Documente Academic
Documente Profesional
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management
Common Congenital Hand
anomalies - Part 2
Christian Dumontier, MD, PhD
FWI- Guadeloupe
Available at www.diuchirurgiemain.org
Camptodactyly
• Camptodactyly = Bent finger [from
the greek κάµπτω (to bend) and
δάκτυλος (finger)]
Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am
1977;2(3):216–24.
Camptodactyly
• Camptodactyly is a clinical
sign, possibly part of a
syndrome, but is never a
disease in its own right
(Flatt).
Flatt AE: The care of congenital hand anomalies. St. Louis, 1977, The CV Mosby Co, pp 147-54
Camptodactyly
Gnamey D. Fréquence des malformations congénitales et héréditaires des doigts. Lille Médical 1973;18(8):950–2.
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am
Clinical presentation
• Most common: sporadic without family history
Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am
1977;2(3):216–24.
Classification
• Many used
Type I Infantile
• Age at presentation
and associated Type II Adolescent
anomalies are more
frequently preferred Type III Syndromic
Benson LS, Waters PM, Kamil NI, et al. Camptodactyly: classification and results of nonoperative treatment. J Pediatr
Orthop 1994;14(6):814–9
Causes suspected
Courtemanche AD. Campylodactyly: etiology and management. Plast Reconstr Surg 1969;44(5):451–4.
Oldfield MC. Campylodactyly: flexor contracture of the fingers in young girls. Br J Plast Surg 1956; 8(4):312–7.
Cause: abnormal volar structures
• Abnormal lumbrical insertion (96% of his cases),
47% FDS anomaly -Mc Farlane
Smith PJ, Grobbelaar AO. Camptodactyly: a unifying theory and approach to surgical treatment. J Hand Surg Am
1998;23(1):14–9.
Carneiro RS. Congenital attenuation of the extensor tendon central slip. J Hand Surg Am 1993;18(6): 1004–7.
Koman LA, Toby EB, Poehling GG. Congenital flexion deformities of the proximal interphalangeal joint in children: a
subgroup of camptodactyly. J Hand Surg Am 1990;15(4):582–6.
As a consequence
• If surgery is considered
Smith PJ, Grobbelaar AO. Camptodactyly: a unifying theory and approach to surgical treatment. J Hand Surg Am
1998;23(1):14–9.
Most authors now favor a stepwise surgery
Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
Physical examination steps
PIP contracture with MCP and
wrist flexion to assess volar plate
and intrinsic joint structures
Physical examination steps
May require Z-plasty, skin graft or
Skin tightness or a pterygium
rotational flap
PIP contracture with MCP and wrist flexion to
assess volar plate and intrinsic joint structures
PIP passive extension with the wrist any change during wrist extension
in extension indicates tightness of flexor tendons
Bouvier’s maneuver (active PIP To identify attenuation of the central
extension with the MP flexed) slip of the extensor mechanism
DIP hyperextension ?
Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
Radiographic evaluation
• Indentation of P2 phalangeal
base
Radiographic evaluation
Foucher G, Lorea P, Khouri RK, et al. Camptodactyly as a spectrum of congenital deficiencies: a treatment algorithm
based on clinical examination. Plast Reconstr Surg 2006;117(6): 1897–905.
Ogino T, Kato H. Operative findings in camptodactyly of the little finger. J Hand Surg Br 1992;17(6): 661–4.
Treatment
• No cost
• No complication
• No functional impairment
Possible aggravation
with time
Non-operative treatment
Miura T, Nakamura R, Tamura Y. Long-standing extended dynamic splintage and release of an abnormal restraining
structure in camptodactyly. J Hand Surg Br 1992;17B:665-672.
Non-operative treatment
• Passive stretching protocols
( 4 times / day, 5 minutes)
• Active extension
strentghening
FromYannascoli
• Static splinting at night
(sometimes dynamic splinting
at day)
• Passive manipulation: 5
minutes, 20 times a day to
take advantage of the creep
phenomenon,
Rhee SH et al. Effect of Passive Stretching on Simple Camptodactyly in Children Younger Than Three Years of Age. J
Hand Surg 2010;35A:1768–1773
Non-operative treatment
Before TTT
After
Rhee SH et al. Effect of Passive Stretching on Simple Camptodactyly in Children Younger Than Three Years of Age. J
Hand Surg 2010;35A:1768–1773
Non-operative treatment may
improve bone remodeling
• 48 fingers in 20 patients
• Statistically significant
radiological parameters
improvement
Hong SW et al. Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With
Camptodactyly . J Hand Surg Am. 2019 (in Press)
Surgery : Contra-indications ?
