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Etiology, Evaluation, and Management Options for the Stiff Digit

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Etiology, Evaluation, and Management Options for the Stiff Digit Review Article Etiology, Evaluation, and Management Options for the Stiff Digit Abstract Louis W. Catalano III, MD The stiff digit may be a consequence of trauma or surgery to the hand ’ O. Alton Barron, MD and fingers and can markedly affect a patient s level of function and quality of life. Stiffness and contractures may be caused by one or a Steven Z. Glickel, MD combination of factors including joint, intrinsic, extensor, and flexor Shobhit V. Minhas, MD tendon pathology, and the patient’s individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, From the Department of Orthopedic surgery consists of open joint release, tenolysis of flexor and/or Surgery, NYU Langone Orthopedic extensor tendons, and external fixation devices. Outcomes after Hospital, New York, NY. treatment vary depending on the joint involved along with the severity Dr. Catalano or an immediate family of contracture and the patient’s compliance with formal hand therapy member serves as a paid consultant to Smith and Nephew. Dr. Barron or and a home exercise program. an immediate family member has received IP royalties from and serves as a paid consultant to Extremity Medical and serves as a board igital stiffness is a common The initial management of the stiff member, owner, officer, or committee Dcomplication after trauma and finger includes nonsurgical modali- member of the American Shoulder surgery and can markedly impair ties such as serial casting, splinting, and Elbow Surgeons and the function and quality of life of pa- and guided therapy to restore nor- American Society for Surgery of the 1 Hand. Dr. Glickel or an immediate tients. Without treatment, this may mal motion. Surgery is indicated for family member serves as an unpaid result in permanent contractures. patients with persistent contracture consultant to Acumed, LLC and Although the practical demands of and functional compromise. In this serves as a board member, owner, the hand vary between individuals, review, we highlight the relevant officer, or committee member of the American Society for Surgery of the the basic functions of pinch, grasp, anatomy of the digit, the clinical Hand. Neither Dr. Minhas nor any and grip are crucial for an indepen- evaluation and differential diagnosis immediate family member has dent productive life. of finger contractures, treatment op- received anything of value from or has stock or stock options held in a Osseous stability with a congruent tions, and outcomes. commercial company or institution articular surface, integrity and related directly or indirectly to the strength of the musculotendinous subject of this article. unit, tendon gliding, and pliable skin Anatomy J Am Acad Orthop Surg 2019;27: and soft tissues are all required for e676-e684 full digital range of motion (ROM). Metacarpophalangeal Joint DOI: 10.5435/JAAOS-D-18-00310 An understanding of the anatomy The metacarpophalangeal (MCP) and pathology associated with spe- joint is a multiaxial condyloid joint Copyright 2018 by the American Academy of Orthopaedic Surgeons. cific contractures is imperative for that allows for flexion, extension, effective treatment (Figures 1 and 2). abduction, adduction, and a small e676 Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Louis W. CatalanoIII, MD, et al Figure 1 A, Illustration of digital extensor apparatuses. B, Dorsal dissection of digit demonstrating extensor mechanism. DIP = distal interphalangeal, MCP = metacarpophalangeal, PIP = proximal interphalangeal degree of circumduction. It consists course toward the volar base of the The collateral ligaments are lax in of the capsule, two proper collateral proximal phalanx. The accessory extension (the same cam effect reversed), ligaments, two accessory collateral ligaments originate volar to the col- so MCP joints that remain extended ligaments, and the volar plate. The lateral ligaments on the metacarpal will become stiff as the lax ligaments joint capsule is loose in its substance head and fan out to blend with the contract. This tendency worsens as but stabilized by connective tissue on collateral ligaments, attaching to the we age, and it can become difficult to all sides, attaching to the articular rim proximal phalanx and the volar overcome within 4 to 6 weeks. of the metacarpal head and base of plate. The metacarpal head is trape- the proximal phalanx. The redun- zoidal in shape, being wider volarly. dancy of the capsular tissue allows This shape and the collateral liga- Proximal Interphalangeal for variable hyperextension of the ments’ eccentrically dorsal origin to Joint proximal