surgical options

Last reviewed 01/2018

Surgical options for camptodactyly must address the contracture at the proximal interphalangeal joint (PIPJ) and also the imbalance between flexor and extensor function around the joint. They include:

• if joint is passively correctable:
• approached via a midlateral incision on the digit with a zigzag incision on the palm
• exploration of joint and release of any tendinous structures which might be tethering in flexion
• release of joint contractures:
  • may mean addressing in isolation or combined the skin, fascia, tendon sheaths, intrinsic tendons, checkrein ligaments, collateral ligaments or volar plate:
    • skin contractures are addressed with Z-plasty lengthening or a skin graft
    • an anomalous lumbrical muscle is resected at its insertion but requires full exploration along its length; an abnormal insertion can be confirmed if pulling on the tendon does not result in PIPJ extension
    • palmar interosseous anomalies are not uncommon, particularly passing to the ring finger; needs partial division of the intermetacarpal ligament
    • flexor digitorum superficialis is assessed by traction on it proximal to the A1 pulley in the palm in both directions; anomalies causing failure of PIPJ flexion require division of either the origin or insertion depending on where the abnormality resides
  • Saffar procedure: release of all flexor structures in a subperiosteal plane on volar side of joint, collateral, accessory collateral and check rein ligaments
• to counter lack of extension at central slip, either plicate the extensor or tendon transfer to the extensor apparatus:
  • options for tendon transfer include the lumbrical, flexor digitorum superficialis or extensor indicis proprius tendons
  • for the FDS tendon transfer:
    • independent function for the FDS to the little finger is required
    • the tendon is divided at the level of the A3 pulley in the digit and passed back into the palm
    • it is then passed distally and dorsally to be weaved into the lateral band and central slip at the level of the middle phalanx
    • if the FDS to the little finger is absent, the equivalent tendon to the ring finger can be used for the little finger
    • tension on the tendon transfer is adjusted to give about 70 degrees of MCPJ flexion and full interphalangeal joint extension
    • a K wire may be required to hold the position for three weeks
  • post-operative splintage
• if joint is fixed in position or shows signs of bony derangement:
  • typically, salvage procedures are required and a minimal improvement can be expected
  • the approach may need to be changed to compensate for skin shortage; typically, z-plasty lengthening is carried out on the digits or, if there is a severe contracture, skin grafting may be required
  • dorsal closing wedge angulation osteotomy of the proximal phalanx to correct flexion and ulnar inclination; results in loss of full flexion and an impaired palmar grasp
  • rarely, arthrodesis with the joint in about 40 degrees of flexion