The syndactyly is a very common deformity that occurs in the 4th and 5th toes, 3rd and 4th toes, 1st and 2nd toes, and 2nd and 3rd toes, or in severe cases, the 1st to 5th toes are all joined together. In some cases, the syndactyly is accompanied by multiple toes, commonly 4 or 5 toes with multiple toes of the little toe. The onset of the disease is related to genetic factors and may be caused by embryonic local developmental stagnation and obstruction of toe differentiation.
Clinical manifestations
1, soft tissue and toe: normal skeletal development, joint integrity, flexion and extension is basically normal, only the skin soft tissue connected. In mild cases, the two toes are only too shallow, in severe cases, the two toes are very close to each other, the skin is very tense, and even the toenails are connected together, with the appearance of a giant toe, but the X-ray shows that the bones are completely separated. Tian Xiaofei, Hand Surgery Department, Children’s Hospital of Chongqing Medical University
2. Bony syndactyly: the two toe bones merge, in the lighter cases, only some of the toe bones stick together, usually near one or two separate, the end toe bones are connected, and some toenails come together. In severe cases, the two toe bones are completely fused, and even the joints do not exist, the treatment is more difficult.
3, and toes combined with multiple toes: common for 4, 5 toes combined with small toes multiple toes, or 1, 2 toes and toes combined with bunions multiple toes, some bone and joint deformity is heavy.
Treatment principle
1. Separate the syndactyly and repair the normal appearance and function so as to facilitate walking in shoes.
2. The surgical method and time should be determined by the degree, type, age and location of the deformity.
Soft tissue syndactyly can be operated at the earliest at the age of half a year, bony syndactyly is usually operated at the age of about 1 year, syndactyly with multiple toes can be operated at the age of half a year if the bone and joint deformity is not heavy, and at the age of 1-3 years if the bone and joint deformity is heavy.
Special note: If you review the literature, you may find that the best age for surgery is much older than I have stated, or even that you should not have surgery until you go to school. I dare not say that there are many doctors who simply copy the outdated theories of the old-timers, but I would like to say that based on my 18 years of experience and a survey of syndactyly cases in our hospital for the past 10 years, I have come to the conclusion that older children who walk in shoes have a higher chance of severe scar growth after syndactyly surgery due to friction between the toes, and some children even have to be operated on again to remove the scar implant, and after another operation The scar may still recur after the surgery. The toe scar will be painful when walking due to friction and will end up in a situation where it is better not to do it. In contrast, the scar growth is rarely apparent in young infants who are not yet walking at the age of 1 year after syndesmosis surgery. Therefore, I advocate that it is best to operate on syndactyly within 1 year of age, and no later than 3 years of age.
3.Surgical methods
(1) Toe Z-forming method: It is suitable for the looser webbing of the shallow part of the syndesmosis, and Z-forming usually does not cause skin defects and does not require skin implants.
(2) Toe separation full-thickness skin grafting method: applicable to most soft tissues and part of the bony toe, in the base of the toe dorsal, design rectangular skin flap forming toe Pu, serrated incision separation and toe, forming staggered skin flap part can be inlaid suture, the remaining skin defect area full-thickness skin graft repair. In the case of multiple toes, it is generally not advisable to do this at the same time on both sides of the same toe to prevent blood flow and necrosis of the affected toe.
If there is a toe with multiple toes, according to the x-ray performance, decide the multiple toes that need to be removed, you can use the skin of the multiple toes to repair the skin defect between the separated toes.
(3) Flap method: In case of severe complete bony syndactyly (very rare), the exposed area of the toe bone after toe separation is too large to be covered by a flap, and the bone cannot be repaired by a skin graft, so a tipped flap transfer should be considered.
Typical cases
Case 1, half a year old, left foot 4 and 5 toes together, with polydactyly and redundant toenail, curled toe deformity of the 4th toe (flexion and rotation overlap below the 3rd toe).
X-rays showed polydactyly of the 5th toe, which was a duplication of the middle phalanx.
The surgery was performed under 3x magnification, with excision of the polydactyly, interphalangeal arthroplasty, juxtaposition of the toes, full-thickness skin grafting, and tightening of the lateral ligament of the joint capsule of the 4th toe to correct the curl. The skin graft was not packed and fast suction suture was applied. After the first dressing change 2 weeks after surgery, we saw that the skin graft was completely survived and the toe and toe pulp were in good shape. There is no postoperative long term photo for the time being, but we have called the parents to ask them and they are doing well.
