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SCIENTIFIC ARTICLE

ClosingWedge Osteotomy of Abnormal Middle

Phalanx for Clinodactyly

Munawar Ali, MD, Teresa Jackson, MD, Ghazi M. Rayan, MD

Purpose To report a series of clinodactyly patients to report clinical and radiographicoutcomes after closing wedge osteotomy and K-wire fixation of abnormal middle phalanges.

Methods Twenty-five fingers from 17 patients were included in the study. All patients hadmore than 25° of angulation and were treated with closing wedge osteotomy. Subjective andobjective data with radiographic assessment were compared preoperatively and postopera-tively.

Results Male gender was predominant in our series (14 of the total 17 patients). Familyhistory was positive for clinodactyly in 4 patients. The appearance of all fingers improvedafter surgery. Angular deformity was corrected on average from 33° preoperatively to 9°postoperatively. Analysis of radiographs showed deformity correction from 29° preopera-tively to 5° postoperatively. Preoperative and postoperative arc of motion measurementswere available for 10 patients. Distal interphalangeal joint arc of motion decreased from 84°prior to surgery to 81° after surgery, whereas proximal interphalangeal joint arc of motionwas unchanged.

Conclusions Closing wedge osteotomy of the abnormal middle phalanx for clinodactyly hasprovided our patients with adequate correction of the deformity, improved hand function, andhas provided high satisfaction for parents. This treatment is recommended for moderate (15°to 30°) and severe (�30°) deformities. (J Hand Surg 2009;34A:914–918. Copyright © 2009by the American Society for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Therapeutic IV.

Key words Clinodactyly, closing wedge, osteotomy.

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LINODACTYLY IS A congenital angular deformityof the middle phalanx in the frontal or radioul-nar plane. The small finger is the most fre-

uently involved, but other digits in the hand can beffected as well. The condition is bilateral in the ma-ority of cases. The degree of angulation that constituteslinodactyly varies among different reports. Smith1 de-

From the Hand Surgery Section, Orthopedics Surgery Department, University of Oklahoma andINTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma.

Received for publication November 7, 2007; accepted in revised form January 5, 2009.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: Ghazi M. Rayan, MD, 3366 NW Expressway, Suite 700, Oklahoma City,OK 73112; e-mail: OUHSGMR@aol.com.

0363-5023/09/34A05-0018$36.00/0

pdoi:10.1016/j.jhsa.2009.01.007

14 � © ASSH � Published by Elsevier, Inc. All rights reserved.

ned clinodactyly as angulation in the finger long axisetween the proximal and middle phalanges of greaterhan 8°. Some investigators consider an angulation of

10° to be abnormal, whereas others suggest that cli-odactyly is defined by an angulation of �15°.2

Treatment for clinodactyly may be sought for im-roving aesthetics or function, especially if the defor-ity is severe and progressive. Dutta3 and Hirsch4

onsider this condition to have an autosomal dominantode of inheritance. Hirsch4 investigated the pedigree

f 51 patients and confirmed this pattern of transmis-ion with incomplete penetrance. Surgical treatment isndicated for correcting substantial angular deformityhat can adversely affect hand function. A variety ofurgical techniques have been described.5–9 The choicef the surgical procedure depends on the underlying

athology, the amount of deformity, status of soft tis-

CLOSING WEDGE OSTEOTOMY FOR CLINODACTYLY 915

sues, and the surgeon’s preference. The various surgicaloptions include closing wedge osteotomy,7 openingwedge osteotomy,6,10 reverse wedge osteotomy,8 andphysiolysis.5,9 The treatment most often used is osteot-omy of the middle phalanx to realign the digit. Closingwedge osteotomy7,11 involves removing a bony wedgefrom the middle phalanx on the convex side of theinvolved digit. Opening wedge osteotomy6 entails cre-ating a wedge of bony defect in the middle phalanxalong the concave side, which theoretically lengthensthe digit in addition to correcting the angular deformity.Physiolysis9 is performed around the age of 3 years byremoving the longitudinal portion of physis and inter-posing a fat graft to fill the split physis. This has beendescribed to improve deformity over years as growthcontinues through the horizontal portion of the phy-sis.12,13 Previous publications on this topic had eithermixed or unfavorable results after closing wedge os-teotomy.11

The deformity in clinodactyly patients is due to anabnormally shaped middle phalanx that may be deltashaped. This abnormality, however, can be due to eitheran anomalous longitudinally oriented apophysis (brack-eted) or a short phalanx that lost its distal portion andnormal shape but maintained a proximally based physisthat is not necessarily normal. A literature search didnot reveal any studies on clinodactyly in which allpatients regardless of the middle phalangeal pathologywere treated with closing wedge osteotomy. There areno clear guidelines in the literature about the degree ofangulation that constitutes an indication for surgery.The purpose of this study was to report the results ofclosing wedge osteotomy of the abnormal middle pha-lanx of clinodactyly digits having greater than 25° ofdeformity regardless of pathology.

