Lambda Repair: A Novel Repair Technique for Chronic Boutonnière Deformity.

SUMMARY: Correction of a boutonnière deformity is one of the most demanding challenges in hand surgery. Surgical interventions are usually considered when functional use of the finger cannot be obtained after intense hand therapy. The authors introduce their newly described lambda (λ) repair, which is an easy-to-learn, straightforward surgical technique. The method involves an end-to-side tenorrhaphy of the lateral bands, resembling the Greek λ. Patients who underwent a lambda repair were retrospectively evaluated with preoperative and postoperative measurements of proximal interphalangeal (PIP) joint movement. Four patients (two male, two female; median age, 35.5 years) with a median follow-up period of 9.1 months were included. Three patients underwent lambda repairs for isolated boutonnière deformities, and one patient received a vascularized free toe transfer combined with a lambda repair. The preoperative average PIP joint extension lag or deficit was 28.75 degrees and could be reduced to 15 degrees. Preoperative average PIP joint active flexion was 60 degrees, which was improved to 88.75 degrees. No complications were observed. The lambda repair is a new tool in the reconstruction of boutonnière deformity, further expanding the armamentarium of hand surgeons.

Modification of the Zancolli Lasso Procedure for Simultaneous Correction of Wartenberg's Sign.

Ulnar nerve injury initiates an imbalance between the intrinsic muscles and extrinsic extensors of the ring and small fingers, which leads to the characteristic hyperextension of the metacarpophalangeal (MP) joints and flexion of the proximal interphalangeal joints of these 2 digits-commonly referred to as the ulnar claw hand. In addition to these changes in the static posture of the hand, ulnar nerve palsy severely impairs grasp due to deficient active MP joint flexion. In most cases, motor balance can be restored by preventing MP joint hyperextension and augmenting MP joint flexion using the Zancolli lasso procedure (ZLP). Ulnar neuropathy can cause a second motor imbalance between the ulnar intrinsics and the extensor digit minimi leading to an abduction deformity of the small finger known as Wartenberg's sign. The inability to adduct the small finger can be a great source of frustration to patients. Using a cadaveric biomechanical model, we have developed a simple modification of the Zancolli lasso procedure that simultaneously corrects claw deformity and Wartenberg's sign and we report its efficacy in 2 clinical cases.

The relative motion concept in acute and chronic boutonniere deformity: Invited commentary.

STUDY DESIGN: Retrospective. INTRODUCTION: Boutonniere deformity (BD) is a troublesome injury occurring from rupture of tissue connecting the extrinsic to intrinsic tendon systems. This causes loss of interphalangeal joint balance, and immobilization often results in adherence and difficulty restoring balance. PURPOSES: Review of relative motion flexion (RMF) orthotic use for safe healing during functional activity in 23 patients, and explanation of the rationale. METHODS: Anatomic rationale and clinical experience is reviewed in 8 acute BD patients utilizing RMF orthoses for 6 weeks, and for chronic BD patients, 3 months after serial casting. RESULTS: All patients met the Strickland and Steichen criteria for "excellent" results following treatment, with an average of 35° increase in ROM. DISCUSSION: The anatomic rationale for relative motion recognizes that altering relative positioning between adjacent metacarpophalangeal (MCP) joints produces a protective favorable impact on interphalangeal forces during hand function using 15°-20° greater MCP joint flexion. This provides dorsal and volar protective benefits because the extensor digitorum communis (EDC), a single-muscle-four-tendon system, attaches to the intrinsic lateral band (LB) tendons. With greater MCP flexion, dorsal EDC force is increased, pulling lateral bands medially, while on the volar surface the downward pull of the lumbrical on LB is relaxed due to origin from the flexor digitorum profundus tendon of the injured digit, also a single-muscle-four-tendon system. The RMF orthosis permits protected active motion during functional activity with acute BD. In patients with chronic BD and adequate passive extension, an RMF orthosis for 3 months also produced encouraging results. CONCLUSION: Management of acute BD with RMF orthoses provided earlier recovery of motion and hand function. Similar results occurred for chronic BD using serial casting for adequate extension followed by 3 months of RMF orthotic use and should be attempted prior to surgical intervention, with surgery remaining an alternative.

An in-depth look at zone III and IV anatomy of the finger extensor mechanism and some clinical implications for use of the relative motion flexion orthosis.

