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Finger Stiffness After Fracture
EVIDENCE-BASED MEDICINE
Finger Stiffness After Fracture Jonas L. Matzon, MD,* Kevin Lutsky, MD,* Pedro K. Beredjiklian, MD* THE PATIENT A 48-year-old woman presents with stiffness of the small finger of her dominant hand after closed reduction and percutaneous EatoneBelsky pinning of a displaced proximal phalanx fracture. She did stretching exercises under the supervision of a hand therapist starting 4 weeks after surgery following pin removal. Six months after surgery, she has active and passive proximal interphalangeal (PIP) joint motion from 30 to 60 of flexion and total active motion (TAM) of 150 . THE QUESTION What is the outcome of surgical management of postfracture finger stiffness? CURRENT OPINION The initial treatment of posttraumatic digital stiffness focuses on active motion and self-assisted, therapistassisted, or device-assisted stretching exercises. Surgery is considered in patients with functioning tendons and adequate articular surfaces when stiffness persists in spite of effective stretching exercises.1,4,5 Surgery can offer modest improvements in a subset of patients.1e10,11,13,15,17 THE EVIDENCE In 1954, Curtis described PIP joint capsulectomy in 50 patients with 72 contractures. 11 Half of the patients in the group had a flexion contracture: 10 following flexor tendon repair, 7 secondary to Dupuytren’s disease, and the rest due to fracture, burns, and arthritis. Of From the *Rothman Institute and the Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA. Received for publication August 10, 2015; accepted in revised form August 12, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Pedro K. Beredjiklian, MD, Rothman Institute and the Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.08.004
the patients with extension contractures, 12 were due to proximal phalangeal fractures. Generally good improvements in motion were obtained with partial ligament resections. Ghidella et al12 reviewed the long-term (24-mo minimum) results of 44 patients who underwent surgical treatment of 68 PIP joint contractures, of which 9 (13%) were related to fracture. The overall improvement averaged 7.6 with 30% of patients worse after surgery. In a similar study using complete collateral ligament release for the surgical treatment of 16 PIP joint contractures of various etiologies, Diao and Eaton13 reported an average improvement of 40 . Abbiati et al14 achieved full or near full extension (10 to 15 lag) in 19 patients treated for PIP joint flexion contractures following intra-articular fractures, sprains, and contusions. In this study, 25% of patients had undergone previous surgical treatment for the contracture, and 47% of patients were previously manipulated under anesthesia. Brüser et al15 compared the results of PIP joint contracture release via a midlateral versus palmar incision in 45 fingers, with 6 related to fracture. A midlateral incision was used in 26 fingers. The average motion was notably greater after the midlateral incision (median, 50 ) compared with the palmar incision (median, 30 ). Gould and Nicholson16 described their results of metacarpophalangeal (MP) and PIP joint capsulectomy to address finger stiffness. The authors reported on 105 MP joint capsulectomies in 37 patients and 112 PIP joint capsulectomies (47 dorsal and 65 volar) in 67 patients. For patients with etiologies including trauma and crush injuries, the authors noted improvements of 13 e18 . In contrast, patients with nerve paralysis as the cause of their stiffness had greater postoperative motion gains of 78 e90 . Young et al reviewed their experience with surgical management of stiff joints in the hand. In their series of 61 patients with 135 stiff joints, 37 developed stiffness after nonsurgical treatment of closed or open fractures.17 Of those with MP joint releases (n ¼ 61), 68% gained more than 30 of motion after surgical release, 57% more than 50 , and 32% more
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
FINGER STIFFNESS AFTER FRACTURE
than 70 . In contrast, of those patients with PIP joint releases (n ¼ 74), 63% gained more than 30 of motion after surgical release, 41% more than 50 , and 25% more than 70 . In a cross-sectional study of 84 patients with stiffness after a PIP joint sprain, Bot et al18 investigated the relationship between stiffness and pain self-efficacy. Greater pain self-efficacy (effective coping strategies) was associated with less pain and disability and more motion. Greater magnitude of disability correlated with lower pain self-efficacy and more symptoms of depression.
