J Plast Surg Hand Surg, 2014; Early Online: 1–6 © 2014 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online DOI: 10.3109/2000656X.2014.967698

ORIGINAL ARTICLE

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Analysis of web height ratios according to age and sex Elif Sari Department of Plastic, Reconstructive and Aesthetic Surgery, Kirikkale University Faculty of Medicine, Kirikkale, Turkey Abstract Each component of the web space, a three-dimensional structure, should be carefully created during reconstruction of web space loss. One of these web space components is the web height. In this study, the dorsal view of subjects’ hands was analyzed to determine the web height ratios. The web height ratios were then compared with respect to age and sex. The second and third web height ratios differed between adult men and women and between children and adults. However, no differences were observed among children. This study is unique because it focuses on the web height ratios of all web spaces according to age and sex and provides a very easy-to-use scale that may help surgeons to perform web space reconstruction. Moreover, the present study adds to the literature by providing information on the first web height ratios of the hand. Key Words: Web space, web height, syndactyly, web contracture, hand reconstruction

Introduction The web spaces, which allow movement of the fingers in each anatomical plane, are among the most important and interesting anatomic structures of the hand. Web space anomalies secondary to syndactyly, burns, trauma, or previous surgical procedures may cause functional deficits, intrinsic tightness, or aesthetic problems. Several surgical methods have been suggested in the literature to create new web spaces, including the dorsal triangular flap, dorsally based rectangular flap, and dorsal and volar triangular flaps [1-3]. In 1990, Moss et al. [4] found that the web height in children is located halfway between the metacarpal head and proximal phalangeal head [4]. Additionally, Eaton et al. [5] and Shewell et al. [6] described formulae with which to create new web heights in children. To the best of our knowledge, the web height ratios of adults have not been comprehensively analyzed. Because contralateral normal web spaces may assist the surgeon in determination of the new web heights required for reconstruction, correction of unilateral web space anomalies is not a major challenge. However, bilateral web space loss is a challenge for surgeons in terms of creating an anatomically normal web space height. The aim of the present study was to analyze the web height ratios of each web space according to age and sex in normal subjects. This study was constructed to develop a new useful and simple scale that can be used in reconstructive surgery of web space anomalies in adults and children. Materials and methods Participants All participants were selected from among a healthy population. They comprised children (29 boys and 21 girls) ranging in age from 18 months to 16 years; women (n = 30) ranging in age

from 17–60 years; and men (n = 30) ranging in age from 23– 43 years. Methods The main data were obtained from digital photographs that exhibited the dorsal view of each participant’s right hand. To create an ideal position for web height analysis, the fingers were positioned in full extension and maximum active abduction. The metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were then marked with a surgical pen (Figures 1a–d). Next, a paper ruler was placed adjacent to the hands to standardise their size, and photographs were taken with the same digital camera in all cases (Sony DSC-W30 Cyber-shot, 6.0 megapixels). These photographs were grouped according to age and sex, and the web height ratios were measured with imaging software (Adobe Photoshop CS2). In the present study, web heights were measured as the ratio based on the MCP–PIP length. The measurement procedure included the following steps: (1) Two longitudinal lines were drawn from the adjacent MCP joints to the adjacent PIP joints. (2) A transverse line was drawn from the MCP joint to the adjacent MCP joint. (3) The points corresponding to the apex of the web space were marked on these predrawn lines. (4) The web height ratios were measured in millimetres (Figures 1a–d). The following web height ratios were obtained: a/(a+b), a1/ (a1+b1), and a2/(a2+b2); c/(c+d), c1/(c1+d1), and c2/(c2+d2); e/(e+f), e1/(e1+f1), and e2/(e2+f2); and g/(g+h), g1/(g1+h1), and g2/(g2+h2). The horizontal ratios of the web heights were

Correspondence: Elif Sari, MD, Kirikkale University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, AnkaraKirikkale Road, 7th km. 71450, Yahsihan, Kirikkale, Turkey. Tel: +90 506 381 37 03. Fax: +90 580 225 28 19. E-mail: [email protected] (Received 10 April 2014; accepted 17 September 2014)

