Chronic Finger Injuries

Fig. 8.1

Posttraumatic Proximal Interphalangeal Joint (PIP) Stiffness

PIP Joint Flexion Contracture (Fig. 8.2)

Fig. 8.2

Preoperative PIP joint flexion contracture (a) and radiographic study (b)

It is one of the most common complications of trauma including tendon injuries, fractures, and soft tissue injuries such as post-joint dislocation ligamentous lesions. Chronic edema and immobilization always put the joint in a flexed position, with subsequent contracture of the palmar volar plate of the capsular ligament and the adherence of the collateral ligaments. Flexor tendon adhesions and palmar skin scarring also play important roles in contributing to joint stiffness.

PIP Joint Extension Contracture

Limitation of flexion of the PIP joint may be due to the impaired anatomical structures in the finger after dorsal skin laceration or direct trauma to the joint. These structures include [1] scarring of the dorsal skin and joint capsule [2], adherence of the central extensor tendon [3], contracted interosseous muscle or adherent interosseous tendon, and [4] contracted capsular ligament, particularly the collateral ligament. The consequent immobilization may also contribute to the resulting joint stiffness.

Classifications of PIP contractures have been proposed [2, 3].

While they are not accepted universally, the classification schemes may help the treating physician consider general treatment strategies. For example, Salafia and Chauhan have proposed that contractures may be considered as follows: (a) mild (the PIP joint can be forcibly extended by stretching the skin and may respond to serial casting or splinting), (b) moderate (maximum possible extension remains 50–60° short of full), and (c) severe (the collateral ligaments and palmar plate are contracted so that the PIP contracture is 90° or more). Similarly, Tubiana et al. proposed a classification of Dupuytren’s disease, Grades I–IV (Table 8.1), based on the fixed angle of PIP contracture. Clearly, the more advanced the degree of contracture by either classification scheme, the more difficult the treatment.

Table 8.1

Classification of Dupuytren’s disease

Grade	Total fixed deformity (°)
I	0–45
II	45–90
III	90–135
IV	Over 135 (hyperextension at DIP joint is added to total deformity)

According to Tubiana [3]

Contracture of Distal Interphalangeal (DIP) Joint

Several etiologic factors for distal interphalangeal joint contracture have been reported, but little has been written about isolated DIP flexion contracture. The relationship between the flexor and extensor systems of the digits is both intricate and balanced, such that disruption can affect the entire dynamics of the finger. The development of fixed flexion contractures at DIP joint of the finger, if not detected early and prevented, can lead to abnormal mechanics, with resultant clinical signs and symptoms as severe as a swan neck deformity (Fig. 8.3).

Fig. 8.3

Swan neck deformity after DIP joint contracture in zone I—at 6 months

Volar Plate Avulsion Injuries (MCP, PIP, PID Joints)

Hyperextension of a finger joint, such as a dorsal dislocation, can injure the volar plate (Fig. 8.4a). Injury to the PIP joint is relatively common in athletics, especially ball sports, and collateral ligament damage is often present. The volar plate can be partially or completely torn, with or without an avulsion fracture. The subsequent loss of joint stability may allow the extensor tendon to gradually pull the joint into hyperextension, causing deformity. Maximal tenderness will be located at the volar aspect of the affected joint [4]. Full extension and flexion will be possible if the joint is stable. Radiographs may show an avulsion fragment at the base of the involved phalanx (Fig. 8.4b, c). It also usually involves a collateral ligament tear which often heals with abundant scar tissue leading to a chronic swelling on one side of the joint, which is permanent.

Fig. 8.4

Volar plate tear (a). Radiographic study showing avulsion fragment (b, c)

The severity of joint contractures and the resultant decreased joint ROM will not have the same impact on an employee or on an athlete, especially a ball athlete.

The useful range of motion of long fingers for ball catching depends on the sport, position of the athlete, and the diameter of the ball. Thus, the return to sport of an athlete with a PIP joint stiffness is earlier in a football player than a basketball or handball player who has more hand contact with smaller balls that require broader useful range of motion.

We consider that the last 5° of normal range of extension or flexion of MCP or PIP joints (Table 8.2) are functionally irrelevant and do not determine disability. The useful range of mobility in long fingers of the MCP joint ranges from 20/30° to 85° and of the PIP joint ranges from 40/50° to 95°. The functional ROM of DIP joint is less relevant and ranges from 15/20° to 70/75°.

Table 8.2

Normal range of motion (ROM) for each joint of long fingers

Joint	Movement	Normal ROM (values in °)
MCP	Abduction	0–25
	Adduction	20–0
	Flexion	0–90
	Extension	0–30
PIP	Flexion	0–120
PIP	Extension	120–0
DIP	Flexion	0–80
DIP	Extension	80–0

MCP metacarpophalangeal, PIP proximal interphalangeal, DIP distal interphalangeal

The indication for treatment is mainly functional in the adult ball athlete who must have a hand that strikes and receives effectively. It is also related to the affected finger since the second and third fingers are more functionally important than the fourth or fifth.

8.1.1.4 Management of Long Finger Stiffness

Joint contractures are an unwanted but common consequence of a variety of hand injuries.

Treatment used to improve the joint stiffness should be integrative and problem focused. Pressure therapy, active and passive mobilization through remedial activities, and corrective splinting should be started as soon as problems arise. The greater the joint limitation becomes, the longer the time the splint should be applied. Surgical treatment can be considered only after failure of a long period of conservative treatment.

Important factors to consider during preoperative planning are the duration and extent of the original deformity, the degree of progress with splinting, improvement reaching a plateau, patient tolerance of the treatment program, and the extent of residual deformity. Additionally, radiographic changes within the joint may also influence the choice of surgical technique.

Various surgical techniques have been described with differing results for the treatment of joint contracture. These techniques can be assigned to two categories: open release or distraction histogenesis.

The conventional treatment consists of performing a combination of arthrolysis, tenolysis, and occasionally, as a last resort, arthrodesis or replacement. Frequently, this does not achieve a good result particularly when there is a long delay since the injury [5, 6].

In case of a long-standing and severe MCP joint extension contracture, the joint is usually rigidly fixed by the collateral ligaments and dorsal capsule, requiring operative treatment. Approach is through a dorsal incision; the sagittal band hood fibers are retracted distally or cut if necessary, usually on the ulnar side. The dorsal capsule is transected and the joint is passively flexed. It is usually necessary to transect the ulnar or both collateral ligaments and occasionally necessary to free volar plate adhesions, too, in order to produce satisfactory flexion. Postoperatively, these joints should be maintained in full flexion for the first week; active mobilization is then begun. Night splinting or plaster may be necessary for several weeks.

