Multidigit camptodactyly of the hands and feet

A clinical case of a 12-year-old boy who presented with multidigit, nonsyndromal, progressive camptodactyly is discussed. While bilateral little finger camptodactyly is well described, there is no documentation of camptodactyly involving all fingers and many toes as well as both proximal (PIP) and distal interphalangeal (DIP) joints. This patient responded well to surgery, which was performed on four toes and seven fingers, despite having established radiographic changes of camptodactyly in the PIP joints as well as two DIP joints. This case illustrates that in the skeletally immature patient, successful surgical outcomes can occur even in patients with radiographic bone changes, which themselves may be reversible following PIP contracture release. This patient’s separate fingers presented with deformity at different stages. A single patient with multiple digit involvement is illustrative of the range of clinical presentations and treatment options for camptodactyly. This article serves to inform hand surgeons about the potential consequences of avoiding surgical treatment, the need for a severity staging system, and the breadth of presentations in camptodactyly.     

Hemi-hamate arthroplasty for the management of chronic proximal interphalangeal joint fracture dislocations: Analysis of 21 cases in Indian population and review of the literature

BackgroundChronic fracture-dislocations involving the proximal interphalangeal (PIP) joint are challenging cases. We conducted this study to analyze the outcomes following hemi-hamate autograft reconstruction of such injuries and to compare our results with the existing literature.MethodsA retrospective analysis of 21 patients with chronic dorsal PIP fracture-dislocations that were managed with hemi-hamate autograft reconstruction was done. The average articular surface involvement was 64%. The average duration between injury and surgery was 9.4 weeks (range, 6–16). Quick DASH (Disabilities of Shoulder and Hand) scores, VAS (Visual Analog Scale) scores, range of motion of the PIP joints, DIP (distal interphalangeal) joints, and MCP (metacarpophalangeal) joints were measured during serial follow-up visits.ResultsUnion and graft incorporation was seen in all cases. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05). The mean flexion of the MCP joint improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at the end of four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05). The average hand grip strength was 85% of the normal side.ConclusionHemihamate autograft reconstruction is a suitable procedure for the management of chronic PIP joint fracture-dislocations, especially in cases with extensive involvement of the articular surface.Level of evidenceIII.     

Alternative to the distal interphalangeal joint arthrodesis: lateral approach and plate fixation

PURPOSE: Several fixation techniques for distal interphalangeal (DIP) joint arthrodesis have been described, with good clinical results and complication rates between 10% and 20%. We propose an alternative technique and fixation method using a lateral approach and 1.3-mm plate and screws fixation. METHODS: Between March and September 2005, 11 patients, totaling 15 fingers, had DIP joint arthrodesis by the described technique. The indications were posttraumatic arthritis in 8 fingers, degenerative or rheumatoid arthritis in 5 fingers, and isolated flexor digitorum profundus tendon lesions in 2 fingers. Patients were analyzed for osseus union, pain relief, and functional mobility of the finger. RESULTS: Arthrodesis relieved pain and restored stability at the 12th week, on average, with osseous union in all patients. All patients maintained full proximal interphalangeal joint motion with pulp-to-palm distance of zero at 6 months of follow-up evaluation. There were no rotational or angular deformities, nail bed lesions, or skin complications. CONCLUSIONS: The lateral approach with plate and screws fixation is an option for DIP joint arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Intraoperative Fracture of a Pyrocarbon PIP Total Joint—A Case Report

Pain or dysfunction of the finger joints due to arthritis or traumatic injuries that fail medical management may necessitate arthroplasty or joint replacement. The goals of the finger joint implant arthroplasty are to relieve pain, to correct deformity, and to improve the function and appearance of the hand. Several prosthetic implants have been used for the replacement of the proximal interphalangeal (PIP) joint. Pyrocarbon materials, a form of pyrolytic carbon, a ceramic-like material, have proven to be strong, durable, resistant to wear and nonreactive in the body. The Ascension PIP pyrocarbon total joint is a bicondylar, anatomically shaped, articulating implant that allows joint flexion–extension, while providing some restriction of adduction–abduction motion. A review of the literature of pyrocarbon PIP prosthesis reveals little clinical data. The case of a 33-year-old man with posttraumatic arthritis proximal interphalangeal joint right long finger is reported. The case was treated surgically using the Ascension PIP total joint. During the insertion of the implant, the proximal component fractured at the sub-articular collar. The component was removed, and a new implant was inserted without complication. Critical evaluation revealed that there was an inadequate resection of the volar lip resulting in a stress riser on the implant during impaction. Careful attention to this technical point will hopefully minimize the occurrence of this complication as the availability and use of these implants increases.     

