Surgical options

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