SAR Journal of Surgery

Abbreviated Key Title: SAR J Surg

Home page: https://sarpublication.com/journal/sarjs/home ISSN 2707-7748 (P)
DOI: 10.36346/sarjs.2023.v04i04.002 ISSN 2709-6912 (O)

Ca s e R epo rt

Wassel Type IV Thumb Duplication A Case Report and Literature

Review
Sergio Sandoval Tapia (M.D)1, Karla Yuniva Quintero Barajas (M.D) 2, Erick Gerardo Martinez Martinez (M.D)3,
Jose Eduardo Rosales Jimenez (M.D)4, Rebeca Pamela Parra Enciso (M.D)5, Mariano Tovar Ponce (M.D)5, Sergio
Ivan Castaneda Rocha (M.D)6, Emmanuel Stephano Bracho Ruiz (M.D)1*
1Plastic Surgery Department, Hospital Central Norte Pemex, Mexico City, Mexico
2Traumatology Department, Hospital General ISSSTE Dr. Dario Fernandez Fierro,México
3Hospital Central Universitario, Dr Jesús Enrique Grajeda Herrera, Chihuahua, Chihuahua, México
4Alta Especialidad 25 IMSS, Plastic Surgery Service, Monterrey, Nuevo León, Mexico
5Plastic Surgery Service, Hospital Regional de Minatitlan, Pemex, Veracruz, Mexico
6Plastic Surgery Service, Hospital General “Dr. Norberto Treviño Zapata”, Victoria, Tamaulipas, Mexico

*Corresponding Author: Emmanuel Stephano Bracho Ruiz (M.D)

Plastic Surgery Department, Hospital Central Norte Pemex, Mexico City, Mexico

Article History: | Received: 05.08.2023 | Accepted: 08.09.2023 | Published: 15.09.2023 |

Abstract: Thumb polydactyly, also known as radial polydactyly, is the prevailing manifestation of polydactyly. Its
existence has been documented in the hand literature from Digby's initial description in 1645. Preaxial polydactyly,
specifically bifid thumb, has been extensively observed, with a frequency ranging from 0.08 to 1.4 per 1000 live births.
Traditionally, radial polydactyly is classified into three distinct categories: severe hypoplasia, partial duplication, and
entire duplication, which can sometimes be mistaken for pseudo duplication. The classification system developed by
Wassel has emerged as the widely accepted standard for the categorization of thumb polydactyly. The classifications of
surgical treatment procedures are associated with variations. Thumb duplication is categorized as a "duplication" (group
3) in the International Federation of Societies for Surgery of the Hand (IFSSH)/Swanson classification of congenital
malformations of the hand and upper limb. The objective of surgical reconstruction is to achieve a thumb that is both
stable and mobile, while also possessing appropriate dimensions and form. The prevailing method of reconstruction
often involves the excision of the minor digit followed by the subsequent reconstruction of the major digit. Surgical
procedures aim to rectify issues pertaining to deviation, instability, and insufficient dimensions. Moreover, it is worth
noting that a significant proportion of instances will necessitate an additional intervention in order to enhance the
cosmetic and/or functional result.
Keywords: Hand Surgery, Congenital Hand, Duplicated Thumb, Polydactyly, Duplication, Radial Polydactyly.
Copyright © 2023 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original
author and source are credited.

the United States, it ranks as the second most frequently

INTRODUCTION observed congenital anomaly, following syndactyly.
Approximately 1 out of every 600 babies Radial polydactyly shows sporadic occurrence, with a
exhibit various types of upper limb abnormalities. The prevalence of 8 per 100,000 individuals in both black
scientific community has dedicated significant efforts and white ethnic groups. The majority of patients who
over the past few decades to investigate the intricate have thumb duplication express a preference for
molecular pathways that regulate the process of limb surgical therapy, and the success of the initial surgical
development. Recent findings have contributed to a procedure is of special significance in order to prevent
deeper understanding of the process and have provided the need for more complex and difficult revision
information on how the disruption of multiple procedures in the future. Thumb duplication is
biochemical pathways is linked with distinct categorized as a "duplication" (group 3) in the
manifestations of upper limb abnormalities. Thumb International Federation of Societies for Surgery of the
duplication, also known as radial polydactyly, is a Hand (IFSSH)/Swanson classification of congenital
prevalent congenital abnormality affecting the hand. In
Citation: Sergio Sandoval Tapia et al (2023). Wassel Type IV Thumb Duplication. A Case Report and Literature Review. SAR J Surg, 4(4), 46-50.
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malformations of the hand and upper limb. The types of somewhat vague indications on the etiology of a
polydactyly that are included in this classification specific anomaly, the remaining categories in this
include radial polydactyly, central polydactyly, ulnar classification, namely "duplication," "overgrowth,"
polydactyly, and proximal duplications such as ulnar "undergrowth," and "constriction ring syndrome," are
dimelia. While groups 1 and 2, namely "failure of solely descriptive in nature.
formation" and "failure of differentiation," provide