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2 E. Sari

a

b

c

d

Figure 1. Measurement of the web height ratios. (a) First web height ratios [a/(a+b), a1/(a1+b1), a2/(a2+b2)]. (b) Second web height ratios [c/(c +d), c1/(c1+d1), c2/(c2+d2)]. (c) Third web height ratios [e/(e+f), e1/(e1+f1), e2/(e2+f2)]. (d) Fourth web height ratios [g/(g+h), g1/(g1+h1), g2/(g2+h2)].

determined using the a/(a+b), c/(c+d), e/(e+f), and g/(g+h) ratios (Table I). Statistical analysis The Statistical Package for the Social Sciences (SPSS/PC, version 17. 0) was used to analyze the data. Normally distributed web height ratios and homogeneous variations between groups were statistically analyzed by the independent-samples t-test. A p-value of < 0.05 was considered to be statistically significant. Results All children’s ages and mean, minimum, and maximum web space ratios are presented in Table II. The women’s and men’s ages and mean, minimum, and maximum web space ratios are presented in Tables III and IV, respectively. The independent-samples t-test revealed that the c1/(c1+d1), c2/(c2+d2), e1/(e1+f1), and e2/(e2+f2) ratios were significantly different between women and men, indicating that the second and third web space ratios significantly differed according to sex (Table V). However, the statistical analysis showed that the ratios were not different between male and female children (Table VI). Conversely, the a1/(a1+b1), a2/(a2+b2), c1/(c1+d1), c2/(c2 +d2), e/(e+f), e1/(e1+f1), g1/(g1+h1), and g2/(g2+h2) ratios were significantly different between women and girls (Table VII). Additionally, the a1/(a1+b1), a2/(a2+b2), c1/(c1+d1), e/(e+f), e1/(e1+f1), g/(g+h), and g1/(g1+h1) ratios were statistically different between men and boys (Table VIII). Clinical use of web space ratios Case 1 A 19-year-old man was admitted to our clinic with incomplete, simple syndactyly of his left third web space (Figure 2a). First, we

marked his MCP (x, y) and PIP (z, w) joints with a surgical pen. We then measured the x–y, x–z, and y–w distances with a paper ruler (x–y = 15 mm, x–z = 40 mm, and y–w = 45 mm). Next, we identified three points (1, 2, and 3) according to the web height ratios shown in Table IX [e/(e+f), e1/(e1+f1), and e2/ (e2+f2)]. For example, if x–y = 15 mm, then the horizontal ratio e/(e +f) is 0.443, as shown in Table IX. In our patient, the e+f distance corresponded to the x–y distance. Thus, we obtained the e and f distances using a simple equation: e/15 = 0.443 $ e = 6.64 mm According to this equation, the y – 1 distance should be 6.64 mm and the 1 – x distance should be 15.00–6.64 = 8.36 mm. Parallel to these measurements, points 1, 2, and 3 were located on the patient’s hand. We then combined these three coordinates into one point (E) in the patient’s web space (Figures 2a–c). Point E was determined as the peak point of the web space. The reconstruction was performed according to this marking. A functional and anatomic web space was, thus, obtained (Figure 2d). Case 2 A 4-year-old boy was referred to our clinic with bilateral syndactyly in his third web spaces. The third web height ratios were calculated using the data shown in Table IX, and the markings were performed as described in Case 1. In this case, however, we used the child’s web height ratios shown in Table IX to determine points 1, 2, and 3. The peak point of the third web space (point E) was measured using a combination of these points, which could then be used for the reconstruction plan (Figures 3a–e).

Web height ratios 3 Table I. Distances used to obtain the web height ratios.

