Release of Posttraumatic Metacarpophalangeal and Proximal Interphalangeal Joint Contractures
DEFINITION
Posttraumatic metacarpophalangeal (MCP) joint and proximal interphalangeal (PIP) contractures may develop directly as a result of injury to the joints and adjacent tissues or indirectly as a result of excessive immobilization or poor splinting of the hand.
The circumstances precipitating the contracture determine the structures most involved: Joint capsule and collateral ligament contracture
Flexor tendon adhesions
Intrinsic musculature contracture Extensor tendon adhesions
Skin and subcutaneous tissue scarring
The MCP joint generally becomes stiff in the extended position. Flexion contractures are uncommon and, when present, generally do not cause significant disability.
The PIP joint often becomes contracted in the flexed position, although extension and combined contractures are not uncommon.
The key to successfully mobilizing a stiff MCP or PIP joint is anticipating the pathologic causes before surgery.
ANATOMY
MCP joint osteology allows biaxial motion, including circumduction. The articular surface of the metacarpal head is asymmetric, with a relatively flat mediolateral convex arc (abduction-adduction) and a large anteroposterior convex arc (flexion-extension) that extends more volarly (FIG 1A).
The MCP joint is enveloped by a relatively loose capsule inserting onto ridges surrounding the articular cartilage.
Proper collateral ligaments originate from a dorsolateral tubercle on the metacarpal head and insert on the lateropalmar edge of the phalangeal base (FIG 1B).
The volar plate of the MCP joint is an extension of the phalangeal articular surface. Unlike the volar plate of the PIP joint, the volar plate of the MCP joint is collapsible and there is little tendency to produce checkreins.
This is one reason why MCP joint flexion contractures are much less common than those in the PIP joint.
The flexor and extensor mechanisms surround the MCP joint.
Volarly, the flexor sheath lies directly on the palmar plate and is thick, forming the first annular pulley. Dorsally, the extensor tendon gives rise to fibroaponeurotic sagittal bands that wrap around to insert on the
palmar plate. The tendons of the lumbricals and interossei join the dorsal expansion of the extensor. A slip of the dorsal interossei inserts on the dorsolateral aspect of the phalangeal base.
The PIP joint is a simple ginglymus hinge joint stabilized by a boxlike arrangement of structures consisting of the proper and accessory collateral ligaments, the volar plate, and the dorsal capsule (FIG 1C,D).
The joint is most stable in extension, and stability in flexion is provided by the volar plate, proper and accessory collateral ligaments, and flexor tendons, and less so by the dorsal structures.
The collaterals provide radial and ulnar stability. They remain taut throughout the PIP joint range of motion.
The accessory collaterals arise from the proximal phalanx and insert into the volar plate. Because there is no insertion of the accessory collateral into the middle phalanx, they will contract when the PIP joint is immobilized in flexion.
The volar plate resists PIP hyperextension, and the dorsal capsule is relatively weak. Transverse retinacular ligaments connect the extensor and flexor tendon sheath.
PATHOGENESIS
The irregular contour of the MCP joint functions as a cam, transforming joint flexion into translation (or elongation) of the collateral ligaments. When flexed, the MCP joint has minimal capsular volume and is maximally constrained. Conversely, extension allows maximal capsular volume and joint laxity.
Direct trauma to the MCP joint causes joint effusions and hemarthrosis. Hand trauma elsewhere results in edema, which also collects within the MCP joints. In both cases, as the capsule fills with fluid, the MCP joint is hydraulically pushed into a nearly fully extended position.
With time, the dorsal capsule becomes thick and noncompliant, leading to an extension contracture. The overlying extensor mechanism may become adherent to the capsule. The underlying collateral ligaments shorten and scar laterally to the metacarpal head. The volar recess may fill with adhesions between the volar plate and condyles.
The extended MCP joint increases flexor tone and relaxes the extensor mechanism, leading to interphalangeal joint flexion, and may indirectly result in a fixed flexion contracture of the PIP joint.
The combination of extended MCP joints and flexed interphalangeal joints defines the intrinsic-minus hand.
Injury, infection, excess immobilization, and inappropriate splinting may directly result in fixed flexion or extension contracture of the PIP joint.
An accumulation of fluid or blood within the capsule leads to stiffness, as does articular damage.
