Dorsal Approach for Management of Proximal Interphalangeal Joint Flexion Contracture

Proximal interphalangeal (PIP) joint contracture is a common, difficult clinical problem that can arise from minor trauma. Management is difficult because outcomes are unpredictable and often poor, due to residual flexion deformities postoperatively. The dorsal approach for flexion contracture of the PIP joint is not discussed in present literature. In this technique guide, we wish to describe and explain the rationale for a dorsal approach. In our experience, a dorsal approach allows for ease of access to all pathologic structures, with simple positioning of the digit to allow access to volar structures, as well as when addressing more than one digits with a PIP contracture. Finally, similar to the midaxial approach, the dorsal approach also eliminates any volar soft tissue concerns and need for supplemental coverage. Proximal interphalangeal (PIP) joint contracture is a common, difficult clinical problem that can arise from minor trauma. Management is difficult because outcomes are unpredictable and often poor, due to residual flexion deformities postoperatively. The dorsal approach for flexion contracture of the PIP joint is not discussed in present literature. In this technique guide, we wish to describe and explain the rationale for a dorsal approach. In our experience, a dorsal approach allows for ease of access to all pathologic structures, with simple positioning of the digit to allow access to volar structures, as well as when addressing more than one digits with a PIP contracture. Finally, similar to the midaxial approach, the dorsal approach also eliminates any volar soft tissue concerns and need for supplemental coverage. Flexion contracture of the proximal interphalangeal (PIP) joint is a common, difficult clinical problem that can arise from minor trauma. Movement at this joint is responsible for 85% of the total composite motion of the digit; therefore, a contracture can significantly impair global hand function, in particular when more than one digit is involved.1Leibovic S.J. Bowers W.H. Anatomy of the proximal interphalangeal joint.Hand Clin. 1994; 10: 169-178Google Scholar Management is difficult because outcomes are unpredictable and often poor due to residual flexion deformities postoperatively. Previous literature reports gains in flexion from 7.5° to 50°, with these studies being composed of small patient numbers and varying pathologies.2Ghidella S.D. Segalman K.A. Murphey M.S. Long-term results of surgical management of proximal interphalangeal joint contracture.J Hand Surg Am. 2002; 27: 799-805Google Scholar, 3Mansat M. Delprat J. Contractures of the proximal interphalangeal joint.Hand Clin. 1992; 8: 777-786Google Scholar, 4Brüser P. Poss T. Larkin G. Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision.J Hand Surg Am. 1999; 24: 288-294Google Scholar, 5Curtis R.M. Capsulectomy of the interphalangeal joints of the fingers.J Bone Joint Surg Am. 1954; 36A: 1219-1232Google Scholar To date, there is no consensus on the best treatment. Management is further complicated by the complex anatomy of the PIP joint, and the causative structure is difficult to identify. The anatomical structures of the PIP joint to be evaluated and addressed if pathologic include the articular surface, capsule, collateral ligaments, volar plate, extrinsic tendons and sheaths and the skin. Contracture release is typically described approaching the joint from either volar or midaxial with comparable results (50° vs 80°).4Brüser P. Poss T. Larkin G. Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision.J Hand Surg Am. 1999; 24: 288-294Google Scholar, 5Curtis R.M. Capsulectomy of the interphalangeal joints of the fingers.J Bone Joint Surg Am. 1954; 36A: 1219-1232Google Scholar, 6Watson H.K. Light T.R. Johnson T.R. Checkrein resection for flexion contracture of the middle joint.J Hand Surg Am. 1979; 4: 67-71Google Scholar, 7Harrison D.H. The stiff proximal interphalangeal joint.Hand. 1977; 9: 102-108Google Scholar, 8Diao E. Eaton R.G. Total collateral ligament excision for contractures of the proximal interphalangeal joint.J Hand Surg Am. 1993; 18: 395-402Google Scholar, 9Curtis R.M. Management of the stiff proximal interphalangeal joint.Hand. 1969; 1: 32-37Google Scholar, 10Gould J.S. Nicholson B.G. Capsulectomy of the metacarpophalangeal and proximal interphalangeal joints.J Hand Surg Am. 1979; 4: 482-486Google Scholar, 11Sprague B.L. Proximal interphalangeal joint contractures and their treatment.J Trauma. 1976; 16: 259-265Google Scholar A volar approach allows for the most direct approach to the pathologic structures but can result in the need for soft tissue coverage once the digit is extended. A midaxial approach obviates the volar soft tissue insult but often requires dual incisions to approach each side of the joint for a complete release. In this technique guide, we describe and explain the rationale for a dorsal approach. To our knowledge in the existing literature, it has only been described once by Buck-Gramco in a personal commentary in 1995. In our experience, a dorsal approach allows for ease of access to all pathologic structures with simple positioning of the digit to allow access to volar structures. The dorsal approach also allows for ease of access when addressing more than 1 digit with a PIP contracture. Finally, similar to the midaxial approach, the dorsal approach also eliminates any volar soft tissue concerns and need for supplemental coverage. Indications for this approach include PIP flexion contractures with soft tissue amenable to a dorsal approach, digits with volar scarring, and multiple affected digits. Contraindications include a soft tissue envelope that cannot tolerate surgical incision and joint deformity. A 49-year-old left hand–dominant man presented to the clinic for evaluation of a right small finger flexion deformity present for over a year. He could not recall the inciting trauma. On exam, the right small finger had a fixed flexion deformity of the PIP joint. He was able to achieve flexion to 120° but was not able to extend the joint further than 80°. The distal interphalangeal joint was supple, and there was no intrinsic tightness. The presumed cause was a central slip injury resulting in a fixed boutonniere deformity. Clinical photos of the patient’s deformity are presented in Figure1, Figure 2, Figure 3. Written informed consent was obtained from the patient for publication of this case report and accompanying images.Figure 2Attempted extension of the patient’s deformity demonstrating a supple distal interphalangeal joint.