BACKGROUND: For hand therapists and hand surgeons acute and chronic injuries of the extensor mechanism (EM) in zones III-IV are challenging to treat with satisfying results. INTRODUCTION: Early active motion combined with relative motion flexion (RMF) orthoses to manage EM zone III injuries and boutonnière deformity has renewed interest in the complex anatomy and biomechanics of the EM. PURPOSE: To provide an in-depth discussion of EM zones III-IV anatomy with emphasis on inter-tendinous structures, often omitted in simplified, model-wise illustrations which focus mostly on the tendinous structures. METHOD: In collaboration the authors combined on the one hand extensive clinical experience and knowledge of the EM literature and on the other hand decades of anatomical, biomechanical and kinesiology research of the EM with special interest for the spiral fibers, through gross anatomy and microdissection anatomy laboratory work, MRI and ultrasonography studies. RESULTS: The inter-tendinous tissues (i.e., spiral fibers) in zone III are of imminent importance for proper functioning of the EM and to prevent boutonnière deformity to develop after EM surgery or injury. DISCUSSION: Inter-tendinous links between the tendinous structures of the EM are necessary for balanced finger motion. The spiral fibers are described in more detail because of their role in controlling volar migration of the conjoined lateral bands and because their disruption makes development of boutonnière deformity more likely. Understanding the anatomy and biomechanics of the EM may assist in progress toward 'proof of concept' for use of RMF orthoses and controlled early active motion after EM injury or surgery. CONCLUSION: Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics.

Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment.

Finger injuries involving the proximal interphalangeal (PIP) joint are common, particularly among athletes. Injury severity is often underappreciated at initial presentation and may be dismissed broadly as a "jammed finger" injury. Delayed diagnosis and treatment of certain injuries can have an important impact on the patient's chance of regaining full function. Central slip and PIP volar plate injuries are frequently encountered injuries that, if left untreated, can lead to the permanent loss of function of the proximal interphalangeal joint. Despite the differing mechanisms of these 2 pathologies, volar plate hyperextension injuries often present with a PIP joint flexion contracture and mild distal interphalangeal joint hyperextension deformity. This is similar to a boutonniere deformity seen after an injury to the central slip, and thus, has been referred to as a "pseudo-boutonnière" deformity. Distinguishing these 2 diagnoses is important, as treatment differs, and highlights the importance of thoroughly understanding the anatomy and relevant clinical applications when evaluating PIP joint injuries.

Mallet Finger: Two Different Injuries.

Mallet injuries, either tendinous or bony, are common. They are often studied together and typically treated in the same way with extension splintage for 6 to 8 weeks. Yet the evidence clearly shows there are different injuries that present in the same way. Tendinous mallet injuries present in older patients usually following a low energy injury; they are often painless. The commonly injured fingers are the middle and ring. The injuries are almost always single digit without concomitant injuries. There is an extensor lag of a mean of 310 (range 3°-590) in the patients treated in my unit. In contrast, bony mallet injuries occur at a younger age (mean 40 years) and are always due to high energy injuries. The injuries are always painful. The commonly injured fingers are the ring and little fingers. There are multiple injuries in 3% (range 2%-5%) and in 4% to 8% of cases, there are concomitant (nondigital) injuries according to data in my unit. Radiologically there is an appreciably smaller extensor lag; mean 130 (range 0°-400). In particular, bony mallet injuries are extension compression, not avulsion, fractures which should not logically be treated with an extension splint which will reproduce the direction of injury.

Dynamic Rather than Static Procedures in Correcting Claw Deformities Due to Ulnar Nerve Palsy.

The theoretic disadvantage of dynamic tendon transfers is the perception that they are "more complex" than static procedures. The latter may provide a simple solution to claw deformity in a subset of patients; however, they completely disregard the disability associated with loss of the intrinsic musculature. Dynamic procedures reconstruct in part the deficient intrinsic forces and are thus capable of correcting the deformity and some disabilities associated with ulnar nerve palsy. In our practice, we have consistently achieved reasonable correction of claw deformity and improvement in tendon synchrony and grip strength with a modified Stiles-Bunnell, flexor digitorum superficialis tendon transfer.

Dynamic correction of ulnar claw hand deformity with a simple insertion into the lumbrical muscle.

