Saturday, February 23, 2019

Finger Deformity- What happens late?


Clinodactyly, bent finger, may present at birth, in childhood, or with the rapid growth of adolescence.  If the bent finger is mild, it will not limit function and often may be treated with stretching or simply observed.  However, a more notable bent position becomes a functional issue with large object grasp and with simple things like typing.  Treatment begins with therapy including active and passive motion and splinting to decrease the deformity.  And therapy is often very helpful.  However, in some patients, therapy does not provide the desired correction.  Pain in childhood is rare.  However, with more severe camptodactyly, pain can develop over time and, occasionally, arthritis can develop as well.

If the finger position is causing problems, again, this would almost always be functional limitations but could include pain in the older child or adult, surgical intervention is considered.  However, the issue with surgery is that it doesn't always provide the improvement that we desire.  And, it can carry the risk of stiffness.  This bears more discussion.  With camptodactyly, patients can make a full fist- they just cannot completely straighten the finger. Flexion/ making a fist is a crucial function.  If surgery stiffens the finger and full flexion is lost, function can be worse.  While not the point of this post, to minimize the risk (we can't eliminate it) of a loss of flexion, we limit the immobilization after surgery, limit the use of pins, and start early therapy. 

So, with younger patients with camptodactyly, we attempt to remove the block to extension.  And we work hard to maintain full motion.  I have blogged about this previously HERE.  However, an older patient with longstanding camptodactyly may need a different approach.   If the joint degenerates and if arthritis develops, a surgical fusion of the joint in the best functional position makes sense.  This limits motion but puts the finger in the best possible position and removes pain.  And, this raises another controversy- the role of camptodactyly in the development of joint arthritis.  Some believe that the flexed joint position and limited motion increases the risk of joint arthritis.  They also, therefore, recommend early surgery to decrease this risk.  This is not necessarily my approach as I feel this is a decision for the family to make with my role in providing additional information.

Here is a patient without previous treatment and with long standing camptodactyly.  The markedly flexed position of the finger was limiting his function and there was pain.  To address both issues, we fused his joint (no further motion at the middle joint but normal motion at other joints) in a better position of function.  The surgery was successful in removing pain and helping function.  Again, this is a rare option for camptodactyly.

Limited finger extension with camptodactyly.  Long standing problem which has interfered with function.


Long standing camptodactyly with major joint changes and joint arthritis.  This is RARE.


Finger fusion in an adult for treatment of long standing camptodactyly with pain.  Note the improved position of the finger compared to prior to surgery.

Late, painful camptodactyly is rare, thankfully.  This rare case does illustrate important points including the possible development of an arthritis joint and the need for surgery.

We recently wrote a review article for the Journal of Hand Surgery on camptodactyly, focusing on treatment options in kids.  See the highlights in Recent Article


Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu


Sunday, February 3, 2019

Madelungs Deformity Surgical Technique

I have posted a few times on Madelung Deformity, as may be seen HERE.  While there have been a number of surgical techniques recommended over the years, I believe that the dome osteotomy of the distal radius is the best option.  That procedure was described well in this important MANUSCRIPT.

Below is a brief surgical technique video on the dome osteotomy for Madelung Deformity.   While this is not a truly graphic video (no notable blood loss), it does provide a look inside the forearm and shows how this procedure is performed with drills, wires, and chisels (osteotomes).  What I mean to say is that everyone may not want to watch this!

I use this surgery for Madelung Deformity when patients have pain in the central wrist or radial wrist (thumb size).  That is typically in younger patients (example, 12 year old female) and may be part of a surgery which includes excision of Vickers ligament and physiolysis.  However, in older patients with pain on the pinky side of the wrist (the ulnar side), this may not be the best option- instead, an ulnar shortening osteotomy might be the ideal surgery.




Thanks to Andrew Yee for his expertise in creating this video!


Charles A. Goldfarb, MD
My Bio at Washington University
Email me: congenitalhand@wudosis.wustl.edu