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left hand with postaxial polydactyly
Polydactyly or polydactylism (from Greek πολύς (polys), meaning "many", and δάκτυλος (daktylos), meaning "finger"), also known as hyperdactyly, is a congenital physical anomaly in humans, dogs, and cats having supernumerary fingers or toes. Polydactyly is the opposite of oligodactyly (fewer fingers or toes).
- 1 Presentation
- 2 Types of polydactyly
- 3 Classification
- 4 Associated syndromes
- 5 Treatment
- 6 Results and complications
- 7 Epidemiology
- 8 Society and culture
- 9 Other animals
- 10 References
The extra digit is usually a small piece of soft tissue that can be removed. Occasionally it contains bone without joints; rarely it may be a complete, functioning digit. The extra digit is most common on the ulnar (little finger) side of the hand, less common on the radial (thumb) side, and very rarely within the middle three digits. These are respectively known as postaxial (little finger), preaxial (thumb), and central (ring, middle, index fingers) polydactyly. The extra digit is most commonly an abnormal fork in an existing digit, or it may rarely originate at the wrist as a normal digit does. The world record holder for highest number of digits is Akshat Saxena from Uttar Pradesh, India. He was born in 2010 with 7 digits on each hand and 10 digits on each foot, for a total of 34 digits.
The incidence of congenital deformities in newborns is approximately 2%, and 10% of these deformities involve the upper extremity. Congenital anomalies of the limb can be classified in seven categories, proposed by Frantz and O’Rahilly and modified by Swanson, based on the embryonic failure causing the clinical presentation. These categories are failure of formation of parts, failure of differentiation, duplication, overgrowth, undergrowth, congenital constriction band syndrome, and generalized skeletal abnormalities. Polydactyly belongs to the category of duplication. In humans this condition can present itself on one or both hands. The extra digit can be a small piece of soft tissue that can be removed, but it can also contain bone without joints or it may be a complete, functioning digit. Because there is an association between polydactyly and several syndromes, children with a congenital upper extremity deformity should be examined by a geneticist for other congenital anomalies. Likewise if a syndrome is suspected or over two or three generations of the family are affected. Research has shown that the majority of congenital anomalies occur during the 4-week period of embryologic development of rapid limb. Polydactyly has been associated with 39 genetic mutations. More specific loci and genetic mechanisms responsible for disorders of duplications will be defined with time, as molecular research continues. Polydactyly can be divided into three major types, which are discussed below.
Types of polydactyly
Ulnar or postaxial polydactyly
This is the most common situation, in which the extra digit is on the ulnar side of the hand, thus the side of the little finger. This can also be called postaxial polydactyly. It can manifest itself very subtly, for instance only as a nubbin on the ulnar side of the little finger, or very distinctly, as a fully developed finger. Most commonly, the extra finger is rudimentary, consisting of an end phalanx with a nail, and connected to the hand with a small skin pedicle. Mostly one neurovascular bundle can be identified, with no tendons present in the extra digit. In case of a fully developed extra finger, the duplication usually presents itself at the level of the metacarpophalangeal joint. A triplication of the little finger is very rare. Ulnar polydactyly occurs ten times more often in negroid ethnicities and is most common in African populations. The incidence in Caucasians is reported as 1 in 1,339 live births, compared with 1 in 143 live births in Africans and African Americans. Ulnar polydactyly is also often part of a syndrome. In patients with African ancestry ulnar polydactyly mostly occurs isolated, whereas the presentation in Caucasians is often associated with a syndrome. In almost 14% of all patients, this type of polydactyly is hereditary. It usually passes on in an autosomal dominant manner with variable expression and incomplete penetrance. It is genetically heterogenic, meaning that mutations in different genes can be the cause. When the extra digit is pedicled it can be very movable; however, injuries are rare and have never been reported so far.
