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Management of Simple Camptodactyly

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Management of Simple Camptodactyly MANAGEMENT OF SIMPLE CAMPTODACTYLY J. J. SIEGERT, W. P. COONEYand J. H. DOBYNS Fromthe Section of Surgeryof the Hand,Mayo Clinic and MayoFoundation, Rochester, Minne&ota, U.S.A. Froma reviewof 57 patients with flexion deformityof the fingers (camptodactyly),21 patients with 38 digits treated operatively had 18%good or excellent results, whereas14 patients (41 digits) treated conservativelyhad 66% good or excellent results. Milddeformities respondedwell to splints andstretching. Moderatedeformities treated operatively gained extension but at the loss of finger flexion. Severe deformities hadimprovement in extension (averaging19 ° in° operative cases and 27 in conservative), but there wassignificant loss of flexion in the operative group.Overall, 16 of 21 patients had loss of flexion after operative treatment. Conservativetreatment of camptodactylyis recommendedfor digits with less than 60° lack of extension. Operativetreatment should be reserved for failed conservativetreatment. Early joint raotion post-operativelyappears essential andsurgical proceduresthat immobilisethe P.I.P. joints sl~tould be avoided. Journal of HandSurgery (British Volume, 1990) 15B : 181-189 The word "camptodactyly" means "bent finger" in Greek; its numerous synonyms are described in the comprehensive review by Smith and Kaplan (1968). surgical practice, it means a non-traumatic flexion contracture of the proximal interphalangealjoint, usually of the little finger (Fig. 1). Involvement of either the distal interphalangeal joint or the metacarpo-phalangeal joint suggests a post-traumatic cause rather than camp- todactyly. Likewise, camptodactyly should not be con- fused with Kirner’s deformity or with clinodactyly. Camptodactyly may be divided into simple and complex types. Simple camptodactyly consists only of the flexion deformity of the P.I.P. joint (Fig. 2), whereas in complex camptodactyly, there are also other deformi- Fig. 2 Amild familial deformity of late onset. ties such as syndactyly or combinations of clinodactyly and camptodactyly (Fig. 3). by Millesi (1974) and Courtemanche (1969). Although Surgical treatment for camptodactyly has been rec- McFarlaneet al. (1983) recommendedsurgical treatment, ommendedby a number of authors, although long-term no patient with bilateral deformities whohad undergone objective data to support this are often lacking. In an operation on one hand requested surgery on the other series ~reported by Smith and Kaplan (1968), follow-up hand. Engber and Flatt (1977) also suggested surgical eight Of the nine operative cases was for no more than a treatment for progressive cases, although they noted’that year. Similarly, limited data are available in the reports operative treatment was not uniformly satisfying. Non-operative treatment for camptodactyly has re- cently been suggested, but no objective comparison with the results of surgical treatment ,has been made(Hori et al., 1987). The purpose of this paper is to review our experience with both operative and non-operative treatment of simple camptodactyly and to offer recommendations for treatment based on objective long-term follow-up data and a proposed clinical grading method. Material The clinical records of 57 patients treated at the Mayo Clinic for camptodactyly from 1966 through 1986 were reviewed (Tables 1 and 2). Patients with complexmultiple Fig. 1 Typicalflexion deformity of P.I.P. joint of little finger.Finger deformities of the hand (such as camptodactylyassociated lacksfull extension,both actively and passively1 but has:t’ull activeflexion. with syndactyly and camptodactyly in combination with 181 VOL. 15B No. 2 MAY1990 J. J. SIEGERT, W. P. COONEYAND J. H. DOBYNS + + I t + I 182 THE JOURNAL OF HAND SURGERY MANAGEMENT OF SIMPLE CAMPTODACTYLY + }ERY VC:i.. I5B No. 2 MAY1990 183 J. J. SIEGERT, W. P. COONEYAND J. H. DOBYNS I I I IIII + + ++ + I I 184 THE JOURNAL OF HAND SURGERY MANAGEMENTOF SIMPLE CAMPTODACTYLY were lost to follow-up and the remaining 21 patients had a meanfollow-up of 6.8 years (range 10 months-20years; median, 5.4 years). The patients were also grouped into either early-onset deformities (younger than six at time of onset) or late-onset deformities. Operative treatment group In the operatively-treated group of 21 patients (38 digits) with follow-up, 11 had late-onset and 10 had early-onset deformities (Table 1). The average age of the entire group at the time of the first operation was 13.3 years. Presenting symptomswere cosmetic (progressive deformities) in 17, progressive deformity and functional difficulty in three and progression of the deformity with pain in one. There was a positive family history in 11. 