MATERIALS AND METHODS

Demographics

Included in the study were patients with the diagnosis ofclinodactyly of any digit other than the thumb. Associ-ated anomalies such as syndactyly in other fingers in thesame hand were included in the study. All patients withassociated deformities of the same digit such as syn-dactyly to an adjacent finger were excluded from thestudy. Two patients treated with opening wedge osteot-omy were also excluded from the study. Congenitalangular deformities due to bony abnormality other thanthe middle phalanx were also excluded from the study.A total of 25 digits in 17 patients fulfilled the inclusioncriteria and were treated surgically between 1989 and2007. The indications for surgical treatment were de-

formities greater than 25°, progressive deformities (15

JHS �Vol A, Ma

patients), and aesthetic concerns by the parents (2 pa-tients).

All patients were treated or supervised by the seniorauthor (G.M.R.). Family history of any congenitalanomalies was determined, and the patient’s gender,age, and digit involved were also recorded.

Male gender was predominant in our series: 14 of thetotal 17 patients were boys and 3 patients were girls. Ofthe 17 patients, 14 were examined at follow-up by thejunior authors, and x-rays were obtained. One patientwas located out of state and was referred for follow-upto a local hand surgeon in his community. The patientwas interviewed by phone, and digital images of thehand were obtained. Two patients moved out of stateand could not be located. Information about these pa-tients was obtained from their charts, and most recentx-rays were reviewed. Their postoperative chart fol-low-up was 3 and 4 years, respectively. Six patients (2girls and 4 boys) had bilateral finger involvement: 1with bilateral index finger and 5 with bilateral smallfinger involvement. The age at the time of surgeryranged from 1 to 15 years (mean, 9 years). Familyhistory was positive for clinodactyly only in 4 patients.Fifteen patients had isolated clinodactyly. Two patientshad other associated congenital anomalies includinglow-set ears in one and congenital strabismus in theother. Of the 25 digits, the following fingers wereinvolved: small finger (20 digits), index finger (4 dig-its), and middle finger (1 digit).

Subjective data

The patient or parents were asked about appearance ofthe digit and level of hand function during activities ofdaily living before and after surgery and if surgery hadimproved or compromised these activities. The patientand or family were asked at follow-up whether theywere satisfied or dissatisfied with the function and ap-pearance of the digit.

Objective findings

The digit was assessed for any obvious deformity bycomparison with the contralateral digit if uninvolved.The degree of angulation to the ulnar side was measu-red clinically in full finger extension using a goniometer(EBI, Parsippany, NJ; �3° variance) postoperativelyand then compared with preoperative measurements.The degree of angulation was measured by placingthe goniometer hinge at the apex of the deformityand the 2 limbs along the midaxes of the proximal anddistal phalanges. Ten patients had preoperative andpostoperative digital joint measurements. Paired t-

test was used to determine statistical significance

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916 CLOSING WEDGE OSTEOTOMY FOR CLINODACTYLY

between preoperative and postoperative measure-ments.

Radiographic assessment

Preoperative radiographs were evaluated for the degreeof angulation as measured by a goniometer and for anyepiphyseal pathology. Degree of angulation was deter-mined by drawing 2 lines along the midaxes of theproximal and distal phalanges and measuring the angleat their intersection. At follow-up visits, radiographswere obtained and evaluated for the same parametersand degree of correction achieved.

Postoperative complications

Intraoperative and postoperative complications were re-corded by reviewing charts and by inquiry of the familyand included in the data collection. Residual angulationis considered as any remaining deformity greater than10° after surgery. Recurrence of deformity was consid-ered if a patient’s angulation increased from immediatepostoperative to time of follow-up.

