Distal symphalangism: symbrachydactylism arising in a family with distal symphalangism.

A recent survey of congenital hand anomalies has revealed that symphalangism of the distal interphalangeal joint is more frequent than had previously been reported. To date, however, only 3 familial pedigrees have been documented in the literature. The family reported in this article had 9 individuals spanning 4 generations affected with symphalangism of the distal interphalangeal joint. In all cases, this was associated with ankylosis of the distal interphalangeal joint of the second through fifth toes. One child in the family also had brachyphalangism bilaterally as well as a bifid distal phalanx of the thumb. The world's literature does not seem to include a similar case. As with previous cases of fusion of the distal interphalangeal joint, there was little functional disability resulting from this anomaly and we do not recommend operative procedures to restore motion.     

Silicone interpositional arthroplasty of the distal interphalangeal joint

Twenty-three female patients had silicone interpositional arthroplasty of the distal interphalangeal joint in 38 digits. The operative indications were pain and deformity of the distal interphalangeal joint. The underlying diagnosis was osteoarthritis in all but one patient who had rheumatoid arthritis. The average age at the time of operation was 58.3 years. The implants have been in place for a mean period of 72.2 months (range, 12.6 to 123.1 months). At follow-up, extension lag averaged 12.7 degrees and the range of motion of the distal interphalangeal joint had a mean value of 33.2 degrees. Compared with arthrodesis, silicone interpositional arthroplasty offers the advantage of retained motion while preserving stability.     

Osteoarthritis of the distal interphalangeal joint

Osteoarthritis occurs with the highest prevalence in the distal interphalangeal joint of the hand and has been divided into an erosive and a nonerosive form. The pathogenesis of the early stages of osteoarthritis is poorly understood, but considerable emphasis has been placed on the role of cartilage and subchondral bone as well as soft tissue structures such as collateral ligaments and tendons. Radiographic evaluation represents the most standardized method to quantify disease progression, with different systems having been developed for defining and grading radiographic features. This current concepts article examines the recent knowledge base regarding the etiology, pathogenesis, and evaluation of osteoarthritis of the distal interphalangeal joint.     

Nail Changes and Association of Osteoarthritis in Digital Myxoid Cyst

BACKGROUND Digital myxoid cyst is relatively common on the digits. Nail changes and osteoarthritis are usually associated with this pathogenesis.
OBJECTIVE The objective was to clarify this relationship and its significance by analyzing the clinical, radiologic, and pathologic data.
METHODS AND MATERIALS Fifty-one patients with digital myxoid cysts were diagnosed and analyzed during a 5-year period.
RESULTS Thirty-eight (74.5%) of 51 patients showed radiologic evidence of primary interphalangeal joint osteoarthritis in the affected digits. Among the 39 cysts removed surgically and examined pathologically, 28 were myxomatous and 11 were ganglion. Different clinical manifestations of nail change, including longitudinal grooves (20 cases), concave canaliform dystrophy (9 cases), "washboard" transverse lines (5 cases), and longitudinal grooves with beaded ridges (1 case) were found.
CONCLUSION Osteoarthritis of the adjacent terminal joint is an important factor involved in forming digital myxoid cysts. Of the two cyst types, ganglion cysts are related to osteoarthritis more often than myxomatous cysts. Nail changes, secondary to matrix damage, are reliable clinical signs of underlying cyst formation. Understanding the pathogenesis of the digital myxoid cyst in relation to osteoarthritis and nail deformity helps inform the care of these patients.     

Dupuytren's contracture limited to the distal interphalangeal joint--a case report]

A case of Dupuytren's contracture involving only the distal interphalangeal joint of the right little finger is reported. The contracture developed gradually during 6 months, after a minor trauma of this finger. Distal phalanx was fixed in 60 degrees flexion in the distal and 30 degrees flexion in the proximal interphalangeal joints, but it did not disturbed patient's normal daily activity. Proximal interphalangeal flexion was easy reducible, but distal phalanx was settled in fixed flexion deformity. No pathology was seen in the palmar aspect of the midhand. At the exploration, a thickened 1 cm long cord localised at the radial side of the distal interphalangeal joint and extending across this joint was identified, and excised. This resulted in full correction of the flexion deformity. Histopathological examination revealed excised cord to be a fibrous tissue, typical for the Dupuytren's contracture.     

