planned.

In all cases dorsal quadrangular flap and ventral V flap was planned. Finger separated by Cronin’s incision with a plan to cover proximal and distal interphalangeal joint with skin flap. Marking of incision given. Under tourniquet control after elevation of dorsal and ventral flap finger were separated by Cronin’s Zigzag incision safeguarding the neurovascular structure.  Fingertip were separated by inter-digiting flap described by Buck-Gramcko. Webspace created by apposing dorsal and ventral flap. Flap from ventral and dorsal part of skin used to cover proximal and distal interphalangeal joint. Rest raw area left were covered with skin graft. Dressing was done with separate dressing for each finger. 1stdressing was done after 5 days and dressing was done on alternate day after that. Patients discharged after 7-10 days. Follow up of patients done every weekly for first 2 weeks, then weekly for 2 months and then monthly for 6 months to check out any complications like graft loss, hypertrophic scar, web creep, contracture of fingers etc.

20 patients included our study.

Table 1: Sex pattern

Table-1 described distribution of syndactyly between male and female. It was found that males were most commonly affected than female with male female ratio 1.1:0.9

Table 2: Age of presentation

Table-2 described age of presentation. Most common age group affected was more than 20 years of age (40%), followed by 0-5 years age group (25%), followed by 6-10 years (20%), followed by 11-15 year(10%) and least common age group between 16-20 years (5%).

Table- 3: Etiology of syndactyly

Table-3 described aetiology of syndactyly. It was found that most cases were congenital in nature i.e. in 15 out of 20 cases (75%) and 5 cases were acquired following burn i.e. in 25% of cases.

Table 4: Involvement of limb

Table 4 described involvement of part of body. Hands were most commonly affected than foot.  In 13 cases only hand was involved i.e. in 65% of cases, in 5 cases only foot was involved i.e. in 25% cases and in 2 cases both hand and foot was involved i.e. in 10% cases. In hand bilateral hand involvement was most common 9 out of 15 cases i.e. in 60% cases, followed by Left hand only in 4 cases i.e. 26.6% of cases and right hand only was involved in 2 cases i.e. in 13.33% of cases. In foot both foot involved in 4 out of 7 cases i.e. in 57.1% cases, right foot only in 2 cases i.e. in 28.57% cases and left foot only in 1 case i.e. in 14.3% cases.

Table 5: Types of Web space in syndactyly

Table 5 described type of syndactyly. Total 35 web spaces were operated in 20 cases. Most of the syndactyly were simple in nature. Out of 35 web spaces, 27 were simple in nature i.e. in 77.14% cases and 8 were complex in nature i.e. in 22.86%. Out of 27 simple web spaces, 17 were complete and 10 were incomplete. All cases of complex webspace were complete in nature. So total 25 were complete i.e. in 71.4% cases and 10 are incomplete i.e. in 29.6% cases

Table 6: web space involved

Table 6 described web space involvement.24-web space was operated in hand in 15 patients.  It was found that 3rd web space was most commonly involved hand (62.5%) followed by 4th web space (25%), followed by 2nd web space (8.33%) followed by 1stweb space (4.16%).  11-web space were operated in 7 patients in foot. 2nd web space was involved in 6 cases i.e. 54.54% of cases, 1stweb space in 3 cases i.e. in 27.27% of cases and 3rd and  4th web space in  1 case each i.e. in 9.09% of cases.

Table 7: Complications

Table 7 described complication following surgery. It was found that most common complication in our study was hypertrophic scar in 6 out of 35-web space i.e. in 17.14%. 2nd most common complication was graft loss i.e. in 11.42%, contracture in 8.57%, flap tip necrosis and web creep in5.7%, fingertip deviation in 2.8% of web space operated. In no cases neurovascular injury occurred. All cases of graft loss healed spontaneously without any further intervention required.

[Fig.1(a) & (b): complex complete syndactyly] [Fig. 2(a) & (b): planned incision marking]

[Fig. 3(a) & (b): release of syndactyly]  [Fig. 4(a) & (b): flap suturing & placement of graft]

[Fig. 5(a) & (b): at six month of follow up]

20 patients with 35-webspace were operated in our study. All fingers recovered well with minimal complications and normal functioning fingers.

Among 20 patients included in our study 11 were male and 9 were femalewith male female ratio 1.1:0.9. Study conducted by Nangineedi N et al7, Tuma et al8 and Lida et al9 male female ratio was 1:1. Study conducted by Dong et al10male female ratio was 2:1 and Jose et al11 ratio was 1.17. Overall there was slightly male predominance among all studies conducted by different authors.