OUR CURRENT CONCEPTS FOR THIS PATIENT We would counsel the patient that surgery often improves motion but restoration of full motion is unlikely and a notable number of patients lose motion. Intraoperatively, we aim for full motion by addressing all pathologic anatomy including tendon adhesions, capsular or collateral ligament contracture, and retained implants. We prefer to use local anesthesia with little or no sedation so that active motion can be assessed intraoperatively. After surgery, we initiate active motion and stretching exercises within 3 days. REFERENCES
SHORTCOMINGS OF THE EVIDENCE Current best evidence consists entirely of retrospective reviews with relatively short evaluations. Moreover, most studies evaluating surgical treatment of finger stiffness include patients with both variable pathology (fractures, crush injuries, sprains, lacerations, burns, and Dupuytren’s) and inconsistent previous treatment (no treatment, therapy with stretching and manipulation, and surgery), which results in a heterogeneous patient population. Moreover, the surgical techniques vary depending largely on the preferences of the authors. Finally, other factors that may play a role in the results of surgery, such as psychosocial issues (including worker’s compensation, symptoms of depression, and ineffective coping strategies), are not accounted for.
1. Curtis RM. Management of the stiff proximal interphalangeal joint. Hand. 1969;1(1):32e37. 2. Glasgow C, Fleming J, Tooth LR, Hockey RL. The long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: a prospective cohort study. J Hand Ther. 2012;25(1): 38e47. 3. Harrison DH. The stiff proximal interphalangeal joint. Hand. 1977;9(2):102e108. 4. Houshian S, Gynning B, Schroder HA. Chronic flexion contracture of proximal interphalangeal joint treated with the compass hinge external fixator. A consecutive series of 27 cases. J Hand Surg Br. 2002;27(4):356e358. 5. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg. 1998;23(5):827e832. 6. Schneider LH. Tenolysis and capsulectomy after hand fractures. Clin Orthop. 1996;327:72e78. 7. Watson HK, Light TR, Johnson TR. Checkrein resection for flexion contracture of the middle joint. J Hand Surg. 1979;4(1):67e71. 8. Watt AJ, Chang J. Functional reconstruction of the hand: the stiff joint. Clin Plast Surg. 2011;38(4):577e589. 9. Wray RC, Kuxhaus M, Weeks PM. The results of non-operative management of stiff joints in the hand. Plast Reconstr Surg. 1978;61(1):58e63. 10. Yamazaki H, Kato H, Uchiyama S, Ohmoto H, Minami A. Results of tenolysis for flexor tendon adhesion after phalangeal fracture. J Hand Surg Eur. 2008;33(5):557e560. 11. Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am. 1954;36(6):1219e1232. 12. Ghidella SD, Segalman KA, Murphey MS. Long-term results of surgical management of proximal interphalangeal joint contracture. J Hand Surg. 2002;27(5):799e805. 13. Diao E, Eaton RG. Total collateral ligament excision for contractures of the proximal interphalangeal joint. J Hand Surg. 1993;18(3): 395e402. 14. Abbiati G, Delaria G, Saporiti E, Petrolati M, Tremolada C. The treatment of chronic flexion contractures of the proximal interphalangeal joint. J Hand Surg Br. 1995;20(3):385e389. 15. Brüser P, Poss T, Larkin G. Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision. J Hand Surg. 1999;24(2):288e294. 16. Gould JS, Nicholson BG. Capsulectomy of the metacarpophalangeal and proximal interphalangeal joints. J Hand Surg. 1979;4(5):482e486. 17. Young VL, Wray RC Jr, Weeks PM. The surgical management of stiff joints in the hand. Plast Reconstr Surg. 1978;62(6):835e841. 18. Bot AG, Bekkers S, Herndon JH, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after proximal interphalangeal joint sprain or dislocation. Psychosomatics. 2014;55(6):595e601.
DIRECTIONS FOR FUTURE RESEARCH It might be helpful to study stiffness after surgical and nonsurgical treatment of phalanx fractures separately. Large prospective, randomized, multicenter studies could be designed to determine the technical aspects of surgery that influence final motion, including various anesthetic methods (eg, sedation vs wide awake local anesthesia no tourniquet). Large prospective cohort studies might help identify which patients are most likely to improve motion and function after surgical intervention. Psychosocial factors, such as effective coping strategies in response to pain, symptoms of depression, and stress, merit additional study as an important contributor to persistent finger stiffness after injury. Stretching exercises can be quite counterintuitive during recovery from injury, and methods for helping patients feel more comfortable and healthy about their stretches (such as mirror box exercises and other techniques based on cognitive behavioral therapy) can be developed and tested. J Hand Surg Am.