The surgical approach to flexion contracture of PIP joint is well described in literature with checkrein ligament release. In the interphalangeal joints, adhesions and fibrosis occur proximal to the volar plate which does not flex; rather, it slides proximally and distally with flexion and extension of joint. There is normally no ligamentous structure between the volar plate and the assembly lines (two ridges on the volar lateral surfaces of phalanx); otherwise, extension would never be possible. The checkrein ligaments are two pathologic collagenous bands that form between the lateral proximal volar plate and the assembly lines after injury, usually pyramidal in configuration with thicker base attached distally to the volar plate and the thinner but longer apex attached proximally to the assembly line. Although some degree of fibrosis of the capsule and collateral ligaments occurs, the main structure preventing extension in the contracted interphalangeal joints is one or both checkreins. During checkrein resection procedure, the flexor sheath distal to the A2 pulley is exposed and opened. The nutrient artery from the digital artery to vincular system is identified passing beneath the checkreins, approximately 3 mm proximal to the edge of the volar plate (Fig. 8.5a). The proximal edge of the volar plate is identified, and checkreins are cut free from their broad triangular attachments to the proximal edge of the volar plate (Fig. 8.5b). As the collateral ligaments have approximately the same tension in flexion as in extension is almost never necessary to cut these ligaments; full ROM is usually possible once the checkreins are excised. The volar plate should be preserved in all cases. A moderate amount of gentle, passive extension may often be required to break up other small adhesions after checkrein resection, but full extension will occur. Watson et al. achieved full extension in 96 % of PIP joint contractures by checkrein resection as described. The joint is occasionally fixed in extension with K-wire to maintain the release. Following contracture release, the hand is immobilized in a bulky dressing reinforced with dorsal splint for 2–5 days, and when sutures are removed after 12 days, active motion is encouraged and corrective splinting applied [7].

Fig. 8.5

Diagram showing checkrein pathologic bands with transverse communicating vessels 2 mm proximal to the volar plate (a) and its complete excision (b). (G. Chick © 2012, all rights reserved). Inspired by Watson HK; Weinzweig J. Stiff Joints: Green DP, Hotchkiss R, Pederson W.; Green’s operative hand surgery, 4th edition, Vol. 1 (16), Churchill Livingstone, 1999

Extension contractures of IP joints rarely occur as pure joint contractures. They almost always involve structures other than the joint capsule. When performing a dorsal capsulotomy, a dorsolateral approach adequately exposes the hood. The transverse lamina of Landsmeer is divided and the lateral band elevated while preserving the central slip of extensor mechanism. The dorsal capsule is then incised and the joint passively flexed. In severe articular fibrosis, it is occasionally necessary to incise the entire capsule, divide both collateral ligaments, and free the volar plate adhesions.

Volar plate avulsion injuries are another common cause of loss of interphalangeal flexion. Reattachment of the volar plate is performed by formation of a cancellous groove on the volar proximal lip of middle phalanx, leaving the volar plate attached to the assembly line on one side. The joint is mobilized 3–5days postoperatively.

Stiffness or contracture of the DIP joint is seldom a problem unless there is a fixed flexion or hyperextension deformity. A fixed extension deformity can often be treated by dividing the most dorsal and lateral fibers of extensor tendon. Occasionally, complete transaction of the tendon is indicated. Late untreated mallet deformities are seldom adequately salvaged by tendon reconstruction; arthrodesis is frequently the procedure of choice.

However, single-stage surgical release of a digital joint contracture can be problematic. The amount of correction is often dependent on the status of the blood vessels and nerves. Overcorrection may cause cartilage necrosis and neurovascular overstretch and compromise, sometimes requiring subsequent amputation. Allodynia or algodystrophy may result from excessive nerve traction. In addition, there can be a lack of skin cover. Several studies have reported poorer results with increasing number of structures released at surgery. A recent report by Ghidella and coworkers [6] indicated the results of surgical intervention were dependent not only on the severity of contracture but also patient age, prior surgery, bony abnormalities, and the total preoperative arc of motion. The outcome of surgical release is discouraging [5, 6, 8]. This was noted by Foucher et al. and Koller et al. who attributed their poorest results (18–41 %) to digital tenolysis and capsulotomy performed around the PIP joint. The main risk to the patient is worsening of the situation if open surgery is unsuccessful [5, 8]. Foucher et al. noted that the fingers got worse in 12 % of cases after tenolysis. Ghidella et al. reported that the average improvement by open surgery was 8° in 68 PIP contractures. By grouping the patients into simple and complex cases, the average improvements were 17° and 0°, respectively, and emphasized that the best results were achieved in younger patients with less severe diagnosis and preoperative maximum flexion contracture of 45°.

In our experience, digital tenolysis and capsulectomy often mean more extensive surgery per se, which in turn increases problems associated with rehabilitation, with disappointing results.

In an effort to avoid the problems inherent in single-stage surgical releases, there have been many reports in the literature of various forms of primary treatment with dynamic tractions for acute fracture dislocation around PIP joint to avoid contracture, with promising results.

Joint distraction histogenesis techniques were first reported by Kolontay and Miloslavskii [9] in 1987 in the former Soviet Union; thereafter, lengthening techniques for soft tissues were sporadically reported in literature. Patel and Joshi described distraction for chronic fracture dislocations of PIP joint [10]; Bain et al. introduced dynamic extension technique using a compass hinge external fixator (Fig. 8.6) for treatment of PIP joint contracture with good results in two cases, and Houshian and Schroeder reported a mean of 38° of improvement of motion with a mean range of motion of 42° by dynamic extension correction technique using compass hinge external fixator in 27 patients with PIP joint contractures [11, 12].

Fig. 8.6

Photograph showing the compass hinge [12]

Houshian and Schroder reported good short-term results using a monolateral frame (mini-Orthofix external fixator) for distraction correction in ten patients with chronic flexion contractures of the PIP joints with a mean range of motion gain of 54° (Fig. 8.7a–c) [13].

