Pulley Reconstruction to Correct the Dynamic Direction of the Finger for Treatment of IIB Cleft Hand

Purpose: Manske IIB cleft hand is the most common type, which is characterized by severely narrowed first web and rotation of index finger. Some patients suffered from ulnar displacement of flexor tendon system. However, the ulnar displacement was poorly corrected during index to middle transposition during previous procedures and would usually lead to dysfunction of pinch and grip. Here, we developed a new method to correct finger dynamic direction by pulley transposition. Method: In 15 cases with Type IIB cleft hand, incisions from A1 to A2 pulleys were made with pedicle transposition of the flexor tendon and sheath system to the central. A1 pulleys of index and ring fingers were separated to reconstruct transverse ligament. Snow-Littler procedures were performed to reconstruct the first web. Postoperative assessment included subjective considerations of appearance, parent satisfaction, and ability to perform daily activities. Objective assessment included measurement of first web space, index-ring metacarpal separation, pinch strength, and rotation of the index finger. Results: All the patients and parents claimed to be satisfied with the surgery. Pinch grip reached 72% of the opposite hand when that was normal. The radiological measurement of the angle between the first and second metacarpals was 60.8º and the distance between the adjacent metacarpals across the closed cleft was 8 mm. Index rotation was only 1º and the mean thumb-index pinch was 5.6 kg. Conclusions: Pulley transposition can correct the ulnar displacement of flexor tendon system and improve pinch grip strength in Manske IIB cleft hand, which is a supplemental method for physiological and aesthetic reconstruction of cleft hand.