The CoULD Ulnar Polydactyly Classification: A Multicenter Analysis

The Temtamy-McKusick classification defines ulnar/postaxial polydactyly with a well-developed accessory digit as type A and cases with a rudimentary pedunculated digit as type B. Surgeons widely agree on type B treatment, but type A cases present more diverse phenotypes and reconstructive challenges. The authors developed an expanded classification based on radiographic morphology that may help guide surgical treatment.

The multicenter cohort included all type A ulnar polydactyly cases in the Congenital Upper Limb Differences (CoULD) database and additional cases from the Children's Hospital of Philadelphia. Morphologic themes were determined from preoperative radiographs. Clinical relevance was evaluated by discussion and analysis of operative notes to confirm that each subtype carries distinct considerations for reconstruction. Four attending pediatric hand surgeons classified radiographs. Interrater and intrarater reliability were determined by the Cohen κ.

The cohort included 125 type A hands from 84 patients (49% bilateral). Fifteen cases (18%) were syndromic and 37 (44%) reported a family history. Six subtypes emerged from radiographic analysis. Our classification is based on the proximal extent of the skeletal "duplication," comprising A1-hypoplastic, A2-phalangeal, A3-divergent metacarpophalangeal, A4-bifid metacarpal, A5-duplicated metacarpal, and A6-complex types. The authors propose a reconstructive plan for each subtype to aid surgical decision-making. Interrater and intrarater reliability were almost perfect. Raters agreed that all cases were classifiable, achieving 97% initial agreement.

The CoULD Ulnar Polydactyly classification is feasible, comprehensive, and relevant to surgical management. The CoULD Study Group voted to adopt the classification after careful review, reinforcing its potential to frame the care pathway.