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Symbrachydactyly, or central atypical cleft, is classified as a failure of formation. For the adactylous or monodactylous forms, free toe transfer is the treatment of choice. We present 18 free toe transfers in 13 patients for symbrachydactyly. Despite abnormal anatomy, the functional building blocks have always been available and transfer technically possible. The result has been improved function and high levels of parental satisfaction.

Background: Thumb and multiple finger amputations may result in a metacarpal and a metacarpal-like hand deformity. Toe-to-hand transfer is a recognised treatment strategy for this deformity but has risks and is resource intensive. The aim of this study is to conduct a systematic review of the outcomes of toe-to-hand transfer for traumatic metacarpal and metacarpal-like hand deformity in adult patients.

Methods: Multi-database searching with index and free text terms, duplicate standardised screening and extraction, and quality assessment was performed. The inclusion and exclusion criteria were prespecified. We included any randomised controlled trials, cohort studies, case-control studies, as well as interrupted time series, before and after intervention studies.

Results: Screening of 548 articles yielded 20 studies eligible that included 19 retrospective observational studies and one before and after intervention study. A total of 171 patients underwent 274 toe transfers for metacarpal and metacarpal-like hand deformity. No study compared toe-transfer to a control group or to a prosthesis. The before and after intervention study demonstrated significant improvement in activities of daily living, work, aesthetics and satisfaction. Additionally, no significant donor site morbidity occurred in the heterogenous sample. Outcomes from remaining studies at risk of bias suggest that those with a lesser severity of injury and at least two toe transfers score higher in functional tests and scoring systems.

Conclusions: There is limited confidence in the effectiveness of toe transfer for metacarpal and metacarpal-like hand deformity. The available evidence indicates that toe transfer(s) may restore acceptable function permitting activities of daily living, return to original or sedentary occupation and affords satisfaction.

Level of Evidence: Level III (Therapeutic)

Surgical management of constriction ring syndrome (CRS) is individualised due to the heterogenic presentation of the condition. CRS includes constriction rings, acrosyndactyly, nubbins and short digits. Involvement of more than one limb is common and children often need multiple surgeries. Each limb may need staged surgeries. If the child has vascular or lymphatic compromise secondary to a constriction ring, the ring needs to be excised and released in the first few days of life. The rings are released using multiple big Z-plasties in one or two stages. Nerve palsy associated with the rings need early intervention. Tendon transfers may be advised when nerve procedures like neurolysis and nerve reconstruction fail. Acrosyndactyly can be corrected with separation of the fused fingertips. At times, the web is more distal than usual and requires web deepening using partial syndactyly separation techniques and may need full thickness skin grafting. Complex type of acrosyndactyly is difficult to treat as it needs proper planning and staged surgical correction to achieve a five-digit hand. Separation of the syndactyly with web deepening gives more functional length and independence to the digits. The short fingers, especially the thumb, need reconstruction. Non-vascularised toe phalangeal transfer or a microvascular toe transfer can reconstruct a missing digit.

Level of Evidence: Level V (Therapeutic)