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FIG 1 • A. The articular surface of the metacarpal head protrudes volarly, making the capsule (and proper collateral ligaments) taut with flexion. B. MCP joint anatomy can be considered in two layers: the capsule and collateral ligaments, which lie immediately adjacent to the articular surfaces, and the flexor and extensor mechanisms, which envelop the joint. C. Normal anatomy of the PIP joint showing the arrangement of the collateral ligaments and the volar plate. D. Normal PIP anatomy showing the arrangement of the proper and accessory collateral ligaments.
Curtis3,4 has reported that a contracture of the PIP joint can be due to the following:
Contracture of the volar plate or the capsular structures Collateral ligament contracture
Scar contracture over the joint Volar skin contracture
Flexor sheath contracture
Extensor tendon contracture or adhesions Interosseous contracture or adhesions
A bony block or exostosis
Additional causes not pertinent to this chapter include fascia contracture, as in Dupuytren disease.
Watson et al11 reported that a flexion contracture of the PIP joint is due to contracture of the checkreins on the proximal surface of the volar plate.
NATURAL HISTORY
Long-standing scarring and contracture of the MCP or PIP joint capsule almost invariably lead to adhesions to the adjacent flexor sheath and extensor mechanism.
Residual joint kinetics are often altered with joint motion occurring through incongruous articular motions such as pivoting.
Cartilage gradually atrophies and softens with disuse. Surface irregularities may develop.
PATIENT HISTORY AND PHYSICAL FINDINGS
The history should identify the following:
The inciting cause of the joint contracture The time of the insult
Efforts made to mobilize the digit
The hand is evaluated for edema and the return of normal skin creases.
Ongoing swelling and inflammation (FIG 2A) must subside before surgery.
The dorsal soft tissues are assessed for mobility and compliance.
Capsulectomy after burns and crush injuries may fail due to inadequate dorsal coverage. Skin contracture can also be an original inciting cause for digital stiffness.
The MCP and interphalangeal joints are assessed for differences in active and passive motion. Passive motion is always greater than active; however, a large difference suggests extrinsic tendon adhesions.
Bunnell intrinsic tightness test: Intrinsic release may be necessary to mobilize a PIP joint with extension contracture.
Finger threshold sensitivity is checked, along with overall sensitivity to percussion and cold. Vascularity is assessed by checking capillary refill. The painful and insensate stiff finger may be a better candidate for amputation than capsulectomy. Poor vascularity is a relative contraindication to capsulectomy.
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FIG 2 • A. Swollen hand. B. Boutonnière deformity. C. Swan-neck deformity.
Concomitant PIP flexion and distal interphalangeal hyperextension mark a boutonnière deformity (FIG 2B), whereas hyperextension at the PIP joint is a sign of a swan-neck deformity (FIG 2C).
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs of the hand are made to evaluate for extrinsic and intrinsic causes of joint stiffness.
Extrinsic
Metacarpal neck or shaft fracture: Extensor tendon adhesions at the fracture site may restrict MCP joint flexion (passive and active).
Metacarpal fracture malunion: Shortening of the metacarpal results in extensor lag (average of 7 degrees
for every 2 mm of shortening according to Strauch and colleagues12). Apex dorsal metacarpal malunions create a corresponding extensor lag at the adjacent MCP joint.
Proximal phalangeal fracture: Flexor and extensor tendon adhesions at the fracture site may limit active PIP (and sometime MCP) joint motion; passive motion may be maintained.
Proximal phalangeal fracture malunion: Common apex volar proximal phalanx malunions can cause an apparent limitation of MCP joint flexion.
Intrinsic
Intra-articular fracture: Articular incongruity may serve as a bony restraint to joint motion.
Arthritic changes: Cartilage softening and erosion often result in some degree of radiographically apparent arthritis.
A “true” lateral radiograph of the involved joint must be closely examined for significant arthritic changes or any subluxation.
There is little role for computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the digits.
DIFFERENTIAL DIAGNOSIS
MCP extension contracture from extrinsic extensor muscle spasticity or intrinsic muscle paralysis or denervation
MCP loss of flexion from proximal phalanx apex volar malunion
PIP contracture from tendon imbalances, including boutonnière deformity and swan-neck deformity Skin contracture
Dupuytren disease
NONOPERATIVE MANAGEMENT
Nonoperative efforts to improve joint motion must be tried until motion has plateaued and the soft tissues are absolutely quiescent.
As a general rule, inflammation and edema will subside and range of motion will improve for a minimum of 3 to 4 months after a traumatic or surgical insult to the hand.