近指间关节关节镜手术的应用解剖学研究

目的 研究人体近指间关节的解剖结构特点,探索关节镜的手术入路和术中牵引力,为近指间关节关节镜手术的开展提供解剖学基础.方法 对5具国人新鲜尸体示、中、环、小指共40个近指间关节及10个拇指指间关节标本进行解剖学研究,找出合适的关节镜人路和术中牵引力.利用2个废弃指进行临床手术模拟实验研究.结果 选择近指间关节的桡背侧或尺背侧作为关节镜的入路,以3.0 kg的牵引力最为合适.在手术模拟实验中,成功置入1.9 mm的关节镜并清晰地观察到关节内各个结构.结论 近指间关节关节镜手术用于明确关节内病变的诊断和辅助治疗是可行的.     

Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations

PURPOSE: Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach. METHODS: A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws. RESULTS: A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity. CONCLUSIONS: Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Impact of simulated proximal interphalangeal arthrodeses of all fingers on hand function

PURPOSE: To evaluate the impact of simulated proximal interphalangeal (PIP) arthrodeses on hand performance and to assess the resulting compensatory metacarpophalangeal (MCP) joint motions in healthy subjects. METHODS: Fifteen healthy subjects were tested under 2 conditions: (1) with unrestricted distal interphalangeal, PIP, and MCP joints and (2) with the PIP joint fixed at 40 degrees of flexion in all 4 fingers of 1 hand and unrestricted MCP and distal interphalangeal joints. Subjects performed the Jebsen hand function test and 13 activities of daily living. Perceived difficulty in performing tasks was assessed with a study-specific questionnaire. The motion of each finger was monitored using a motion analysis system. RESULTS: The average time to complete the Jebsen test did not increase significantly with simulated PIP arthrodesis, nor did subjects perceive the tasks to be more difficult. Activities of daily living tasks requiring power grasp did not show significant increases in MCP flexion or abduction. Precision handling tasks requiring greater PIP joint flexion did show increased MCP flexion and were associated with greater perceived difficulty. CONCLUSIONS: Our study showed a minimal overall impact from simulated arthrodeses of all 4 fingers at the PIP joints in 40 degrees of flexion when measured by selected lower-demand activities of daily living in healthy subjects. Precision handling tasks that normally use higher degrees of PIP joint flexion, however, were perceived to be more difficult to perform and required greater compensatory motion at the MCP joints. This study does not address directly the impairment that patients with generalized hand arthritis may experience after PIP joint arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level I.     

Anatomic Repair of the Central Slip with Anchor Suture Augmentation for Treatment of Established Boutonniere Deformity

BackgroudThe rupture of the central slip of an extensor tendon of a finger causes a boutonniere (or buttonhole) deformity, characterized by pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Currently, there are no standard treatment guidelines for this deformity. This study aimed to report clinical results of surgery to correct chronic boutonniere deformity.MethodsThis retrospective case series was conducted between January 2010 and December 2018 and only 13 patients with trauma-induced chronic deformity were included. After excision of elongated scar tissue, a direct anatomic end-to-end repair using a loop suture technique with supplemental suture anchor augmentation was conducted. Total active motion was assessed before and after surgery and self-satisfaction scores were collected from phone surveys.ResultsAll patients presented with Burton stage I deformities defined as supple and passively correctable joints. The initial mean extension lag of the PIP joint (43.5°) was improved by an average of 21.9° at the final follow-up (p < 0.001). The mean hyperextension of the DIP joint averaged 19.2° and improved by 0.8° flexion contracture (p < 0.001). The average total active motion was 220.4° (range, 160°–260°). Based on the Souter''s criteria, 69.2% (9/13) of the patients had good results. Only 1 patient reported fair outcome and 23.1% (3/13) reported poor outcome. The average Strickland formula score was 70 (range, 28.6–97.1). In total, 10 patients (77%) had excellent or good results. Of 10 patients contacted by phone, self-reported satisfaction score was very satisfied in 2, satisfied in 3, average in 3, poor in 1, and very poor in 1. Three patients reported a relapse of the deformity during range of motion exercises, 1 of whom underwent revision surgery. One patient complained of PIP joint flexion limitation, and 2 complained of DIP joint flexion limitation at final follow-up.ConclusionsIn chronic boutonniere deformity, central slip reconstruction with anchor suture augmentation can be an easily applicable surgical option, which offers fair to excellent outcome in 77% of the cases. The risk of residual extension lag and recurrence of deformity should be discussed prior to surgery.     