Surgical technique of closing wedge osteotomy

The surgery is done under general anesthesia and up-per-arm tourniquet control. A dorsolateral longitudinalincision is made at the middle phalangeal area over theconvex side of the finger. The extensor mechanism isretracted, and the periosteum of the anomalous middlephalanx incised and reflected off the bone. An oscillat-ing saw is used to remove a 2- to 3-mm bony wedgelaterally through the anomalous apophysis if present. Infingers that are very small, the kerf of the blade willremove sufficient bone and create a defect in the formof a wedge without the need for additional bone exci-sion. The distal cut is made first followed by the prox-imal cut, and the osteotomy is completed with a bonecutter or osteotome leaving the radial periosteum intact.The digit is aligned and the angular deformity is fullycorrected. One or two K-wires (1.4 mm [0.045 in.] or0.9 mm [0.035 in.] according to size of digit) are passedfrom the pulp across the osteotomy transfixing the prox-imal interphalangeal (PIP) joint. Intraoperative x-raysare used to ensure satisfactory placement of the K-wireand correction of the angular deformity. The tourniquetis released and hemostasis achieved. An ulnar guttersplint is applied. The K-wire is removed after 4 or 6weeks (Fig. 1). A range-of-motion home therapy pro-gram is initiated and is usually sufficient for most pa-tients. If necessary, the patient can be referred for a fewformal hand therapy sessions to regain PIP joint and

distal interphalangeal (DIP) joint motion.

JHS �Vol A, Ma

RESULTSProgressive angular deformity (15 patients) and/or ap-pearance (2 patients) were the main reasons for pa-tients’ families seeking treatment. Follow-up for pa-tients ranged from 6 months to 16 years (mean, 6years).

Subjective data

Finger appearance was satisfactory in 25 fingers (96%).Only 1 patient had poor appearance of 1 digit due to aresidual 15° of angular deformity postoperatively froma severe deformity of 31° preoperatively. One patientwho had bilateral surgery experienced occasional coldsensitivity on one side.

Objective findings

Clinical angulation improved from an average of 33°(range, 25° to 55°) preoperatively to an average of9° (range, 5° to 15°) postoperatively. An average of79% (range, 60% to 100%) correction was achievedclinically. Arc of motion at the PIP joint and DIP jointwas compared for 10 patients (14 digits). This showedthat DIP joint arc of motion decreased from 84° preop-eratively to 81° postoperatively (p � .0001). Extensionlag was not seen in any patient because the amount ofshortening was negligible. The patients and familymembers were not aware of this 3° decrease in arc ofmotion. The PIP joint arc of motion was nearly thesame with 102° preoperatively and 101° postopera-tively.

Two of the patients had z-plasty.

Radiographic assessment

Radiographically, the average angulation was 29°(range, 25° to 50°) preoperatively. This improved to anaverage of 5° (range, 5° to 10°) postoperatively (Fig. 2).On average, 24° of correction was achieved both clin-

FIGURE 1: A Osteotomy planned. B Osteotomy closed andfixed with K-wires.

ically and radiographically.

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CLOSING WEDGE OSTEOTOMY FOR CLINODACTYLY 917

Postoperative complications

No intraoperative or immediate postoperative compli-cations were encountered.

By the definitions of residual angulation (defined asany deformity �10o) or recurrence (greater than ini-tially corrected deformity), no patient has developedrecurrence in our series. Only 1 patient had a residualdeformity of 10° after surgery.

DISCUSSIONThe incidence of clinodactyly in North America wasdescribed to be 1 in 1000.3 An incidence of 3% to 5%was reported from Japan.14 The gender distribution wasreported in the United States to be 15% among boys and8% among girls for the little finger and 2% for indexfinger.5 Incidences as high as 19.5%1 and 20%15 werealso reported.

The skeletal basis of clinodactyly is a delta-shapedmiddle phalanx in most cases, which is characterized byan anomalous epiphysis that is oriented longitudinallyalong the short side of the affected bone.10,16 Thedeformity is also described as an abnormal middlephalanx that is triangular or trapezoidal in shape and thepresence of a C-shaped physeal plate or longitudinally

FIGURE 2: A A 6-year-old boy with type 4 deformity. B X-ray6 months postoperatively. D Postoperative x-ray showing heale

bracketed diaphysis.6 Longitudinal growth of the epiph-

JHS �Vol A, Ma

ysis is compromised leading to progressive angulationof the digit toward the convex side.

This abnormality, however, can be due to either ananomalous longitudinally oriented apophysis (brack-eted) or a short phalanx that lost its distal portion andnormal shape but maintained a proximally based physisthat may not be normal.

Burke and Flatt7 in 1979 classified 3 types of clino-dactyly: (1) familial clinodactyly with a dominant in-heritance, and these are usually not associated withother congenital anomalies; (2) clinodactyly in associ-ation with other syndromes; (3) clinodactyly secondaryto epiphyseal injury such as fracture or frostbite. Thislater condition is considered posttraumatic angular de-formity rather than true congenital clinodactyly. Repet-itive hand trauma among young athletes was reported toresult in such deformity.12

Cooney13 classified 4 types of clinodactyly: (1) sim-ple deformity of the middle phalanx, with 15° to 45°angulation; (2) simple complicated, with deformity ofthe middle phalanx of 45° to 60°; (3) complex bony andsoft tissue deformities, with deformity of 15° to 45°; (4)complex complicated bony and soft tissue deformities,with deformity of 45° to 60° and associated macrodac-

e same patient showing bracket epiphysis. C Photograph takeneotomy.

of th

tyly or polydactyly.