During this time, a supervised hand therapy program is essential.
Most MCP contractures occur in extension. In addition to regular exercises, dynamic flexion splints (daytime) and static extension splints (nighttime) are useful.
Most PIP contractures occur in flexion. Treatment begins with application of a nonelastic extension force across the PIP joint for an extended time. This can be done with serial finger casts or commercially available splints such as the Joint Jack (Joint Jack Co., Wethersfield, CT) or wire-foam splints. Once the contracture is corrected, elastic splints such as the Joint Spring or clock-spring splints can be used.
Prosser10 presented one of the few studies to follow patients treated conservatively. Using a Capener splint to be worn for 8 to 12 hours per day over an 8-week period, there was an average improvement in the flexion
contracture from 39 to 21 degrees.10 There was no association between time in the splint with final extension or with final stiffness.
PIP extension contractures are treated conservatively with serial static splints such as a joint-strap system.
Curtis3,4 has reported that these joints do not require surgery if the joint can be passively flexed more than 75 degrees.
The only study in the literature on the results of conservative treatment comes from Weeks et al.15 In a review of 212 patients with 415 stiff PIP joints, 87% responded favorably to nonoperative treatment. The average improvement in total active motion was 36 degrees.
SURGICAL MANAGEMENT
A capsulectomy is indicated only for a contracture not associated with articular incongruity or persistent subluxation of the joint.
A stiff MCP or PIP joint in the face of articular incongruity or subluxation is best treated as an arthritic joint with a salvage type of surgery such as arthroplasty or arthrodesis.
Mild to moderate joint wear is not a contraindication to capsulectomy, particularly in younger patients. Focal areas of articular cartilage irregularity and dorsal osteophytes may be débrided at the time of surgery.
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The literature does not give any specifics as to when to recommend surgery. We usually make this decision when a “functional arc of motion” has not been achieved after a minimum of 3 months of therapy.
There is no absolute functional arc of motion for the MCP joint. In the absence of interphalangeal contractures, we have found that index, middle, ring, and small finger MCP flexion of 30, 35, 40, and 45 degrees, respectively, is generally satisfactory. When the interphalangeal joints have limited flexion, greater degrees of MCP flexion may be useful.
Similarly, 45 degrees or more of total PIP motion is usually satisfactory. Flexion contractures greater than 45 degrees are poorly tolerated and may benefit from surgical release.
Extreme flexion contractures (>60 or 70 degrees) may be best managed with arthrodesis. The results of a capsulectomy are often disappointing.
Extension contractures are better tolerated, especially if there is flexion to at least 75 degrees.
When a patient has exhausted nonoperative management options and joint stiffness exceeds the preceding guidelines, surgery for contracture release is considered.
Preoperative Planning
The patient is required to demonstrate a commitment to therapy before surgery is undertaken. A preoperative meeting between the patient and the therapist is arranged to plan the first postoperative visit and to fabricate a dynamic flexion splint.
If possible, surgery is planned under a form of anesthesia that will allow patient cooperation and active motion during the procedure.
A wrist block with sedation is optimal; however, a Bier block may be used and reversed with deflation of the tourniquet.
In severely scarred hands (eg, massive crush injuries and burn patients), the surgeon must anticipate inadequate dorsal soft tissue and extensor tendon excursion. A transverse incision and extensor tenotomy is indicated and coverage of the residual soft tissue defect is planned and discussed with the patient. Kirschner wire fixation of the MCP joints in flexion may be necessary to maintain a flexed joint and protect the dorsal soft tissue reconstruction.
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FIG 3 • A. A combined MCP extension contracture and PIP flexion contracture of the index finger is approached by extending the dorsal incision distally in the midaxial line. B. Excellent exposure of the finger extensor mechanism is coupled with visualization of the volar aspect of the PIP joint.
Positioning
Patients are positioned supine with the affected extremity on a hand table. A brachial tourniquet is applied that allows access to the forearm should a full-thickness skin graft be necessary.
Approach
The approach for MCP contracture depends on three factors:
The number of involved MCP joints The need to operate on the PIP joint The quality of the dorsal soft tissues
A single MCP joint is approached with a dorsal longitudinal incision. If the PIP joint has an extension contracture, the incision is carried over the PIP in the midline. If the PIP has a flexion contracture, the incision may be extended distally in the midaxial line (FIG 3A).
Multiple MCP joint extension contractures are approached using separate dorsal longitudinal incisions.
