41 Contractures in Articular Phalanx Fractures
41.1 Patient History Leading to the Specific Problem
An 81-year-old man presents with stiffness of the proximal interphalangeal (PIP) joint of the left small finger after open reduction and internal fixation of a transcondylar intra-articular fracture of the head of the proximal phalanx using K-wires and a dorsal locking plate. The patient had injured his small finger as he tried to avoid a fall 12 weeks ago. The finger was immobilized for 2 weeks after surgery. Then active mobilization was encouraged while buddy-tape bandage with the neighboring finger was applied. At the time of referral, the PIP joint was completely stiff and the patient complained of irritation caused by the osteosynthesis. Plain radiographs verified osseous consolidation 11 weeks after reduction (▶Fig. 41.1).
41.2 Anatomic Description of the Patient’s Current Status
The small finger was slightly swollen (▶Fig. 41.2). Scar tissue at the dorsal aspect of the proximal phalanx and PIP joint was consolidated but firmly adhered to the underlying tissue. The K-wires were palpable percutaneously at the ulnar aspect of the PIP joint. The PIP joint was completely stiff (▶Video 41.1). The distal interphalangeal (DIP) and metacarpophalangeal (MCP) joints were not restricted passively. Active flexion and extension of the MCP joint was possible, whereas active mobilization of the DIP joint was not. The extensor plus test for zone 6 tendon adhesion did not reveal pathological findings. This examination evaluates zones 5 and 6, while unrestricted flexion of the MCP joint is feasible with PIP joint flexion regardless of wrist position physiologically. Pathologically, the MCP joint flexion entails extension of the PIP joint or vice versa. Whereas pulp-to-pillar and tiger claw tests were positive for tendon adhesions at the proximal phalanx, the former test examines zones 4 to 6 and is physiological whenever the proximal palm can be reached by the fingers flexed in the MCP and PIP joints while the DIP joints are extended. The latter examination evaluates zones 1 to 3 and is physiological whenever flexion in the PIP and DIP joints of the same finger are possible.
Fig. 41.1 (a, b) This patient presented with stiffness of the proximal interphalangeal joint of the left small finger after fracture repair with K-wires and dorsal locking plate.
Fig. 41.2 Stiff proximal interphalangeal (PIP) joint of the small finger.
41.3 Recommended Solution to the Problem
After a thorough clinical examination, we concluded that the PIP joint contracture is caused by extensor tendon adhesions at zones 3 to 5. It ought to be pointed out that “invasive” osteosynthesis is to be prevented in the first place whenever possible. Based on the anatomic region, dorsal placement of plates will eventually promote tendon adhesion and consecutively joint stiffness. Surgical treatment of contractures demands a stepwise approach with evaluation of joint motion after each operative maneuver in order to prevent destabilization.
As a prerequisite, tissue should be consolidated and conservative therapy should have reached a plateau.
41.3.1 Recommended Solution to the Problem
• Removal of the osteosynthesis.
• Tenolysis of the extensor tendon.
• Arthrolysis of the PIP joint.
41.4 Technique
Facilitating the former incision, sharp dissection and identification of the extensor tendon was performed (▶Fig. 41.3a, b). Longitudinal incision of the central slip revealed the underlying plate (▶Fig. 41.3c). The extensor tendon was released from the underlying hardware using a scalpel. After screw loosening, the plate was removed and debridement of the phalanx was performed (▶Fig. 41.3d–f). Adhesions of the extensor tendon were identified in zones 3 to 5. Before tenolysis was done using an elevator, the remaining K-wires were removed through a separate skin incision. After extensor tenolysis, the PIP joint motion was assessed. Gained range of motion was 20 degrees. The transverse retinacular ligaments were dissected in order to mobilize the extensor apparatus (▶Fig. 41.3g). Then a dorsal capsulotomy allowed arthrolysis of the PIP joint. The dorsal capsule was incised transversely and the elevator was introduced into the joint (▶Fig. 41.3h). It was crucial to release the palmar plate and palmar pouch since adhesions limited joint motion significantly (▶Fig. 41.3i). After closure of the central slip, the PIP joint was released successfully with joint motion from 10 to 100 degrees (▶Fig. 41.3j, ▶Video 41.2).
41.5 Postoperative Photographs and Critical Evaluation of Results
The gained intraoperative motion from 10 to 100 degrees was excellent. It is imperative to instruct the patient to start physical therapy immediately. Patient education is crucial. We recommend intensive physical therapy immediately after surgery while sufficient analgesia is guaranteed (▶Fig. 41.4).
41.6 Teaching Points
• Precise clinical examination in order to identify the pathology.
• Stepwise surgical approach using loupe magnification.
• Sufficient identification of all anatomic structures beginning at the site of normal tissue planes.
• Sharp dissection and preparation of the extensor apparatus using scalpel and elevator.
• After each surgical step, examination of tendon gliding and joint motion is imperative.
• Immediate postoperative physical therapy is recommended, and sufficient analgesia ought to be provided.
• Edema containment is of utmost importance.
• Strict exercises may last for 6 months in order to maintain joint motion.