Fig. 8.7

Mini-Orthofix external fixator applied to PIP joint before correction (a) and after correction (b). PIP joint showing joint distraction before removal of the device (c) [12]

Over the years, skeletal fixation devices have relied on traction to create an extension moment at the PIP joint, thus applying distraction forces to the contracted tissues. Those devices relied on the principle of applying incremental stress (lengthening) to the contracted tissues, followed by a period of sustained, static force during which biologic creep was to occur. For many devices, that incremental stress was applied once to four times daily while the device was worn by the patient. Many previous devices were bulky and cumbersome and required fixation via transversely oriented hardware, making application to more than one finger difficult or impossible.

In 2005, Natividade da Silva et al. presented a case of a delayed (20 years) work-related traumatic flexion deformity of the PIP joint of the left index and middle fingers (Figs. 8.2 and 8.8) [14]. This was the result of a complete division of both flexor tendons of both fingers. The range of movements, both active and passive, were limited to 90/100° in the index finger and 95/100° in the middle finger.

Fig. 8.8

Preoperative view devices assemble (a) and result 6 months postoperative (b, c)

Following joint distraction using the lengthening device—Antão^TM, Portugal (Fig. 8.8a)—the patient was able to achieve an active and passive range of movements of 10/100° for the PIP joint of the index finger and 40/100° of the middle (Fig. 8.8b, c). The lengthening of the device was adjusted daily, up to maximum tolerated length, determined by appearance of moderate pain rather than skin perfusion. This clinical case shows the simplicity of our technique for the correction of joint contractures. In the presented case, the limitation of motion was attributed to adhesions of the flexor tendons and contracture of the ligaments and capsule of the affected joints. The progressive distraction of the joint allowed the lengthening of the contracted structures, with simultaneous rupture of the flexor tendon adhesions, without causing any damage to neural or vascular structures. Once the desired length is achieved, the fixator should be held in situ for a week and in long-standing contracture for 2 weeks. This allows the stretched tissues to mature in their new position and tissue inflammation to subside.

Temporary DIP joint flexion contracture following distraction correction of PIP joint is indeed a persistent problem that may be treated by hand therapy following deformity correction. We avoided this, by transfixation of DIP joint, using a Kirschner wire during the PIP joint distraction.

Distraction correction differs from extension correction using the compass hinge used by Bain et al. and Houshian et al. in that contractures are automatically corrected when the joint is subjected to gradual distraction. By distracting the offending structures responsible for contractures such as the capsule, the collateral ligaments and the palmar plate with the so-called checkrein ligaments are all lengthened, especially the volar structures, as the distractor is placed volarly. This distraction restores the length of the contracted structures.

More recently, Slater et al. described a new device, the Digit Widget (Fig. 8.9a, b), which is designed to correct PIP flexion contractures by a minimally invasive surgical technique. The device relies on the application of torque (the product of applied force times the lever arm length) to correct the angular deformity of the involved digit. It employs the principle that a gentle extension torque, applied continuously, stimulates the growth and elongation of contracted soft tissues, thus regaining, maintaining, or increasing extension of the joint. The Digit Widget is fixed to the dorsal aspect of the involved finger so it can be applied to more than one digit simultaneously. The application of continuous torque rather than application of intermittent sudden stress promotes subsequent creep—probably a better method for achieving that goal [15].

Fig. 8.9

(a) dorsal view, (b) lateral/radial view. Intraoperative photos show the Digit Widget [14]

However, all these researchers excluded patients with flexion contractures combined with scar tissue around the joints from burn or crushing. To restore function in these patients, surgical release of all contracted tissue seems to be inevitable, and the resultant skin defect should be covered with stable skin to prevent recurrence. In 2009, Hahn et al. evaluate the effect of cross-finger flaps after extensive surgical release of contracted tissue and vigorous postoperative extension exercise for long-standing (10 years or more) severe flexion contractures with palmar scarring of the fingers. In these patients, tethering by the scar tissue and contractures of the palmar plates and collateral ligaments were the main cause of contracture. In all of our patients, surgical release of contracted tissue was inevitable to achieve maximal extension of the joint during the operation. The resultant skin defect was covered by a cross-finger flap, which was slightly larger than the defect from a neighboring finger to prevent contracture with time. By covering with stable and redundant skin, vigorous ROM exercises were possible just after healing of the operative wound. With this technique and postoperative management, a mean of 79.4° of increase of motion was achieved in comparison with preoperative values [16]. The authors believe that early vigorous exercises after covering the defect with stable skin led to excellent clinical results.

Similarly, treatment of athletes’ long finger stiffness may be optimized if minimal difficulties are anticipated. Intermittent regimes of active and passive mobilization together with the properly prescribed corrective splinting programs should be started as soon as problems arise or in postoperative period. Conservative treatment is the gold standard, and it may be all that is necessary for the quickest possible return to sports activities, which is the priority for an athlete.

8.1.1.5 Conclusion

A stiff hand is an unwanted but common consequence of a variety of hand injuries. The biological responses of the injured tissue in severe trauma are difficult to manage. Sometimes, minor trauma to the involved finger can also result in stiff joints if the patients are extremely withdrawn and cannot manage due to some psychological troubles. Therefore, managing the stiff finger joint is not only a matter of competition between the pace of prioritized treatment and the growth of scar tissues but a matter of psychological reassurance to the patients and the close relationship between the surgeon and patient as a whole.

The more the joints become stiff, the longer the tissues should spend at their end ranges in a fixator in order to improve the passive range of joint motion. At the same time, long hand therapy programs with intermittent regimes of active and passive mobilization—regardless of the technique—seem to be the vital measure.

Apart from these, accurate judgment, flexible attitude as well as prompt action are needed to tailor the treatment program for every individual patient. Good communication between surgeon and therapist as well as between surgeon and patients is important to ensure the best efficacy of treatment.

Key Points

Joint stiffness remains an unwanted but common phenomenon complicating severe hand injuries.
The most common posttraumatic joint contractures are the metacarpophalangeal joint extension contracture, proximal interphalangeal joint flexion contracture and extension contracture, and thumb web contracture—the positions that patients find to be more comfortable to rest their hands after injury.
The useful range of mobility in long fingers for ball athletes depends on the sport, position of the athlete, on the affected finger, and is related to the diameter of the ball.
Treatment used to improve the joint stiffness should be individualized, integrative, and problem focused.
Surgical treatment—as in open release or distraction histogenesis—can be considered only after failure of a long period of conservative treatment.