Radial or preaxial polydactyly
This is a less common situation, which affects the side of the hand towards the thumb. Radial polydactyly refers to the presence of an extra digit (or extra digits) on the radial side of the hand. It is most frequent in Asian populations and it is the second most common congenital hand disorder. The incidence of radial polydactyly is reported as 1 in every 3,000 live births. The clinical features of radial polydactyly will depend upon the extent of duplication. Radial polydactyly varies from a barely visible radial skin tag to complete duplication. Thumb polydactyly varies from barely visible broadening of the distal phalanx to full duplication of the thumb including the first metacarpal. Radial polydactyly is frequently associated with several syndromes.
This is a very rare situation, in which the extra digit is on the ring, middle or index finger. Of these fingers, the index finger is most often affected, whereas the ring finger is rarely affected. This type of polydactyly can be associated with syndactyly, cleft hand and several syndromes. Polysyndactyly presents various degrees of syndactyly affecting fingers three and four.
Classification is done by using x-ray imaging to see the bone structures
The classification of ulnar polydactyly exists of either two or three types. The two-stage classification according to Temtamy and McKusick involves type A and B. In type A there is an extra little finger at the metacarpophalangeal Joint, or more proximal including the Carpometacarpal joint. The little finger can be hypoplastic or fully developed. Type B varies from a nubbin to an extra, non-functional little finger part on a pedicle.Sometimes that can be from a radiation. According to the three-type classification, type I includes nubbins or floating little fingers, type II includes duplications at the MCPJ, and type III includes duplications of the entire ray.
The Wassel classification is the most widely used classification of radial polydactyly It is based upon the most proximal level of skeletal duplication:
- Type 1: distal phalanx
- Type 2: interphalangeal joint
- Type 3: proximal phalanx
- Type 4: metacarpophanlangeal joint
- Type 5: metacarpal phalanx
- Type 6: carpometacarpal joint
- Type 7: triphalangeal thumb
The most common type is Wassel 4 (about 50% of such duplications) followed by Wassel 2 (20%) and Wassel 6 (12%).
The classification of central polydactyly is based on the extent of duplication and involves the following three types: Type I: a central duplication, not attached to the adjacent finger by osseous or ligamentous attachments. It frequently does not consist of bones, joints, cartilage, or tendons. Type IIA: a nonsyndactylous duplication of a digit or part of a digit with normal components and articulates with a broad or bifid metacarpal or phalanx. Type IIB: a syndactylous duplication of a digit or part of a digit with normal components and articulates with a broad or bifid metacarpal or phalanx. Type III: a complete digital duplication, which has a well-formed duplicated metacarpal. 
Polydactyly can occur by itself, or more commonly, as one feature of a syndrome of congenital anomalies. When it occurs by itself, it is associated with autosomal dominant mutations in single genes, i.e. it is not a multifactorial trait. But mutation in a variety of genes can give rise to polydactyly. Typically the mutated gene is involved in developmental patterning, and a syndrome of congenital anomalies results, of which polydactyly is one feature or two.
|174200||Postaxial A1||GLI3 at 7p13|
|174500||Preaxial II||SHH at 7q36|
|174700||Preaxial IV||GLI3 at 7p13|
At this moment, 97 genetic syndromes have been associated with different kinds of polydactyly.
Ulnar polydactyly is often bilateral and associated with syndactyly and polydactyly of the feet. This can be a simple or complex polydactyly. Ulnar polydactyly occurs as an isolated congenital condition, but can also be part of a syndrome. The syndromes which occur with ulnar polydactyly are: Greig cephalopolysyndactyly syndrome, Meckel syndrome, Ellis–van Creveld Syndrome, McKusick–Kaufman syndrome, Down syndrome, Bardet–Biedl syndrome, Smith–Lemli–Opitz syndrome
Type VII of radial polydactyly is associated with several syndromes: Holt–Oram syndrome, Fanconi anemia: aplastic anemia at the age of 6, Townes–Brocks syndrome, Greig cephalopolysyndactyly: also occurs with ulnar polydactyly.
The syndromes associated with central polydactyly are: Bardet–Biedl syndrome, Meckel syndrome, Pallister–Hall syndrome, Legius syndrome, Holt–Oram syndrome, Also, central polydactyly can be associated with syndactyly and cleft hand.
