Purpose
An ideal classification system promotes communication and guides treatment for congenital
upper limb differences (CULDs). The Oberg, Manske, and Tonkin (OMT) classification
utilizes phenotypic presentation and knowledge of developmental biology for the classification
of CULDs. In this consensus decision-making study, we hypothesized that CULDs that
are difficult to classify would be identically classified by a group of experienced
pediatric hand surgeons.
Methods
An international consortium of 14 pediatric hand surgeons in 3 countries contributed
a group of 72 difficult-to-classify CULD cases. These were identified from the clinical
practices of the surgeons and from associated registries. Through a Delphi-type process,
repeated efforts were made to obtain consensus for the correct OMT classification
of each case utilizing clinical images and radiographs.
Results
The first round of discussion yielded a universal consensus for 57 cases. The remaining
15 cases continued to be put through additional rounds of the Delphi-type process.
The repeat classification and discussion resulted in a final yield of 93% complete
consensus in classification by the OMT. The primary challenge in diagnosis was differentiating
cleft hand from ulnar longitudinal deficiency, identified as group A. Five cases were
in this group, yet 2 remained without a clear consensus. Another controversial group,
group B, was termed “brachy-polydactyly” and consisted of 3 cases where diagnoses
varied between sympolydactyly, symbrachydactyly, or complex syndactyly.
Conclusions
The Delphi-type process was feasible and effective and allowed a 93% consensus in
the diagnosis of difficult-to-classify cases by the OMT Classification. There remain
limitations and controversies with the OMT system, especially when classifying hands
with less than 5 skeletal digits, syndactyly, and those with diagnostic overlap between
ulnar longitudinal deficiency and cleft hand and those considered “brachypolydactyly.”
An improved understanding of the underlying etiology may be needed to determine the
final diagnosis in difficult-to-classify conditions.
Clinical Relevance statement
A consensus-seeking approach is effective and feasible in addressing difficult-to-classify
CULDs.
Key words
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Article info
Publication history
Published online: September 09, 2022
Accepted:
July 20,
2022
Received:
September 5,
2021
Publication stage
In Press Corrected ProofFootnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2022 by the American Society for Surgery of the Hand. All rights reserved.
