Sunday, January 28, 2018

Surgery for Camptodactyly

Camptodactyly is the bent (flexed) position of a finger.  I have previously blogged about camptodactyly HERE, but wanted to share my updated surgical strategy.

Surgery is considered for camptodactyly when therapy is not expected to be effective or if therapy has failed to lead to improvement.  It is absolutely my preference to always begin camptodactyly treatment with therapy.  That includes passive stretching as well as splinting.  Splints may include resting splints to stretch the finger (s) at night as well as splints that are spring loaded to wear for shorter periods of time ( LMB link).  For some patients, the initial deformity- that is the severity of the flexion position- is too much to allow effective splinting.  And, for others, splints simply do not make enough of a difference in straightening the finger(s).  In these cases, surgery is considered.  The primary goal of surgery for camptodactyly is to release the tight structures on the palm side of fingers- these structures are different for each patient but typically include skin, tendons, muscles, and possibly the joint (PIP joint).  Only rarely is it necessary to strengthen the tendons which straighten the finger.

A treatment algorithm has evolved based on the treatment of many children with camptodactyly.  While a variety of different anatomical structures have been related to camptodactyly, in our experience, four surgical steps are key to a satisfactory correction.

1) Address the lack of skin on the palm side of the joint.  There is almost always a lack of skin which means that once the other issues are corrected, there will be a skin deficit.  I do not believe skin grafts are the best treatment option and instead favor a rotation flap.  The use of skin from the side of the finger to rotate over the palm side of the joint has been very effective for our patients.  See pictures below. 

2) The tight flexor digitorum superficialis (FDS) tendon is a part of the bent posture of the finger.  The other finger flexor, the FDP is expected to be present and, therefore, we typically release the FDS tendon.  This removes one major contributor the finger flexion position.

3) The PIP joint itself is tight in the flexed position in patients with a more severe camptodactyly.  While a formal joint release (or volar plate release) is sometimes required, we have had success with joint manipulation as a means to straighten the joint.  This requires less surgical dissection and allows a faster procedure and, I believe, a faster recovery.

4) I try to avoid pinning the joint.  We have used kirshner wires to pin the joint temporarily in a straight position.  I have found benefit to avoiding the pins and simply casting/ splinting the joint for 2 weeks after surgery.

Here are a few pictures, before and after surgery, of a recent patient with all 4 fingers affected.  By definition, this patient has a distal arthrogryposis. 
4 finger camptodactyly

4 finger camptodactyly with a lack of skin on the palmar side.

After surgery for camptodactyly, the skin flaps are visible and the fingers straighten.

After surgery for camptodactyly, the skin flaps are visible and the fingers straighten.

After surgery for camptodactyly, the skin flaps are visible and the fingers straighten.
Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

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