SCIENTIFIC ARTICLE

Central Ray Deficiency: Subjective and Objective

Outcome of Cleft Reconstruction
Charles A. Goldfarb, MD, Ben Chia, MD, Paul R. Manske, MD

Purpose To assess the long-term subjective and objective outcome of cleft reconstruction in
patients with central ray deficiency.
Methods Twelve patients with 16 central ray deficiency hands were included. Each hand had
been treated with cleft reconstruction using soft tissue and/or bony procedures. A surgeon
and parent assessed the subjective outcome using a visual analog scale to compare preop-
erative and postoperative appearance. Objective outcome was assessed with a clinical
examination for digital range of motion and with a radiographic examination for preoperative
and postoperative divergence angles of the index finger and ring finger metacarpals and
phalanges.
Results The surgeon’s visual analog scale score significantly increased from 4 to 7. Nine
parents were very satisfied, 4 were satisfied, and 3 were somewhat satisfied with hand
appearance. A ring finger proximal interphalangeal joint flexion contracture averaging 31°
was the most notable clinical finding. The metacarpal divergence angle significantly im-
proved from 33° to 12°, and the phalangeal divergence angle significantly improved from 38°
to 12°.
Conclusions Cleft reconstruction improves hand appearance in patients with central deficiency. A
new technique of quantifying the radiographic divergence of the border rays of the cleft
demonstrates improved alignment at long-term follow-up. (J Hand Surg 2008;33A:1579–1588.
Copyright © 2008 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Appearance, central deficiency, cleft hand, reconstruction, transposition.

LEFT HAND, OR CENTRALlongitudinal deficiency, web space.4 Central longitudinal deficiency should be

C is a variable absence or an abnormal formation

of the central ray(s) of the hand.1–3 The classic
presentation includes a central V-shaped cleft and ab-
distinguished from the broad U-shaped cleft in sym-
brachydactyly, which affects a single extremity and
presents with finger nubbins as a notable clinical find-
sence of 1 or more central digits, abnormalities or ing.1
syndactyly of bordering fingers, and a deficient first The absent central digits usually do not impact func-
tion; Flatt2 noted that “the cleft hand is a functional
From the Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes triumph and a social disaster.” Function is affected
Jewish Hospitals, St. Louis, MO. primarily by an insufficient first web space.3 However,
This investigation was performed at the St. Louis Shriners Hospital for Children, St. Louis, MO. the absent central digits invariably negatively affect
Received for publication February 18, 2008; accepted in revised form May 6, 2008. hand appearance and may be socially prohibitive, and
No benefits in any form have been received or will be received related directly or indirectly to the surgical closure of the cleft is usually recommended.
subject of this article. Some variation of the procedure described by Snow
Correspondingauthor:CharlesA.Goldfarb,MD,DepartmentofOrthopaedicSurgery,660South and Littler at the 4th International Congress of Plastic
Euclid, Campus Box 8233, St. Louis, MO 63110; e-mail: goldfarbc@wudosis.wustl.edu. Surgery in Rome in 1967 is commonly used4,5 to close
0363-5023/08/33A09-0018$34.00/0 the central cleft and simultaneously widen the thumb–
doi:10.1016/j.jhsa.2008.05.010
index finger space by transposing a volar pedicle flap