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Name of distance a b a1 b1 a2 b2 c d c1 d1 c2 d2 e f e1 f1 e2 f2 g h g1 h1 g2 h2

Description Distance between the first MCP joint and the point on the transverse line which corresponds to the apex of the first web space Distance between the point on the transverse line which corresponds to the apex of the first web space and the second MCP joint Distance between the first MCP joint and the point on the longitudinal line on thumb which corresponds to the apex of the first web space Distance between the point on the longitudinal line at thumb which corresponds to the apex of the first web space and the first PIP joint Distance between the second MCP joint and the point on the longitudinal line on the second proximal phalanx which corresponds to the apex of the first web space Distance between the point on the longitudinal line on the second proximal phalanx which corresponds to the apex of the first web space and the second PIP joint Distance between the second MCP joint and the point on the transverse line which corresponds to the apex of the second web space Distance between the point on the transverse line which corresponds to the apex of the second web space and the third MCP joint Distance between the second MCP joint and the point on the longitudinal line on the second proximal phalanx which corresponds to the apex of the second web space Distance between the point on the longitudinal line at the second proximal phalanx which corresponds to the apex of the second web space and the second PIP joint Distance between the third MCP joint and the point on the longitudinal line on the third proximal phalanx which corresponds to the apex of the second web space Distance between the point on the longitudinal line on the third proximal phalanx which corresponds to the apex of the second web space and the third PIP joint Distance between the third MCP joint and the point on the transverse line which corresponds to the apex of the third web space Distance between the point on the transverse line which corresponds to the apex of the third web space and the fourth MCP joint Distance between the third MCP joint and the point on the longitudinal line on the third proximal phalanx which corresponds to the apex of the third web space Distance between the point on the longitudinal line at the third proximal phalanx which corresponds to the apex of the third web space and the third PIP joint Distance between the fourth MCP joint and the point on the longitudinal line on the fourth proximal phalanx which corresponds to the apex of the third web space Distance between the point on the longitudinal line on the fourth proximal phalanx which corresponds to the apex of the third web space and the fourth PIP joint Distance between the fourth MCP joint and the point on the transverse line which corresponds to the apex of the fourth web space Distance between the point on the transverse line which corresponds to the apex of the fourth web space and the fifth MCP joint Distance between the fourth MCP joint and the point on the longitudinal line on the fourth proximal phalanx which corresponds to the apex of the fourth web space Distance between the point on the longitudinal line at the fourth proximal phalanx which corresponds to the apex of the fourth web space and the fourth PIP joint Distance between the fifth MCP joint and the point on the longitudinal line on the fifth proximal phalanx which corresponds to the apex of the fourth web space Distance between the point on the longitudinal line on the fifth proximal phalanx which corresponds to the apex of the fourth web space and the fifth PIP joint

Table III. Web height ratios in women.

Table II. Web height ratios in children. Ratio a/(a+b) a1/(a1+b1) a2/(a2+b2) c/(c+d) c1/(c1+d1) c2/(c2+d2) e/(e+f) e1/(e1+f1) e2/(e2+f2) g/(g+h) g1/(g1+h1) g2/(g2+h2)

Children (n = 50) Minimum Maximum 0.353 0.620 0.000 0.362 0.000 0.475 0.206 0.537 0.301 0.613 0.240 0.538 0.241 0.500 0.267 0.603 0.300 0.586 0.209 0.511 0.300 0.571 0.321 0.636

Women (n = 30) Mean 0.464 0.112 0.123 0.401 0.438 0.425 0.403 0.448 0.451 0.392 0.420 0.473

SD 0.062 0.121 0.141 0.058 0.075 0.063 0.061 0.074 0.070 0.063 0.068 0.078

Ratio a/(a+b) a1/(a1+b1) a2/(a2+b2) c/(c+d) c1/(c1+d1) c2/(c2+d2) e/(e+f) e1/(e1+f1) e2/(e2+f2) g/(g+h) g1/(g1+h1) g2/(g2+h2)

Minimum 0.322 0.000 0.000 0.308 0.262 0.273 0.346 0.282 0.329 0.364 0.294 0.283

Maximum 0.595 0.000 0.000 0.481 0.503 0.493 0.625 0.438 0.542 0.545 0.456 0.581

Mean 0.448 0.000 0.000 0.422 0.366 0.378 0.452 0.362 0.420 0.426 0.370 0.420

SD 0.068 0.000 0.000 0.041 0.068 0.057 0.054 0.042 0.056 0.042 0.046 0.069

4 E. Sari Table IV. Web height ratios in men.

Table VII. Comparison of web height ratios between girls and women. Independent-samples t-test, p < 0.05.