Other syndromes including polydactyly include Acrocallosal syndrome, Basal cell nevus syndrome, Biemond syndrome, Ectrodactyly-ectodermal dysplasias-cleft lip/palate syndrome, Mirror hand deformity, Mohr syndrome, Oral-facial-digital syndrome, Rubinstein-Taybi syndrome, Short rib polydactyly, and VATER association. It can also occur with a triphalangeal thumb.
Ulnar polydactyly usually does not interfere with hand function, but for social reasons it can be treated operatively.
Type A ulnar polydactyly
The treatment of Type A ulnar polydactyly is complex as its goal is to remove the accessory digit while maintaining a stable, functional small finger. When the duplicated proximal phalanx articulates with a common, broad metacarpal head, the ulnar collateral ligament must be considered. In those cases with a common articulation or with a sixth metacarpal the muscle executing the abduction of the little finger (abductor digiti minimi) must be preserved. In patients with a common metacarpal articulation an elliptical incision at the base of the post-axial digit is made. This incision may be extended proximally in order to adequately expose the abductor digiti minimi. The ulnar collateral ligament and the insertions of the abductor digiti minimi are then elevated with a periosteal sleeve. The duplicated extensor and flexor tendons to the ulnar digit are transected and after that the digit is amputated at its articulation with the metacarpal. If the articular surface is wide the metacarpal may be shaved. At last the collateral ligament and abductor digiti minimi are reinserted at the base of the preserved proximal phalanx and a wire is then placed across the reconstructed joint. In patients with a duplicated metacarpal, the accessory digit is amputated in a standard ray fashion with transfer of the abductor digiti minimi to the retained small finger.
Type B ulnar polydactyly
In this situation there is an absence of osseous and ligamentous structures. The surgical technique is analogous to radial polydactyly, in which the level of duplication and anatomical components should guide operative treatment. The pedicled ulnar extra digit can be removed by suture ligation to devise the skin bridge of the newborn child. This might be easier than an excision of the extra digit when the child is 6 to 12 months old. Ligation occludes the vascular supply to the duplicated digit, resulting in dry gangrene and subsequent autoamputation. This must be done with consideration of the presence of a neurovascular bundle, even in very small skin bridges. When the ligation is done inappropriately it can give a residual nubbin. Also, a neuroma can develop in the area the scar. An excision can prevent the development of a residual nubbin and the sensibility due to a neuroma. For infants with ulnar type B polydactyly the recommended treatment is ligation in the neonatal nursery. Studies have shown that excision of the extra digit in the neonatal nursery is a safe and simple procedure with a good clinical and cosmetic outcome.
Because neither of the two thumb components is normal, a decision should be taken on combining which elements to create the best possible composite digit. Instead of amputating the most hypoplastic thumb, preservation of skin, nail, collateral ligaments and tendons is needed to augment the residual thumb. Surgery is recommended in the first year of life, generally between 9 and 15 months of age.
Surgical options depend on type of polydactyly.
This type of procedure is recommended for Wassel types 1 and 2 (in which both thumbs are severely hypoplastic) by some congenital hand surgeons. The technique contains a composite wedge resection of the central bone and soft-tissue. This will be achieved with approach of the lateral tissue of each thumb. The goal is to achieve a normal thumb, what concerns the size, which is possible. If the width of the nail bed is greater than 70% of the contralateral thumb, it may be split. Then the nail bed will be repaired precisely.
Ablation with collateral ligament reconstruction
This type of procedure is used for all Wassel types of polydactyly and is the most commonly used technique. It is recommended in all cases of thumb duplication with a hypoplastic, less-functional thumb. Otherwise, one could consider the Bilhaut-Cloquet. The ulnar thumb is preferably preserved as it is the more developed one in most cases.
By detaching the radial collateral ligament from distal to proximal, a periosteal sleeve can be preserved. In this way, the radial collateral band of the radial digit, will function as the absent radial collateral ligament of the preserved ulnar thumb.