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1579

1580 CENTRAL RAY DEFICIENCY

had sufficient preoperative and postoperative data and a

TABLE 1. Central Longitudinal Deficiency
Classification minimum 5-year follow-up to allow inclusion in this
investigation.
Types* The long-finger phalanges were absent in all patients
Manske Ogino
except 2; one patient had a small remnant of proximal
phalanx and one had a transverse proximal phalanx.
I: Normal web space I: Cleft hand without The long-finger metacarpal was present in 12 of the 16
missing digit hands and absent in 4; two had a Y-shaped distal
IIA: Mildly narrowed first II: Defect of single finger long-finger metacarpal. Seven hands had a ring finger–
web space ray
small finger syndactyly.
IIB: Moderately narrowed III: Defect of two finger
first web space rays
Operative techniques
III: Syndactylized first IV: Defect of 3 finger
web space rays Central cleft: Sixteen hands in 12 patients were treated
IV: Merged with cleft V: Defect of 4 finger rays with cleft closure and reconstruction at a median age of
19 months (range, 12–39 months). Operative time av-
*The Manske classification3 is based on the quality of the first web
space. The Ogino classification10 is based on the bony central
eraged 95 minutes (range, 63–120 minutes). The oper-
deficiency. ative procedure was at the discretion of the operating
surgeon (P.R.M.) and was based on the specific features
of the cleft and the first web space. Generally, the
surgeon performed 1 of 2 types of cleft reconstruction
from the cleft into the first web. Many variations, using (Table 3): soft tissue only or soft tissue and bony
different skin incisions, such as transposition of a dorsal reconstruction.
pedicle flap from the cleft to the first web, have also A soft tissue– only correction was performed in 9
been reported.6 –9 The index ray is often transposed to hands. In 5 hands, the long-finger metacarpal was com-
the base of the third metacarpal to facilitate cleft closure pletely excised, and a soft tissue closure of the cleft was
and first web space widening.4,9 Clear indications for performed. In 3 hands (with an absent long-finger meta-
index ray transposition versus a soft tissue cleft closure carpal), a soft tissue cleft closure was performed. The
alone have not been reported. final hand was reconstructed with a soft tissue closure
There have been few outcome reports on the opera- without resection of the metacarpal. A transverse meta-
tive treatment of central deficiency that provide objec-
carpal ligament reconstruction was performed in 8 of
tive outcome data5,6,10; nonetheless, the general results
the 9 hands to reapproximate and to maintain a close
from these reports have been satisfactory. The purpose
proximity of the distal aspect of the ring finger and
of this investigation was to assess the long-term out-
index finger metacarpals. This was accomplished by
come of patients with central deficiency treated surgi-
suturing together the A1 pulleys11 or by using tendon/
cally with cleft closure and first web space reconstruc-
fascia grafts10 wrapped around the adjacent metacarpal
tion. Specifically, we evaluated hand appearance with
necks.
particular attention to the cleft, finger range of motion,
and radiographic measurements of divergence at the A soft tissue and bony reconstruction was performed
cleft site. in 7 hands. In 5 hands, the majority of the long-finger
metacarpal was excised, retaining the base, and the
MATERIALS AND METHODS second ray was transposed3,5,9 to the base of the long-
In this retrospective evaluation, we reviewed all patients finger metacarpal. In 2 hands without a long-finger
treated at our pediatric orthopedic hospital with cleft metacarpal, an oblique osteotomy of the index-finger
hand to identify those with a central deficiency with metacarpal was performed to place the index ray in a
absence of only the long finger (phalanges with or more ulnar position.
without absence of the metacarpal) (Tables 1, 2). Insti- First web space: There were 5 Manske3 type I hands, 7
tutional review board approval for this investigation type IIA hands, 1 type IIB hand, and 3 type III hands.
was obtained, and all pertinent radiographs, clinical The web space was not addressed in the 5 type I
photographs, and medical records were evaluated. hands. Three of the patients with type IIA hands had
There were 17 patients with absence of the central digit a z-plasty, 2 had a rotational flap from the cleft, and
treated surgically with cleft closure between 1977 and 2 were not treated at the time of the cleft reconstruc-
2001; 12 of these patients (16 central deficiency hands) tion. The single patient with a type IIB hand was

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TABLE 2. Basic Patient Information

Type*
Associated Musculoskeletal
Patient Side Affected Family History Anomalies Manske Ogino

1 R No No I II
2 L No No I II
R III II
3 R Yes Right foot deficiency and IIA II
syndactyly, EEC
4 R Yes No IIA II
L IIA II
5 R No No I II
6 R Yes Left foot syndactyly, IIB II
duplicated great toe
7 R Yes No III II
8 R No No IIA II
9 R No No IIA II
10 R Yes Left index finger I II
clinodactyly
L I II
11 L No No III II
12 L Yes Right foot syndactyly IIA II
R IIA II

*The Manske classification3 is based on the quality of the first web space. The Ogino classification10 is based on the bony central deficiency.
EEC, ectrodactyly ectodermal dysplasia and cleft lip/palate syndrome.