Numerous methods of tendon transfers are available to correct claw hand deformity. In this article, we describe a simple insertion of the transferred flexor digitorum superficialis tendon, into the lumbrical muscle and proximal tendon. Sixty patients underwent surgery for claw hand correction. These were equally divided into three groups undergoing; modified Stiles Bunnell procedure; 'lasso' insertion into A1 pulley and the lumbrical insertion procedure. Evaluation was done with proximal interphalangeal joint angle measurements, grip strength and using the Brand's criteria, 1 year after surgery. The improvements were comparable among the three groups. Insertion into the lateral bands has been a standard method of claw correction. In addition to correcting the hyperextension of the metacarpophalangeal joint, it transmits force for interphalangeal joint extension and restores the sequence of flexion of fingers, thus making the grasp effective. Insertion into the lumbrical muscle belly and proximal tendon shows similar results. It can be performed via a single incision in the palm, reducing operative time.

Evaluation of tautening method in repair of advanced mallet finger without bone fracture.

Many different repair methods have been described in the frequently seen mallet finger deformity, but without consensus. The present study aimed to present an alternative tautening technique in mallet finger repair and to compare it versus classical direct repair. Patients with untreated chronic mallet finger of more than three months' progression, treated surgically between March 2017 and October 2020, were included. Two surgical methods were applied to restore extensor function of the distal interphalangeal joints. In the first group, the granulation tissue was excised and the extensor tendon was repaired directly. In the second group, granulation tissue was not excised, and the extensor tendon was tautened by plication. Outcomes were evaluated according to Miller's criteria. Fort-six patients were included: group 1, 25 patients; group 2, 21 patients. Mean age in group 1 was 36.2 years and 33.4 years in group 2. Mean follow-up in group 1 was 14.8 months and 13.9 in group 2. Extensor lag was similar (5.6°) in both groups at the end of the sixth month. On Miller's mallet finger criteria, group 1 scored 3.4 points and group 2 3.4 points (p > 0.05). The tendon tautening method helps to start physiotherapy early, the learning curve is short, and it provides functionally positive results and a low complications rate. We think that this method should be evaluated in chronic mallet finger deformities without bone fracture.

Correction of ulnar claw hand and Wartenberg's sign.

Ulnar claw hand usually occurs when the ulnar nerve is damaged distally. Claw hand deformity is characterized by metacarpophalangeal hyperextension and interphalangeal flexion, making it impossible to oppose the fingers and thumb. Bouvier's test is used to guide the procedure. Palliative surgery requires prior preparation of paralytic hands. In case of a positive Bouvier's test, Zancolli's lasso technique is preferred because of its effectiveness. Capsuloplasty with anteroposterior transosseous fixation is used if the bone is strong enough and when flexor digitorum profondus muscle is inactive and does not allow flexor digitorum superficialis tendon transfer. In case of a negative Bouvier's test with interphalangeal extension deficit of 45° of less, direct interossei muscle restoration techniques by active transfers are performed. If the interphalangeal extension deficit is more than 45°, proximal interphalangeal arthrodesis is indicated. Wartenberg first described actively irreducible abduction of the little finger. Wartenberg's sign is seen when ulnar paralysis occurs, and during ulnar nerve regeneration. Treatment of isolated Wartenberg's sign consists of re-routing the extensor digiti minimi. Among the other techniques, Belmahi's "tie lasso" is preferred when flexible claw hand is associated with Wartenberg's sign.

Effectiveness of Quickcast Versus Custom-Fabricated Thermoplastic Orthosis Immobilization for the Treatment of Mallet Fingers: A Randomized Clinical Trial.

BACKGROUND: Mallet finger is a common injury involving a detachment of the terminal extensor tendon from the distal phalanx. This injury is usually treated with immobilization in a cast or splint. The purpose of this study is to compare outcomes of mallet fingers treated with either a cast (Quickcast) or a traditional thermoplastic custom-fabricated orthosis. METHODS: Our study was a prospective, assessor-blinded, single-center randomized clinical trial of 58 consecutive patients with the diagnosis of bony or soft tissue mallet finger treated with immobilization. Patients were randomized to either an orfilight thermoplastic custom-fabricated orthosis or a Quickcast orthosis. Patients were evaluated at 3, 6, and 10 weeks for bony and 4, 8, and 12 weeks for soft tissue mallets. Skin complications, pain with orthosis, compliance, need for surgical intervention, and extensor lag were compared between the 2 groups. RESULTS: Both bony and soft tissue mallet finger patients experienced significantly less skin complications (33% vs 64%) and pain (11.2 vs 21.6) when using Quickcast versus an orfilight thermoplastic custom-fabricated orthosis. The soft tissue mallet group revealed a greater difference in pain, favoring Quickcast (6.2 vs 22). No significant difference in final extensor droop or need for secondary surgery was found between the 2 groups. CONCLUSIONS: Quickcast immobilization for the treatment of mallet finger demonstrated fewer skin complications and less pain compared with orfilight custom-fabricated splints.