Thanks to the parents, they were able to come back for a follow-up visit 5 months after the surgery. The pictures were taken in the standing position, the little foot was spread out, and the little toe felt slightly fat, but the scar of the little baby is really not obvious, and it should not be visible after 1 year
Case 2, 2.5 years old, multiple toes on the right 4 and 5 toes.
X-rays showed soft tissue syndactyly.
A full-thickness implant was separated from the syndactyly, and the same implant was not packed and closed with fast suction sutures.
Three months after the operation, the toe and toe pulp were in good shape, and the child was advised to wear looser shoes, the scar was light, and the implant was darker in color, which would improve later.
Toe Pu, the child wore sandals, the foot was a little dirty, huh?
Case 3, 9 months old, left foot 4 and 5 toes together with small toe polydactyly, X-rays show a polydactyly between 4 and 5 toes, no corresponding metatarsal, should be removed. x-rays not found yet, will be added later.
Excision of the medial polydactyly, use of some of the polydactyly skin to repair the trauma after the separation of the syndactyly, very small area of skin defect implanted with full-thickness skin, fast suction suture without packing. For this kind of multi-toe between 4 and 5 toes, after removal of the multi-toe, there is too wide toe Pu, 4 and 5 toes are separated too much, if packing between the two toes, it will aggravate the separation of the two toes, so it is not suitable to pack.
More than 20 days after the operation, parents are still afraid to wash their children’s feet, the scab of the wound has not yet finished falling off. In fact, it is possible to wash the feet normally. This child started wrapping 4 and 5 toes with a small elastic bandage after taking this picture to further reduce the distance between the toes. In fact, it should get better on its own after wearing shoes, but the parents were so eager to correct it that they were more aggressive.
Six months after surgery
Let’s post pictures of the post-operative scar in a large child with syndactyly.
Case 1, a boy, was 10 years old when he underwent a full-thickness grafting procedure to separate his syndesmosis, which was accompanied by mild megalodontia. The parents did not ask for treatment of the megalodon, but only performed the separation of the megalodon. After the operation, the child did not come back in time for follow-up.
Case 2, boy, 13 years old, more than half a year after the juxtaposition of the toes, the same severe scar hyperplasia was seen on the trabecular edge.
One month after the surgery, he had some mild scarring at the margin, which was treated with medication and did not worsen this time.
Of course, not every older child who walks in shoes will have severe keloid hyperplasia, but because they are already walking, there is more friction and a greater chance of keloid hyperplasia. The most decisive factor is the body type, that is to say, children with keloid body may have keloid hyperplasia regardless of their age, as early as 10 months old child and toe post-operative keloid hyperplasia, while the largest 13 years old surgical scar is very light, as to whether the child is a keloid or not there is no special method to clarify before surgery, and the same child, the wound reaction in different parts of the body is different, toe because of easy The toes are prone to scarring and even keloids due to friction.
Therefore, parents of babies with syndactyly are reminded that it is best to operate on their children within one year of age, and no later than three years of age. The surgical separation of syndactyly in small infants is difficult and requires skilled anatomical and microsurgical techniques. In addition, it is important to note that surgery on small infants also requires safe anesthesia techniques for infants and children. Therefore, it is best to be treated at a children’s hospital.
The advantage is that there is no skin implant and the recovery is faster. The disadvantage is that the scar on the dorsal side of the toe is more pronounced and I usually use it only for toe merging.
Case 1, female, 7 months old, syndactyly with polydactyly.
X-rays showed excess metatarsal bones in multiple toes.
The dorsal longitudinal incision was made to remove the redundant metatarsal bone.
Pentagonal flap shaped toe web
Three months after the surgery, the child came back to the hospital to have both hands operated on together. The scar growth period has just ended because it is only 3 months postoperative, so it is still obvious. Note that there is a transverse scar on the dorsal root of the 4th and 5th toe, which is common in non-implantation syndactyly.
The webbing is in good condition. The biggest defect after this syndactyly is the short little toe, but this is not caused by the doctor, but by the short development itself.
Since October 2012, we have been combining a pentagonal flap with a V-tip flap and designing a biplane flap to form the phalanges with good results.
The child, male, 1 year and 4 months old, had 4 and 5 syndactyly with polydactyly on the right foot.
He was separated from the syndactyly, the polydactyly was removed, and a bipedal flap was used to create the webs without skin grafting.