treated with a rotational flap from the cleft. Finally, imbrication of the extensor mechanism, and 1 had an
the 3 patients with type III hands were treated with extensor indicis proprius transfer.
rotational flaps and full-thickness skin grafts. Three
patients required a secondary procedure on the first Assessments
web space (2 had revision procedures to deepen the Subjective data:
first web space at an average of 18 months after the
● One of the authors (C.A.G.) not involved in the
initial surgery, and 1 type IIA patient who did not
have the first web addressed at the initial procedure initial surgical procedures evaluated clinical pho-
had a thumb–index finger z-plasty). tographs before and after surgical intervention (at
last follow-up) for all 16 hands (Figs. 1, 2). Using
Ring finger–small finger syndactyly: Seven hands had ring a visual analog scale (VAS), he rated the hand
finger–small finger syndactyly. Three of these 7 hands appearance with particular attention paid to the
were reconstructed at the time of the initial cleft recon- cleft. A score of 1 corresponded with a severely
struction, and 2 were treated as secondary procedures. abnormal hand, and a score of 10 corresponded
In 2 patients, the syndactyly was not reconstructed per with a normal hand. Scores were averaged and
the desires of the family. rounded to the closest whole number for reporting
Additional procedures: Additional bony procedures were and comparison.
performed for 6 hands at an operative session separate ● The primary caregiver, most commonly the pa-
from that of the cleft reconstruction. Three hands (5 tient’s mother, was queried by a research assistant
digits) required a rotational osteotomy of the index- not involved in the care of the patient as to the
finger or ring-finger metacarpal or phalanges. Three caregiver’s satisfaction with the surgical interven-
hands were treated for an extensor lag at the proximal tion including appearance, function, and pain.
interphalangeal (PIP) joint of the ring finger; 2 had an Choices included very satisfied, satisfied, some-

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TABLE 3. Operative Details for Cleft Reconstruction and Additional Procedures

Age at Third Second to Third Transverse
Side Surgery Third Metacarpal Metacarpal Metacarpal Ligament
Patient Affected (Mo) Metacarpal Excision Transposition Reconstruction

1 R 12 Y-shaped Yes No No
2 L 14 Y-shaped No (bifid portion No No
excised)
2 R 21 Present Yes Yes No
3 R 13 Present Yes No No
4 R 19 Present Yes No Yes
4 L 21 Present Yes Yes Yes
5 R 19 Present Yes No Yes
6 R 12 Y-shaped No (bifid portion No Yes
excised)
7 R 13 Present Yes No Yes
8 R 38 Present Yes Yes No
9 R 39 Absent NA Yes, oblique osteotomy No
of second metacarpal
10 R 12 Present Yes Yes Yes
10 L 20 Absent NA No Yes
11 L 20 Present Yes Yes No
12 L 19 Absent NA No Yes
12 R 20 Absent NA Yes, oblique osteotomy No
of second metacarpal

NA, not applicable.

FIGURE 1: Clinical appearance of a typical cleft in a central deficiency hand prior to reconstruction: A dorsal view and B volar view.

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FIGURE 2: Clinical appearance of a typical cleft in a central deficiency hand after reconstruction: A dorsal view and B volar view.

FIGURE 3: Radiograph before reconstruction with depiction of measurement technique for both A metacarpal and B phalangeal
divergence angles. The metacarpal divergence angle was 40°, and the phalangeal divergence angle was 60°.

what satisfied, and not satisfied. Older patients was paid to the presence of a flexion deformity at
provided input on these questions. the PIP joint and to finger alignment abnormalities.
Objective data: Radiographic data:
● Postoperative range of motion of the index, ring, ● Preoperative, immediate postoperative, and final
and small fingers was assessed. Particular attention postoperative radiographs were reviewed to assess

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1584 CENTRAL RAY DEFICIENCY

for alignment of the digits bordering the cleft. We suring the angle formed by lines drawn through the
determined the angle of divergence between the center of their longitudinal axis on a standard
index-finger and ring-finger metacarpals by mea- posteroanterior x-ray. Similarly, we measured the
angle of divergence between the index-finger and
ring-finger proximal phalanges—the phalangeal
divergence angle (Figs. 3 and 4).
Statistical analysis
A statistical analysis was performed to assess the data.
Paired t-tests were used to assess change in VAS scores
and the change in the divergence angle. Significance
was set at .05.