Behandlung der posttraumatischen Schwanenhalsdeformität

Swan-neck deformity of the finger, defined as hyperflexion of the distal interphalangeal (DIP) joint and hyperextension of the proximal interphalangeal (PIP) joint, can significantly limit hand function. Axial trauma to the finger is a typical injury during ball sports with hyperextension of the proximal interphalangeal (PIP) joint. Treatment is conservative with fingersplint (anti-swan-neck-splint). The established deformity can also thus be treated. However, surgical correction is often desired. In the case of long standing swan-neck deformities where flexion deformity of the DIP is marked, good results can be reliably achieved with Littler-II tenodesis. In mild flexion deformity of the DIP refixation of the palmar plate or superficial tenodesis (Littler I tenodesis) is indicated.     

A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation

Background

Our understanding of finger functionality associated with the specific muscle is mostly based on the functional anatomy, and the exact motion effect associated with an individual muscle is still unknown. The purpose of this study was to examine phalangeal joints motion of the index finger generated by each extrinsic muscle.

Methods

Ten (6 female and 4 male) fresh-frozen cadaveric hands (age 55.2 ± 5.6 years) were minimally dissected to establish baseball sutures at the musculotendinous junctions of the index finger extrinsic muscles. Each tendon was loaded to 10% of its force potential and the motion generated at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints was simultaneously recorded using a marker-based motion capture system.

Results

The flexor digitorum profundus (FDP) generated average flexion of 19.7, 41.8, and 29.4 degrees at the MCP, PIP, and DIP joints, respectively. The flexor digitorum superficialis (FDS) generated average flexion of 24.8 and 47.9 degrees at the MCP and PIP joints, respectively, and no motion at the DIP joints. The extensor digitorum communis (EDC) and extensor indicis proprius (EIP) generated average extension of 18.3, 15.2, 4.0 degrees and 15.4, 13.2, 3.7 degrees at the MCP, PIP and DIP joints, respectively. The FDP generated simultaneous motion at the PIP and DIP joints. However, the motion generated by the FDP and FDS, at the MCP joint lagged the motion generated at the PIP joint. The EDC and EIP generated simultaneous motion at the MCP and PIP joints.

Conclusion

The results of this study provide novel insights into the kinematic role of individual extrinsic muscles.     

Distal interphalangeal joint injuries

Pain-free stability in the DIP joint is essential for effective stable pinch. Distal interphalangeal joint injuries usually achieve this function when treated as described. Stiffness in the DIP joint is not ideal, but its presence after treatment is not a major functional limitation if the joint is painless and aligned in the proper position. Mallet fingers are common injuries that usually are treated in extension splinting. Profundus injuries are uncommon injuries that require a high degree of clinical suspicion and are complex to repair. Due to its close proximity, the PIP joint can suffer from coexistent, unrecognized injury. Furthermore, the uninjured PIP joint can become stiff from unnecessary splinting. Therefore, it is essential that the PIP joint be carefully assessed and treated, if necessary, so that full motion can be maintained in the PIP joint. As with any hand injury, treatment and rehabilitation of the DIP joint should be designed to be effective, yet should not compromise overall hand function. It is logical that the more traumatic the injury, the stiffer the joint will become. It is equally logical that more involved surgical repairs also have a high yield of postoperative stiffness. The treating physician is encouraged to share this knowledge with the patient prior to initiating treatment, as this will decrease patient dissatisfaction.     