Suggested Readings

Natividade da Silva P, Barbosa R, Ferreira P et al (2005) Correction of long term joint contractures of the hand by distraction. A case report. Br J Plast Surg 58:1148–1151

This is a case report of a delayed (20 years) traumatic flexion deformity of PIP joint of index and middle fingers of left hand after complete division of both flexor tendons of both fingers. This clinical case shows the low cost, low morbidity, and the simplicity of application of joint distraction technique for correction of long fingers joint contractures, using a very simple lengthening device that is easy to assemble and adjust compared to other devices usually employed.

Hahn SB et al (2010) Correction of long standing proximal interphalangeal flexion contractures with cross finger flaps and vigorous postoperative exercises. Yonsei Med J 51(4):574–578

This is one of the only studies evaluating patients with flexion contractures associated with scar tissue around the joints. To restore function in these patients, surgical release of all contracted tissue seems to be inevitable, and the resultant skin defect should be covered with stable skin to prevent recurrence. This study evaluates cross-finger flaps after extensive surgical release of contracted tissue and vigorous postoperative extension exercises for long-standing severe flexion contractures with palmar scarring of the fingers.

Wong JMW (2002) Management of stiff hand: an occupational therapy perspective. Hand Surg 7(2):261–269

Treatment used to improve joint stiffness should be integrative and problem focused. Splintage, pressure therapy, and active mobilization are treatment modalities that occupational therapists use to improve hand function. This article helps surgeons to understand the process of tissue healing and different functions of splints for best results.

8.1.2 Stiffness of the Thumb

Guy-Paul Muller² and Grégoire Chick⁴

Guy-Paul Muller (Corresponding author)

Email: guy-paul.muller@mail.pf

Grégoire Chick

Email: chick@la-main.ch

URL: http://www.la-main.ch

Abstract

Depending on the joint and sector of mobility involved, stiffness can affect ball catching, propulsion, and striking. The metacarpophalangeal joint (MCP) of the thumb requires stability to provide pollicidigital grips. Trapeziometacarpal (TMC) joint mobility is necessary for complex movements of the thumb column. Interphalangeal (IP) joint mobility compensates for overlying joint stiffness and increases ball grip. A wide first web opening is a key factor in ball control. Regardless of the stiffness level, treatment should first address the cause. Surgical treatment should only be considered for athletes if they have failed to respond to a sufficiently long period of conservative treatment. To adapt the treatment, a semiotic analysis must be performed to differentiate joint stiffness from stiffness due to periarticular soft tissues. Physical therapy must be provided after surgery to maintain the range of motion achieved through the intervention. The presence of symptomatic arthritis often suggests that the treatment effects may shorten the athlete’s career. For this reason, the best treatment strategy is prevention, including strict observance of immobilization positions and fixation rules.

8.1.2.1 Introduction

Stiffness of the thumb column or closure of the first web space can be handicapping when grabbing, throwing, or hitting a ball. The athlete’s resulting disability depends on the type of ball sports and the position held. Although finger mobility is essential, the stability of the thumb’s metacarpophalangeal (MCP) joint is critical for pollicidigital gripping. The trapeziometacarpal (TMC) joint must remain mobile and congruent to allow complex thumb movements. Retraction of the first web space should be prevented by observing immobilization principles.

8.1.2.2 Posttraumatic TMC Joint Stiffness

TMC joint stiffness can result in a more or less marked limitation of the abduction, adduction, and/or opposition of the thumb column. Flexion and adduction contractures may develop. The resulting functional deficit depends on the mobility sector involved, the demands, the presence of pain, and/or the decrease in grip strength [17].

Relevant Anatomy

The TMC joint is a double-saddle joint (Fig. 8.10) with two degrees of mobility. Its asymmetric nature contributes to its relative incongruence. It is stabilized by a dorsally fragile joint capsule, which is reinforced by a complex ligament structure (Fig. 8.11) that includes the posterior, anterior, and intermetacarpal ligaments [18].

Fig. 8.10

Anatomical specimen of a trapezium with a saddle-shaped surface for articulation with the base of the first metacarpal bone

Fig. 8.11

Ligaments of the TMC joint (According to Bettinger et al. [18]): (1) SAOL superficial anterior oblique ligament, (2) DRL dorsoradial ligament, (3) POL posterior oblique ligament, (4) DAOL deep anterior oblique ligament or “palmar beak ligament”, (5) IML intermetacarpal ligament, (6) DIML deep intermetacarpal ligament, (7) UCL ulnar collateral ligament, (8) DTT dorsotrapezotrapezoidian ligament, (9) VZZ ventrotrapezotrapezoidian ligament, (10) APL abductor pollicis longus. (G. Chick © 2012, all rights reserved)

Physiology

Mobility

The muscles of the first web space ensure the mobility of the TMC joint. They provide pure flexion/extension and abduction/adduction around two perpendicular axes. The geometric configuration of the joint allows for a third movement: automatic circumduction around the longitudinal axis. Complex movements of the hand, such as finger-thumb opposition, combine pure movements and circumduction of the thumb to varying degrees (Fig. 8.12). These movements are made possible by ligament tensioning caused by contractions of the intrinsic muscles inserted into the joint [19–21].

Fig. 8.12

Effect of TMC Joint Stiffness on Ball Grip

Depending on the sport, the hand can propel (rugby, basketball, volleyball), hit (volleyball), or grip (handball, rugby, football) a ball. Complex technical movements such as spinning are a combination of basic movements. Stiffness in adduction and extension can limit thumb opposition and commissural opening, causing difficulties in catching and throwing balls. However, stiffness has little effect on hitting (Fig. 8.13). Stiffness in abduction and flexion impedes, distancing the thumb from the volar side of the hand and thus handicaps the hand hitting the ball (Fig. 8.14). TMC stiffness can also result in technical limitations, mainly in extreme positions, while a moderate limitation in the neutral position has little effect on hand function in ball sports.

Fig. 8.13

(a) TMC stiffness in adduction/extension altering the ability to catch the ball and limiting the adhesion of the ball in the hand, (b) gripping a ball in absence of TMC stiffness

Fig. 8.14

TMC stiffness in abduction/flexion right hand. (a) The thumb hinders the hand that strikes the ball. (b) The hand cannot be opened flat

Clinical Examination

Clinical examination should assess the pain, mobility, and strength and should measure the functional impact with questionnaires such as the Quick Dash [22].

