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Traumatic lesions of tendons and ligaments of the proximal interphalangeal joint
Traumatic Lesions of Tendons and Ligaments of the Proximal lnterphalangeal Joint - - G . Brunelli, E. Morelli, and V. Salvi
T R A U M A T I C LESIONS OF T E N D O N S A N D L I G A M E N T S OF T H E P R O X I M A L I N T E R P H A L A N G E A L JOINT
G. BRUNELLI, Brescia; E. MORELLI, Legnano; and V. SALVI, Turin This paper reports the experience of the authors in the management of trauma involving the capsule, ligaments and tendons of the proximal interphalangeal joint. Lesions of this type have attracted little attention, particularly in the nonspecialist literature. The general term .sprains, in fact, has been assigned to a large number of lesions that are really open to specific identification, and display different anatomical and pathological patterns. It goes without saying that they require specific treatment. Iselin, F. (1971), Redler and Williams (1967), and Rodriguez (1973), among the most recent papers, have stressed the importance of recognising these lesions and ensuring their correct surgical management. ANATOMICAL PATTERN
The dorsal area contains tendons and ligaments: the central band of the extensor tendon and the two lateral bands held in place by the transverse retinacular ligament. The lateral area includes the collateral ligament running lengthwise from the proximal to the middle phalanx; between the collateral ligament and the volar plate there are some fibres which are called the glenoidal part of the collateral ligament or accessory collateral ligament. In the volar area the volar plate has a membranous part proximally and a fibrous part distally, which together form the glenoidal ligament or volar plate. This is closely connected to the fibrous sheath of the flexor tendons. MECHANISMS OF INJURY Forced flexion during active extension of the finger can cause rupture of the
medial band and spiral fibres. The two lateral bands slip forwards in front of the axis of the proximal interphalangeal joint and thus become flexors of the proximal interphalangeal joint and over-extend the distal interphalangeal joint. This results in typical "boutonni6re" deformity, or prolapse of the proximal interphalangeal joint, to use the more precise terminology suggested by Van der Meulen (1972). Forced lateral deviation of the finger can cause rupture of the collateral ligament followed, in many cases, by trapping of one of the stumps inside the joint, so that spontaneous healing is impossible. (One of the authors has occasionally observed one of the lateral bands between the articular surfaces.) A very similar picture has been described by Stener (1962) in the thumb. Rupture of the collateral ligament can be associated with laceration of the volar plate: this happens very often in its accessory part. Forced dorsal deviation of the finger can cause rupture of the volar plate, which
may occur in the membraneous portion, in the fibrous portion, or at the fibrous attachment of the latter to the base of the middle phalanx. The Hand--Vol. 7
No. 1
1975
43
Traumatic Lesions of Tendons and Ligaments of the Proxi,mal Interphalangeal Joint --G. Brunelli, E. Morelli, and V. Salvi
Fig. 1. When the clinical symptoms gives positive indication of rupture the stability of the joint must be checked under local anaesthesia. Abnormal lateral deviation (left) indicates rupture of the collateral ligament; abnormal hyperextension indicates rupture of the volar plate (right).