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Men (n = 30) Ratio a/(a+b) a1/(a1+b1) a2/(a2+b2) c/(c+d) c1/(c1+d1) c2/(c2+d2) e/(e+f) e1/(e1+f1) e2/(e2+f2) g/(g+h) g1/(g1+h1) g2/(g2+h2)

Minimum 0.360 0.000 0.000 0.339 0.263 0.323 0.356 0.336 0.378 0.329 0.270 0.278

Maximum 0.545 0.337 0.365 0.525 0.538 0.533 0.511 0.533 0.544 0.500 0.465 0.593

Mean 0.460 0.011 0.012 0.430 0.403 0.414 0.443 0.418 0.456 0.432 0.378 0.446

SD 0.047 0.062 0.067 0.046 0.065 0.050 0.042 0.052 0.049 0.041 0.057 0.078

Girls (n = 21) Ratio Mean SD a/(a+b) 0.466 0.072 a1/(a1+b1) 0.117 0.118 a2/(a2+b2) 0.137 0.151 c/(c+d) 0.395 0.061 c1/(c1+d1) 0.433 0.081 c2/(c2+d2) 0.422 0.066 e/(e+f) 0.391 0.072 e1/(e1+f1) 0.436 0.064 e2/(e2+f2) 0.449 0.072 g/(g+h) 0.397 0.058 g1/(g1+h1) 0.416 0.058 g2/(g2+h2) 0.481 0.083

Women (n = 30) Mean SD 0.448 0.068 0.000 0.000 0.000 0.000 0.422 0.041 0.366 0.068 0.378 0.057 0.452 0.054 0.362 0.042 0.420 0.056 0.426 0.042 0.370 0.046 0.420 0.069

df t p 49 0.949 0.347 20 4.531 < 0.001* 20 4.150 < 0.001* 49 1.940 0.058 49 3.194 0.002* 49 2.504 0.016* 49 3.428 < 0.001* 32 4.637 < 0.001* 49 1.623 0.111 49 2.023 0.049* 49 3.119 0.003* 49 2.847 0.006*

*p < 0.05.

Table V. Comparison of web height ratios between women and men. Independent-samples t-test, p < 0.05. Men (n = 30) Ratio Mean SD a/(a+b) 0.460 0.047 a1/(a1+b1) 0.011 0.062 a2/(a2+b2) 0.012 0.067 c/(c+d) 0.430 0.046 c1/(c1+d1) 0.403 0.065 c2/(c2+d2) 0.414 0.050 e/(e+f) 0.443 0.042 e1/(e1+f1) 0.418 0.052 e2/(e2+f2) 0.456 0.049 g/(g+h) 0.432 0.041 g1/(g1+h1) 0.378 0.057 g2/(g2+h2) 0.446 0.078

Women (n = 30) Mean SD 0.448 0.068 0.000 0.000 0.000 0.000 0.422 0.041 0.366 0.068 0.378 0.057 0.452 0.054 0.362 0.042 0.420 0.056 0.426 0.042 0.370 0.046 0.420 0.069

df t p 58 0.843 0.403 29 1.000 0.326 29 1.000 0.326 58 0.677 0.501 58 2.162 0.035* 58 2.586 0.012* 58 0.734 0.466 58 4.605 < 0.001* 58 2.651 0.010* 58 0.631 0.530 58 0.583 0.562 58 1.357 0.180

*p < 0.05.