RESULTS
Subjective data
The surgeon’s VAS score improved from 4 (range,
2–7) preoperatively to 7 (range, 5–9) postoperatively, a
significant improvement (p ⫽ .02). When subdivided
by severity (Manske3 type), the 5 type I hands had an
average VAS score of 5 preoperatively and 8 postop-
eratively (significant improvement, p ⫽ .007). The 8
FIGURE 4: Radiograph after reconstruction in the patient of
type II hands (including type IIA and IIB) had an
Figure 3. The metacarpal divergence angle and the phalangeal average VAS score of 4 preoperatively and 7 postop-
divergence angle were both 20°, one of the largest eratively (significant improvement, p ⬍ .002). Finally,
postoperative deformities in this series. the 3 type III patients had an average VAS score of 3

TABLE 4. Postoperative Finger Range of Motion

Index Finger (°)

MCP MCP PIP DIP

Joint Joint PIP Joint Joint DIP Joint Joint
Name Side Extension Flexion Extension Flexion Extension Flexion

1 R 10 80 Normal Normal Normal Normal

2 R Normal Normal Normal Normal Normal Normal
2 L Normal Normal Normal Normal Normal Normal
3 R Normal Normal Normal Normal Normal Normal
4 R Normal 65 Normal Normal Normal Normal
4 L Normal 65 Normal 85 Normal Normal
5 R Normal 55 Normal 60 Normal Normal
6 R Normal Normal Normal Normal
7 R Normal Normal 25 Normal Normal 20
8 R Normal Normal 10 Normal Normal 0
9 R Normal Normal Normal Normal Normal Normal
10 R 10 Normal 30 80 Normal 0
10 L 10 Normal Normal 85 Normal 15
11 L Normal Normal Normal Normal Normal Normal
12 R Normal Normal Normal Normal Normal Normal
12 L Normal Normal Normal Normal Normal Normal
Number of joints with normal 13 12 13 12 16 12
motion (n)
Average range of motion for those 10 66 22 78 NA 9
joints without full motion (°)

MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal; NA, not applicable.
(Continued)

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preoperatively and 6 postoperatively (significant im- data in each patient as documented in the medical
provement, p ⫽ .02). record. Three hands had a residual rotational abnormal-
Subjectively, 9 parents were very satisfied about the ity of the ring finger at the time of final follow-up;
hand appearance, 4 were satisfied, and 3 were only function was not affected in these patients.
somewhat satisfied. All believed the hand appearance
was improved, and none were dissatisfied with the final Radiographic data
hand appearance. Four patients with bilateral involve- The divergence angles are noted in Table 5.
ment were included in this investigation; 2 of the care- The metacarpal divergence angle between the index-
givers were satisfied with both hands, and 2 were very finger and ring-finger metacarpals averaged 33° (range,
satisfied with 1 hand and only somewhat satisfied with 10° to 60°) preoperatively, 15° (range, 5° to 40°) im-
the other. Four patients had rare pain and the other 8 mediately after surgery, and 12° (range, 0 to 40°) at
denied pain. Subjective functional improvements were final follow-up. The improvement from before surgery
most commonly attributed to restoration of the first web to final follow-up was significant (p ⫽ .0005) as was
space. All patients were able to perform normal daily the improvement from before surgery to immediately
activities with the affected hand(s). after surgery (p ⫽ .002). There was no significant
difference in the metacarpal divergence angle immedi-
Objective data ately after surgery compared with that at final follow-up
Postoperative range of motion was considered normal (p ⫽ .16).
for all 3 fingers in 7 hands (5 patients); the other 9 hands The phalangeal divergence angle between the index-
had some loss of motion involving at least 1 joint (Table finger and ring-finger proximal phalanges averaged 38°
4). The most notable abnormality was the limited active (range, 25° to 80°) before surgery, 15° (range, 0 to 45°)
and passive extension of the ring-finger PIP joint. Only immediately after surgery, and 12° (range, 10° conver-
9 hands had full PIP joint extension of the ring finger, gent to 50°) at final follow-up. The improvement from
and the other 7 hands had an average 31° loss of before surgery to final follow-up was significant (p ⬍
extension (range, 20° to 55°). These postoperative .003) as was the improvement from before surgery to
range of motion data were similar to the preoperative immediate after surgery (p ⬍ .007). There was no