This is the most extensile method and facilitates management of associated extensor tendon adhesions and PIP contractures (FIG 3B).
Two adjacent MCP joints may also be approached by making a dorsal longitudinal incision centered in the web between affected rays.
If necessary, it is safe to extend this incision as a Y onto each digit to complete a tenolysis or operate on the PIP joints.
Multiple MCP joints may be also approached by making a single transverse incision lying just proximal to the metacarpal heads.
This approach is preferred only when the dorsal soft tissues are fibrotic and noncompliant. In this situation, the surgeon should plan for skin graft or flap coverage of the anticipated defect.
The surgical approach for isolated PIP joint contractures varies with the procedure used.
A capsulectomy for a flexion contracture is performed through a lateral approach, a checkrein release
through a volar approach, and percutaneous release laterally.
A dorsal skin incision could be used with a capsulectomy for an extension contracture or when there is a previous dorsal incision or specific hardware to remove.
External fixation requires no incision.
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TECHNIQUE
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Metacarpophalangeal Joint Contractures
Dorsal Capsulectomy of the Joint
Make the skin incision based on the aforementioned considerations (TECH FIG 1A). Carry dissection down sharply to the extensor mechanism, preserving small dorsal nerves.
If the soft tissues about the MCP joint are excessively scarred, identify the extensor mechanism proximally and distally with careful development of soft tissue planes in between.
Raise full-thickness soft tissue flaps over the length of the extensor mechanism (TECH FIG 1B).
Use a Freer elevator to lyse adhesions beneath the extensor mechanism, especially over the metacarpal proximally (TECH FIG 1C).
As described by Curtis3,4 and later Tsuge,13 the extensor tendon is bisected sharply over the MCP joint (TECH FIG 1D); the sagittal fibers are preserved. Do not carry the extensor split into the transverse fibers of the extensor hood.
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TECH FIG 1 • A. Separate dorsal longitudinal incisions are planned for multiple MCP joint extension contractures. B. Full-thickness soft tissue flaps are raised at the level of the extensor mechanism. C. The extensor mechanism is split longitudinally. D. Each side of the extensor tendon is freed of adhesions to the adjacent tissues. E. The dorsal capsule is excised. F. The proper collateral ligaments are released from the metacarpal head. G. MCP flexion is reassessed.
In the index or small finger, the split is made between the extensor communis and the extensor proprius tendons.
Retract each half of the extensor tendon and attached sagittal band to expose the joint capsule.
At times, it may be painstakingly difficult to develop the interval between the extensor mechanism and capsule, and a combination of both sharp and blunt dissection is necessary.
The capsule is usually quite thick and generally should be excised rather than released (TECH FIG 1E).
Attempt passive finger flexion; it usually is limited, necessitating release or excision of the collateral ligaments (TECH FIG 1F).
Start dorsally and release the proper collateral ligaments from the collateral recess and from any adhesions to the metacarpal head. Often, the collateral origin may be gently pried away from the metacarpal head with a Freer elevator.
Dense adhesions and excessively thick collateral ligament tissue may need to be incised at the
metacarpal origin and removed.
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TECH FIG 2 • A-C. The wrist is located to the left and the finger to the right in each figure. A. The leading edges of the sagittal fibers are identified and liberated from the underlying dorsal capsule. B. Sagittal fibers are retracted distally and the capsule is incised transversely. C. A Freer elevator is used to release the proper collateral ligament origins.
Reassess passive MCP flexion (TECH FIG 1G). If flexion remains inadequate or the joint “jumps” or “snaps” when reaching full extension, then the accessory collaterals may need to be released as well.
The goal is an incremental collateral ligament release— enough to restore joint motion but not compromise stability, especially on the radial (pinch) side.
Assess the volar recess and release any adhesions between the volar plate and condyle with a Freer elevator.
Failure to release the volar adhesion can result in joint “hinging” with dorsal gapping of the joint during flexion.
The joint should now have a smooth arc of passive motion without any hinging during flexion or snapping into extension. Ninety degrees of flexion can usually be achieved.
If the patient is under a wrist or Bier block anesthesia, check active flexion.
Alternatively, a short incision may be made on the volar ulnar aspect of the forearm and traction applied to the appropriate extrinsic flexor tendons.
If active flexion is limited, consider performing a flexor tenolysis.
We consider releasing the flexor at the same setting, although the tenolysis may be staged, emphasizing passive motion between surgeries.