Table VI. Comparison of web height ratios between boys and girls. Independent-samples t-test, p < 0.05. Ratio a/(a+b) a1/(a1+b1) a2/(a2+b2) c/(c+d) c1/(c1+d1) c2/(c2+d2) e/(e+f) e1/(e1+f1) e2/(e2+f2) g/(g+h) g1/(g1+h1) g2/(g2+h2) *p < 0.05.

Boys (n = 29) Mean SD 0.462 0.056 0.109 0.125 0.113 0.135 0.406 0.056 0.442 0.072 0.427 0.062 0.412 0.051 0.457 0.079 0.452 0.071 0.389 0.067 0.424 0.076 0.467 0.074

Girls (n Mean 0.466 0.117 0.137 0.395 0.433 0.422 0.391 0.436 0.449 0.397 0.416 0.481

= 21) SD 0.072 0.118 0.151 0.061 0.081 0.066 0.072 0.064 0.072 0.058 0.058 0.083

df 48 48 48 48 48 48 48 48 48 48 48 48

t 0.230 0.221 0.591 0.693 0.452 0.308 1.149 0.976 0.177 0.479 0.411 0.613

p 0.819 0.826 0.557 0.492 0.653 0.759 0.256 0.334 0.861 0.634 0.683 0.543

Discussion Contrary to popular belief, surgical recreation of web spaces is a difficult process. The surgeon must aim to obtain normal functional and aesthetic features. The web space is a threedimensional structure; the web width and thickness are two of these three dimensions. Many surgical procedures have been developed to attain a normal web width and thickness [7]. The third dimension is the web height, determined by the peak point of the web space. Planning this dimension is very important because correct measurement leads to optimal functional and aesthetic results. The present study demonstrated that web height ratios are significantly different between children and adults. However, with the exception of the second and third web height ratios, no such difference was seen between women and men. Likewise, the web height ratios between boys and girls were not significantly different. However, the horizontal ratios differed in the present study. Nevertheless, the difference in the web height ratio of the first web space between children and adults is noteworthy. The web height ratio of the first web space in adults was lower than that in children. This difference among

Table VIII. Comparison results of the web height ratios of boys and men. Independent-samples t-test, p < 0.05. Ratio a/(a+b) a1/(a1+b1) a2/(a2+b2) c/(c+d) c1/(c1+d1) c2/(c2+d2) e/(e+f) e1/(e1+f1) e2/(e2+f2) g/(g+h) g1/(g1+h1) g2/(g2+h2) *p < 0.05.

Boys (n = 29) Mean SD 0.462 0.056 0.109 0.125 0.113 0.135 0.406 0.056 0.442 0.072 0.427 0.062 0.412 0.051 0.457 0.079 0.452 0.071 0.389 0.067 0.424 0.076 0.467 0.074

Men (n Mean 0.460 0.011 0.012 0.430 0.403 0.414 0.443 0.418 0.456 0.432 0.378 0.446

= 30) SD 0.047 0.062 0.067 0.046 0.065 0.050 0.042 0.052 0.049 0.041 0.057 0.078

df 57 41 41 57 57 57 57 57 50 57 57 57

t

p

0 4 4 2 2 1 3 2 0 3 3 1

0.884 < 0.001* 0.001* 0.080 0.030* 0.371 0.013* 0.029* 0.837 0.004* 0.011* 0.281

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Web height ratios 5

2a

2b

2c

2d

Figure 2. A 19-year-old man was admitted to our clinic with incomplete, simple syndactyly of his left third web space. (a) The marking points on the hand. (b) Points 1, 2, and 3 were found using Table IX. (c) The combination of these three points in a plane indicated point E, which corresponded to the web height (peak point of the web space). (d) Postoperative view of the hand. Table IX. Mean web height ratios of the healthy participants. This table may be useful for determining the new web height in hand deformities. Ratio a/(a+b) a1/(a1+b1) a2/(a2+b2) c/(c+d) c1/(c1+d1) c2/(c2+d2) e/(e+f) e1/(e1+f1) e2/(e2+f2) g/(g+h) g1/(g1+h1) g2/(g2+h2)