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918 CLOSING WEDGE OSTEOTOMY FOR CLINODACTYLY

Authors classified patients in 4 groups from 1 to 4according to severity of angular deformity. We recom-mend nonoperative treatment for patients with physio-logic angulation �5° (group 1) and those with mildangulation between 5° and 10° (group 2). However,patients with mild deformity deserve observation forpotential progression. We recommend surgical treat-ment for patients with moderate (15° to 30°) and severe(�30°) deformities (groups 3 and 4). The only patientwith residual angulation �10° after surgery of ourpatients had severe deformity before surgery.

Burke and Flatt7 used closing wedge osteotomy fortreating clinodactyly. They observed that proximal pha-langeal involvement is associated with greater angulardeformity. Jones16 noted that after resection of theabnormal epiphysis, the phalanx showed longitudinalgrowth. Light and Ogden6 proposed osteotomy of thephalanx with fat interposition. Carstam and Theander8

reported 1 case of cartilaginous bracket resection andnoted a correction of 10° over 12 months. Vickers9

reported a series of 12 digits in which he resected themidzone of the abnormal physis and interposed a fatgraft. The renewed growth was manifested by increasein length and decrease in angular deformity over time.He reported excellent functional and aesthetic resultsthough angular measurements were not documented. AlQattan11 has recently published his surgical results in10 index fingers using closing wedge osteotomy andrecommended that Vickers physiolysis should be usedearly and that closing or open wedge osteotomy shouldbe followed later on if deformity persists.

Our patients achieved satisfactory outcome after sur-gical treatment in the form of closing wedge osteotomyof the abnormal middle phalanx regardless of the pha-langeal pathology.

Closing wedge osteotomy is indicated for angular

JHS �Vol A, Ma

deformity in clinodactyly greater than 25°. It correctsthe angular deformity, maintains motion in the PIPjoint, and results in satisfactory appearance and func-tional outcome.

REFERENCES1. Smith DW. Recognizable patterns of human malformation: genetic,

embryologic and clinical aspects. Major Probl Clin Pediatr 1970;7:1–368.

2. de Marinis FM, de Marinis R. Frequency of clinodactyly in childrenbetween the ages of 5 and 12. Acta Genet Med (Roma) 1955;4:192–204.

3. Dutta P. The inheritance of the radially curved little finger. ActaGenet Stat Med 1965;15:70–76.

4. Hersh AH, DeMarinis F, Stecher RM. On the inheritance and de-velopment of clinodactyly. Am J Hum Genet 1953;5:257–268.

5. Zhang G, Kato H, Yamazaki H. Physiolysis for correction of thedelta phalanx in clinodactyly of the bilateral little fingers. Hand Surg2005;10:297–302.

6. Light TR, Ogden JA. The longitudinal epiphyseal bracket: implica-tions for surgical correction. J Pediatr Orthop 1981;1:299–305.

7. Burke F, Flatt A. Clinodactyly. A review of a series of cases. Hand1979;11:269–280.

8. Carstam N, Theander G. Surgical treatment of clinodactyly causedby longitudinally bracketed diaphysis (“delta phalanx”). Scand JPlast Reconstr Surg 1975;9:199–202.

9. Vickers D. Clinodactyly of the little finger: a simple operativetechnique for reversal of the growth abnormality. J Hand Surg1987;12B:335–342.

10. Wood VE, Flatt AE. Congenital triangular bones in the hand. J HandSurg 1977;2:179–193.

11. Al-Qattan MM. Congenital sporadic clinodactyly of the index finger.Ann Plast Surg 2007;59:682–687.

12. Rayan G, Grana W. Angular deformity in the middle fingers inyoung athlete. Am J Sports Med 1982;10:51–54.

13. Cooney WP. Camptodactyly and clinodactyly. In: Carter P, ed.Reconstruction of the child hand. Philadelphia: Lea & Febiger, 1991.

14. Fujita H, Iio K, Yamamoto K. Brachymesophalangea and clinodac-tyly of the fifth finger in Japanese children. Acta Paediatr Jpn 1964;31:26–30.

15. Roche AF. Clinodactyly and brachymesophalangy of the 5th finger.Acta Paediatr 1961;50:387–391.

16. Jones GB. Delta phalanx. J Bone Joint Surg 1964;46B:226–228.

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