Mobility

Assessing TMC joint mobility is difficult and poorly reproducible (Table 8.3) [23]. It is more often global than specific and includes the following [24]:

Table 8.3

The mean normal articular amplitudes [23]

	Flexion/extension (°)	Abduction/adduction (°)	Automatic rotation (°)
Normal articular range of motion	41	51	21

The Kapandji test for circumduction [25]
Bourrel’s angle for opposition and rotation of the thumb column (Fig. 8.15)

Fig. 8.15

Bourell’s angle: It corresponds to the angle between the axis of the thumbnail and that of the fourth finger, when pulps of these fingers are in contact (measures the opposition and rotation of the thumb column) (a) normal (b) TMC stiffness: The ability to rotate is slightly reduced (clinical case of Fig. 8.14: TMC stiffness in the right hand)
The M1/M2 opening angle
The adduction of the thumb column in centimeters (Fig. 8.16)

Fig. 8.16

Measurement of the adduction of the thumb column in cm (According to Kapandji et al. [26])

Strength

Strength evaluation should include grip strength (using a Jamar dynamometer), lateral (lateral pinch) and distal key pinch strength measurements of the thumb index. The measurements should always be taken bilaterally.

Complementary Examinations

PA and lateral X-rays of the thumb column are the key examination. Kapandji views allow a TMC joint analysis [26], particularly measuring the height of the trapezial cavity and joint congruency. CT arthrogram may also be useful for accurate measurement of joint spaces.

Causes

TMC stiffness—with or without arthritis—can result from articular or extra-articular causes [27–29].

Articular Causes

These causes include cartilage and/or scarring lesions of the joint, which cause adhesions and destruction of the capsuloligamentous apparatus:

Articular fractures of the trapezium or fractures of the base of the first metacarpal
TMC joint sprains and dislocations
Articular wounds of the TMC joint
Septic arthritis
Intra-articular foreign bodies

Extra-articular Causes

Periarticular soft tissue lesions (tendons, muscles) and/or algodystrophy may cause TMC joint stiffness.

Iatrogenic Causes

TMC joint stiffness may be due to the insufficient or inappropriate treatment, such as transarticular pinning, the persistence of an intra-articular displacement, or the presence of material within the joint. It may also be due to delayed treatment, prolonged or incorrect immobilization, and failed rehabilitation.

Arthritic Origin

Arthritis is the most common cause of long-term TMC joint stiffness. It may be secondary to an articular malunion or chronic instability [30] and may be primary or rheumatic. Posttraumatic decompensation of the underlying arthritis raises responsibility issues.

Treatment

Conservative Treatment

A sufficiently long period of conservative treatment should always be the first-line therapy. Physical therapy and rehabilitation devices usually help recover a normal range of motion. Physical therapy includes gentle passive mobilization followed by active mobilization with isometric contract-relax exercises and electrotherapy. Static splints should be rigid during the night and flexible during the day, when they are worn for a few hours. The web opening should be maintained and the adduction maintained. The splints should be regularly adjusted in all three planes. Dynamic splints are not appropriate for TMC joint stiffness because they only provide correction in one spatial plane. Rehabilitation for several weeks or months is necessary before considering any surgical treatment [31, 32].

Surgical Treatment

Surgical treatment is rarely required for isolated TMC joint stiffness and should only be performed if medical treatment has failed. The type of surgery will depend on the state of the articular cartilage and the cause of the stiffness.

Arthroscopy

The recent contributions of arthroscopy have changed the strategies for joint surgery, although its efficacy and indications for small joints have yet to be determined (please see the corresponding chapter). For isolated TMC joint stiffness, arthroscopy primarily provides an accurate assessment of the progressive arthritic degeneration. Badia [33] proposed an arthroscopic classification of lesions that can be combined with clinical information to suggest surgical treatment that depends on the disease stage. Arthroscopy remains an effective tool for the early degenerative stages when X-ray images are normal despite the pain and functional impairment. Synovectomy combined with joint debridement and ligament tightening by thermal shrinkage seem to yield favorable results. Arthroscopic arthrolysis is a potential future surgical option.

Open Surgery

Indications for open TMC joint arthrolysis are rare, and a Gedda-Moberg volar approach is recommended in such cases. The radial artery is first identified and protected over the first web space. The procedure starts by sectioning the intermetacarpal ligament and assessing the web space opening achieved. The dorsoradial and posterior oblique ligaments are sectioned, and the passive pronation of the first metacarpal is evaluated. To our knowledge, the results obtained have not yet been published. Intra-articular osteotomy may be required to correct a joint malunion in displacement greater than 1 mm with absence of cartilage damage.

In most cases, the presence of arthritis precludes any joint preservation procedure. In these cases, the following options are possible (please see the chapter on thumb arthritis):

TMC arthrodesis is a paradoxical procedure that may be justified for manual laborers and young workers who have painful stiffness in the dominant hand and damaged joint surfaces. The optimal position for the arthrodesis is 40° of forward flexion and 20° of radial abduction. The main risk is nonunion [34].
Arthroplasties, with or without a prosthesis [35, 36].
Trapeziectomy, with or without ligamentoplasty [37–41].
TMC denervation may be indicated for cases involving pain. The procedure does not require postoperative immobilization, should not reduce general strength, and does not impede further surgery. A selective anesthesia test of the nerve branches directed towards the joint should be performed first [42, 43].

Recommended Treatment for Athletes

In cases where well-monitored medical treatment fails or where there is functional impairment, the following options may be considered.

In the absence of arthritis, arthrolysis (preferably arthroscopic) should enable a faster return to practicing sports. Osteotomies may be performed for malunions without arthritis.
If arthritis is present, the corresponding therapeutic strategy should be used (please see the corresponding chapter).

Prophylaxis

TMC joint stiffness treatments are primarily preventive and are based on the following rules:

Restoring an anatomical articular surface in cases of articular fractures (displacement <1 mm).
A volar approach (Gedda-Moberg) is preferred because it results in less stiffness.
No transarticular pinning (with respect to the TMC joint space).
Ligament repair should be protected by immobilization, preferably with pins in case of instability.
For immobilization, M1/M2 angle should be 30º in the three spatial planes.
The duration of immobilization should be less than 4 weeks for articular fractures and less than 3 weeks for dislocations.
Early rehabilitation should be initiated to avoid stiffness.
Posture splints should be used to avoid retraction of the first web space.