Fig. 2 (a) Dorsal lesions: severe prolapse of the proximal interphalangeal joint is due to complete rupture of the central band of the extensor tendon and the spiral fibres. (b) Lateral lesions: when abnormal lateral deviation is demonstrated under local anaesthesia, the collateral ligament (indicated by the arrow) is completely detached, (c) Volar lesions: on the right the flexor tendon; through the lacerated volar plate (V.P.) the head of the proximal phalanx (P.I.) is visible. DIAGNOSIS
Sudden and intense distraction m a y cause t e m p o r a r y dislocation of the joint by tearing of ligaments, but the appearances afterwards m a y suggest only a simple sprain. W h e n the clinical picture suggests the possibility of rupture of ligaments, a b n o r m a l lateral or dorsal deviation must be assessed u n d e r local anaesthesia (Fig. 1). TREATMENT
P r i m a r y repair Dorsal lesions: Splintage in extension m a y be sufficient in mild prolapse of the proximal interphalangeal joint. Severe cases (Fig. 2a) will need surgery. T h e area is exposed by a dorsal incision and the medial b a n d is reattached to the d o r s u m
44
The Hand---Vol. 7
No. 1
1975
Traumatic Lesions o] Tendons and Ligaments o[ the Proximal lnterphalangeal Joint - - G . Brunelli, E. Morelli, and V. Salvi
of the base of the middle phalanx. If the two lateral bands have slipped downwards they must be attached to the medial band with some stitches. L a t e r a l lesions: Surgery is indicated in a l l complete ruptures of the collateral ligament due to the possibility of interposition, since conservative treatment can lead to severe interference with joint function. The ligament (Fig. 2) is exposed by a lateral incision and is repaired with stitches. V o l a r lesions: When abnormal dorsal deviation is noted under local anaesthesia, surgical repair of the plate is preferable to conservative management. A lateral incision gives a view of the collateral ligament and the volar plate which, as we have said before, m a y b o t h be lacerated. Suture of the divided ligament is sufficient (Fig. 2c),
In our experience primary repair can be carried out for twenty to thirty days after injury, or up to sixty days in the case of young subjects. If the joint is still unstable after this time, or if there is loss of joint function, secondary surgery becomes necessary.
Secondary repair Proximal prolapse can be corrected by means of a number of methods. These are well known and need no further c o m m e n t here. In the case of lateral lesions, collateral ligament function can be restored by a tendon graft passed through two tunnels in the distal part of the proximal phalanx and the base of the middle phalanx. Old volar plate lesions can allow hyperextension or, more frequently because of the retraction and adhesions, a flexion contracture of the proximal interphalangeal joint. Hyperextension deformity can be treated by using one of the procedures proposed for the swan-neck deformity. Flexion deformity must be treated releasing the adhesions a n d excising the volar plate and, if necessary, the accessory collateral ligament (Curtis, 1954).
REFERENCES CURTIS, R. M. (1954) Capsulectomy of the Interphalangeal Joints of the Fingers. Journal of Bone and Joint Surgery, 36A: 1219-1232. ISELIN, F. (1971) Traitement des Entorses et Luxations R6centes des Doigts Monographie du G.E.M. No. 4 Traumatismes Osteoarticulaires de la Main 67-70. Paris. L'Expansion Ed. REDLER, I. and WILLIAMS, J. T. (1967) Rupture of the Collateral Ligaments of the Proximal Interphalangeal Joint of the Fingers. Journal of Bone and Joint Surgery, 49A: 322-326. RODRIGUEZ, A. L. (1973) Injuries to the Collateral Ligaments of the Proximal Interphalangeal Joints. The Hand 5: 55-57. STENER, B. (1962) Displacement of the Ruptured Ulnar Collateral Ligament of the Metacarpo-phalangeal Joint of the Thumb. Journal of Bone and Joint Surgery 44-B: 869-879. VAN DER MEULEN, J. C. (1972) Causes of Prolapse and Collapse of the Proximal Interphalangeal Joint. The Hand 4: 147-153.