15 of the 21 patients had bilateral involvement. Six had involvement of only one hand, and in only two did the deformity occur in the non-dominant hand. 38 digits were operated on, 23 of which were little fingers. All patients had full finger flexion before operation. The complaint was limitation of extension, of which the mean was 53.4° (range, 15°-95°). Conservative treatment group In the conservatively treated group of 14 patients (41 digits), nine had late-onset and five had early-onset deformities (Table 2). The average age of the conservative group at the onset of treatment was 14.1 years (range 2- 30 years). Most patients were between the ages of 11 and 17..years. Five patients had involvement of only one hand, the dominant one in each. In the 23 hands, 41. digits were treated, 23 of which were fifth digits. In six Fig. 3 (a) Early-onset deformity of P.I.P. joints of middle, ring and little fingers, associated with complexclinodactyly of middle hands, the deformity involved the index, middle, ring, and ring fingers. (b) Fixed flexion of ulnar three digits not and little fingers. Five of the 14 conservatively-treated passively correctable. patients had a family history of camptodactyIyy. The major presenting complaints were progressive cosmetic significant rotational deformities) were excluded. This deformities (11 patients) and a combination of progres- study was confined, therefore, to simple camptodactyly. sion and functional loss (three patients). Onepatient with The patients could be grouped into three types (Table 3). cosmetic concerns also complained of occasional pain. Of the 57 patients, 37 were female. 25 were treated Patients in both treatment groups expressed difficulty operatively (Table 1) and 17 conservatively (Table 2). in playing the piano, typing, wearinggloves, writing, and the conservative group, three patients were lost to follow- performing manual labour. up; the other 14 patients had a meanfollow-up period of Associated conditions in the 35 patients were general- 6.5 years (range, 14 months-13.7 years; median, 6.2 ised ligamentous laxity (one patient), severe scoliosis years). In the operatively-treated group, four patients (one), pectus excavatum(one), congenital club foot tibial deficiency syndrome(one), Perthes’ disease (one), and toe contractures (two patients). Table 3~Types of patients Methods No. Operative treatment ~ I Genetic consultation only 15 ~ II Deformity, mild or moderate 17 ~ III Deformity, severeor progressive 25 Of the 21 patients whohad surgical treatment, most had a release of the flexor digitorum superficialis, as recom- GERY ~. 15B No. 2 MAY1990 185 J. J. SIEGERT, W. P. COONEYAND J. H. DOBYNS mended by Smith and Kaplan (1968). Table 4 summarises Table5--Classification of results the operative treatment in these 21 patients and 38 digits. ° The surgical exposure generally involved either a Z- Excellent: Correction to full extension, with less than 15 loss of P.I.P.joint flexion plasty or a Bruner incision on the palmar aspect of the Good : Correction to within 20° of full P.I.P. joint extension, or little finger, but in a few cases only a small transverse more than 40° increase in P.I.P. joint extension, with incision was made. The flexor digitorum superficialis was less than 30° loss of flexion ° isolated and any abnormality noted. A detailed review of Fair: Correction to within 40 of full P.I.P. joint extension, or more than 20° increase in P.I.P. joint extension, with the surgical records revealed that an abnormal lumbrical less than 45° loss of flexion insertion or flexor tendon anatomy was ,specifically Poor: Less than 20° of improvementin P.I.P. joint extension, or searched for in 17 of the 21 patients. Of these 17, only less than 40° of total P.I.P. joint motion two had abnormal lumbrical insertions. One other patient had an abnormal superficialis insertion and partial deficiency of the extensor mechanism.Four patients had extremely tight superficialis tendons, one of whomalso had unusually tight palmar fascial bands. Three patients Results of treatment had unusually small superficialis tendons, one of whom also had tight fascial bands. Onepatient had only unusual The results were classified as shownin Table 5. palmar fascial bands. In six of the 17 patients, no specific Following operation, there were no excellent and only anomalies were noted during exploration. seven good results; six were fair and 25 poor (Table 1). ¯ After release of the superficialis, a decision was made The° average lack of extension before operation was 53 about the joint capsule. In seven patients, a palmar and afterwards 43°, an°. average improvementof only 10 capsulotomy was performed and in five, the’, collateral Ten of the 21 patients had measurable improvement in ligaments were released. In ten patients, the P.I.P. joint extension. Loss of flexion, however, was quite common, was pinned in
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