Key Points

The causes of TMC joint stiffness are mainly iatrogenic.
TMC joint stiffness treatment is primarily preventive.
If medical treatment fails for a professional athlete, the surgical indications must be cautious and adapted to the cause of the stiffness and its impact on the hand function pertinent to his sport.

8.1.2.3 Posttraumatic MCP Joint Stiffness

When the hand hits, guides, throws, or unexpectedly finds itself in the path of a ball, the MCP joint of the thumb may suffer a sprain, dislocation, or fracture. Approximately 19 % of MCP sprains are due to ball sports, of which a third are due to volleyball [29, 44, 45]. These lesions may be complicated by MCP joint stiffness.

Normal Mobility and Useful Range of Motion

The MCP joint of the thumb is a condylar joint that plays a critical role in thumb stability, while the TMC joint ensures mobility. The anatomical shape of the MCP provides three sectors of mobility.

The mobility in flexion/extension varies significantly from one individual to another. The normal range is between 10° and 90° of flexion. In lax subjects, hyperextension varies from 0° to 60° but can become pathological and disabling when it exceeds 60°. De la Caffinière and Mansat [46] have proposed evaluating stiffness based on residual MCP mobility sectors:

Extension stiffness from 0º to 30º
Extension stiffness in the useful range (from 30° to 70°)
Extension stiffness in flexion range (from 70° to 90°)

Although this useful range concept is valid for the MCP joints of the fingers, it does not take into account the variations observed in the MCP joint of the thumb:

The low lateral mobility in extension disappears in flexion.
The pronosupination is low.

This concept of useful range is critical and varies depending on the joints and fingers considered. Table 8.4 shows the results obtained by Hume et al. [21, 47], who assessed the amplitudes of normal MCP joint mobility:

Table 8.4

The functional/useful ranges of motion of the MCP and IP joints of the thumb

	Range (°)	Average (°)	SD (°)	Median (°)
MCP joint	10–32	21	± 5	22
IP joint	2–43	18	± 5	19
Overall functional arc	21–65	18	± 5	39

According to Hume [21]

0–56° for 85 % of the population
0–27° for 15 % of the population

This variability in the useful flexion range influences the surgical indications. Most useful grips (such as the key pinch, distal pinch, and power grips) involve almost full extension of the MCP joint in a range between 0° and 20° of flexion. For large precision grips, the radial inclination increases the web space opening. The reference position of the MCP joint can be determined at 20° of flexion.

Effect of MCP Joint Stiffness on Ball Grip

We can distinguish between stiffness in extension and in flexion [48]:

Stiffness in extension results in reduced active and passive flexion range of motion (Fig. 8.17).

Fig. 8.17

MCP stiffness in extension of the right thumb: (a) volar view, (b) dorsal view
Stiffness in flexion results in reduced active and passive extension range of motion (Fig. 8.18).

Fig. 8.18

MCP stiffness in flexion: (a) abduction, (b) adduction

The consequences of extension stiffness are negligible if the MCP joint stiffness is isolated and is in the functional position (i.e., in nearly complete extension between 0° and 20°, which is almost the reference position). The web space opening is preserved, and the mobility of the thumb column is preserved by the TMC joint. Grabbing and hitting a ball and technical moves in handball, volleyball, and rugby are not affected. Dribbling in basketball remains possible (Fig. 8.19). Stiffness in flexion is less common and has a major impact because the thumb is in the palm and it impedes lateral pinches (key pinch) and power grips of balls of large and small diameters. It is difficult to grab a ball due to the reduced web opening caused by the extension deficit. The ball cannot fit into the web space, and grip strength is reduced (Fig. 8.18). The “adherence” of the hand to the surface of the ball is impaired. Hitting is hampered on the radial side of the hand by the thumb column because it does not remain on the volar side.

Fig. 8.19

MCP stiffness in extension. The grip of the ball in handball remains possible

Differential Diagnosis Between Joint and Tendon Stiffness

The causes of extension stiffness are diverse and may be isolated or combined [29, 48]:

Dorsal cutaneous scarring lesions
Adherence of the extensor apparatus to the periosteum or the joint capsule
Retraction of the dorsal fibers of the collateral ligaments
Arthritis and articular malunions
Symphysis of the volar plate cul-de-sac

Stiffness in flexion may have the following causes:

Retraction of the skin on the volar side
Retraction and adherence of the flexor tendon system in the finger channel
Retraction of the volar plate and filling of its cul-de-sac
Retraction of accessory collateral ligaments
Articular osteochondral lesions

The following can be used to differentiate between articular and extra-articular stiffness [49]:

A history of extensor or flexor tendon lesions
Poor extension of the interphalangeal (IP) joint due to retraction of the flexor pollicis longus (FPL) and/or deficits in the specific testing of the FPL
A bow-stringing effect on the FPL due to lesions on the pulleys
Lack of IP flexion due to adherence of the extensor tendons
MCP and IP joints X-rays

Overall, stiffness that is secondary to wounds is often mixed and requires tenoarthrolysis. Stiffness that is secondary to sprains and fractures is usually articular.

Conservative Treatment

Not all cases of joint stiffness require surgical treatment. Surgery is only indicated after well-conducted and consistent rehabilitation efforts fail [50, 51]. Stiffness in the functional position should be distinguished from stiffness that affects technical moves. Stiffness in extension responds well to conservative treatment, such as dorsal massages to improve vitality and to restore a gliding motion between the extensor mechanism and the joint capsule, the extensor, and the subcutaneous fat. Passive and active global and specific rehabilitation helps activate the extrinsic flexors and extensors. Dynamic flexion splints of the thumb should be used as soon as MCP flexion is possible. They are worn during the day and replaced by postural splints at night. Establishing the rehabilitation gains is a long-term process that can take several months. Stiffness in flexion is less responsive to conservative treatment, especially if it involves the flexor tendon. A global extension splint, possibly dynamic, should be worn for 5–7 h/day or at night as soon as possible. It is contraindicated in cases of ulnar ligament laxity. Global action braces may be used if the stiffness is painful, while more selective splints can be used for painless stiffness. Conservative treatment should last at least 12 weeks before considering surgery.