Release the tourniquet and achieve hemostasis with bipolar electrocautery.
While keeping the MCP joint flexed, close the extensor mechanism with 4-0 interrupted inverted nonabsorbable braided suture and close the skin with nonabsorbable interrupted sutures.
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TECH FIG 3 • A. Release of MCP extension contractures in the severely burned hand is accomplished through a transverse skin incision and extensor tenotomy. (continued)
If bleeding from scar is excessive, then use a small rubber vascular loop or a quarter-inch Penrose drain to stent open the wound to allow drainage for the first 24 hours.
A dorsal splint is applied to maintain the MCP joints in 70 degrees of flexion.
Limited Dorsal Capsulotomy of the Metacarpophalangeal Joint
In mild contractures, a dorsal capsulectomy may not be necessary. Bode and Gottlieb1 have described a limited capsulotomy.
Expose the extensor mechanism as described earlier (see TECH FIG 1).
Use a Freer elevator to release the extensor mechanism and sagittal bands from the dorsal capsule (TECH FIG 2A).
Retract the dorsal capsule distally.
Incise the capsule transversely at the distal dorsal aspect of the metacarpal head (TECH FIG 2B).
The incision extends from one collateral recess to the other.
Using a Beaver blade or Freer elevator directed to the periphery of the capsulotomy, perform a stepwise release of the collateral ligaments off the metacarpal head (TECH FIG 2C).
Extensor Tenotomy of the Metacarpophalangeal Joint
In long-standing densely scarred multidigit MCP contractures, the extensor communis tendon may need to be tenotomized to achieve flexion (TECH FIG 3A).
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TECH FIG 3 • (continued) B. The MCP joints are maintained in flexion with Kirschner wires. C. The dorsal soft tissue defect is covered with a pedicled tensor fascia lata flap.
Make a tenotomy at the distal margin of the sagittal bands. Capsulectomy and collateral ligament release follow as described earlier.
At closure, sew the proximal tendon to the sagittal bands; close the extensor hood on itself in the midline dorsally.
Given the chronicity of these contractures, consider temporary Kirschner wire fixation of the MCP joints in flexion (TECH FIG 3B).
Kirschner wire fixation is especially useful for protection of skin grafts or flaps when the dorsal soft tissues are deficient (TECH FIG 3C).
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Proximal Interphalangeal Joint Contracture
Capsulectomy for Proximal Interphalangeal Joint Flexion Contracture
If there is an adequate skin envelope, the finger is approached through a midaxial incision (TECH FIG 4A).
Make a radial incision centered over the PIP joint; it is usually 4 cm long.
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TECH FIG 4 • A. Skin incision. B. The transverse retinacular ligament is protected and the collateral ligament is exposed for excision. C. The collateral ligaments are excised. (continued)
Retract the neurovascular structures volarly and protect them. Take care to preserve the dorsal branch of the digital nerve, which typically crosses the proximal aspect of the incision.
Open the flexor sheath just distal to the A2 pulley.
Excise a segment of pulley if it is contracted. Perform a formal flexor tenolysis as necessary.
If a more extensive tenolysis is required, the incision can be extended volarly over the flexor sheath. Take care to avoid injury to the digital nerve and artery that cross the operative field at the level of the web space.
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TECH FIG 4 • (continued) D. Extensor tenolysis is done if required.
Excise a volar segment of collateral ligament (including the underlying capsule) using a no. 69 Beaver blade while carefully protecting the transverse retinacular fibers (TECH FIG 4B). Excise the entire accessory collateral ligament as necessary.
Isolate and preserve the transverse retinacular fibers by bluntly dissecting perpendicular to the fibers (TECH FIG 4C).
Do not excise the volar plate (joint capsule), but expand the volar pouch by lifting the volar plate from the phalanges with a Freer elevator. Lengthen the interossei as needed.
If there is still stiffness after completing the dissection on the radial side of the finger, then make a similar incision on the ulnar side of the digit.
The ulnar incision is usually only 3 cm long, as the flexor and extensor tendon disorders have already been addressed. If there is concern that extensor tendon adhesions may limit active extension after release of the flexion contracture, then an extensor tenolysis is performed by elevating the dorsal skin. During the extensor tenolysis, protect the central slip insertion (TECH FIG 4D).
A skin graft or local flap may be required if there is inadequate soft tissue coverage after joint mobilization.