1: Wassel’s classification system

The method of classification developed by soft tissue, deformities in the axial plane, instability in
Wassel is now recognized as the widely used standard the joints, and impaired functionality.
for the classification of thumb polydactyly. This system
utilizes radiographic observations to describe the extent
of bone duplication. The phalanges and metacarpals of
CASE REPORT
the thumb are categorized as bifid, duplicated, or A male newborn about 6 months old appears
unaffected, based on their proximal-to-distal with a "extra thumb" for evaluation. The family who is
orientation. A Roman numeral is assigned to indicate reporting this was there when the baby was born. The
the extent of bifurcation or duplication as it progresses child's health is fine in all other respects, and there is no
proximally. Congenital hand surgeons are most familiar history of congenital hand abnormalities in the family.
with this. The provided information lacks details Upon closer inspection, there are two thumbs that are
regarding the dominance of the thumb, potential fully developed, each of which has nail plates as well as
convergence or divergence at certain joint levels, joint flexion and extension creases located over the
stability, and the existence of any soft tissue anomalies. interphalangeal joint (IP). The metacarpophalangeal
Type I is characterized by the presence of a bifid distal (MCP) joint is stable despite its appearance of being
phalanx, whereas Type II is defined by complete broad. It would indicate that the MCP joint of the more
duplication of the distal phalanx. Type III is radial thumb is capable of active flexion, extension, and
characterized by the presence of a bifid proximal abduction. There does not appear to be any additional
phalanx accompanied by duplication of the distal anomalies.
phalanx. On the other hand, Type IV is classified as
complete duplication of both the proximal and distal SURGICAL TECHNIQUES
phalanges. Type V is characterized by the duplication Most of the time, removal and reconstruction
of both the proximal and distal phalanges, along with a are the most popular ways to treat thumb duplication.
bifid metacarpal. On the other hand, Type VI is But how hard the repair is will depend on how the
classified as the total duplication of both the phalanges dominant thumb performs. When there is no bone link
and metacarpal. Type VII is characterized by the to the digit to be kept and the joints of this digit are
presence of thumb duplication together with a stable, a simple excision is the right choice. After
triphalangeal component. The Wassel classification, removing the duplicated thumb's middle piece, the
despite its limitations, has contributed to our Bilhaut-Cloquet Procedure involves joining together
comprehension of the skeletal abnormalities in radial equal amounts of bone, soft tissue, and nail tissue.
polydactyly and serves as the primary framework for Some people say that there is no reason to do the classic
future categorization systems. The primary shortcoming Bilhaut-Cloquet treatment because the side effects of
of this approach is in its failure to consider the intricate limited joint movement and nail ridge are not
anatomical complexities associated with this congenital acceptable. This may be true for most type I and type II
hand anomaly, such as deficiencies and redundancy in thumb duplications, for which these methods can

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usually control deviation and instability at the IP joint. have the epiphysis, the physis, and a piece of the
This procedure can make a normal-sized thumb with a metaphysis. Fixation is hard to do. Also, it is not
stable interphalangeal joint. However, it is hard to unusual for this bone piece to come with a very small
accurately join all of the bone segments, nail fold, nail piece of nail bed. Patients with asymmetric bifid
bed, and articular surface, and there are often problems thumbs should not have the modified Bilhaut-Cloquet
with the reconstructed thumb's physeal growth, joint operation done. Instead, the smaller thumb should be
stiffness, and/or nail plate. In the Modified Bilhaut- cut off or only its soft parts should be used. Type I
Cloquet Procedure, some of the fingers' long parts must polydactyly doesn't need this modified method because
be joined together. The nail and terminal phalanx of the the bifid distal phalanges can be fixed with the original
better thumb are used, along with a part of the terminal technique without breaking the distal interphalangeal
phalanx of the lesser thumb. This may be the most usual joint. When the metacarpophalangeal joint is involved,
combination. The hard part is matching the small piece as it is in type IV and other polydactylies, the results of
of bone at the end to the strong end of the phalanx. In the combination operation are generally not good.
order to keep the collateral ligament, the bone must

