Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO.
Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia.
J Hand Surg Am. 2024 Apr;49(4):379.e1-379.e7. doi: 10.1016/j.jhsa.2022.07.007. Epub 2022 Sep 9.
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.
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.
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.
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.
A consensus-seeking approach is effective and feasible in addressing difficult-to-classify CULDs.
理想的分类系统可促进交流并指导先天性上肢差异（CULD）的治疗。Oberg、Manske 和 Tonkin（OMT）分类法利用表型表现和发育生物学知识对 CULD 进行分类。在这项共识决策研究中，我们假设一组经验丰富的儿科手部外科医生可以对难以分类的 CULD 进行相同的分类。
来自 3 个国家的 14 位国际儿科手部外科医生组成了一个小组，提供了一组 72 例难以分类的 CULD 病例。这些病例是从外科医生的临床实践和相关登记处中确定的。通过 Delphi 式的过程，利用临床图像和 X 光片，反复努力获得每个病例的正确 OMT 分类的共识。
第一轮讨论使 57 例病例达成普遍共识。其余 15 例病例继续通过 Delphi 式过程的额外轮次进行讨论。重复分类和讨论最终使 OMT 分类达到 93%的完全共识。诊断的主要挑战是区分手裂畸形和尺侧纵向缺陷，将其归类为 A 组。该组有 5 例，但仍有 2 例未达成明确共识。另一个有争议的组 B 称为“短指-多指畸形”，包括 3 例病例，其诊断在并指畸形、短指畸形或复杂并指畸形之间存在差异。
Delphi 式过程是可行且有效的，可使 OMT 分类法对难以分类的病例达成 93%的共识。OMT 系统仍然存在局限性和争议，特别是在手部少于 5 个骨骼指、并指和尺侧纵向缺陷与手裂畸形之间存在诊断重叠以及那些被认为是“短指-多指畸形”的病例。需要进一步了解潜在病因，以确定难以分类情况下的最终诊断。
寻求共识的方法可有效且可行地解决难以分类的 CULD。