Elevation of the APB and FPB is performed in Wassel type 4 duplication; this can be accomplished via the periosteum or separately. As the tendons insert proximally, the elevation is performed proximally too to potentially rebalance the ulnar thumb. After the radial thumb is amputated, the ulnar elements are centralized and fixed with a Kirschner wire. In most cases, a longitudinal and sagittal osteotomy is needed to centralize the bony parts of the ulnar thumb. While the soft-tissue of the radial thumb was preserved, it is now attached to the radial side of the ulnar thumb together with the periosteal sleeve. The APB and FPB of the ablated radial thumb are attached to the distal phalanx for more stability. If necessary, the extensor pollicis longus and the flexor pollicis longus are reattached to centralize their course.
In Wassel type 5 and 6 the opponens pollicis muscle must be transferred to the ulnar metacarpal. Soft tissue with collateral ligament reconstruction is used to avoid any angular deformity in the preserved thumb. Tendon centralization is also often used for correction. Still, cases with osseous deformities may happen. To provide alignment, osteotomies are necessary to be done. This operation may need bone grafting, which is obtained from the amputated thumb.
On top plasty procedure
This type is indicated when one thumb is larger proximally and the other thumb has a larger distal component. (The procedure is initially described as a way to lengthen amputated digits.) The goal is to create a functional thumb by combining less-hypoplastic components. On top plasty procedure is rarely employed in the treatment of congenital thumb duplication. It is might be necessary for Wassel types 4, 5, 6.
At the level of the mid-proximal phalanx or mid-metacarpal, the distal component is transferred to the proximal component. The tendons of the distal component are preserved as the rest of the distal component is amputated. The neurovascular bundle which supplies the distal component is reserved and transferred proximally.
Early osteotomy and ligament reconstructions should be done to prevent deformities, such as angular growth deformities.
The surgical treatment of central polydactyly is highly variable. After the surgery the hand must be functional and stable, but also aesthetically pleasing. This requires intraoperative creativity and flexibility. The surgeon must also consider whether retention of a fully functional supranumerary digit is preferable to surgical intervention. In contrast, a functional, four-fingered hand achieved via ray amputation may be preferable to a five-fingered hand with a deformed or stiff reconstructed finger.
Cases of polysyndactyly are approached through a standard opposing zig-zag incision. The incision is favored toward the accessory digit, preserving extra skin for subsequent closure. Depending on the level and extent of duplication, the flexor and extensor tendons may require centralization or rebalancing. Also, the collateral ligaments must be preserved or reconstructed. Wide articular surfaces should be narrowed and phalangeal wedge osteotomies may be required to provide an axial alignment. Attention must also be given to reconstruct the intermetacarpal ligament. Furthermore, one should take in mind the provision for adequate web-space soft tissue.
Results and complications
Type A ulnar polydactyly
There are no substantive outcome studies regarding the function of these hands following surgical intervention. This is mainly caused by the fact that there is a generally normal function of these patients’ hands following ablation with collateral ligament reconstruction. In a study on 27 patients undergoing surgical excision for Type A ulnar polydactyly, only one complication was noted in the form of an infection However, no investigators have objectively reviewed functional range of motion or articular stability.
Type B ulnar polydactyly
In a study on 21 patients with Type B ulnar polydactyly treated with suture ligation it was found that the duplicated digit was typically amputated at an average of 10 days and no complications of infection or bleeding were reported. In a large study on 105 patients treated with suture ligation an overall complication rate of 23.5% was reported, citing a residual tender or unacceptable bump in 16%, infection in 6%, and bleeding in 1% of patients. In general, suture ligation is safe and effective when applied to appropriate cases of Type B polydactyly in which no substantial ligamentous or osseous structures are present within the pedicle. Parents should be educated as to the progression of necrosis, and that revision of residual tissue or scar may be necessary when the child is 6 months of age or older.