Results of surgical treatment of Dupuytren's disease in women: a review of 109 consecutive patients

PURPOSE: Dupuytren's disease is not as commonly reported in women as in men. Our literature search yielded only two such studies. The purpose of this study was to further examine the presentation and surgical outcome of Dupuytren's disease in women, including complications and to compare these outcomes to a similar cohort of men and to previous studies of Dupuytren's disease in women. METHODS: A retrospective case series review was undertaken, and we identified all women who were admitted for surgical correction of Dupuytren's disease since 1990. Comparison was made with men operated during the same period. Pre- and postoperative measurements for lack of extension at the metacarpophalangeal joint (MCPJ), proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint were made by the senior author. SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, Il) was used for statistical analysis. The t test was used to compare the two groups. RESULTS: One hundred nine women were identified, with 119 operated hands, out of a total of 657 patients operated. Comparisons were made with 548 men. The average age at presentation was 63 years in women, and there was no significant difference between the two groups. One hundred five of the patients had digital involvement. The little and ring fingers were involved most frequently. Thirty-four had involvement of the MCPJ. Mean preoperative contracture was 35 degrees . Mean postoperative contracture was 1 degrees . Proximal interphalangeal joint involvement was seen in 66 patients. Mean preoperative contracture was 42 degrees . Mean postoperative contracture was 7 degrees . Distal joint involvement was identified in only 4 digits. There was no statistical difference with the men as regards digital involvement and joint involvement; however, correction at the PIP joint was significantly lower. Fasciectomy was performed in 107 cases (90%), fasciectomy and local flap in 7 cases (6%), and dermafasciectomy in 5 cases (4%). The most common complication was digital nerve/artery injury (6 patients), and disease recurrence rate was 22%. These were statistically similar to the men. CONCLUSIONS: Dupuytren's disease is less prevalent in women but its symptomatic presentation is similar to that in men, with more severe involvement of the PIP joint and a similar recurrence rate. The surgical outcomes, however, were equivalent with regard to final contracture correction, recurrence, and complication rates.     

Treatment of Symptomatic Distal Interphalangeal Joint Arthritis with Percutaneous Arthrodesis: a Novel Technique in Select Patients

Arthrodesis of the distal interphalangeal (DIP) joint is a reliable means of achieving pain relief in a symptomatic DIP joint afflicted by a variety of degenerative, inflammatory, or posttraumatic conditions. Successful arthrodesis is more reproducible when rigid compression of the joint is achieved. The emergence of an increasing number of commercially available headless or variable pitch compression screws reflects the growing trend among hand surgeons to utilize rigid stabilization of the DIP joint so that motion at more proximal levels can be initiated immediately without affecting arthrodesis rates. Successful closed percutaneous DIP arthrodesis can be achieved in a patient with hypertrophic osteoarthropathy, passively correctable deformity, and patients at increased risk for perioperative soft tissue complications associated with open arthrodesis. We present a novel percutaneous DIP fusion technique utilizing a cannulated headless compression screw in a select group of patients. The sagittal plane diameters of the distal and middle phalanges are templated. Cannulated headless compression screws, 2.4 and 3.0 mm, with short or long terminal threads at the leading end of the screw are selected based upon patient-specific anatomic considerations. Pain-free status and radiographic fusion were achieved in both patients (gout arthropathy, n = 1; posttraumatic arthritis, n = 1) at an average of 6 weeks postoperatively. Our current indications, along with pearls and pitfalls with this technique, are reviewed. In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques.     

Simultaneous fracture-dislocations of the distal and proximal interphalangeal joints

Sixteen cases of simultaneous fracture-dislocations of both the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints in the same finger that were treated during the past 10 years were classified into three types: the swan-neck injury (dorsal fragment of the base of the distal phalanx at the DIP joint and palmar fragment of the base of the middle phalanx at the PIP joint); the double-hyperextension injury (palmar fragments at the DIP and PIP joints); and the straight-finger injury (with dorsal and palmar bone fragments at the DIP joint). The results of treatment were more satisfactory in PIP joints than in DIP joints.     

Ligament reconstruction and tendon interposition for advanced posttraumatic arthritis of the proximal interphalangeal joint: 3 case reports

Although prosthetic replacement of the proximal interphalangeal (PIP) joint can restore function, it is associated with high rates of complications and is considered unsuitable for active young patients. Resection arthroplasty of the PIP joint offers an alternative, but it requires adequate soft tissue integrity and cannot correct lateral instability. The authors present an alternative resection arthroplasty technique for the PIP joint, which includes collateral ligament reconstruction and tendon interposition using a free tendon graft. This procedure can be performed in advanced posttraumatic arthritis of the PIP joint and provides acceptable motion and adequate lateral stability.     