In our study youngest patient operated was at the age of 2 year and oldest patient was 34 years with mean age of 11.7 years. Majority of patients belonged to more than 20 years age group i.e. 40%. Study conducted by Nangineedi N et al7their range of patients are 1 year to 55 years with average age is 12.7 years similar to our study but most common age group is below 20 years of age. Study conducted by Tuma et al8 youngest patient was 8 monthsold and oldest was 21 years and 4.8 years was median age. Study conducted by Lida et al9 youngest patient was 8 months old and oldest patient was 11 months old and 10 months was mean age. Study conducted by Dong et al10age ofyoungest patient was 5 month and oldest patient was 35 months and 16.7 months was mean age. Study conducted by Jose et al11 range was 6 months to 13 years with median age was 2.7 years. Results in our study slightly different form other study because most of the patients in our study belonged to low socioeconomic status. So because of ignorance patients present late for surgery. They come for surgery just before marriage.

In our study most of patients were congenital syndactyly in 75% of cases and 25% were acquired following burn. Study conducted by Nangineedi N et al7 75.67% were congenital and 24.3% were acquired. Out of acquired cases 18.91%, presented following burn and 5.4% presented following trauma. Study conducted byTuma et al8 and Dong et al10all cases were congenital in nature. So in all study congenital syndactyly were more common than acquired varities.

In our study of 65% patients has syndactyly of hand only, 25% patients has syndactyly of foot only and 10% patients has syndactyly of both hand and foot. Out of hand syndactyly Bilateral hand involved in 60% cases, left hand only in 26.6% cases and right hand only in 13.33% of cases. Study conducted by Nangineedi N et al7 isolated right hand involved in 40.54% of cases, isolated left hand in 24.37% of cases and bilateral hand involved in 21.62% of cases. Study by Tuma et al8  Bilateral hand involved in 40.9% 0f cases , right hand only in 22.7% of cases and Left hand only involved in 36.4% cases. Study by Dong et al10 Bilateral hand involved in 54.2% of cases and unilateral hand combinedly involved in 45.8% of cases. So it was found that Bilateral hand was involved most commonly than unilateral hand. In congenital syndactyly bilateral hand was most commonly involved and acquired syndactyly unilateral hand was most commonly involved

In our study of foot syndactyly bilateral foot involved in 57.1%, right foot only in 28.6% cases and left foot involved in 14.3% cases. Study by Nangineedi N et al7isolated right foot involved in 42.85%, left foot only in 14.28% of cases and bilateral foot in 42.85% of cases. Study by Lida et al9 isolated right foot involved in 50% , left foot involved in 25% of cases and Bilateral foot involved in 25% of cases. So bilateral foot most commonly involved than unilateral foot.

In our study total 35 webspaces were operated. Out of which 77.14% were simple in nature and 22.86% were complex in nature. Out of 27 simple cases 17 were complete and 10 were incomplete. All case of complex syndactyly all were complete. So 71.4% were complete and 29.6% were incomplete. 2 cases involving syndactyly both hand and foot pre-axial polydactyly present. Study conducted by Nangineedi N et al7 86.48% web spaces were simple and 13.5% were complex, 70% were complete and 30% were incomplete in nature similar to our study. Study by Tuma et al8simple syndactyly present in 36.4% of casesand complex syndactyly present in 63.6% of cases. Out of 8 simple syndactyly 6 were complete and 2 were incomplete and all complex syndactyly were complete in nature. So 20 out of 22 (90.9%) were complete in nature and 2 were incomplete in nature i.e. 9.2%. Study by Dong et al10 65.7% were complete and 34.3% were incomplete in nature. Syndactyly is presented in heterogeneous manner so variations present among different study.

 In our study, in hand 3rdwebspace was most commonly affected (62.5%) followed by 4th webspaces (25%) followed by 2nd webspaces (8.33%) and 1stwebspace was least commonly involved (4.16%). In foot 2nd web space was most commonly involved (54.54%), followed by 1stwebspace (27.27%), followed by 3rd and 4th webspace (9.09%) each. Study by Nangineedi N et al7 3rd webspace most commonly involved in hand and in foot 1st and 2nd webspace most commonly involved. Study by Tuma et al8 3rd webspace most commonly involved (32.4%) followed by 2nd (29.7%) followed by 4th (18.9%). Study by Lidaet al9 2nd web most commonly involved (87%) in foot. Study by Dong et al10 3rd web most commonly involved (68.6%) followed by 4th web followed by 2nd web (14.2%) in hand. Study by Jose et al11 3rd webspace most common than 2nd webspace in hand.