Advantages: By combining two hypoplastic thumbs a sufficient thumb size is acquired. Furthermore the IP and MCP joints are very stable as the collateral ligaments are not violated during reconstruction. Disadvantages: Violation during reconstruction can lead to growth arrest or asymmetric growth. Nail deformity could also occur after reconstruction. Although the joint are stable, restriction of flection may be possible. The average IP flexion in a reconstructed thumb is 55 degrees less than the contralateral thumb. MCP flection averaged 55 degrees in reconstructed thumbs, compared to 75 degrees in the contralateral thumb.
Ablation with collateral ligament reconstruction
Advantages: The reconstructed joints tend to remain flexible. Also, it preserves the nail bed and physis, this increases the prevention of nail deformities over time. Disadvantages: Although surgeons try to obtain a stable thumb of appropriate size, instability of the IP and MCP joint may occur, as well as a size mismatch. Thumbs are defined as unacceptable if IP joint deviation exceeds 15 degrees, MCP joint deviation exceeds 30 degrees, and thumb size is inappropriate based on the examiner’s assessment. Also, thumb size one-third greater or less than the contralateral thumb is defined as unacceptable.
On-top plasty procedure
No surgical outcomes studies exist for evaluating the function of the thumbs after an on-top plasty reconstruction.
Few clinical outcome studies exist regarding the treatment of central polydactyly. Tada and colleagues note that satisfactory surgical correction of central polydactyly is difficult to achieve and that outcomes are generally poor. In Tada’s study, 12 patients were reviewed. All patients required secondary surgical procedures to address flexion contractures and angular deviation at the IP joint level. However, several primary factors contribute to the complexity of central polydactyly reconstruction. Hypoplastic joints and soft tissues that predispose the reconstructed finger to joint contracture, and angular deformities as well as complex tendon anomalies, are often difficult to address. Therefore, treatment is wholly dependent on the anatomic components present, the degree of syndactyly, and the function of the duplicated finger.
The condition has an incidence of 1 in every 500 live births. Postaxial hand polydactyly is a common isolated disorder in African black children, and autosomal dominant transmission is suspected. Postaxial polydactyly is more frequent in blacks than in whites and is more frequent in male children. In contrast, postaxial polydactyly seen in white children is usually syndromic and associated with an autosomal recessive transmission. One study by Finley et al. combined data from Jefferson County, Alabama, United States and Uppsala County, Sweden. This study showed incidence of all types of polydactyly to be 2.3 per 1000 in white males, 0.6 per 1000 in white females, 13.5 per 1000 in black males, and 11.1 per 1000 in black females.
Society and culture
People with polydactyly
- Zerah Colburn, American prodigious math calculating savant
- Gemma Arterton, an actress who has starred in Prince of Persia and Quantum of Solace, was born with an extra finger on each hand. The vestigial digits were removed when she was a child.
- Anne Boleyn, former Queen of England, was rumoured to have six fingers on one hand. Though, considering this rumour first emerged in the 1580s from a Catholic dissenter, it is unlikely to be true.
- Antonio Alfonseca, professional baseball player known as "El Pulpo" - Spanish for "the Octopus" in regards to his extra finger
- Hampton Hawes, jazz pianist, was born with six fingers on each hand (extra fingers were surgically removed shortly after birth).
- Henry II the Pious
- Robert Chambers, purported author of Vestiges of the Natural History of Creation, and his brother William: six digits each limb
- Kamani Hubbard, a boy born with a rare case of polydactyly with both 12 fully functioning fingers and 12 toes
- Varalakshmi V, a girl from Bangalore with eight fingers in each hand and about four to five extra toes in each foot
- Sasee Suriyaah L, London, has an extra toe in her right foot. The fifth toe and the extra toe are conjoined to form a heart shape.
- Hrithik Roshan, a Bollywood actor born with a supernumerary thumb on his right hand
- Nayanthara, an Indian actress, with a rudimentary finger on her left hand
- Garfield Sobers, West Indian cricketer, had an extra finger on each hand which he removed himself during childhood "with the aid of catgut and a sharp knife"
- Danny Garcia, boxing champion, has 6 toes on his right foot.