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Vol. -, - 2015
Finger Stiffness After Fracture Jonas L. Matzon, MD,* Kevin Lutsky, MD,* Pedro K. Beredjiklian, MD* THE PATIENT A 48-year-old woman presents with stiffness of the small finger of her dominant hand after closed reduction and percutaneous EatoneBelsky pinning of a displaced proximal phalanx fracture. She did stretching exercises under the supervision of a hand therapist starting 4 weeks after surgery following pin removal. Six months after surgery, she has active and passive proximal interphalangeal (PIP) joint motion from 30 to 60 of flexion and total active motion (TAM) of 150 . THE QUESTION What is the outcome of surgical management of postfracture finger stiffness? CURRENT OPINION The initial treatment of posttraumatic digital stiffness focuses on active motion and self-assisted, therapistassisted, or device-assisted stretching exercises. Surgery is considered in patients with functioning tendons and adequate articular surfaces when stiffness persists in spite of effective stretching exercises.1,4,5 Surgery can offer modest improvements in a subset of patients.1e10,11,13,15,17 THE EVIDENCE In 1954, Curtis described PIP joint capsulectomy in 50 patients with 72 contractures. 11 Half of the patients in the group had a flexion contracture: 10 following flexor tendon repair, 7 secondary to Dupuytren’s disease, and the rest due to fracture, burns, and arthritis. Of From the *Rothman Institute and the Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA. Received for publication August 10, 2015; accepted in revised form August 12, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Pedro K. Beredjiklian, MD, Rothman Institute and the Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.08.004
the patients with extension contractures, 12 were due to proximal phalangeal fractures. Generally good improvements in motion were obtained with partial ligament resections. Ghidella et al12 reviewed the long-term (24-mo minimum) results of 44 patients who underwent surgical treatment of 68 PIP joint contractures, of which 9 (13%) were related to fracture. The overall improvement averaged 7.6 with 30% of patients worse after surgery. In a similar study using complete collateral ligament release for the surgical treatment of 16 PIP joint contractures of various etiologies, Diao and Eaton13 reported an average improvement of 40 . Abbiati et al14 achieved full or near full extension (10 to 15 lag) in 19 patients treated for PIP joint flexion contractures following intra-articular fractures, sprains, and contusions. In this study, 25% of patients had undergone previous surgical treatment for the contracture, and 47% of patients were previously manipulated under anesthesia. Brüser et al15 compared the results of PIP joint contracture release via a midlateral versus palmar incision in 45 fingers, with 6 related to fracture. A midlateral incision was used in 26 fingers. The average motion was notably greater after the midlateral incision (median, 50 ) compared with the palmar incision (median, 30 ). Gould and Nicholson16 described their results of metacarpophalangeal (MP) and PIP joint capsulectomy to address finger stiffness. The authors reported on 105 MP joint capsulectomies in 37 patients and 112 PIP joint capsulectomies (47 dorsal and 65 volar) in 67 patients. For patients with etiologies including trauma and crush injuries, the authors noted improvements of 13 e18 . In contrast, patients with nerve paralysis as the cause of their stiffness had greater postoperative motion gains of 78 e90 . Young et al reviewed their experience with surgical management of stiff joints in the hand. In their series of 61 patients with 135 stiff joints, 37 developed stiffness after nonsurgical treatment of closed or open fractures.17 Of those with MP joint releases (n ¼ 61), 68% gained more than 30 of motion after surgical release, 57% more than 50 , and 32% more
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
FINGER STIFFNESS AFTER FRACTURE
than 70 . In contrast, of those patients with PIP joint releases (n ¼ 74), 63% gained more than 30 of motion after surgical release, 41% more than 50 , and 25% more than 70 . In a cross-sectional study of 84 patients with stiffness after a PIP joint sprain, Bot et al18 investigated the relationship between stiffness and pain self-efficacy. Greater pain self-efficacy (effective coping strategies) was associated with less pain and disability and more motion. Greater magnitude of disability correlated with lower pain self-efficacy and more symptoms of depression.