Most common complication in our study was Hypertrophic Scar formation (17.14%), followed by partial graft loss (11.42%) Followed by finger contracture (8.57%), flap tip necrosis and web creep (5.71%) cases and fingertip deviation in (2.8%) of webs. Study by Nangineedi N et al7 hypertrophic scar in 4.76% , contracture in 9.5%, hyperpigmentation in 4.76% of web operated. In none case flap necrosis occurred. Study by Tuma et al8 graft loss in 9.1%, recurrence in 4.5% and overall good results in 87% of web. Study by Lida et al9 no complications. Study by dong et al10 web creep occurred in 3% case. Study by Jose et al11 web creep in 5% cases. There was difference in complication rate because of different surgeon has different experience and different working condition.

It can be concluded that male most commonly involved than female. Congenital syndactyly more common than Acquired.  Among Acquired cases burn was most common. Simple syndactyly was more common than complex and complete was most common than incomplete type. Hand most commonly involved than foot with bilateral hand involvement most common than unilateral involvement in hand and foot. 3rd webspace most commonly involved in hand and 2nd webspace most commonly involved in foot.  Good aesthetic functional hand can be achieved with proper planning of surgery, proper tissue handling and proper followup. Awareness among patients must be done to do surgery at early date to prevent deformity in delayed surgery.

Funding: No funding sources

Conflict of interest: None declared

Ethical   approval:   The   study   was   approved   by   the Institutional Ethics Committee

It can be concluded that male most commonly involved than female. Congenital syndactyly more common than Acquired.  Among Acquired cases burn was most common. Simple syndactyly was more common than complex and complete was most common than incomplete type. Hand most commonly involved than foot with bilateral hand involvement most common than unilateral involvement in hand and foot. 3rd webspace most commonly involved in hand and 2nd webspace most commonly involved in foot.  Good aesthetic functional hand can be achieved with proper planning of surgery, proper tissue handling and proper followup. Awareness among patients must be done to do surgery at early date to prevent deformity in delayed surgery.

Funding: No funding sources

Conflict of interest: None declared

Ethical   approval:   The   study   was   approved   by   the Institutional Ethics Committee

1. Upton J. Congenital anomalies of the hand and forearm.In:McCarthyJG,red.Plasticsurgery.New York, NY: WB Saunders; 1990;8:5218–398.
2. Harvey I, Thomas K, Copeland J, Borschel GH. CT angiography-guided single stage release of adjacent webspaces in non-Apert syndactyly. J Hand Surg Eur. 2015;40:625–32.
3. Dobyns J. Congenital hand deformities . In: Green DP, ed. Operative Hand Surgery. New York , NY: Churchill Livingstone;1993:255-536.
4. Flatt AE. The Care of Congenital Hand Anomalies. St. Louis, MO: C.V. Mosby;1977.
5. Tentamy S, McCusick V. The genetics of hand malformations. Birth Defects Orig Artic Ser, 1978;14 (3):i-xviii, 1-619.
6. Mei H, Zhu G, He R, Liu K, Wu J, Tang J. The preliminary outcome of syndactyly management in children with a new external separation device. J PediatrOrthop B. 2015;24:56–62.
7. Nangineedi N, Harish GP, Rafi M. Management of syndactyly: a clinical study. Int Surg J2019;6:2806-12
8. Tuma P, Arrunategui G, Wada A, Friedhofer H, Ferreira MC. Rectangular flaps technique for treatment of congenital hand syndactyly. Rev HospClinFac Med Sao Paulo. 1999;54(4):107-10.
9. Iida N, Watanabe A. The Modified 3-square Flap Method for Reconstruction of Toe Syndactyly. PlastReconstrSurg Glob Open. 2016;4(7):793
10. Dong Y, Wang Y. The use of a dorsal double-wing flap without skin grafts for congenital syndactyly treatment A STROBE compliant study Medicine (Baltimore). 2017;96(30):e7639.
11. Jose RM, Timoney N, Vidyadharan R, Lester R. Syndactyly correction: an aesthetic reconstruction. J Hand Surg Eur. 2010;35(6):446-50.