phalanx, distraction, and a the axis of rotation create a cam The proximal interphalangeal (PIP) small degree of axial rotation. The effect as the proximal phalanx is joint is a single-axis hinge or ginglymus volar plate limits hyperextension of flexed and the collaterals are joint that allows for flexion and the MCP joint. stretched. Hence, MCP joint flex- extension while resisting any motion The collateral ligaments arise from ion tensions the collateral liga- in the coronal plane. Similar to the the radial and ulnar subcapital area ments, creating maximum MCP MCP joint, the PIP joint consists of of the dorsal metacarpal head and joint stability. the capsule, two proper collateral August 1, 2019, Vol 27, No 15 e677 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. The Stiff Digit Figure 2 Interosseous Muscles Seven intrinsic interosseous muscles are present in the hand (four dorsal and three volar), and their tendons run dorsal to the deep transverse in- termetacarpal ligaments. The dorsal interossei are abductors, lying on the radial aspect of the index and middle fingers and the ulnar aspect of the middle and ring fingers, with the abductor digit quinti as the abductor to the small finger. Each dorsal in- terosseous, apart from the third, contains a superficial head arising from the metacarpals, inserts deeply by a medial tendon onto the base of the proximal phalanx and are deep to the sagittal band. This functions to abduct and weakly flex the proximal phalanx. The deep head becomes Radial dissection of digit demonstrating collateral ligaments. PIP = proximal the lateral tendon, inserting into the interphalangeal transverse fibers and lateral band, which are superficial to the sagittal ligaments, two accessory ligaments, sion, compared with the MCP or bands. This functions to flex and and the volar plate. distal interphalangeal (DIP) joints weakly abduct the proximal phalanx The dorsal capsule of the PIP joint is where they are not present. and extend the middle and distal connected to the central tendon, Whereas the MCP joints tend to phalanges. The transverse fibers from which also provides a dorsal stabi- develop extension contractures, the PIP each lateral band arch dorsally and lizing force. The collateral ligaments joints most commonly develop flexion act to flex the proximal phalanx. arise from a small recess in the head of contractures. This is a function of both More distally, the oblique fibers the proximal phalanx and insert onto overpull of more powerful flexor ten- from the lateral bands overlie the the volar aspect of middle phalanx dons and the flexed posture of the PIP distal third of the proximal phalanx and the volar plate. Unlike the MCP joints. Over time, volar plate, collateral toinsertatthebaseofthemiddle joint, no cam effect is present and the ligaments, and flexor sheath con- phalanx and act to extend the mid- tension of the collateral ligaments is tractures can contribute to chronic PIP dle phalanx. The lateral bands are uniform throughout flexion and flexion contractures. then joined by the lateral slips of the extension of the joint. extensor tendon and form the con- Also, unlike the MCP joint, the joined lateral bands, which unite at volar plate has two distinct regions: Distal Interphalangeal Joint the distal third of the middle pha- the fibrocartilaginous distal part is The DIP joint is also a single axis lanx to form the terminal tendon, the articular component that is qua- hinge or ginglymus joint. The joint which inserts at the base of the drangular in shape and a thin mem- capsule is reinforced by the collateral distal phalanx to extend the DIP branous proximal component. The ligaments that extend from the head joint. lateral aspects of the distal volar plate of the middle phalanx to the sides of The three palmar interossei do not anchor the collaterals to the middle the volar plate, with the accessory have separate muscle bellies and do phalanx. Also a proximal expansion ligaments lying more volar. The volar not insert onto the proximal phalanx. exists on both sides of the volar plate plate also serves as an accessory inser- Instead, they insert onto the ulnar margins which extend to the volar tion for the flexor digitorum profundus lateral band of the index and radial margins of the proximal phalanx, tendon. Additionally, the terminal lateral band of the ring and little fin- which are referred to as checkreins or extensor mechanism attaches the dorsal gers. They act to adduct the index, check ligaments. They are unique to edges of the collateral ligaments and ring, and little fingers toward the the PIP joint and limit hyperexten- provides dorsal support. middle finger; assist in flexion of the e678 Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
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