Distal interphalangeal joint silicone interpositional arthroplasty: surgical technique and functional outcome

Distal interphalangeal joint arthroplasty is effective in alleviating the pain of degenerative arthritis while preserving motion and stability. This procedure was undertaken as an alternative to arthrodesis for 17 women with osteoarthritis and 1 woman with rheumatoid arthritis. Silicone interpositional arthroplasty was performed in 31 digits of patients whose mean age was 58.3 years. The patients were evaluated at an average of 72.2 months (range, 12.6 to 123.1 months) after surgery. All patients reported that their primary preoperative symptom of pain was effectively eliminated by the procedure. At reevaluation, the active range of motion of the distal interphalangeal joint averaged 32.2 degrees and extension lag averaged 12.7 degrees . Lateral stability of the distal joint was present in all but one middle finger implant. Two implants were removed at 3 months postoperatively for wound problems and one at 31 months because of prothesis fracture.     

Flexor digitorum profundus tendon tension during finger manipulation.

Abstract The purpose of this study was to measure the tension in the flexor digitorum profundus (FDP) tendon in zone II and the digit angle during joint manipulations that replicate rehabilitation protocols. Eight FDP tendons from eight human cadavers were used in this study. The dynamic tension in zone II of the tendon and metacarpophalangeal (MCP) joint angle were measured in various wrist and digit positions. Tension in the FDP tendon increased with MCP joint extension. There was no tension with the finger fully flexed and wrist extended (synergistic motion), but the tendon force reached 1.77 +/- 0.43 N with the MCP joint hyperextended 45 degrees with the distal interphalangeal and proximal interphalangeal joints flexed. The combination of wrist extension and MCP joint hyperextension with the distal interphalangeal and proximal interphalangeal joints fully flexed, what the authors term "modified synergistic motion," produced a modest tendon tension and may be a useful alternative configuration to normal synergistic motion in tendon rehabilitation.     

The mechanism of the intrinsic-minus finger: a biomechanical study

To demonstrate in the cadaver model that the sequence of extension of the flexed metacarpophalangeal and proximal interphalangeal joints of the intrinsic-minus finger can be explained on the basis of moment ratios about these joints, the engineering concept of free body analysis was applied. Intrinsic-minus fingers, i.e., fingers of a cadaver in which all forces exerted by the intrinsic muscles were removed, were observed to hyperextend maximally at the metacarpophalangeal joint before extension of the proximal interphalangeal joint began. Mathematical calculation of moments provides an explanation of this sequence. This study confirmed that, when an equilibrium of forces at the hyperextended metacarpophalangeal joint is reached, the proximal interphalangeal joint is incompletely extended. These forces include: (1) the proximal pull of the extensor tendon; (2) the distal loading of the extensor tendon by the flexor tendons; (3) the force preventing spanning of the laminae.     

Digital artery tortuosity and elasticity: a biomechanical study

The gross structure of the digital artery distal to the proximal interphalangeal joint is significantly different from its proximal portion. Previous research in this laboratory has revealed that over half of all fingers exhibit marked tortuosity of this artery in juxtaposition to the distal interphalangeal joint. Any structure with a large amount of bending will have the properties of a spring. An understanding of these properties may help in creating tension-free anastomoses during finger tip replantation. The elastic strength and energy storage capacities of the distal digital artery were measured in 26 cadaver arteries.     

Flexor digitorum profundus tendon excursions during controlled motion after flexor tendon repair in zone II: a prospective clinical study.