• Non-motivated/compliant
patient
• No functional impairement
• Long-standing articular
deformity ?
Operative treatment
• Skin tightness ➠ Zplasty, rotational
flaps, FTSG,…
• In 35 cases of isolated small finger camptodactyly, only 50% had less than 15°
flexion deformity with 33% unable to regain full flexion, average dpc1.8 cm (Mc
Farlane).
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am 1977;2(3):216–24.
Siegert JJ, Cooney WP, Dobyns JH. Management of simple camptodactyly. J Hand Surg Br 1990;15(2): 181–9.
Ogino T, Kato H. Operative findings in camptodactyly of the little finger. J Hand Surg Br 1992;17(6): 661–4.
McFarlane RM, Classen DA, Porte AM, et al. The anatomy and treatment of camptodactyly of the small finger. J Hand Surg Am 1992;17(1):35–44.
Koman LA, Toby EB, Poehling GG. Congenital flexion deformities of the proximal interphalangeal joint in children: a subgroup of camptodactyly. J
Hand Surg Am 1990;15(4):582–6.
Operative treatment
Evans BT, Waters PM, Bae DS. Early results of surgical management of camptodactyly. J Pediatr Orthop 2017;37(5):
317–20.
Stepwise approach
• 83% good to excellent results (Smith)
4.FDS tenotomy
Step 1 to 4, and step 9
5.Release of PIP joint contracture always performed
6.Correction of PIP extension lag
Step 5 to 8 are
7.PIP joint pinning
performed according to
8.Terminal tenotomy prep examination and
9.Release of the tourniquet intraoperative findings
Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018) 237–249
Wall LB, Ezaki M, Goldfarb CA. Camptodactyly Treatment for the Lesser Digits. J Hand Surg Am. 2018;43(9):874.e1-e4.
Skin and subcutaneous release
Kamnerdnakta S, Brown M, Chung KC. Camptodactyly Correction. Operative Techniques in Hand and Wrist Surgery,
Chund KC (eds). 2018. pp842-849
Assessment of lumbricals and FDS anatomy
Kamnerdnakta S, Brown M, Chung KC. Camptodactyly Correction. Operative Techniques in Hand and Wrist Surgery,
Chund KC (eds). 2018. pp842-849
Release of PIP contracture
• Ranges of motion for the PIP joint and DIP joint are initiated via proximal and
middle phalanx blocking exercises.
• Passive PIP joint flexion is avoided if an extension transfer has been performed.
• Six weeks postoperative : passive flexion of the PIP joint for patients with tendon
transfer. A dynamic finger extension splint may be initiated. The static extension splint
is now worn only at night.
• Surgery can improve patients but will not give a normal finger,
and can sometimes aggravate the symptoms
Hersch, AH, De Marinus, F, Stecher R. On the inheritance and development of clinodaclyly. Am. J Human Gen., 1953;
5: 257-268.
Fujita H, Iio K, Yamamoto K. Brachymesophalangea and clinodac- tyly of the fifth finger in Japanese children. Acta
Paediatr Jpn 1964; 31:26 –30.
Classification
• 3 types
• Clinodactyly secondary to
epiphyseal injury (fracture,
frostbite…)
Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Poznanski AK et al. Clinodactyly, Camptodactyly, Kirner’s Deformity, and Other Crooked Fingers. Radiology 1969; 93:
573-582.
Clinodactyly in Apert Clinodactyly in a tri-
Syndrome phalangeal thumb
Norat F et al. Les clinodactylies : phalange delta et déformation de Kirner. Chirurgie de la main 27S (2008) S165–S173
« Familial » clinodactyly
Hersch, AH, De Marinus, F, Stecher R. On the inheritance and development of clinodaclyly. Am. J Human Gen., 1953;
5: 257-268.
Clinodactyly in art
• Characterized by an anomalous
epiphysis (C-shaped) that is
oriented longitudinally along the
short side of the affected bone
leading to progressive angulation
of the digit toward the convex side
Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Clinical presentation
Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Poznanski AK et al. Clinodactyly, Camptodactyly, Kirner’s Deformity, and Other Crooked Fingers. Radiology 1969; 93:
573-582.
Indications for treatment
• Minor deformity
• Those with marked angulation of the small finger at the DIP joint can
accommodate by abduction of the metacarpophalangeal joint.
Carstam N, Theander G. Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis (‘‘delta
phalanx’’). Scand J Plast Reconstr Surg 1975;9:199–202.
Jones GB. Delta phalanx. J Bone Joint Surg Br 1964;46:226–8.
Wood VE, Flatt AE. Congenital triangular bones in the hand. J Hand Surg Am 1977;2:179–93.
