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Split-hand-foot malformation 4
Other Resources UpToDate PubMed

Split-hand-foot malformation 4

Contributors: Mack Su, Susan Burgin MD
Other Resources UpToDate PubMed


There are 6 autosomal dominant p63-associated ectodermal dysplasia syndromes:
This summary focuses on SHFM4.

All ectodermal dysplasias result from the abnormal development of structures derived from the outer embryonal layer such as the skin, hair, teeth, nails, and eccrine and sebaceous glands. While these 6 syndromes are classified as distinct entities, their overlapping phenotypes suggest that they may be part of a spectrum of related syndromes.

p63 is a transcription factor with homology to the tumor suppressor p53. Studies in mice have demonstrated that, unlike p53, p63 expression is localized to whiskers, oral mucosa, and distal limbs. Furthermore, mice lacking p63 are born with translucent skin and without appendages (whisker pads, teeth). It has been postulated that p63 plays an important role in epidermal stratification and the maintenance of epidermal stem cells.

While all 6 syndromes show abnormalities in p63, each syndrome tends to demonstrate mutations in specific domains. SHFM4, EEC, OFC8, and ADULT syndromes are associated with missense mutations in the DNA binding domain. In contrast, mutations in the sterile alpha motif / transcription inhibitory domain (SAM / TID), which is downstream of the DNA binding domain, result in AEC syndrome phenotypes. Missense mutations in between the transactivation domain and DNA binding domain or truncation of the SAM / TID are typical of limb-mammary syndrome.

SHFM4 is one of several heterogeneous disorders characterized primarily by defects in the central rays of the hands or feet, resulting in median clefts of the hands and/or feet. In addition to ectrodactyly, patients can present with syndactyly and hypoplasia or aplasia of the phalanges, metacarpals, and metatarsals. SHFM4 accounts for approximately 10%-15% of isolated split-hand / foot malformations.


Q71.60 – Lobster-claw hand, unspecified hand
Q72.70 – Split foot, unspecified lower limb

13624003 – Congenital cleft hand
205358006 – Split foot

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Differential Diagnosis & Pitfalls

  • EEC syndrome – ectodermal defects involving hair, nails, and skin and cleft lip / palate
  • ADULT syndrome – ectodermal defects involving hair, nails, skin, and teeth
  • Adams-Oliver syndrome (AOS) – aplasia cutis congenita of the scalp
  • Focal dermal hypoplasia – cutaneous streaks of atrophy with telangiectasias
  • Split-hand / foot malformation with long bone deficiency (SHFLD) – tibial aplasia

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Last Reviewed:08/26/2020
Last Updated:01/24/2022
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Split-hand-foot malformation 4
A medical illustration showing key findings of Split-hand-foot malformation 4
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