Die Arthrolyse der Fingermittel- und Fingergrundgelenke

With regard to finger joint contractures, proximal interphalangeal (PIP) flexion contractures and metacarpophalangeal (MP) extension contractures are of utmost clinical importance. Exact clinical examination allows differentiation between pure joint contractures and complex cases. For PIP flexion contractures, a midlateral incision is preferable to a palmar approach, if possible. In this article, the indications, surgical techniques, and postoperative management concerning PIP flexion and MP extension contractures are addressed, and published results are discussed. Complete surgical contracture release, consistent postoperative treatment, and good compliance are the prerequisites for satisfying results.     

Surgical treatment for boutonniere deformity of the fingers. Retrospective study of 47 patients]

Disruption or laceration of the central slip of the extensor tendon at the proximal interphalangeal (PIP) joint with volar displacement of the lateral bands can result in the so-called boutonniere deformity which includes loss of extension at the PIP joint and compensatory hyperextension of the distal interphalangeal (DIP) joint. Many procedures has been described in the literature and no standard treatment can be recommended. The authors reports a series of 47 cases of posttraumatic boutonniere deformity. The mean follow-up was five years. Majority of patients were males (38 males). The mean age was 41 years-old (17-82 y.o.). The etiology was in 23 cases a missed subcutaneous disruption of the central slip of the extensor tendon and in 24 cases an inappropriate treatment of laceration of the extensor apparatus at the dorsal aspect of the PIP joint. The involved digit was in seven cases the index finger, in 14 cases the long finger, in 14 cases the ring finger and in 12 cases the little finger. It is essential to distinguish the supple boutonniere deformity without or after physical therapy (34 cases) and the stiff boutonniere deformity even after a hand physical therapy program (13 cases). Results were assessed on pain and active range of motion of the PIP joint as well as the range of motion of the DIP joint. Supple boutonniere deformities, except one treated by an isolated distal tenotomy of the extensor tendon (1/34), was treated by a procedure of reconstruction of the extensor apparatus including resection-suture of the central slip and redorsalisation of the lateral bands when there was a DIP hyperextension with a moderate flexion deformity of the PIP joint, and (33/34) with 90% of excellent and good results. Poor results (4/33) were due in two cases to the absence of physical therapy, in one case to septic osteoarthritis and in one to secondary rupture of the suture. For the 13 stiff boutonniere deformities, when the PIP flexion deformity was moderate, a distal tenotomy performed to correct the DIP hyperextension was satisfactory in three cases with a useful result (20 degrees-70 degrees). For destroyed PIP joint (osteoarthritis), two silicone spacers were implanted with also a satisfactory result (30 degrees-70 degrees). In the eight remaining cases, a teno-arthrolysis was performed combined with a reconstruction of the extensor apparatus as described. Six poor results were obtained with arthritic PIP joints (which should have required initially silicone implants), and two fair results (30 degrees-60 degrees) with non-destroyed PIP joints. Supple boutonniere deformity must always be treated by initial physical therapy. Surgical procedure with reconstruction of the extensor apparatus is satisfactory if the PIP joint is normal. When there is PIP osteoarthritis, it may be beneficial to perform a two-stage technique with tenoarthrolysis followed hand therapy and a secondary reconstruction of the extensor apparatus as these last procedure give satisfactory results on a supple boutonniere deformity.     

Anterior tenoarthrolysis for severe flexion contracture of the fingers (the "TATA" operation): a review of 50 cases

The "hook finger", with both proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint flexion contractures, often after multiple previous operations, is difficult to treat. This paper reports the results of 50 fingers in 49 patients in which the TATA (Téno-Arthrolyse Totale Antérieure) salvage procedure, described by Saffar in 1978, was carried out. Thirty-seven of 50 (74%) of these fingers had had at least one previous operation, most on the flexor apparatus. The mean PIP and DIP extension deficit pre-operatively was 133 degrees with a mean PIP lag of extension of 83 degrees . With a mean follow-up of 7.8 years, 45 fingers were improved, five were not and none was worsened. The mean PIP and DIP extension deficit postoperatively was 47 degrees , with a mean PIP lack of extension of 31 degrees . The overall gain in extension deficit of both joints was 86 degrees and of the PIP was 52 degrees . One PIP joint developed septic arthritis immediately after surgery. The benefit of this salvage operation is mainly in the change of the active range of motion to a more functional arc.