TABLE 4. Postoperative Finger Range of Motion (Continued)

Ring Finger (°) Small Finger (°)

MCP MCP PIP DIP MCP MCP PIP DIP

Joint Joint PIP Joint Joint DIP Joint Joint Joint Joint PIP Joint Joint DIP Joint Joint
Extension Flexion Extension Flexion Extension Flexion Extension Flexion Extension Flexion Extension Flexion

10 Normal 20 Normal Normal Normal 10 Normal Normal Normal Normal Normal

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal 50 Normal 85 Normal 35 Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal 45 Normal Normal 20 Normal Normal Normal Normal Normal Normal
Normal 60 80 0 Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal 55 Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal 35 65 Normal 10 Normal Normal 15 85 Normal Normal
10 65 30 Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal 60 35 75 Normal Normal Normal 60 15 Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
14 12 9 12 16 13 15 15 14 15 16 16

10 59 43 56 NA 22 10 60 15 85 NA NA

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TABLE 5. Radiographic Measurements of the Metacarpal and Phalangeal Divergence Angles

Metacarpal Divergence Angle (°) Phalangeal Divergence Angle (°)

Immediately Final Immediately Final

Patient Side Preoperative Postoperative Postoperative Preoperative Postoperative Postoperative

1 R 30 5 0 25 0 5
2 R 60 40 45 45 45 50
2 L 60 10 10 50 5 5
3 R 40 0 20 65 15 20
4 R 25 15 15 55 15 5
4 L 45 35 25 30 10 10
5 R 7 0 0 82 5 25
6 R 45 25 25 60 30 10
7 R 25 15 0 40 5 0
8 R 25 20 0 30 20 25
9 R 60 20 20 40 20 0
10 R 25 0 0 15 10 10
10 L 15 15 15 0 15 15
11 L 15 10 10 30 15 15
12 R 30 15 0 25 20 0
12 L 15 20 0 10 10 0
Average 33 15 12 38 15 12

t-test: Metacarpal immediately postoperative:Metacarpal final, p ⫽ .164; Metacarpal preoperative:Metacarpal immediately postoperative, p ⬍ .023;
Metacarpal preoperative:Metacarpal final, p ⬍ .005.
Phalangeal immediately postoperative:Phalangeal final, p ⫽ .321; Phalangeal preoperative:Phalangeal immediately postoperative, p ⬍ .007;
Phalangeal preoperative:Phalangeal final, p ⬍ .003.

significant difference in the phalangeal divergence an- this difference was not significant (p ⫽ .35), suggesting
gle immediately after surgery compared with that at that a larger preoperative divergence angle did not pre-
final follow-up (p ⫽ .32). dispose to a larger, final divergence angle (Table 5). We
There was no significant difference between the evaluated 3 variables that we believed may have con-
metacarpal and phalangeal divergence angles at any tributed to the failure to maintain a straighter alignment:
measurement point (p ⬎ .83). the presence/absence of a third metacarpal, the perfor-
The metacarpal divergence angles improved at the mance of a second to third metacarpal transposition, (ie,
immediate and final postoperative evaluation in 14 of Snow-Littler procedure), and the performance of a
the 16 hands; 1 hand had an increased angle at the transverse metacarpal ligament reconstruction. We
immediate postoperative evaluation but improved at the were unable to demonstrate that any of these 3 surgical
final evaluation, and 1 was unchanged. Similarly, 14 of factors decreased the risk of a persistent divergence
the 16 preoperative phalangeal divergence angles im- angle of more than 15°.
proved at the immediate and final postoperative evalu-
ations; 1 was unchanged at the immediate postoperative DISCUSSION
visit but improved at the final evaluation, and 1 had The subjective results of this investigation were very
increased proximal phalangeal divergence angle at both good in that families were satisfied with the surgical
postoperative evaluations. intervention and found the appearance of the hand to be
Seven of the 16 hands (including the 2 hands with improved; this is similar to less vigorous outcome eval-
increased divergence) had a final metacarpal or phalan- uations of previous reports.5,6,10,11 The VAS scores,
geal divergence angle of more than 15°. The preoper- range of motion measurements, and the metacarpal and
ative metacarpal divergence angle averaged 34° in phalangeal divergence angle measurements provide an
those patients compared with 31° in the other patients; objective confirmation of the improved appearance.