An overview of mallet finger injuries.

Mallet finger describes a fingertip deformity where the distal interphalangeal joint (DIPJ) of the affected digit is held in flexion, unable to extend the distal phalanx actively. The deformity is typically a consequence of traumatic disruption to the terminal extensor tendon at its insertion at the proximal portion of the distal phalanx or slightly proximally at the level of the DIPJ. Patients typically present with a history describing the event of injury with a typical mallet deformity. Common mechanisms include sport activities causing a direct blow to the finger, low energy trauma while performing simple tasks such as pulling up socks or crush injuries from getting the finger trapped in a door. The DIPJ can be passively extended, but this extension of the joint cannot be maintained once the passive extension is stopped. The Doyle classification can be used to categorise and dictate treatment. The extensor lag associated with the deformity does not improve spontaneously without treatment. Inappropriate management can lead to chronic functional loss and stiffness of the finger. The majority of closed mallet splints are Doyle type I, which can be managed non-surgically with external splints, worn full-time to keep the fingertip straight until the tendon injury or fracture heals. Surgical techniques is considered for other types of mallet injuries. Techniques used include closed reduction and Kirschner wire fixation, open reduction and internal fixation, reconstruction of the terminal extensor tendon and correction of swan neck deformity.

A Pragmatic and Evidence-Based Approach to Mallet Finger.

A mallet finger is a common injury that results from a sudden flexion force on an extended distal phalanx or rarely, from hyperextension of the distal interphalangeal joint. Mallet finger can be purely tendinous or bony when associated with an avulsion fracture. The management of this injury is largely conservative with the use of a splint, although surgery may be indicated for select patients. There is little consensus on the indications for surgery or the suitable surgical technique. The aim of this review article is to provide a pragmatic and evidence-based approach to mallet finger that will guide the treating surgeon in providing best care for their patient.

Phalangeal Intra-Articular Osteochondroma Caused a Rare Clinodactyly Deformity in Children: Case Series and Literature Review.

Background: Various factors are discovered in the development of clinodactyly. The purpose of this retrospective study was to present a group of children with a rare clinodactyly deformity caused by phalangeal intra-articular osteochondroma and evaluate the efficacy of various treatment methods. Methods: All child patients that were treated for finger problems in our center between Jan 2017 and Dec 2020 were reviewed. A detailed analysis was made of the diagnosis and treatment methods in eight rare cases. X-rays and histopathology were applied. Results: A preliminary analysis of 405 patients in total was performed, and we included eight cases in our final analysis. This cohort consisted of 2 girls and 6 boys, with a mean age of 5.74 ± 3.22 years (range: 2y5m to 11y). Overall, four patients had their right hand affected and four patients had their left hand affected. One patient was diagnosed as having hereditary multiple osteochondroma (HMO) while the other seven patients were all grouped into solitary osteochondroma. Osteochondroma was proven in all of them by histopathology examination. Preoperative X-rays were used to allow identification and surgery planning in all cases. All osteochondromas were intra-articular and in the distal end of the phalanges, which is located opposite the epiphyseal growth area. All of the osteochondromas developed in half side of the phalanges. The angulation in the finger long axis was measured, and resulted in a mean angulation of 34.63 ± 24.93 degree (range: 10.16-88.91 degree). All of them received surgery, resulting in good appearance and fingers straightening. No recurrence was recorded. Conclusions: This retrospective analysis indicates that 10 degrees can be selected as the angulation level for diagnosis of clinodactyly deformities. What's more important, the abnormal mass proven by X-rays should be included as the classical direct sign for diagnosis. The first choice of treatment is surgery in symptomatic osteochondromas.

Functional reconstruction of a hand that was severely deformed due to Jaccoud's arthropathy.

A 54-year-old woman suspected of having localised systemic sclerosis (SSc) started steroid treatment around 40 years old. She had Jaccoud's arthropathy in her right hand with severe deformities but no bone erosion. The metacarpophalangeal (MP) joint of the index through the little fingers was dislocated palmo-ulnarly with flexion contracture of about 120° and a swan-neck deformity. The palmar skin crease was digging deeply into the skin and was soggy. Severe boutonnière deformity of the thumb was also noted. Due to her severely deformed hand, she could not grasp large objects or show her hand in public. Reconstructive surgery was performed in two stages using finger joint arthroplasty or fusion at the digital joints. After surgery, the appearance as well as the function of the hand was successfully restored. She was able to grasp the steering wheel of her car and was extremely satisfied with the results of the surgery.