- Mao Tse-tung's third wife Jiang Qing reportedly had six toes on her right foot.
- Drew Carey, actor and comedian, has six toes on his right foot, according to his autobiography.
- Yoandri Hernández Garrido, alias "veinticuatro" ("twenty four" in Spanish), has six fully formed fingers on both hands and six perfect toes on each foot.
- American Chicago blues guitarist Hound Dog Taylor was born with polydactyly on both hands, although around age 41, he removed the extra finger on his right hand.
Fictional characters and polydactyly
- The Darkover series (1958-2013) by Marion Zimmer Bradley prominently features a six-fingered species called the Chieri. Mixed Human-Chieri offspring and families resulting from such pairing are among the most important protagonists of the series (some inheriting the six-fingered hands of their ancestors).
- The Princess Bride is a comedy adventure book and film in which the vizier Count Tyrone Rugen is known as the 'Six-Fingered Man', having six digits on his right hand.
- Farewell My Concubine (1993) is a Chinese film in which a mother is told her son will not be accepted into a boy's performance troupe due to his supernumerary finger. She has the extra finger chopped off as a result.
- The Contortionist's Handbook (2002) by Craig Clevenger is about the life of John Dolan Vincent, a drug-using forger who was born with an extra finger on his left hand.
- The Silence of the Lambs (1988) by Thomas Harris features the character Hannibal Lecter who has a duplicate middle finger on his left hand. This physical anomaly was never portrayed in the film adaptation.
- Umineko: When They Cry (2007) is a Japanese murder mystery dōjin soft visual novel series in which one of the characters, Kinzo Ushiromiya, suddenly went missing. An impaled burnt corpse was later found in the boiler room and was later identified as him when the family looked at his feet. Battler, one of his grandchildren, was surprised by the presence of an extra digit on his foot. Genji then told him that Kinzo was born with polydactyly.
- Gattaca (1997) is a sci-fi film about a world that potential children are selected through preimplantation genetic diagnosis to ensure they possess the best hereditary traits of their parents. A Schubert Impromptu was altered so it can only be played by one with six digits in each hand.
- The Chrysalids (US title: Re-Birth; 1955) by John Wyndham is a science fiction novel about a post-apocalyptic world where genetic invariance has been elevated to the highest religious principle, and humans with even minor mutations are considered "Blasphemies" and the handiwork of the Devil. One of the main characters, a young girl called Sophie, keeps secret the fact that she has six toes on each foot.
- Monk (2002–2009) features Detective Adrian Monk who lost his beloved wife to a car bomb. Monk spends much of the run of the series searching for a six-fingered man who was involved in the bombing.
- Shigurui (2003-2012) is a Manga written by Norio Nanjo with an animated TV adaptation. Kogan Iwamoto, Grandmaster of the Kogan-Ryuu Dojo has six fingers on his right hand. His technique "Nagare Boshi" (Shooting Star) is known and feared by many Samurai.
- "Adventure Time" is a cartoon written by Pendelton Ward. One of the characters, an ancient hero named Billy, has 6 fingers on each hand.
- "Gravity Falls" is a cartoon created by Alex Hirsch. A hand with six fingers is a recurring icon in the show, most notably appearing on the covers of the books 2 and 3. Oddly, some characters in Gravity Falls have five fingers while others have the "standard" four.
- Schoolhouse Rock's "Little Twelvetoes" has 12 fingers and 12 toes.
Polydactyly is a common trait in several heritage chicken breeds, including Silkies.
A number of mutations of the LMBR1 gene, in dogs, humans, and mice, can cause polydactyly. Dogs, like other canids, normally have four claws on their rear paws; a fifth is often called a dewclaw and is especially found in certain dog breeds, including the Norwegian Lundehund and Great Pyrenees.
Polydactyly was believed to be common in the earliest tetrapods, the number of digits settling to the common five on each foot in amniotes and four to the hand and five to the foot in amphibians in the early Carboniferous; see Polydactyly in early tetrapods
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