The parents sent pictures 1 month after the surgery, the webs were in good shape, the wound was still a little red and swollen, and the scar had not yet had time to grow (scar growth is 1-3 months after surgery).
After 3 months, the parents sent pictures of mild scarring, which should gradually fade later (scarring usually stops growing after 3 months post-op and fades after 6 months).
Even if there is no polydactyly between the juxtaposed toes, most do not require skin grafting using a bipedal flap to form the toe webs, or even 3 toes can be separated together. In the case of 1 and 2 toe juxtaposition, with proper design, the lateral aspect of the bunion can also be done without skin grafting. Of course there will still be some small skin grafting in cases where the skin is very tight in the juxtaposition.
Child, female, 8 months.
Left foot 1, 2, 3 incomplete parallel toes, shallow toe web between 2 and 3, parents also requested deepening.
The right foot had incomplete syndactyly of toes 1 and 2.
Immediately after the operation, the toe webs were made slightly wider, and the flap closed all the wounds exactly after separation.
There was no bleeding at all during the surgery, and after the surgery, the dressing was applied with pressure, and the inner gauze would bleed a little, and the patient could be discharged after 3 days of medication change.
There are always parents who struggle with the age of surgery. Although I advocate doing it earlier, it is not the old view that older children are prone to scar growth, but I think that after walking children like to walk on the ground, and children are not happy when they are not allowed to walk for 2 or 3 weeks after surgery.
Moreover, with the basic non-implantation of the toe now, there has not been a single case of obvious keloid hyperplasia, and some of the older children over 3 years old who had it done last year and this year have had their scars basically softened about six months after surgery.
Child, female, 3 years old
Immediate postoperative toe webbing was made wider
Six months after the surgery, the shape and function are normal, and the scar is basically softened, and it will be further whitened and softened in the future.
Now, the 4 and 5 juxtaposed toes with polydactyly, using a bipedal flap to form the toe webs without any implant at all, has been made into a very delicate and procedural procedure, which took a quick 40 minutes or so. The postoperative period was quick, 40 minutes or so, except for the wound marks.
Unfortunately, nearly 30 cases have been done using the bipedal flap, but there are very few photos of the postoperative wound after it has grown well, and very few parents send pictures of the sick children in the field who have done it. I can only guess that the results are good, no problem, so they refuse to pay attention to me.
This one is local, 3 years and 4 months
2 months after surgery
3 months after surgery
The following case is the most touching to me, came from far away, the other side of the ocean, but can insist on sending pictures as I requested, and promised to send them every year, and the pictures are still very clear. I can only say that the quality is really different, in fact, this may not be the best results, now the surgery way to do more delicate, but only this has the whole recovery process pictures, thank you very much for the cooperation of parents.
The child, female, 3 years old
3 days after surgery, medication was changed before discharge. In fact, you can also not change the medicine, after 3 weeks of post-operative bandage, parents can open the bandage at home, my surgery are using fast absorbing thread, no need to remove the thread.
3 months after surgery, parents sent pictures, slightly swollen
Six months after the surgery, the parents sent me a picture, the scar is mostly faded
Finger webbing is normal
I believe we will have pictures of the first year after surgery!
Many doctors will still implant the skin and tend to make the little toe bigger, which is not a good look and will affect the girls to wear pointy shoes in the future. Nowadays, not only is the practice very short, it has been done procedurally and the post-operative appearance is much better, and you can make the little toe very slim and really in line with the opposite side.
A slim little toe!
The child above is still waiting for a return visit.
February 18, 2014, thanks to a few local Chongqing parents who were able to come back for a follow-up visit after my phone call, choose two to post pictures of the ones who cooperated better. How else can I explain that this surgery is my best?
Before the surgery, the left 4 and 5 juxtaposed toes with multiple toes of the little toe.
Immediately after the surgery, the multiple toes were removed and the toes were separated without skin grafting.
3 weeks after surgery, the bandage was opened, this is a more obvious redness and swelling, take it out so that some post-operative parents are also so relieved.
8 months after surgery, the scar is almost invisible
Before surgery, the ectropion of the little toe was completely corrected
It looks like a natural toe web
The flexion of the little toe is as normal as the opposite side
In the other child, there were 4 or 5 parallel toes with polydactyly of the little toe, and this polydactyly was connected to the little toe.
No skin implant immediately after surgery
Six months after surgery, most of the scar has softened
The same as the natural webbing of the toes
The flexion of the little toe is normal
Abduction of the little toe is normal
I have done some similar cases myself, 3 years and 4 months old boy.