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The Stiff Finger

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abdullah kattan

on 10 December 2015

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Transcript of The Stiff Finger

" An ever-present menace in hand surgery is the decided tendency for the hand to stiffen and to stiffen in the position of non function ''
- STERLING BUNNELL, 1956 The hand is an organ whose parts affect its entire function

One stiff finger can impair the function of the entire hand EDEMA injured and uninjured structures Acute impairment of movement
fluid in tendon, sheath, capsule Chronic
synovial spaces distend
capsules and collateral lig shorten The Stiff Finger PIP Anatomy Flex/Ext VP Capsule
Collateral lig (CL)
Accessory CL (ACL)
Volar plate (VP)
Checkrein (swollowtail) lig - Prevents hyperextension

- MCP VP →
Crisscross fibers that allow contraction of VP
with flex/ext


- PIP VP →
No contraction, but slides prox/dis with flex/ext Interossei - 4 dorsal abductors
- 3 volar adductors - DI have sup/deep heads (except 3rd)
Sup head (abd + week PP flex)
Deep head (flex PP + week abd + ext
MP/DP) DIP Flex/Ext No checkrein lig
VP is part of FDP instertion
Terminal tendon forms the dorsal capsule Lumbricals - Arise from FDP tendons
- Join the radial lateral bands at mid PP
- Extend IPs and assist in MP flex
- Lumbrical contaction pulls FDP distally and
lateral band proximally - Only extensors of PP (through saggital
bands)
- Central slip extend MP
- Terminal tendon (2 conjoint lateral bands)
extend the DP Extrinsic Extensors Exam Does the stiffness change with
the movement of other joints? - Seesaw effect:
With a non-articular contracting structure spannig two joints, when one joint is flexed, then oher can be extended and vise versa.

- Bunnell's Intrinsic tightness test:
Effect of MP position on PIP flexion
Positive if PIP flex with MP ext < PIP flex with MP flex
Indicates intrinsic tightness as a factor Is there extrinsic tightness?? - Extensor tightness:
Tight IP flexion with wrist / MCP flexed

- Flexor tightness:
Tight IP extension with wrist / MCP extended Treatment Nonoperative Operative Reduce edema
Rest the digit to reduce inflammation
Stretch soft tissue (low load stress)

Passive/active exercises
Heat/cold
Splinting Types of splinting:
Static
Serial static Alter cell proliferation
Dynamic and elasticity Should be continued as long as there is improvement MCP
Usually extension contracture
Dynamic daytime splinting
Static progressive night splinting
Diligent patient & knowledgable therapist PIP
Final common pathway of flex cont. is the VP
Edema → thickening of VP and checkrein lig → adhesion and loss of gliding
Dynamic splinting or serial casting

Extensor tendon adhesion → ext cont. Extension Contracture PIP Beside extensor tendon by dividing the transverse retinacular lig
Extensor tenolysys
Protect central slip insertion
Release capsule → CL →ACL
Assess flexion !!
Test for intrinsic tightness
Splint and start therapy MCP Capsulotomy and CL release
Dorsal extensor tendon splitting approach
T-shaped incision through dorsal capsule
Release CL Technique +/- ACL
Free VP
Splint in flexion +/- K-wire and start therapy PIP VP and Checkrein ligaments Flexion Contracture Volar approash:
Bruner incision
Flexor sheath opened between A2-A4
Release checkrein → VP → ACL →CL
Check extension !!
Check vascularity !!
Splint in extension & start therapy

Midlateral approach:
Divide transverse retinacular ligament
Reported to have better outcomes Intrinsic Contracture Edema around the interosseous muscles
Limit PIP flexion then MP extension
May need distal or proximal intrinsic release Final Thoughts!! Very challenging condition
Prevention is better than cure
> one structure involved
More structures = worse results = more recurrence
Splint/therapy > surgery
Dedicated patient
Aim to improve ROM not restore it MCP Volar flare of MP head affects capsule and CL
Extension:
Lax and jt is unstable
Flexion:
Taut and jt is stable Capsule
Collateral lig (CL)
Accessory CL (ACL)
Volar plate (VP) Flex/Ext/Abd/Add/Circumduction - Usually more than one structure is involved
- Different elements of contracture are revealed as others are released non functional ROM
normal articular surface
no progress with non-operative measures
dedicated, committed and compliant patient contracture will recur Factors limiting extension
Volar skin contracture
Adherent flex tend
Contracted superficial fascia
Cdheren CL
Subluxed/adherent lat bands
Bony blocks Factors limiting flexion
Dorsal skin contracture
Adherent ext tend
Contracted IO
Contracted CL
Bony block What is/are the limiting factor/s?? Is the stiffness fixed ?? - Fixed → difficult to determin etiology by exam

- Limited movemement present → may be able to speculate a cause but still difficult

- AROM vs PROM
PROM > AROM → musculotendinous (incomplete unit or adherence or both)
PROM = ARM → capsular or bony block Quadrigia Lumbrical plus Decreased flexion of an uninjured finger due to limited excursion of an adjacent FDP
Common musculotendinous origin Pull of FDP is through lumbricals rather than insertion
Paradoxical IP extension (at least partially) Abdullah Kattan
Feb 10 2011 To cut or not to cut ????
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