Intratendinous metal markers were used to study flexor digitorum profundus tendon excursions during early controlled motion with dynamic flexion traction and to evaluate their significance for results after flexor tendon repair in zone II. The mean excursion was 1 mm along the middle phalanx and 5.6 mm along the proximal phalanx. This corresponded to a mean excursion per 10 degrees of controlled distal and proximal interphalangeal joint motion of 0.3 and 1.2 mm, respectively. Compared to active motion, controlled motion of the distal interphalangeal joint mobilized the tendon with an efficiency of 36% and controlled motion of the proximal interphalangeal joint mobilized the tendon with an efficiency of 90%. Controlled-motion excursions induced by the distal interphalangeal joint along the middle phalanx had little influence on subsequent active range of motion in the distal interphalangeal joint, whereas excursions along the proximal phalanx (for which the proximal interphalangeal joint was largely responsible) did have a significant influence on subsequent total active interphalangeal range of motion.     

Soft tissue distraction using pentagonal frame for long-standing traumatic flexion deformity of interphalangeal joints

Objective:Interphalangeal joint contracture is a challenging complication of hand trauma,which reduces the functional capacity of the entire hand.In this study we evaluated the results of soft tissue d...     

Coverage of dorsal distal skin defects of the digits. Techniques and indications

Distal dorsal skin defects of the digits could be considered as a surgical entity. The coverage of this area is challenging according to the following points: the proximity of the distal interphalangeal joint, the thinness of the extensor apparatus and the vicinity of the nail. Among the numerous flaps described, the homodigital turnover pedicled flaps appear the most effective option rather than cross-finger flaps.     

Goniometry of the proximal and distal interphalangeal joints, Part II: placement prefereces, interrater reliability, and concurrent validity.

The purposes of this repeated-measures single-case-design study were to describe goniometric placement preferences and their effect on the measurement of the proximal and distal interphalangeal joints, to determine interrater reliability, and to determine concurrent validity. Thirty-nine therapists measured one patient dorsally and laterally with the DeVore and the 6" clear goniometers. No significant differences were found between the two goniometers used in the study. Comparison of the means of lateral and dorsal measurements revealed that the only joint associated with a significant difference was the contracted index proximal interphalangeal joint (p=0.0347). Preferences did affect the standard deviations and ranges but not the means of the measurements. Interrater reliability was high (ICC 2,1: 0.99 and 0.86). Clinical and radiographic measurements were markedly different from each other (paired-difference t-tests), leading to inconclusive concurrent validity.     

伸肌腱止点重建治疗锤状指畸形

目的介绍应用重建伸肌腱止点治疗锤状指畸形的方法和疗效。方法对13例锤状指患者,于末节指骨终腱止点处作粗糙面熏取掌长肌腱游离移植。肌腱近端用3/0缝合线重叠缝合,远端用4/0丝线作“8”字缝合后绕行至指端皮肤外打结。远侧指间关节用直径1.0mm克氏针固定过伸位10°～15°,近侧指间关节石膏托固定屈曲位30°～40°。4周后拆除牵引线及外固定进行近侧指间关节及掌指关节功能锻炼,6周后拔除克氏针进行末节屈伸功能锻炼。结果随访2个月～2年,按Dargan功能评定法:优11例,良1例,可1例,优良率92.3%。结论伸肌腱止点重建术是治疗锤状指畸形的有效方法。     

末节断指再植的功能评价

目的报道末节断指再植的远期功能效果.方法对38例42指末节断指再植成功者进行了平均2年3个月(10个月～4年6个月)的随访.结果拇指指间关节与手指远侧指间关节的平均主动活动度分别为49°和52°,两点辨别觉平均7.2mm.根据Tamai标准评价功能结果,42指中优25指,良17指.结论应强调精确吻合指神经的必要性,仅吻合一根指神经或不吻合指神经者感觉恢复较差;对累及关节的离断以关节融合为佳;再植后的萎缩为充盈不良或失用所致.     