If there is insufficient volar skin or unstable volar skin, then raise a cross-finger flap from the adjacent finger. When a cross-finger flap is used, make a transverse incision over the volar aspect of the PIP
joint and extend it with a radial midaxial incision.
Curtis3,4 originally described pinning the joint in extension for 1 week, but most surgeons do not follow this recommendation.
Some authors have advocated resecting the superficialis tendon to avoid recurrence. The author's
personal experience suggests that this is not helpful. Favre and Kinnen5 reported their results for release of the superficialis at the time of a trigger release, but there is no data in the literature to support release of the superficialis in routine cases.
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TECH FIG 5 • A. The flexor sheath is exposed and the checkrein ligament on the proximal edge of the volar plate is exposed. B. Watson's technique for release of the checkrein ligaments to correct a PIP flexion contracture.
Checkrein Ligament Release for Proximal Interphalangeal Flexion Contracture
According to Watson et al,14 the volar plate does not flex but rather slides proximally and distally with flexion and extension. PIP joint adhesions causing contracture occur proximal to the volar plate and involve the checkrein ligaments.
Excision of the volar plate or division of the collateral ligaments is rarely required to achieve full extension.
The joint is approached volarly, often with a V-Y incision to address palmar skin contracture. Open the theca between the A2 and A4 pulleys and retract the flexor tendons (TECH FIG 5A). Release the checkrein ligaments, preserving the nutrient vessel (TECH FIG 5B).
If there is still a contracture after release of the checkreins, release the dorsal portion of the collaterals or the oblique retinacular ligament of Landsmeer.
This technique is helpful if a palmar exposure is required for excision of Dupuytren disease or during flexor tendon reconstruction.
Percutaneous Collateral Ligament Release for Proximal Interphalangeal Flexion Contracture
Stanley et al11 described a percutaneous release of the collateral ligaments for persistent PIP flexion contractures.
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TECH FIG 6 • A. Cross-section shows placement of the no. 69 Beaver blade parallel to the proximal phalanx and adjacent to the PIP collateral ligament origin. B. Sagittal view demonstrates the technique of “sweeping” the Beaver blade and detaching the collateral ligament from its origin.
Place a no. 69 Beaver blade percutaneously adjacent to the proximal phalangeal head (TECH FIG 6A). Disinsert the proper collateral ligaments with a sweeping-type motion (TECH FIG 6B).
Gently manipulate the finger into extension.
Use of an External Fixator for Proximal Interphalangeal Flexion Contracture
Three types of distractors have been used.
Houshian et al8 used a Pennig mini-external fixator (Orthofix Ltd., Surrey, England) with 2-mm threaded pins.
Kasabian et al9 described the use of a multiplanar distractor used for mandible reconstruction.
The use of a Digit Widget (Hand Biomechanics Lab, Inc., Sacramento, CA) has become popular (TECH FIG 7).
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TECH FIG 7 • Application of the Digit Widget for PIP flexion contractures.
An external frame is applied without any soft tissue release.
Houshian et al8 distracts a one-fourth turn (¼ mm) each day until 5-mm distraction of the joint is achieved.
The frame is left in place for 4 to 6 weeks. Houshian leaves the frame in place for one week after distraction is stopped.
Capsulectomy for Proximal Interphalangeal Joint Extension Contracture
Make a dorsal curvilinear incision.
Preserve the transverse retinacular ligament by blunt dissection and excise the proper collateral ligaments with a no. 69 Beaver blade as described earlier (TECH FIG 8).
Perform a dorsal capsulectomy and an extensor tenolysis. If there is intrinsic tightness, perform a lengthening or release.
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TECH FIG 8 • Through a dorsal incision, the transverse retinacular ligament is protected and the collateral ligament is excised. The dorsal capsule is also released.
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Persistent stiffness
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Failure to recognize intrinsic contracture, inadequate skin
envelope, and flexor sheath contracture
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Unrecognized reflex sympathetic dystrophy
Postoperative instability
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Failure to preserve transverse retinacular fibers or
excessive release of the soft tissues
Preoperative flexion contracture
more than 75 degrees
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Consider an arthrodesis rather than soft tissue release.
Best patients for a release
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Younger patient, without a crush injury, reflex sympathetic
dystrophy, or revascularization
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Preoperative flexion contracture of less than 43 degrees
PEARLS AND PITFALLS
MCP joint
Indications ▪ The patient must have participated in a well-supervised rehabilitation protocol
and be committed to another 8-12 weeks of therapy.
