What is the recommended approach for reconstructive surgery in a pediatric patient with polydactyly, classified by the Wessel type?

Polydactyly Reconstruction Based on Classification

Surgical reconstruction of polydactyly should be performed by a pediatric plastic surgeon or pediatric surgeon before 12 months of age for optimal outcomes, with the specific surgical approach determined by whether the duplication is preaxial (radial/thumb), postaxial (ulnar/small finger), or central. 1, 2

Immediate Assessment and Referral

• All newborns with polydactyly require systematic examination to exclude syndromic associations before focusing solely on the hand anomaly 1
• Look specifically for chondroectodermal dysplasia (Ellis-van Creveld syndrome) in ulnar polydactyly cases 2
• Refer to a pediatric plastic surgeon or pediatric surgeon with specific training in congenital hand differences for all children under 5 years requiring surgical procedures 1
• Critical pitfall: Do not delay referral beyond early infancy, as optimal surgical timing is before 12 months for major reconstructive procedures 1

Surgical Approach by Type

Postaxial (Ulnar/Small Finger) Polydactyly

• Simple excision or suture ligation of the supernumerary digit is typically sufficient for postaxial polydactyly, which is the most common type 3
• This is the most straightforward form to manage surgically 2, 3

Preaxial (Radial/Thumb) Polydactyly

• Reconstructive techniques are required to ensure a functional, stable thumb rather than simple excision 3
• Surgical strategy should include appropriate tendon and muscle relocations in the initial surgery 4
• Quantify preoperative angulation of duplicated digits to determine whether soft tissue correction alone versus osteotomy is needed to minimize residual or recurrent deformity 5
• For Wassel types V and VI specifically, initial surgery should focus on tendon and muscle relocations; opponensplasty and osteotomy are typically reserved for secondary procedures if needed 4
• Consider on-top plasty for "unequal" preaxial polydactyly where neither duplicate digit is clearly preferred on its own 5
• Expect that approximately 24% of complex thumb polydactyly cases (Wassel V-VI) may require additional surgery to address insufficient thumb opposition, radial instability of the MCP joint, or narrowing of the first web space 4

Central Polydactyly

• Reconstruction is most challenging for central polydactyly and requires specialized surgical expertise 3
• This type is much less common than preaxial or postaxial forms 3

Timing Considerations

• Surgery should be performed before 12 months of age for major reconstructive procedures to optimize outcomes 1
• Timing is based on safety of anesthesia and socialization of the affected child 2
• Do not delay surgery after diagnosis regardless of age, as patients experience significant psychosocial consequences from the cosmetic aspect of the anomaly 6
• Even adult patients can achieve excellent or good cosmetic and functional results, though earlier intervention prevents years of social stigma 6

Specialist Selection

• Children under 5 years must be cared for by a pediatric surgeon or pediatric plastic surgeon who has completed specific training in congenital hand differences 1, 7
• If local expertise is unavailable, contact a pediatric surgeon at a regional pediatric surgical center, as outcomes are significantly better with specialized pediatric surgical care 7

Follow-up Requirements

• Careful follow-up observations are essential, particularly for complex thumb polydactyly, as reoperation may be needed for suboptimal initial outcomes 4
• Monitor specifically for narrowing of the first web space (1-2 metacarpal angle <40°) and radial instability of the MCP joint (1st metacarpal-proximal phalanx angle >20°) on radiographs obtained while the patient holds a cone 4