Distal Radius Physeal Bar and Ulnar Overgrowth: Indications for Treatment.

BACKGROUND: Distal radius physeal bar with associated growth arrest can occur because of fractures, ischemia, infection, radiation, tumor, blood dyscrasias, and repetitive stress injuries. The age of the patient as well as the size, shape, and location of the bony bridge determines the deformity and associated pathology that will develop. METHODS: A search of the English literature was performed using PubMed and multiple search terms to identify manuscripts dealing with the evaluation and treatment of distal radius physeal bars and ulnar overgrowth. Single case reports and level V studies were excluded. RESULTS: Manuscripts evaluating distal radial physeal bars and their management were identified. A growth discrepancy between the radius and ulna can lead to distal radioulnar joint instability, ulnar impaction, and degenerative changes in the carpus and triangular fibrocartilage complex. Advanced imaging aids in the evaluation and mapping of a physeal bar. Treatment options for distal radius physeal bars include observation, bar resection±interposition, epiphysiodeses of the ulna±completion epiphysiodesis of the radius, ulnar shortening osteotomy±diagnostic arthroscopy to manage associated triangular fibrocartilage complex pathology, radius osteotomy, and distraction osteogenesis. CONCLUSIONS: Decision-making when presented with a distal radius physeal bar is multifactorial and should incorporate the age and remaining growth potential of the patient, the size and location of the bar, and patient and family expectations.

Proximal Humerus Fractures: What Alignment is Acceptable in Children 10 and Up?

BACKGROUND: Fractures of the proximal humerus in skeletally immature patients are rare, and even rarer still in individuals approaching skeletal maturity. Concepts regarding remodeling potential, amount of deformity and functional demands can guide our treatment decision making, but criteria are poorly defined. The purpose of this manuscript is to discuss the issues and the best available evidence. METHODS: A search of the English literature was carried out using PubMed to identify papers on the topic of proximal humerus fractures in skeletally immature individuals. RESULTS: The literature available on the topic of pediatric proximal humerus fractures is limited, especially regarding fractures in patients approaching skeletal maturity. Certainly, as the remodeling potential decreases and the amount of deformity and functional demand increase, the need for operative treatment increases. The exact tolerances and criteria have not been established. A variety of surgical techniques exist, and have been shown to be helpful. CONCLUSIONS: Operative treatment may be necessary in individuals approaching skeletal maturity. Concepts discussed in this paper regarding remodeling, amount of deformity and functional demand may help the surgeon to make appropriate treatment decisions. Future prospective comparative studies which are pending will hopefully shed further light on this matter.

Flexor Digitorum Superficialis tendon transfer for a long-standing boutonniere deformity finger - a retrospective study of 11 cases.

INTRODUCTION: A long-standing boutonniere deformity is challenging to treat because of well-established complex pathophysiological changes in the extensor expansion mechanism. The role of ulnar slip flexor digitorum superficialis tendon transfer for central slip reconstruction in such chronic deformities is analyzed and correlated with the functional outcome. HYPOTHESIS: Ulnar slip FDS tendon corrects the long-standing boutonniere deformity and replicates anatomical repair. METHODS: We conducted a retrospective study between 2014 and 2016 and operated on 11 patients by FDS tendon transfer to the extensor expansion's central slip. We compared the preoperative and postoperative range of movements in the proximal interphalangeal joint, distal interphalangeal joint, Visual analogue score, and grip strength. Also, we statistically correlated various parameters and non-parameters affecting the functional outcomes. RESULTS: The mean time interval between the injury and surgery was 39 months. The average follow-up of our study was 15.4 months. Ten of the 11 patients had good functional outcomes with statistically significant improvement in the movements and grip strength (p<0.05). CONCLUSIONS: Ulnar slip FDS tendon transfer is effective for central slip reconstruction in a long-standing boutonniere deformity. Minimal degrees of proximal interphalangeal joint extension deficit is inevitable due to the chronicity and adaptive changes in the ligament-tendon-bone complex. LEVEL OF EVIDENCE: IV; retrospective case study.