Surgical Treatment

This section focuses on arthrolysis and tenoarthrolysis, which are open surgical procedures. Percutaneous arthrolysis, which may be used for other joints of the hand, seems to be of limited use because it does not allow access to intra-articular adhesions and risks damaging noble structures. Distraction methods are of little interest, and procedures under anesthesia are contraindicated [23]. The indications for small joint arthroscopy [52] and arthroplasty [53] of the hand remain poorly established (please see the corresponding chapter), which is partly due to the limited literature available on the subject. Arthroscopy is rarely used on the MCP joint of the thumb, except for Stener lesions resulting from severe sprains. Arthroscopy can be used to treat purely articular joint stiffness, although articular joint stiffness is rare in cases of flexion stiffness of the MCP joint [33, 54, 55].

The indications for surgery and the corresponding prognosis depend on several factors, such as the athlete’s level, the type of ball sports they play, the mobility sector involved, the cause of the trauma, vascularization, sensitivity, skin viability, the state of the tendons and the joint, and the time elapsed since the beginning of the stiffness.

Stiffness in Extension

Due to good functional tolerance, the indications for surgery are rare in ball sports. The surgical approach is either dorsomedial and sinuous or dorsoradial and sinuous. The skin flap is retracted while protecting the dorsal venous network and dorsal sensory collaterals. The extensor pollicis longus (EPL) and brevis (EPB) tendons are tenolysed upstream of the MCP joint. Using a blunt spatula, the lateral band is lifted from the plane of the joint ligaments. The extensor is then lifted with an atraumatic retractor. A dorsal capsulotomy is performed, and the joint is released up to the metacarpal volar cul-de-sac (if possible) using an atraumatic blunt elevator. At this point, passive flexion is attempted. If flexion is impossible, the sagittal bands are partially sectioned along and one millimeter from the extensor mechanism. This procedure exposes the dorsal metacarpal insertion of the collateral ligaments, from which the more dorsal metacarpal fibers may be sectioned if necessary. The surgery should target a useful range rather than a flexion of 90°. Arthrolysis is a progressive procedure that is performed on request, following a specific sequence determined during the preoperative evaluation. Satisfactory joint congruency must be ensured in flexion, and a dorsal gap should be avoided [47].

Stiffness in Flexion

In certain cases, the hand’s reduced capacity in ball sports is significant, and conservative treatment is less effective. The surgical strategy often depends on the type of damaged tissue. Stiffness due to an isolated lesion of the capsular ligaments may respond favorably to ergotherapy. Skin lesions, which are usually of extra-articular origin, may respond favorably to plastic surgery or flaps. When the FPL or several lesions are involved, the strategy should include tactical coverage to protect the tendon. The anterior Bruner’s incision should be large. The collateral neurovascular bundles should be identified and protected, and the oblique pulley should be conserved. The A1 pulley can be excised, however. The flexor tendon is gently freed from its adhesions and from the volar plate with a blunt spatula and a no. 15 blade. The tendon can then be moved laterally. In rare cases, the volar plate may need to be released from the metacarpal neck. The main medial and lateral ligaments should be conserved. A blunt elevator can be used to lift the intra-articular adhesions up to the dorsal part of the joint. The accessory collateral ligaments that are retracted in flexion can be sectioned. The joint should not be destabilized [48]. If the articular cartilage is damaged, arthrolysis and tenoarthrolysis are no longer indicated and arthrodesis in a functional position of approximately 20° of flexion should be considered [56, 57]. Prosthetic MCP arthroplasty for ball sports is questionable [55].

Postoperative Management

The released elements have a natural tendency to retract, setting the joint in the preoperative position. Postoperative treatment should start on the first day after the surgery and should aim at maintaining the range obtained through the surgery [23]. Swelling and pain should be prevented in the early postoperative hours. In some difficult cases and depending on the patient’s pain threshold, continuous analgesia may be administered with a catheter. Rehabilitation is analytic and global and as painless as possible. From day one, a postural brace stabilizing the joint in the final position should be worn at all times, except during rehabilitation sessions. Global or dynamic flexion or extension splints should be worn from postoperative day 8, depending on the area involved. The frequency of use depends on the patient’s tolerance. Assuming that the skin has healed, rehabilitation should be performed daily from the 15th day, and splints should be worn day and night and combined with physical therapy against scarring fibrosis.

Results

One of the prognostic factors is the time elapsed since the beginning of the stiffness, and it is responsible for cortical exclusion, muscle atrophy, and cartilage lesions. The goal is pain relief and stability with a useful range around the reference position of 20°. The adhesion of the hand to the ball depends on the pressure exerted by the opposition of the thumb and fingers, and the web opening (TMC) has a major effect on MCP mobility. To date, no series have been published on the results of treating MCP stiffness in ball sports.

Return to Sports Practice

The postoperative rehabilitation program is long, and the patient should be informed that the benefits from the intervention stabilize around the fourth postoperative week and are established after 3 months.

Key Points

MCP joint mobility is highly variable, and the useful sector is around 20°.
Stiffness in extension is well tolerated and responds more favorably to conservative treatment.
Stiffness in flexion penalizes technical movements in ball sports and is often treated surgically.

8.1.2.4 Stiffness of the Interphalangeal (IP) Joint of the Thumb

The IP joint is a trochlear joint with one axis of movement allowing flexion/extension. The two phalanges are joined by the volar plate, which is covered by the FPL, and the main and accessory collateral ligaments [46, 58].

IP joint stiffness may be articular or extra-articular [23].

The articular causes include traumatic, degenerative, or inflammatory disorders that alter the articular surfaces.
The extra-articular causes include fibrous retraction of the capsuloligamentous structures, skin lesions, and FPL or EPL lesion sequelae [59].

Normal Mobility, Useful Range

The normal articular ranges of motion are 30–40° in extension and 70–90° in flexion. Hyperextension has no specific function, while flexion adjusts the precision of the grip depending on the gesture being performed. The FPL stabilizes the IP joint in the 0° position during the key pinch. Fine grips are terminal pinch in IP extension or distal nail pinch when the IP joint is stabilized at approximately 45° of flexion.

Hume et al. [21] showed that the normal range of motion of the IP joint varies from 5° to 73° (the functional amplitudes are shown in Table 8.4). During gripping, the average degree of flexion of the IP joint is from 28° to 36°. Due to the shape and size of the ball, such a degree of flexion is not required for seizing a ball.

Hand movements in ball sports do not require an IP joint flexion beyond 20°. The IP joint should be at 0° extension to absorb energy when catching a ball (e.g., during volleyball, basketball, and handball). The IP joint should be stabilized in slight flexion (from 10° to 20°) when holding a ball. This angle supports the P2 pulp and opposes the other fingers, which in turn provides adhesion to hold the ball.

