28 Finger Contractures
28.1 Patient History Leading to the Specific Problem
The patient is a 23-year-old man who was involved in a motorcycle accident sustaining a left femur fracture, left bone forearm fracture, and left brachial plexus palsy. Physical examination as well as neurophysiologic studies and CT/myelogram indicated avulsion injury of nerve roots C5, C6, and C7. After a period of observation, the patient recovered 4/5 function of the C8 and T1 nerve root (lower trunk) innervated muscles. At 6 months post-injury, the patient underwent a left brachial plexus exploration and spinal accessory to suprascapular nerve transfer as well as a partial ulnar nerve to biceps branch of the musculocutaneous nerve (Oberlin’s transfer).
At 18 months postsurgery, the patient has regained only limited elbow and shoulder animation (▶Video 28.1) while developing a claw deformity of index, long, ring, and small fingers. The patient is limited functionally by the claw deformity in that he has little functional use of the hand and is unable to grasp objects, despite his ability to flex the digits.
28.2 Anatomic Description of the Patient’s Current Status
On physical examination, the patient demonstrates prominent claw deformities of the index, long, ring, and small fingers. He has flexor digitorum profundus function but no interosseous muscle function, owing to the incomplete nature of his lower trunk injury (▶Video 28.1).
The metacarpophalangeal (MCP) joints of index, long, ring, and small fingers are fixed in 40 degrees of hyperextension, while the proximal interphalangeal (PIP) joints have range of motion as follows:
• Index finger: −60/100 degrees.
• Long finger: −45/100 degrees.
• Ring finger: −45/100 degrees.
• Small finger: −45/105 degrees.
28.3 Recommended Solution to the Problem
• Full passive motion of the PIP joints should be restored preoperatively through a structured hand therapy program.
• Due to the relative weakness of the flexor digitorum sublimis (FDS) muscles, transfer of the FDS to the lateral bands of the individual digits will not achieve the desired result of PIP extension with MCP flexion.
• Volar MCP joint capsulodesis is performed to prevent MCP joint hyperextension and improve grip.
28.4 Technique
Through a volar transverse incision in the palm at the level of the distal palmar crease, the flexor tendon sheath is isolated. The A1 pulley is released, the flexor digitorum profundus and FDS tendons are retracted, and the volar capsule of the MCP joint is identified. A distally based flap of the volar capsule of the MCP joint is created. A single suture anchor is placed in the metacarpal neck with attached a 2–0 braided suture. The distally based flap is advanced to the extent that the MCP joint is placed in the resting position of 0-degree extension. The distally based flap is then secured to the neck of the metacarpal using the 2–0 braided suture attached to the previously placed suture anchors (▶Fig. 28.1). The procedure is repeated for each of the MCP joint indicated for claw deformity correction. In this case, the index, long, ring, and small finger MCPs were corrected.
28.5 Postoperative Photographs and Critical Evaluation of Results
At 3 months postoperative, the distal palmar incision was well healed. The MCP joints of the index, long, ring, and small fingers had been maintained to 0-degree extension (▶Fig. 28.2). The patient had the ability to flex the digits at PIP in order to grasp as an assisting hand, which was the goal of surgery. The patient’s grasp has been made more functional with the correction of the MCP hyperextension
28.6 Teaching Points
• Ulnar nerve palsy or lower trunk palsy is a severe injury.
• Clawing of the digits resulting from ulnar nerve palsy or lower trunk palsy creates a functionally compromising hand deformity.
• Correction of the MCP joint hyperextension can be accomplished by advancement of the volar MCP joint capsule.
• The goal of claw deformity correction is to restore func-tional use of the hand for assistance in activities of daily living.
