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Surgical treatment of fixed flexion contractures in the hands of institutionalised patients
SURGICAL CONTRACTURES
TREATMENT OF FIXED FLEXION IN THE HANDS OF INSTITUTIONALISED PATIENTS M. NEEDOFF and A. MOULTON
From Harlow Wood Orthopaedic Hospital, Mansjeld, Nottinghamshire
Three severely demented elderly patients had fixed flexion contractures of all fingers of one or both hands. This caused an unpleasant problem of hygiene and of nail ingrowth into the palm. A surgical solution to this problem is described, with good results. Journal ofHand
Surgery
(British Volume, 1991)
Patients Three patients, one man and two women, with fixed flexion contractures of one or both hands were referred from a local psychogeriatric unit. In each of these hands, the contractions affected the four ulnar digits and were so severe as to be causing unpleasant hygiene problems with maceration and ingrowth of the fingernails into the palms. All the patients were severely demented and totally incapable of looking after themselves. In the two patients where only one hand was affected, the other hand was not being used to any significant degree. There was, therefore, no question of any surgical attempt to restore function in the affected fingers. A tour of the wards in the same hospital revealed two more patients who were developing the same condition, but whose hands were not yet fully closed. Examination of these hands did not reveal any structural abnormalities and, in particular, there was no sign of Dupytren’s disease. Under general anaesthesia, it was not possible to extend the fingers more than a centimetre, confirming the permanent nature of the contracture. Through a longitudinal volar incision proximal to the wrist and flexor retinaculum, the deep and superficial flexor tendons were identified, exposed and then divided. This produced an immediate and satisfactory release which allowed easy access to the palm. The wounds were then closed and the hands splinted for two weeks until sutures were removed. All the wounds healed without problems. At follow up after a minimum of nine months, the contractures have shown no signs of recurrence. Discussion The psycho-flexed hand syndrome has been described by Frykman et al. (1983) in severely depressed patients.
VOL.
16B No. 4 NOVEMBER
1991
16B: 449
They found fixed flexion contractures of the ulnar three fingers, affecting the dominant hand of five of these patients. Our cases are somewhat different, in that all the fingers (but not the thumbs) were involved and the patients were all severely demented and elderly. The clenched fist syndrome has been described by Simmons and Vasile (1980), but again this differs from our cases in that the deformity of the clenched fist syndrome is passively correctable. Various surgical and non-surgical methods of treatment have been tried, with poor results. We felt that, because of the permanent nature of the mental states of these patients, there was nothing to be gained from an extensive flexor release as has been described for patients with cerebral palsy (Inglis and Cooper, 1966) or any form of tendon transfer. Division of the flexor tendons at the wrist is a quick, simple procedure ; all skin wounds healed quickly and the contractures have shown no signs of recurrence.
References FRYKMAN, G. K., WOOD, V. E. and MILLER, E. B. (1983). The Psychoflexed Hand. Clinical Orthopaedics and Related Research, 174: 153-157. INGLIS, A. E. and COOPER, W. (1966). Release of the Flexor-Pronator Origin for Flexion Deformities of the Hand and Wrist in Spastic Paralysis. A Study of Eighteen Cases. Journal of Bone and Joint Surgery, 48A: 5: 847-857. SIMMONS, B. P. and VASILE, E. R. G. (1980). The clenched fist syndrome. Journal of Hand Surgery, 5 : 5: 42&427.
Accepted: 21st December 1990 yC.HM. Needoff, F.R.C.S., Ortbopaedic Registrar, Queen’s Medical Centre, Nottingham NG7 0 1991 The British Society for Surgery of the Hand
449
TREATMENT OF FIXED FLEXION IN THE HANDS OF INSTITUTIONALISED PATIENTS M. NEEDOFF and A. MOULTON
From Harlow Wood Orthopaedic Hospital, Mansjeld, Nottinghamshire
Three severely demented elderly patients had fixed flexion contractures of all fingers of one or both hands. This caused an unpleasant problem of hygiene and of nail ingrowth into the palm. A surgical solution to this problem is described, with good results. Journal ofHand
Surgery
(British Volume, 1991)
Patients Three patients, one man and two women, with fixed flexion contractures of one or both hands were referred from a local psychogeriatric unit. In each of these hands, the contractions affected the four ulnar digits and were so severe as to be causing unpleasant hygiene problems with maceration and ingrowth of the fingernails into the palms. All the patients were severely demented and totally incapable of looking after themselves. In the two patients where only one hand was affected, the other hand was not being used to any significant degree. There was, therefore, no question of any surgical attempt to restore function in the affected fingers. A tour of the wards in the same hospital revealed two more patients who were developing the same condition, but whose hands were not yet fully closed. Examination of these hands did not reveal any structural abnormalities and, in particular, there was no sign of Dupytren’s disease. Under general anaesthesia, it was not possible to extend the fingers more than a centimetre, confirming the permanent nature of the contracture. Through a longitudinal volar incision proximal to the wrist and flexor retinaculum, the deep and superficial flexor tendons were identified, exposed and then divided. This produced an immediate and satisfactory release which allowed easy access to the palm. The wounds were then closed and the hands splinted for two weeks until sutures were removed. All the wounds healed without problems. At follow up after a minimum of nine months, the contractures have shown no signs of recurrence. Discussion The psycho-flexed hand syndrome has been described by Frykman et al. (1983) in severely depressed patients.
VOL.
16B No. 4 NOVEMBER
1991
16B: 449
They found fixed flexion contractures of the ulnar three fingers, affecting the dominant hand of five of these patients. Our cases are somewhat different, in that all the fingers (but not the thumbs) were involved and the patients were all severely demented and elderly. The clenched fist syndrome has been described by Simmons and Vasile (1980), but again this differs from our cases in that the deformity of the clenched fist syndrome is passively correctable. Various surgical and non-surgical methods of treatment have been tried, with poor results. We felt that, because of the permanent nature of the mental states of these patients, there was nothing to be gained from an extensive flexor release as has been described for patients with cerebral palsy (Inglis and Cooper, 1966) or any form of tendon transfer. Division of the flexor tendons at the wrist is a quick, simple procedure ; all skin wounds healed quickly and the contractures have shown no signs of recurrence.
References FRYKMAN, G. K., WOOD, V. E. and MILLER, E. B. (1983). The Psychoflexed Hand. Clinical Orthopaedics and Related Research, 174: 153-157. INGLIS, A. E. and COOPER, W. (1966). Release of the Flexor-Pronator Origin for Flexion Deformities of the Hand and Wrist in Spastic Paralysis. A Study of Eighteen Cases. Journal of Bone and Joint Surgery, 48A: 5: 847-857. SIMMONS, B. P. and VASILE, E. R. G. (1980). The clenched fist syndrome. Journal of Hand Surgery, 5 : 5: 42&427.
Accepted: 21st December 1990 yC.HM. Needoff, F.R.C.S., Ortbopaedic Registrar, Queen’s Medical Centre, Nottingham NG7 0 1991 The British Society for Surgery of the Hand
449