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Dorsal appearance of the patient’s deformity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The incision is placed dorsally, either directly central if soft tissue is not a concern or sweeping gently radial or ulnar at the level of the PIP joint itself if concerns for soft tissue tension at the termination of the procedure are expected. Figure 4 demonstrates the straight central incision that was used for the case example. The incision is carried through the skin and subcutaneous tissue to the level of the extensor mechanism. Soft tissue flaps are raised radially and ulnarly. Care is taken to protect any neurovascular structures encountered. The extensor mechanism from the central slip proximally to the beginning of the confluence of the lateral bands is exposed. Regardless of the etiology of the flexion contracture, the lateral bands will have migrated volarly due to the flexion contracture. These are the first structures released from their connection to the transverse retinacular ligaments to allow dorsal migration as demonstrated in Figure 5. Next, the volar plate and checkrein ligaments are released proximally. The ladder branch of the digital arteries is a landmark that can be used for the proximal extent of the volar plate (Fig. 6). The release off of the proximal phalanx should be started at this level and continued distally. A freer elevator across the bone dorsal to the volar plate allows for easy removal. The accessory collateral ligament insertion onto the volar plate is then released. Care is taken to preserve the proper collateral ligament attachment to the middle phalanx to maintain stability. The volar portion of the proper collateral ligament can be partially released to allow for more extension but should be maintained (Fig. 7).Figure 7For release of the volar plate both radially and ulnarly, our preferred technique is using a freer elevator to sweep across, detaching the volar plate.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The next structures evaluated are the flexor tendons and their sheath (Figure 8, Figure 9). Care is taken to identify and protect the digital neurovascular bundles while exposing the sheath. The sheath is excised using tenotomy scissors. Hemi-slips of the flexor digitorum superficialis can be incised without significant clinical impact if found to be tight.Figure 9The flexor sheath was the final remaining taut structure in this patient preventing extension.View Large Image Figure ViewerDownload Hi-res image Download (PPT) At this time, we were able to achieve full extension of the PIP joint (Fig. 10). The dorsal structures (Figure 11, Figure 12) became redundant in full extension. The central slip was dissected longitudinally and imbricated using 4-0 nonabsorbable sutures (Fig. 13). The lateral bands were sutured to the reconstructed central slip to prevent recurrence of volar migration. A singular cross-pin was placed across the joint to be maintained for 3 weeks to prevent recurrence of flexion. The wound was closed with 4-0 nylon horizontal mattress sutures.Figure 11Attention is returned dorsally.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 12The redundant extensor mechanism is addressed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 13The extensor mechanism is imbricated and repaired, and a PIP joint cross-pin is placed to hold the extension achieved.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient was placed into an ulnar gutter postoperative splint with the metacarpophalangeal joints held at 90° and interphalangeal joints fully extended. This was transitioned to a custom molded orthoplast splint at the first postoperative visit. The pin was pulled at 3 weeks with initiation of active range of motion home exercise program directed by the surgeon. Passive motion is allowed at 8 weeks. Early motion is critical to success of the contracture release and prevention of recurrent contracture. Formal therapy is typically recommended if the patient is unable to perform exercises on their own or plateaus at any point in their progress. The dorsal approach to the PIP joint allows for ease of access to all critical structures requiring release with the significant added benefit of minimal soft tissue closure concerns. It is the senior author’s (R.J.G.) preferred way of addressing PIP flexion contractures, allowing for ease of exposure to a challenging clinical problem. Outcomes remain variable, likely dependent on initial pathology as well as number of structures requiring release as detailed in previous literature. However, with ease of exposure and minimization of postoperative soft tissue concerns, the dorsal approach to the PIP joint can add an element of ease to a challenging operation. In particular, this approach can help in a case when there are multiple digits involved, which would make a midaxial approach particularly difficult. It should be included in a surgeon’s armamentarium in addition to the other approaches to the PIP joint as a safe and expeditious manner of approaching a difficult problem.