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There are few objective outcome data in the previous have not used the flexor digitorum superficialis trans-
studies of central deficiency reconstruction to allow fer10 to address this deficiency. The flexed posture of
comparison. the ring-finger PIP joint did not cause marked func-
The radiographic outcome of central deficiency re- tional difficulties but was primarily an appearance
construction has not been previously reported. Use of issue.
an index-finger and ring-finger metacarpal divergence One technical component of the reconstruction of
angle and/or proximal phalanx divergence angle allows central ray deficiency that has received extra attention is
an objective assessment of cleft reconstruction to pro- the reconstruction of the transverse metacarpal ligament
vide an improved understanding of alignment. The between the index-finger and ring-finger metacarpals.
metacarpal divergence angle measures the true “cleft” Tada10 primarily used an autogenous tendon graft in a
angle and allows an accurate assessment of any recon- circular fashion through both metacarpals and called it
struction. The phalangeal divergence angle is also help- “an essential part of closure of the cleft.” Ogino11
ful as it measures the clinical alignment of the digits cautioned overtightening such tendon grafts and instead
that, by definition, includes any compensatory angula- used flaps from the adjacent flexor sheaths. This recon-
tion (or convergence) of the metacarpophalangeal or struction was in an anatomic position and was not
PIP joints. In this series, surgery provided a significant susceptible to overtightening. A simple, alternative
improvement in both angles that was maintained at final method is to cut the adjacent A1 pulleys and suture
follow-up. Rider et al.5 measured divergence as the them together.1 Rider et al.5 reported on the Snow-
distance in millimeters between the index-finger and Littler procedure in 13 hands with central deficiency.
ring-finger metacarpal heads. Although this measure- They reconstructed the transverse metacarpal ligament
ment technique provides objective data, we believe use in 8 of the 13 hands. Notably, the 5 hands without
of divergence angles is less dependent on patient size reconstruction had no evidence of instability or radio-
and radiographic magnification and is, therefore, a more graphic divergence.
useful measurement. Our investigation did not find a difference in final
Seven of the 16 hands had a final metacarpal diver- divergence angle in patients with or without reconstruc-
gence angle or phalangeal divergence angle greater than tion of the transverse metacarpal ligament. If good
15°. We evaluated 3 variables that we believed may balance and alignment are achieved at surgery by bony
have contributed to the failure to maintain a straighter transposition, a reconstruction of the transverse meta-
alignment: the presence/absence of a third metacarpal, carpal ligament may not be necessary. In contrast, if
the performance of a second to third metacarpal trans- good balance and alignment are not achieved at the time
position (i.e., Snow-Littler procedure), and the perfor- of surgery, it is unlikely the ligament reconstruction can
mance of a transverse metacarpal ligament reconstruc- balance the hand to a satisfactory degree.
tion. We were unable to demonstrate that any of these One weakness of this study is the small number of
3 features affected the final angle of divergence. patients included; however, this limitation is frequently
Seven of the 16 hands in this investigation had a seen in patients with uncommon congenital abnormal-
notable flexion contracture of the ring-finger PIP ities. We believe the size of our patient group is accept-
joint. Ogino11 previously noted that the ring-finger able considering the narrow inclusion criteria and the
flexion deformity was likely related to “dysfunction” relatively structured approach to the cleft reconstruction
of the intrinsic muscles. He recommended flexor for these patients. Additionally, this study evaluated the
digitorum superficialis transfer to the base of the subjective and objective outcome of the cleft deformity
proximal phalanx of the ring finger or a split transfer, specifically. Although our objective measures could
in the case of index finger–ring finger divergence, to accomplish this goal, the subjective outcome (both for
the radial base of the ring finger and ulnar base of the the surgeon and for the parent) is less easily isolated to
index finger. Tada10 also noted that there was re- the cleft. The surgeon and the parents were instructed to
duced active extension of the PIP joint of the ring focus their assessment to the cleft (ideally avoiding
finger due to hypoplasia of the third lumbrical. We consideration of the first web space and the ring and
agree with these hypotheses, as the radial-sided in- small fingers); in practicality, this may have been dif-
trinsic structures to the ring finger are likely to be ficult to accomplish.
affected by the central ray deficiency. The presence
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