The innervation of the proximal interphalangeal joint and its application in neurectomy

In an anatomic study of 64 fingers, we demonstrated that the proximal interphalangeal joint is innervated by branches of the palmar digital nerves. The number of articular branches ranges from two to four and their origins from the digital nerve are between 2 and 8 mm from the proximal interphalangeal joint. In a clinical series of 24 neurectomies in 21 patients, there was a significant improvement in pain and range of motion in 22 fingers. We conclude that neurectomy is a therapeutic option in the treatment of osteoarthritis of the proximal, interphalangeal joint.     

Surgery of the hand in severe systemic sclerosis

Ten patients with scleroderma and severe hand problems required surgery, and seven were available for follow-up (two died from scleroderma-related complications and one was lost to follow-up). The mean duration of follow-up was 4 (range 1.5-9) years. Thirty-three procedures were carried out, including five metacarpophalangeal joint excisional arthroplasties, 13 proximal interphalangeal joint fusions, ten distal interphalangeal joint fusions, and one thumb interphalangeal joint fusion. The metacarpophalangeal joint excision arthroplasties and proximal interphalangeal joint fusions were performed for the correction of severe fixed "finger-in-palm" deformities. Lesions of cutaneous calcinosis were removed in four patients. Fixation was satisfactory in all cases of interphalangeal joint fusion, with no cases of nonunion. Wound healing was satisfactory in six of seven patients. A second surgical procedure was required in three patients for the removal of tension band wires following interphalangeal fusion. Calcinosis was effectively removed using a high-speed dental burr. The results of hand surgery for systemic sclerosis are reliable, but goals must be limited and patient expectations should be modest.     

Dorsal Dislocation of the Distal Interphalangeal Joint and Volar Dislocation of the Metacarpophalangeal Joint in the Same Finger: A Case Report

Double dislocations of the finger interphalangeal and/or metacarpophalangeal joints are a rare entity. Sixty-four cases of distal and proximal interphalangeal joint double dislocations have been previously reported. Five cases of metacarpophalangeal and interphalangeal double dislocations of the thumb have also been reported. Only one case has been reported in the English literature regarding simultaneous dislocations of the distal interphalangeal and metacarpophalangeal joints in the nonthumb digit. The directions of the dislocation were the same; both were dorsal. We report, to our knowledge, the first ever case of a double dislocation a non-thumb digit in opposing directions—volar at the metacarpophalangeal joint and dorsal at the distal interphalangeal joint.     

Instructional Course Lecture. Arthrodesis of the interphalangeal joints with headless compression screws

Interphalangeal arthrodesis is a reliable method of pain relief for arthritic proximal and distal interphalangeal joints in the fingers. Indications include osteoarthritis, acute trauma, chronic reconstruction for trauma, rheumatoid and other inflammatory arthritides, and at the distal interphalangeal joint, chronic mallet finger deformity and unreconstructible flexor tendon defects. Solid arthrodesis imparts stability to the digital skeleton. Headless compression screws can be reproducibly inserted and are a good method to provide fixation adequate to accomplish interphalangeal arthrodesis. Surgical technique involves a dorsal incision and preparing the skeleton for good bony apposition. Exact technique for screw insertion depends on the specific screw used. Union rates range from 85% to 100% in published studies, with time to union of 7 to 10 weeks.     

Surgical treatment of degenerative osteoarthritis of the fingers

Degenerative osteoarthritis of the long fingers is rare and surgical management is often necessary if there is joint pain, however this indication should not only be based on radiographic imaging. The specific anatomical problems of the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are described. The surgical approach for each joint is described as well as functional management, in particular that of the extensor apparatus. Mobility should always be preserved for the MCP, arthroplasties are recommended for the PIP except for the index, and arthrodesis for the DIP. The different and most frequently used implants are described as well as the indications and expected results. The indications are discussed in relation to the limited results in the literature as well as the preferences of a panel of French hand surgeons.