2: Surgical management

3: Surgical Algorithm

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4: Preop / 7 days post surgery

entailing the excision of the lesser finger, typically

DISCUSSION referred to as the radial. A comparative analysis with
Three categories of hand polydactyly have the contralateral thumb reveals that the thumb intended
been described; preaxial (thumb), central (index, long, for preservation exhibits reduced dimensions and
and ring fingers), and postaxial (small finger) potential absence of specific anatomical elements. Due
polydactyly [5]. Preaxial polydactyly is reported to be to these rationales, certain individuals exhibit a
the most common category among white and Asian preference for employing the term "split" thumb as
populations .The objective of surgical reconstruction is opposed to thumb duplication. The clinical assessment
to achieve a thumb that is both stable and mobile, while evaluates various aspects including the soft tissue
also possessing appropriate dimensions and form. The volume and configuration, the condition of the nail
concepts of stability and size are closely associated with folds, the stability of collateral ligaments during radial
strength, particularly in relation to grip and pinch and ulnar deviation, and the degree of hypermobility,
capabilities. The range of motion of the thumb is mostly specifically in the hyperextension plane of both
determined by the condition of the carpometacarpal interphalangeal (IP) and metacarpophalangeal (MCP)
(CMC) joint. In Wassel types I to IV, the CMC joint is joints. The potential global instability of either one or
often unaffected, however types V and VI may exhibit both factors will significantly undermine their
different levels of malformation or incomplete functionality. The occurrence of this condition
development. The range of motion at the frequently arises from extrinsic tendon anomalies
metacarpophalangeal (MCP) and interphalangeal (IP) affecting the flexor pollicis longus (FPL) and the
joints, while essential for optimal thumb functionality, extensors. These anomalies involve abnormalities in the
may be somewhat less significant. The variability of origin and insertion of the tendons, which exert
normal MCP joint mobility include both the degree of deforming stresses on unstable and underdeveloped
flexion and the occurrence or non-occurrence of joints.
hyperextension. The impairment of tip pinch arises
from the loss of flexibility in the interphalangeal (IP) The occurrence of divergence of proximal
joint. However, it is noteworthy that youngsters are able phalanges at the metacarpophalangeal (MCP) joint level
to efficiently adapt for this deficit without perceiving and convergence at the interphalangeal (IP) joint level
any discernible decline in functionality. When faced is frequently observed in Wassel type IV duplications,
with a dilemma about the balance between stability and especially when the thumbs exhibit equal dimensions.
mobility, it is justifiable for the surgeon to prioritize These present challenging issues for the reconstructive
joint stability over distal joint motion, provided that the surgeon. The primary objective is to effectively restore
carpometacarpal (CMC) joint remains undamaged. The the retained thumb during the removal of the smaller
aesthetic significance of the thumb's shape is a crucial finger, taking into consideration any anatomical
aspect to consider. When devising surgical irregularities that may hinder optimal functionality,
reconstruction strategies, it is imperative to consider the namely those that contribute to instability and
various aspects of thumb function that require careful deviation-related issues. Typically, a basic radiological
consideration. It is readily apparent to the casual evaluation suffices in acquiring the further data required
observer that there exists a dominant thumb. for surgical strategizing. Obtaining accurate posterior-
Nevertheless, it is possible that there are shortcomings anterior and lateral views of each duplicated thumb can
in the preservation of the thumb. Parents are advised provide challenges in certain cases. The findings of the
that the surgical procedure may encompass the clinical examination must be accompanied with their
rebuilding of the dominant thumb, rather than solely relevance. The utilization of an X-ray image of the
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contralateral thumb becomes advantageous in the

evaluation of bone dimensions and morphology, as well
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