What is the recommended treatment for clinodactyly with a delta phalanx?

Management of Clinodactyly with Delta Phalanx

For clinodactyly with delta phalanx, early physiolysis with fat graft interposition is the recommended surgical treatment, particularly in children under 6 years of age with trapezoidal delta phalanges, as it provides effective correction while allowing continued growth. 1

Understanding Clinodactyly with Delta Phalanx

Clinodactyly is a congenital lateral deviation of a finger, most commonly affecting the little finger, caused by an abnormally shaped middle phalanx (delta phalanx). The delta phalanx has a longitudinal growth plate on the short side, leading to progressive angular deformity as the child grows.

Surgical Management Options

Early Physiolysis (Preferred Approach)

• Technique: Removal of the central part of the epiphysis (the portion restricting longitudinal growth) with fat graft placement in the resultant defect 1
• Optimal timing: Between 2-6 years of age 2
• Benefits:
  • Simple and quick procedure
  • Allows for growth and correction over time
  • Avoids need for more invasive osteotomy later
  • Mean correction of 79% in long-term studies 1
• Best candidates:
  • Children under 6 years (mean correction 17.9° vs 6.5° in older children) 2
  • Trapezoidal phalanges (mean correction 12.5° vs 2.8° in triangular phalanges) 2
  • More severe deformities (≥40°) show better correction (mean 20°) 2

Osteotomy

• Indications:
  • Older children with completed growth
  • Cases where physiolysis was insufficient
  • Severe functional limitations
• Types:
  • Reversed wedge osteotomy for delta phalanx at proximal phalangeal level 3
  • Closing wedge osteotomy for brachymesophalangism 3

Treatment Algorithm

1. Assessment:

   • Determine severity of angular deformity (measure in degrees)
   • Identify type of delta phalanx (trapezoidal vs triangular)
   • Evaluate functional limitations and cosmetic concerns

2. For children under 6 years with trapezoidal delta phalanx:

   • Perform physiolysis with fat graft interposition
   • Follow for at least 6 years to monitor correction
   • Expected correction: 79% reduction in angular deformity 1

3. For children over 6 years or with triangular delta phalanx:

   • Consider physiolysis with understanding of more limited correction
   • Prepare for possible need for osteotomy if correction insufficient

4. For adolescents with completed growth:

   • Osteotomy is the primary surgical option

Expected Outcomes and Follow-up

• Long-term studies show mean preoperative angle of 38° corrected to 8° after physiolysis 1
• Complete correction (residual deformity <10°) achieved in 15 of 27 fingers 1
• Correction occurs gradually over years, requiring patient/parent counseling
• Regular follow-up is necessary to monitor:
  • Degree of correction
  • Growth of the phalanx
  • Functional improvement
  • Need for additional procedures

Potential Complications

• Premature fusion of the proximal transverse physis (observed in 2 of 10 fingers that underwent repeat physiolysis) 2
• Insufficient correction requiring later osteotomy (rare with proper patient selection)
• Second physiolysis procedures are generally not beneficial (8 of 10 cases showed no additional benefit) 2

Key Considerations for Clinicians

• Early referral to a pediatric hand surgeon is essential for optimal timing of intervention
• Parental counseling about the gradual nature of correction is important
• The simplicity and effectiveness of physiolysis make it preferable to osteotomy when performed at the appropriate age
• Surgical intervention should be considered when there are functional limitations or significant cosmetic concerns

Early physiolysis represents a significant advancement over traditional osteotomy approaches for growing children with clinodactyly, offering effective correction while preserving growth potential.