OUR CURRENT CONCEPTS FOR THIS PATIENT We would counsel the patient that surgery often improves motion but restoration of full motion is unlikely and a notable number of patients lose motion. Intraoperatively, we aim for full motion by addressing all pathologic anatomy including tendon adhesions, capsular or collateral ligament contracture, and retained implants. We prefer to use local anesthesia with little or no sedation so that active motion can be assessed intraoperatively. After surgery, we initiate active motion and stretching exercises within 3 days. REFERENCES
SHORTCOMINGS OF THE EVIDENCE Current best evidence consists entirely of retrospective reviews with relatively short evaluations. Moreover, most studies evaluating surgical treatment of finger stiffness include patients with both variable pathology (fractures, crush injuries, sprains, lacerations, burns, and Dupuytren’s) and inconsistent previous treatment (no treatment, therapy with stretching and manipulation, and surgery), which results in a heterogeneous patient population. Moreover, the surgical techniques vary depending largely on the preferences of the authors. Finally, other factors that may play a role in the results of surgery, such as psychosocial issues (including worker’s compensation, symptoms of depression, and ineffective coping strategies), are not accounted for.
1. Curtis RM. Management of the stiff proximal interphalangeal joint. Hand. 1969;1(1):32e37. 2. Glasgow C, Fleming J, Tooth LR, Hockey RL. The long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: a prospective cohort study. J Hand Ther. 2012;25(1): 38e47. 3. Harrison DH. The stiff proximal interphalangeal joint. Hand. 1977;9(2):102e108. 4. Houshian S, Gynning B, Schroder HA. Chronic flexion contracture of proximal interphalangeal joint treated with the compass hinge external fixator. A consecutive series of 27 cases. J Hand Surg Br. 2002;27(4):356e358. 5. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg. 1998;23(5):827e832. 6. Schneider LH. Tenolysis and capsulectomy after hand fractures. Clin Orthop. 1996;327:72e78. 7. Watson HK, Light TR, Johnson TR. Checkrein resection for flexion contracture of the middle joint. J Hand Surg. 1979;4(1):67e71. 8. Watt AJ, Chang J. Functional reconstruction of the hand: the stiff joint. Clin Plast Surg. 2011;38(4):577e589. 9. Wray RC, Kuxhaus M, Weeks PM. The results of non-operative management of stiff joints in the hand. Plast Reconstr Surg. 1978;61(1):58e63. 10. Yamazaki H, Kato H, Uchiyama S, Ohmoto H, Minami A. Results of tenolysis for flexor tendon adhesion after phalangeal fracture. J Hand Surg Eur. 2008;33(5):557e560. 11. Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am. 1954;36(6):1219e1232. 12. Ghidella SD, Segalman KA, Murphey MS. Long-term results of surgical management of proximal interphalangeal joint contracture. J Hand Surg. 2002;27(5):799e805. 13. Diao E, Eaton RG. Total collateral ligament excision for contractures of the proximal interphalangeal joint. J Hand Surg. 1993;18(3): 395e402. 14. Abbiati G, Delaria G, Saporiti E, Petrolati M, Tremolada C. The treatment of chronic flexion contractures of the proximal interphalangeal joint. J Hand Surg Br. 1995;20(3):385e389. 15. Brüser P, Poss T, Larkin G. Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision. J Hand Surg. 1999;24(2):288e294. 16. Gould JS, Nicholson BG. Capsulectomy of the metacarpophalangeal and proximal interphalangeal joints. J Hand Surg. 1979;4(5):482e486. 17. Young VL, Wray RC Jr, Weeks PM. The surgical management of stiff joints in the hand. Plast Reconstr Surg. 1978;62(6):835e841. 18. Bot AG, Bekkers S, Herndon JH, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after proximal interphalangeal joint sprain or dislocation. Psychosomatics. 2014;55(6):595e601.
DIRECTIONS FOR FUTURE RESEARCH It might be helpful to study stiffness after surgical and nonsurgical treatment of phalanx fractures separately. Large prospective, randomized, multicenter studies could be designed to determine the technical aspects of surgery that influence final motion, including various anesthetic methods (eg, sedation vs wide awake local anesthesia no tourniquet). Large prospective cohort studies might help identify which patients are most likely to improve motion and function after surgical intervention. Psychosocial factors, such as effective coping strategies in response to pain, symptoms of depression, and stress, merit additional study as an important contributor to persistent finger stiffness after injury. Stretching exercises can be quite counterintuitive during recovery from injury, and methods for helping patients feel more comfortable and healthy about their stretches (such as mirror box exercises and other techniques based on cognitive behavioral therapy) can be developed and tested. J Hand Surg Am.
r
Vol. -, - 2015