Approach ▪ A transverse skin incision is more likely to restrict flexion and more prone to breakdown in the postoperative period; however, a transverse skin incision facilitates soft tissue coverage of multiple MCP joints when operative release of the severely crushed or burned hand is undertaken.
Capsulectomy and collateral release
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Adhesions between the volar plate and condyles may be responsible for limited flexion after release of the proper collateral ligaments.
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Accessory collateral ligament release may be necessary to achieve full extension without catching.
Associated pathology
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Intraoperative attempts at active flexion by the patient will identify associated flexor tendon adhesions in a surprisingly large number of patients.
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Flexor tenolysis may be made by extending the dorsal incision in the midaxial line or by making a separate Brunner-type volar approach.
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PIP joint
POSTOPERATIVE CARE
Patients are instructed in strict elevation until the first postoperative visit.
The wounds are assessed 48 to 72 hours after surgery and, if stable, immediate active-assisted range of motion is begun.
Wound care and edema control measures are also instituted. A nonadherent gauze should be applied until the wound is watertight. A Coban wrap and gauze finger sleeve limit swelling. Once the wound is healed, compression gloves or elastic finger sleeves further decrease swelling.
Therapy may quickly advance to include active and passive range of motion as the status of the extensor mechanism allows.
For MCP extension contractures:
Patients are maintained in a static splint full time to keep the MCP joints in 70 degrees of flexion. A daytime dynamic flexion splint is applied at about 1 week once the initial postoperative swelling has subsided (FIG 4).
If Kirschner wire fixation was performed, then only interphalangeal joint motion is begun immediately and MCP therapy is delayed until wire removal at 7 to 10 days.
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FIG 4 • Dynamic flexion splinting is instituted after surgery for correction of MCP joint extension contracture.
Patients are reassessed 2 to 3 weeks after surgery. If there is a significant extensor lag (as may follow an extensive extensor tenolysis), a dynamic extension splint can be alternated with the dynamic flexion splint during the day.
Nighttime static splinting is continued for a minimum of 6 to 8 weeks. Therapy is usually continued for about 3 months.
PIP release often benefits from early dynamic splinting during the day and passive splinting at night.
OUTCOMES
Final motion is often much less than that obtained at surgery but often makes a substantial difference in hand function.
Motion plateaus 3 to 6 months after surgery.
Results are best when the joint can be mobilized with capsulectomy alone. Each additional procedure, such as
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tenolysis, increases postoperative swelling and scar formation, limiting long-term gains.4
In some cases, an improvement in MCP or PIP joint motion of 30 to 45 degrees is a reasonable expectation.2,16
According to Gould and Nicholson,7 improvement in MCP and PIP motion depends on the cause of the contracture. In a study of 105 MCP capsulectomies and 112 PIP capsulectomies, patients with direct joint trauma (fractures or crush injuries) gained an average of about 20 degrees of active motion, slightly more for the MCP and less for the PIP. Patients with indirect causes of capsular contracture (nerve injury,
stroke, or skin burns) did better.7
Ghidella et al6 reported on the results of 68 PIP capsulectomies. The average overall improvement was a
disappointing 7 degrees.6 The best results occurred in young patients without a history of crush injury, pain syndrome, or revascularization. The average improvement measured 17 degrees in this group compared with 0 degree when there was a “complex diagnosis.”
Houshian et al8 reported a mean improvement of 67 degrees in 94 patients. Better results were observed
in patients younger than 40 years old.8 Only 12 superficial infections were observed without major complications. There are no reported results using the Digit Widget. Unfortunately, the authors have not been able to reproduce Houshian's results.
COMPLICATIONS
Wound dehiscence and infection Persistent or recurrent contracture Extensor rupture
Ulnar deviation of the finger at the MCP joint Postoperative subluxation or dislocation Injury to the dorsal branch of the digital nerve
REFERENCES
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Bode L, Gottlieb M. Dorsal capsulectomy of the metacarpophalangeal joint. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore: Williams & Wilkins, 1996:923-929.
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Buch VI. Clinical and functional assessment of the hand after metacarpophalangeal capsulotomy. Plast Reconstr Surg 1974;53:452-457.
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Curtis R. Stiff finger joints. In: Grabb W, Smith J, eds. Plastic Surgery. Boston: Little, Brown, 1979:598-603.
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Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am 1954;36-A(6):1219-1232.
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