36 Stiffness and Hardware Problems in Nonarticular Phalanx Fractures
36.1 Patient History Leading to the Specific Problem
A 34-year-old right-hand-dominant woman presented to our department complaining of pain and persistent stiffness of her right small finger after open reduction and plate fixation of a proximal phalanx fracture 3 months prior elsewhere (▶Fig. 36.1). After surgery, the patient was immobilized over 2 weeks in an intrinsic plus splint. Then, after radiological follow-up control (▶Fig. 36.2), the patient was advised to look after physical therapy.
36.2 Anatomic Description of the Patient’s Current Status
A hypertrophic scar was found on the dorsal aspect of the proximal phalanx of the small finger. Range of motion (ROM) of the small finger was severely decreased with painful stiffness and fixed flexion of 20 degrees in metacarpophalangeal (MCP) joint and almost 50 degrees in proximal interphalangeal (PIP) joint, while good ROM was preserved in all other small joints.
36.3 Recommended Solution to the Problem
In many patients, the trauma, the operation, and the postoperative immobilization are by themselves apt to create tendon adherences and joint stiffness. Measures of prevention are several and they aim to keep tendon irritation as low as possible to prevent tendinous adhesions through early postoperative mobilization.
Once the stiffness occurred, the condition should be treated early and aggressively, if allowed by the situation. In such situations, our first approach consists of a multimodal conservative treatment model, including physical and occupational therapy several times a day, special pain management, and, if indicated, psychological support. Goal of treatment is both the—at least partial—restoration of ROM and a sufficient pain management.
Then, once ROM is consistently improved and maintained over few weeks and indication for surgery persists (e.g., irritating plate, fixed contraction), decision-making in between different surgical strategies is mainly influenced by following two factors: the underlying cause of stiffness/joint contracture (scarred contraction, adhesions of the tendon, ligamentous/capsular shrinking) and the affected bone/joint itself (e.g., MCP vs. PIP, malrotation).
Contracted scars are treated by excision and corrected through Z-plasty or local flap plasty. Tendinous adhesions are treated by extensive adhesiolysis, while treatment of ligamentous/capsular shrinking is based on release techniques, which differ in between MCP and PIP joints because of their different anatomical structures.
ROM in the PIP joint is limited through the collateral ligaments, the palmar plate (which as a quite inelastic complex reinforces—stabilized through checkrein ligaments—the palmar joint capsule) and the accessory collateral ligaments, which insert on the palmar plate (▶Fig. 36.3). Consequently, the most common cause of PIP joint contraction is caused by a shrunken palmar plate and subsequently shortened accessory collateral ligaments. Typically, an identical extension deficit is found in active and passive ROM examination.
In contrast, the MCP joint contraction is characterized by shrinkage of the posterior collateral ligaments and, because of different anatomical course of these ligaments, contraction is often in hyperextension of the joint.
If a motion-related, intra-articular pain condition persists, an additional joint denervation should be taken into consideration.
Surgery is performed in regional anesthesia and upper arm tourniquet. A dorsal S-shaped incision under excision of hypertrophic tissue is made over the proximal phalanx from the MCP to the PIP joint (▶Fig. 36.4a). The subcutaneous tissue is gently prepared, exposing extensor tendon system, detaching subcutaneous adhesions, while dorsal veins and sensory nerves are preserved (▶Fig. 36.4b). The lateral extensor band is then identified at the PIP joint level and the extensor hood is gently lifted with a blunt dissector (▶Fig. 36.4c). The underneath lying plate is exposed dissecting gently adhesive tissue between the plate and the tendon. Subsequently, the screws and the plate are removed.