Children 0.464 0.112 0.123 0.401 0.438 0.425 0.403 0.448 0.451 0.392 0.42 0.473

Women 0.448 0* 0* 0.422 0.366 0.378 0.452 0.362 0.420 0.426 0.370 0.420

Men 0.460 0.011* 0.012* 0.430 0.403 0.414 0.443 0.418 0.456 0.432 0.378 0.446

Richterman et al. [8] recently used anteroposterior X-ray images of the hand to measure the web space. However, because of incomplete bone ossification, application of this method is very difficult in children. We propose the use of photographs to determine the new web height. In contrast to the method described by Richterman et al., which determined the web height using a single coordinate, we propose the employment of two coordinates to determine the web height. Moreover, the results obtained by Richterman et al. were based on the total length of the finger, and such a method is not useful for patients with amputated or complex middle and distal phalangeal deformities. In the present study, we measured the mean web space ratios in healthy subjects and evaluated them according to age and sex. These mean ratios are presented in Table IX. The surgeon should measure the distances between the MCP and PIP joints and adjacent MCP joints during the operation. While surgically planning the new web height, the surgeon is able to check and use these ratios described in Table IX according to the patient’s age and sex. The surgeon can, thus, determine the coordinates of the new web height for the individual patient. The combination of these coordinates provides the web height (peak point) of the web space. Moreover, previous studies have not described the ratios of the adult population. The present study contributes to the literature by presenting web height ratios according to age. Another important aspect of the present study is that it sheds lights upon the web space ratio of the first web space, which varies with age (Table IX). The present study has some limitations. First, the study included few infants (0–2 years of age) and involved a small sample. Because of this, we could not compare the measurements within the groups. Second, the mean web height ratios obtained in the present study cannot be used in patients with complex proximal phalanx anomalies. Finally, the difference in the web height ratio of the first web space between children and adults was notable. Therefore, further detailed studies of the first web space should be performed based on the results obtained in the present study.

*a1 and a2 measurements were 0, so the ratios are 0.

the population is critical because the flap design for reconstruction of the first web space is performed based on these web height ratios. Therefore, this issue should be considered during the reconstruction of the new web space.

3a

3b

3c

3d

Conclusion In conclusion, this study is unique because it focuses on the web height ratios of all web spaces according to age and sex. It also provides a very easy-to-use scale that can help surgeons to perform web space reconstruction. Finally, the present study

3e

Figure 3. (a) Preoperative picture of a 4-year-old boy who was referred to our clinic with bilateral syndactyly. (b–d) Same hand measurements and markings using Table IX. (e) Postoperative view of the web space.

6 E. Sari adds to the literature by providing data on the web height ratios of the first web space. Declaration of interest: The author reports no conflicts of interest. No sources of support or funding were received for this work.

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References [1] Davis JS, German WJ. Syndactylism. Arch Surg 1930;21:32–75. [2] Bauer TB, Tondra JM, Trusler HM. Technical modification in repair of syndactylism. Plast Reconstr Surg 1956;17:385–92.

[3] Cronin TD. Syndactylism: results of zig-zag incision to prevent postoperative contracture. Plast Reconstr Surg 1956; 18:460–8. [4] Moss ALH, Foucher G. Syndactly: can web space creep be avoided? J Hand Surg 1990;15B:193–200. [5] Eaton CJ, Lister GD. Syndactly. Hand Clin 1990;6:555–75. [6] Shewell PC, Nancarrow JD, Fatah F. Quantifying interdigital web morphology. J Hand Surg 1992;17B:198–200. [7] Kalliainen LK, Schubert W. The management of web space contractures. Clin Plast Surg 2005;32:503–14. [8] Richterman IE, DuPree J, Thoder J, et al. The radiographic analysis of web height. J Hand Surg Am 1998;23:1071–6.

Analysis of web height ratios according to age and sex.

Each component of the web space, a three-dimensional structure, should be carefully created during reconstruction of web space loss. One of these web ...
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