Closing wedge osteotomy
Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
Closing wedge osteotomy
• Dorsolateral longitudinal incision over the
convex side of the finger.
Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
Closing wedge osteotomy
• Angular deformity improve
from 33° preop to 9° postop
(X-rays correction from 29°
to 5°)
6 years old boy, 6 months FU
• DIP joint arc of motion
decreased from 84° prior to
surgery to 81° after surgery,
Goldfarb CA, Wall LB. Osteotomy for clinodactyly. J Hand Surg Am. 2015;40(6):1220-1224
Opening wedge osteotomy
• A single 0.045-inch Kirschner
wire is placed retrograde in the
distal phalanx, slightly radial to
midline.
Goldfarb CA, Wall LB. Osteotomy for clinodactyly. J Hand Surg Am. 2015;40(6):1220-1224
Opening wedge osteotomy
• 13 fingers in 9 patients treated Preop Postop
between 2003 and 2011.
Clinical 34°
• Average age at surgery was 7° (0-35°)
angle (20-45°)
nine years. FU was 25 months
Piper SL, Goldfarb CA, Wall LB. Outcomes of Opening Wedge Osteotomy to Correct Angular Deformity in little finger
Clinodactyly J Hand Surg Am. 2015;40(5):908-913
Others
• Realignement
Carstam N, Theander G. Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis (‘‘delta
phalanx’’). Scand J Plast Reconstr Surg 1975;9:199–202.
Surgical techniques
The limiting factor is tightness of all the soft tissues, and Z-
plasty of the skin does little to help (Jones, 1964).
The extensor mechanism and the neurovascular structures
are at risk
• Physiolysis (Vickers)
Vickers D. Clinodactyly of the little finger: a simple operative technique for reversal of the growth abnormality. J Hand
Surg Br 1987;12:335–42.
Physiolysis
Vickers D. Clinodactyly of the little finger. A simple operative technique for reversal of the growth abnormality. J Hand
Surg Br 1987; 12B(3):335-342
Vickers’s Physiolysis
• 22 patients (27 fingers) over a 13 years period with 7,4 years FU
• Final angulation was 8° (79% correction) obtained in most cases within 1 year
Medina J, Lorea P, Elliot D,Foucher G. Correction of Clinodactyly by Early Physiolysis: 6-Year Results. J Hand Surg
Am. 2016;41(6):123-127
Vickers’s Physiolysis
• 14 patients (24 fingers) over a 6
years period with 54 months FU
El Sayed L, Salon A, Glorion C, Guéro S. Physiolysis for correction of clinodactyly with delta phalanx: Early
improvement. Hand Surgery and Rehabilitation 38 (2019) 125–128
Conclusion
Slakey JB, Hennrikus WL. Acquired thumb flexion contracture in children. J Bone Joint Surg 1996;78B:481–483.
Kikuchi N, Ogino T. Incidence and development of trigger thumb in children. J Hand Surg 2006;31A:541–543. Rodgers
WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg 1994;19A:364–368.
Pediatric trigger thumb
• Prevalence at 1 year is approximately
3,3 per 1,000 live birth.
Dinham JM, Meggitt BF. Trigger thumbs in children. J Bone Joint Surg 1974;56B:153–155.
Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of pediatric trigger thumb. J Bone
Joint Surg 2008; 90A:980 –985.
Natural history
Tan AH, Lam KS, Lee EH. The treatment outcome of trigger thumb in children. J Pediatr Orthop B 2002;11:256–259.
Dunsmuir RA, Sherlock DA. The outcome of treatment of trigger thumb in children. J Bone Joint Surg 2000;82B:736–
738.
Watanbe H, Hamada Y, Toshima T, Nagasawa K. Conservative treatment for trigger thumb in children. Arch Orthop
Trauma Surg 2001;121:388 –390.
Non-operative treatment: splinting
• Nighttime IP joint extension splinting in 40 trigger thumbs for
an average of 10 months.
• A1 pulley release
McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
When to perform surgery ?
• Children who had surgery after the age of 3 years took
longer (many months) to correct the contracture - Ger.
Ger E, Kupcha P, Ger D. The management of trigger thumb in children. J Hand Surg 1991;16A:944–947.
Dinham JM, Meggitt BF. Trigger thumbs in children. A review of the natural history and indications for treatment in 105
patients. J Bone Joint Surg 1974;56B:153–155.
McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
Outcomes of surgical release
• Overall, favorable results may be expected after surgical release.
Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Questionnaire
• For treatment of a 2-year-old with a 6-month
history of a locked trigger thumb,
Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Conclusion
Choukran