Physical anomaly involving extra fingers or toes
Medical condition
Polydactyly is a birth defect that results in extra fingers or toes. The hands are more commonly involved than the feet. Extra fingers may be painful, affect self-esteem, or result in clumsiness.
It is associated with at least 39 genetic mutations. It may either present alone or with other defects. Cases may run in families. The underlying mechanism involves an error in limb bud formation during early development. Diagnosis may occur before birth via prenatal ultrasound as early as nine weeks. Xrays may be useful after a child is a year old. The opposite is oligodactyly (fewer fingers or toes).
Treatment varies from removal by cautery to more involved surgery. While putting a tight band around the base has been carried out, this is not typically recommended. If surgery is required, this is often done around two years of age. Occasionally multiple surgeries are required.
Polydactyly is present in about 4 to 12 per 10,000 newborns. It is the most common defect of the hands and feet. In the United States, Black people are more commonly affected than white people. The term is from from gre " "πολύς" (polys)" 'many' and " "δάκτυλος" (daktylos)" 'finger'.
 ;templatestyles src="Template:TOC limit/styles.css" / ;
Signs and symptoms.
In humans/animals this condition can present itself on one or both hands or feet. 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.
Polydactyly can be divided into three major types, which are discussed below, which depend on the location of the additional digit.
In 2019 it was found that in cases of polydactyly with a fully functional additional digit, muscles to control the extra digit may be duplicated, resulting in increased motor control that allows the patient to carry out certain tasks with one hand that would normally require two.
Ulnar or postaxial.
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 African populations. The incidence in Caucasians is reported as 1 in 1,339 live births, compared with 1 in 143 live births in Africans. 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, though in a retrospective review, only 4 of 37 cases of ulnar polydactyly in Caucasians were syndromic.
Radial or preaxial.
This is a less common situation, in which the affectation is on 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 Indian 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.
Central.
This is a rare condition, 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 other syndromes.
Polysyndactyly presents various degrees of syndactyly affecting fingers three and four.
Causes.
Polydactyly is associated with different mutations, either mutations in a gene itself or in a cis-regulatory element responsible for the expression of a specific gene. Mutations in Hoxa- or Hoxd clusters are reported leading to polydactyly. Interactions of Hoxd13 and GLI3 induce synpolydactyly, a combination of extra and consolidated digits. Other signal transduction pathways in this context are the Wnt signaling pathway or Notch.
In the specific case of preaxial polydactyly (Hemingway mutant), a cis-acting mutation approximately 1Mb upstream of SHH gene has been implicated. Normally SHH is expressed in an organiser region, called the zone of polarizing activity (ZPA) on the posterior limb side. From there it diffuses anteriorly, laterally to the growth direction of the limb. In the mutant, smaller ectopic expression in a new organiser region is seen on the anterior side of the limb. This ectopic expression causes cell proliferation delivering the raw material for one or more new digits.
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.
Polydactyly has been linked to the prenatal environment in a 2020 study showing a relationship to maternal PM10 pollution exposure in China.
Types include:
Syndromes.
Because polydactyly can be part of a syndrome (known genetic defect) or association (genetic defect not known), children with a congenital upper extremity deformity should be examined by a geneticist for other congenital anomalies. This should also be done if a syndrome is suspected, or if more than two or three generations of the family are affected.
As of 2009, 97 genetic syndromes have been associated with different kinds of polydactyly.
Examples of syndromes include Diamond–Blackfan anemia, and the VACTERL association, 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.
Ulnar.
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, such as: Trisomy 13, Greig cephalopolysyndactyly syndrome, Meckel syndrome, Ellis–van Creveld syndrome, McKusick–Kaufman syndrome, Down syndrome, Bardet–Biedl syndrome, Smith–Lemli–Opitz syndrome.
Radial.
Type VII of radial polydactyly is associated with several syndromes:
Holt–Oram syndrome, Fanconi anemia (aplastic anemia by the age of 6), Townes–Brocks syndrome, and Greig cephalopolysyndactyly (also known to occur with ulnar polydactyly).
Central.
The syndromes associated with central polydactyly are:
Bardet–Biedl syndrome, Meckel syndrome, Pallister–Hall syndrome, Legius syndrome, Holt–Oram syndrome. Central polydactyly can also be associated with syndactyly and cleft hand.
Evolution.
From an evo-devo point of view, polydactyly is a phenotypic variation or innovation, as the fingers and toes arise in places where nothing is phenotypically present in the wild type. Although it is initiated by a point mutation, it occurs as a polyphenism with different numbers of toes. The analysis of the additional toe numbers of Maine Coon cats revealed that the number of toes follows a developmental bias: 2 additional toes occur much more frequently than 4, these more frequently than 6 or 8 additional ones. Also, for the evo-devo theory, polydactyly cannot be adequately explained by genetic mutation alone, but only by constructive development, i.e. the ability of development to produce a complex phenotypic output. The corresponding symbolic generation of toes can now be shown in computer models.
Diagnosis.
Classification is performed by using x-ray imaging to see the bone structures. In 1961, Frantz and O’Rahilly proposed that congenital anomalies of the limb could be classified in seven categories, 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. In 1976 this was modified by Swanson. Polydactyly belongs to the category of duplication. As of 2009, research has shown that the majority of congenital anomalies occur during the 4-week embryologic period of rapid limb development. 
Ulnar.
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. 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.
Radial.
The Wassel classification is the most widely used classification of radial polydactyly, based upon the most proximal level of skeletal duplication. The most common type is Wassel 4 (about 50% of such duplications) followed by Wassel 2 (20%) and Wassel 6 (12%).
Central.
The classification of central polydactyly is based on the extent of duplication and involves the following three types:
Type I is a central duplication, not attached to the adjacent finger by osseous or ligamentous attachments; it frequently does not include bones, joints, cartilage, or tendons.
Type IIA is 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 is 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 is a complete digital duplication, which has a well-formed duplicated metacarpal.
Treatment.
Ulnar.
Ulnar polydactyly usually does not interfere with hand function, but for social reasons it can be treated operatively.
Type A.
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.
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