DOI: 10.1097/01.SAP.0000064005.79406.52

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Issn Print: 0148-7043

Publication Date: 2003/12/01


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Invited Discussion: The Inadequate Index Finger

Joseph Upton

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This excellent paper presents two clinical cases in which an index ray, which had been released previously from a complete or incomplete simple syndactyly, was formally transposed or “pollicized” into the thumb position. The description of both cases is clear and the outcomes are less than those that would be achieved if the index ray were completely normal preoperatively. This presentation raises the issue that is not discussed very often in the congenital hand literature: the inadequate index finger.In many clinical cases a less than optimal index finger is available for potential pollicization: (1) the Holt-Oram syndrome with a syndactylized index ray, (2) an index joined to the long finger with a complete simple syndactyly (i.e., typical cleft hand, index-long syndactyly with absent or hypoplastic thumb), (3) a stiff index finger associated with a complete or partial absence of the radius, (4) the stiff index ray with a fixed proximal interphalangeal joint flexion contracture with or without a complete or partial absence of the radius, (5) the mirror hand (ulnar dimelia), or (6) the five-fingered hand.
The clinical deficiencies of the index ray are obvious on physical examination, and the major question is whether anything can be accomplished surgically to improve either the clinical function or the appearance or the hand. The absence of flexion creases indicates deficient joint structures plus or minus inadequate extrinsic flexor or extensor musculotendinous units. The presence of a complete or incomplete syndactyly means that there has been very little motion in utero. At surgery, fibrous bands are present between the phalanges, which may not appear joined on radiographs. Flexion contractures (camptodactyly) may be present in the index or all digits (Figs 1–5).
For those involved with the surgical correction of congenital hand differences, these clinical situations do not present frequently but occur more often than anticipated. In my own experience with 230 pollicizations performed during the past 25 years, one of these clinical scenarios is present at least 15% of the time. 1 There are no standard guidelines for treatment in the literature, and surgical recommendations are more dependent on a given surgeon’s experience than practical reasoning. Most recommendations have been overwhelmingly conservative. 1–16
Options for reconstruction include the following:
The possible combination of deformities with congenital hand differences is infinite and there are many instances in which it is possible to pollicize an index digit after a number of previous procedures involving this ray have been completed. Most examples involve either a syndactylized index finger within a mitten hand for a typical cleft hand in which the index and long fingers are joined within a simple syndactyly. 18 In either case the syndactyly is released before formal repositioning of the index digit.
The determination of what to do and how to do it can be made much easier by an analysis of larger series of pollicizations. 3,5,6,8–10,12–14,16 The quality of the result depends predominantly on the preoperative condition of the index ray. Optimal results are predictable following a well-executed operation on an index finger with normal active and passive range of motion and a full complement of median and ulnar innervated thenar intrinsic muscles. The radius is usually normal in these children. In the six conditions listed earlier, the index and long digits have diminished motion, and the ring and small (fifth) digits are the mobile and functional digits. In these hands the position of the pollicized index finger is crucial so that it be well positioned for a pinch to the long finger and a grasp to the fifth finger.
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