Impact of IP Joint Stiffness on Seizing a Ball

Stiffness in the useful range of motion 10°/0°/20° has little effect on technical movements. Beyond this range, stiffness in flexion may impair receiving and holding a ball and disrupt the technical level of performance. The hand must be able to conform to the shape of the ball. In stiffness in flexion, only the distal portion of the pulp will be used for seizing a ball, which reduces the possibilities for adhesions. The IP joint contracture also reduces the first web space opening and limits the fitting of the ball into the hand. In this position, the FPL loses some of its stabilizing properties (Fig. 8.20).

Fig. 8.20

IP joint stiffness in flexion, left thumb: (a) side view, (b) web view

Conservative Treatment

In principle, conservative treatment is indicated before surgery and when the articular cartilage is healthy, that is, in cases of extra-articular IP joint stiffness. The prognosis depends on the type of IP joint stiffness, the condition of the skin, and the possible involvement of the FPL. The treatment may last for 3 months.

Stiffness in Extension

Specific and global techniques should be used: place-hold exercises, postural, and any other means needed to prevent fibrosis. A dynamic short flexion splint of the thumb may be more specific for the IP joint because it stabilizes the MCP and P1. The flexion bandage is attached radially and should be used for 6 h a day. Postural splints are of little use here [50].

Stiffness in Flexion

Conservative treatment is more difficult because the FPL is usually involved. The treatment employs splints and the standard rehabilitation described above. The extension splint, which is attached in the direction of the opening of the hand, is adapted for the IP joint. The thermoformed short thumb splint stabilizes the MCP and includes P1. The extension band pulls on P2. The duration of use is approximately 8 h daily, and this better-tolerated splint should be worn at night as soon as possible [51].

Surgical Treatment

Surgery may be proposed after conservative treatment fails. The indication is based on the hand gestures in sports, associated pain, and the cause of the stiffness.

Stiffness in Extension

If the cartilage is healthy or slightly damaged, a dorsal tenoarthrolysis should be performed, together with skin cover if the lesions are complex. Homodigital flaps (Hueston type) are usually sufficient. Beasley’s approach in H can expose the EPL tendon. Any skin lesions are excised with the incision while incorporating the reconstruction flap. The recovery of skin flexibility is crucial. The tendon is released at its medial and lateral edges with a no. 15 blade. The tendon hook is used to lift the EPL tendon and expose the joint. The cartilage is then evaluated. A blunt spatula can be used to release any articular adhesions. If a P2 dorsal osteophyte is present, it should be excised with a 3-mm osteotome without weakening the EPL insertion. The nail matrix should be preserved to avoid iatrogenic onychodystrophy. In rare cases, the dorsal proximal insertion of the main ligaments on P1 should be sectioned [47].
If the articular cartilage is damaged and the joint is painful, it is preferable to perform an arthrodesis. Positioning the arthrodesis close to the extension (between 0° and 10°) seems to be the most appropriate in the context of ball sports. It should not exceed 20° of flexion.

Stiffness in Flexion

This condition is less well tolerated, is resistant to conservative treatment, and usually requires surgical intervention. Lesions of the FPL are often involved, and the indications for surgery depend on the state of the cartilage.

In case of arthritis, arthrodesis [60] is the treatment of choice (please see the corresponding chapter).
When the joint is healthy, the stiffness is secondary to lesions of the FPL and/or a volar skin retraction (following a traumatic wound). The anterior Bruner incision should be designed to incorporate the skin reconstruction procedure chosen. Different homo- and hetero-digital fasciocutaneous flaps can be used, and collateral bundles are controlled and protected. The FPL procedure depends on the lesions. A tenolysis should be nontraumatic and should respect the oblique pulley. Lengthening the FPL may be necessary and should be performed at the musculotendinous junction (of Le Viet or Rouhier), which allows an advancement of 15 mm [61, 62]. In rare cases, the volar plate can be released at the P1 neck without destabilizing the joint. Severe lesions of the flexor system may be an indication for an arthrodesis rather than a tendon graft, which is more complex and gives random results. Correcting the IP contracture is crucial for technical movements in ball sports.

Postoperative Management

The postoperative management is variable depending on the type of stiffness and the size of the lesions. It may include dynamic flexion splints worn several hours a day combined with rehabilitation therapy (please see the corresponding chapter). The postoperative treatment should be maintained for 3–6 months.

Results and Return to Sports

There are no published series on treating IP joint stiffness in ball sports. In extension stiffness, the return to sports should be possible within 10–12 weeks of arthrodesis surgery. In case of arthrolysis or tenoarthrolysis, the delay will be longer and will depend on the associated movements conditioned by the initial lesions (flap) and the pain resolution. In flexion stiffness, a return to sports is possible within 3–6 months, depending on whether the treated lesions were simple or complex (involving the joint, FPL tendon, and skin). The FPL action is important for ball sports, and arthrodesis is preferable in cases with a weak or even inactive FPL.

Key Points

Flexion stiffness in the IP joint of the thumb impairs athletic performance in ball sports, while an extension position between 0° and 20° will be of little consequence.
The prognosis depends on the type of lesion and on the state of the flexor tendon.
Arthrodesis is the procedure of choice if the joint is altered.

8.1.2.5 Contracture of the First Web Space

The Anatomy of the First Web Space

The Skin Envelope

The envelope is a plastic functional unit. The integumentary coating is formed by two isosceles triangles, the base of which defines the free edge of the web space. The dorsal skin on the social side is thin, flexible, and mobile. The volar skin is thicker and docked to the volar fascia by vertical septa [63].

Content

The Skeleton

The bony skeleton of the first web space is composed of a mobile segment (the TMC joint and first metacarpal) and a fixed segment (the second metacarpal).

The Muscles

The muscles that form the first web space are spread in a fan-like pattern between the first and second metacarpals [23], with one or several heads of insertion:

The first dorsal interosseous muscle
The first volar interosseous muscle (variable)
The adductor muscle of the thumb
The short flexor (deep beam)

The Aponeuroses

The aponeuroses of the first web space define three muscular compartments for the following muscles:

The dorsal interosseous muscle
The volar interosseous muscle (variable)
The adductor and short flexor muscles of the thumb

Neurovascular Structures

The neurovascular structures are divided into two networks (volar and dorsal) that provide vascularization (anastomoses) and innervation to the first web space.