The H a n d ~ V o l . 7
No. 1
1975
45
T R A U M A T I C LESIONS OF T E N D O N S A N D L I G A M E N T S OF T H E P R O X I M A L I N T E R P H A L A N G E A L JOINT
G. BRUNELLI, Brescia; E. MORELLI, Legnano; and V. SALVI, Turin This paper reports the experience of the authors in the management of trauma involving the capsule, ligaments and tendons of the proximal interphalangeal joint. Lesions of this type have attracted little attention, particularly in the nonspecialist literature. The general term .sprains, in fact, has been assigned to a large number of lesions that are really open to specific identification, and display different anatomical and pathological patterns. It goes without saying that they require specific treatment. Iselin, F. (1971), Redler and Williams (1967), and Rodriguez (1973), among the most recent papers, have stressed the importance of recognising these lesions and ensuring their correct surgical management. ANATOMICAL PATTERN
The dorsal area contains tendons and ligaments: the central band of the extensor tendon and the two lateral bands held in place by the transverse retinacular ligament. The lateral area includes the collateral ligament running lengthwise from the proximal to the middle phalanx; between the collateral ligament and the volar plate there are some fibres which are called the glenoidal part of the collateral ligament or accessory collateral ligament. In the volar area the volar plate has a membranous part proximally and a fibrous part distally, which together form the glenoidal ligament or volar plate. This is closely connected to the fibrous sheath of the flexor tendons. MECHANISMS OF INJURY Forced flexion during active extension of the finger can cause rupture of the
medial band and spiral fibres. The two lateral bands slip forwards in front of the axis of the proximal interphalangeal joint and thus become flexors of the proximal interphalangeal joint and over-extend the distal interphalangeal joint. This results in typical "boutonni6re" deformity, or prolapse of the proximal interphalangeal joint, to use the more precise terminology suggested by Van der Meulen (1972). Forced lateral deviation of the finger can cause rupture of the collateral ligament followed, in many cases, by trapping of one of the stumps inside the joint, so that spontaneous healing is impossible. (One of the authors has occasionally observed one of the lateral bands between the articular surfaces.) A very similar picture has been described by Stener (1962) in the thumb. Rupture of the collateral ligament can be associated with laceration of the volar plate: this happens very often in its accessory part. Forced dorsal deviation of the finger can cause rupture of the volar plate, which
may occur in the membraneous portion, in the fibrous portion, or at the fibrous attachment of the latter to the base of the middle phalanx. The Hand--Vol. 7
No. 1
1975
43
Traumatic Lesions of Tendons and Ligaments of the Proxi,mal Interphalangeal Joint --G. Brunelli, E. Morelli, and V. Salvi
Fig. 1. When the clinical symptoms gives positive indication of rupture the stability of the joint must be checked under local anaesthesia. Abnormal lateral deviation (left) indicates rupture of the collateral ligament; abnormal hyperextension indicates rupture of the volar plate (right).
Fig. 2 (a) Dorsal lesions: severe prolapse of the proximal interphalangeal joint is due to complete rupture of the central band of the extensor tendon and the spiral fibres. (b) Lateral lesions: when abnormal lateral deviation is demonstrated under local anaesthesia, the collateral ligament (indicated by the arrow) is completely detached, (c) Volar lesions: on the right the flexor tendon; through the lacerated volar plate (V.P.) the head of the proximal phalanx (P.I.) is visible. DIAGNOSIS
Sudden and intense distraction m a y cause t e m p o r a r y dislocation of the joint by tearing of ligaments, but the appearances afterwards m a y suggest only a simple sprain. W h e n the clinical picture suggests the possibility of rupture of ligaments, a b n o r m a l lateral or dorsal deviation must be assessed u n d e r local anaesthesia (Fig. 1). TREATMENT
P r i m a r y repair Dorsal lesions: Splintage in extension m a y be sufficient in mild prolapse of the proximal interphalangeal joint. Severe cases (Fig. 2a) will need surgery. T h e area is exposed by a dorsal incision and the medial b a n d is reattached to the d o r s u m
44
The Hand---Vol. 7
No. 1
1975
Traumatic Lesions o] Tendons and Ligaments o[ the Proximal lnterphalangeal Joint - - G . Brunelli, E. Morelli, and V. Salvi
of the base of the middle phalanx. If the two lateral bands have slipped downwards they must be attached to the medial band with some stitches. L a t e r a l lesions: Surgery is indicated in a l l complete ruptures of the collateral ligament due to the possibility of interposition, since conservative treatment can lead to severe interference with joint function. The ligament (Fig. 2) is exposed by a lateral incision and is repaired with stitches. V o l a r lesions: When abnormal dorsal deviation is noted under local anaesthesia, surgical repair of the plate is preferable to conservative management. A lateral incision gives a view of the collateral ligament and the volar plate which, as we have said before, m a y b o t h be lacerated. Suture of the divided ligament is sufficient (Fig. 2c),
In our experience primary repair can be carried out for twenty to thirty days after injury, or up to sixty days in the case of young subjects. If the joint is still unstable after this time, or if there is loss of joint function, secondary surgery becomes necessary.
Secondary repair Proximal prolapse can be corrected by means of a number of methods. These are well known and need no further c o m m e n t here. In the case of lateral lesions, collateral ligament function can be restored by a tendon graft passed through two tunnels in the distal part of the proximal phalanx and the base of the middle phalanx. Old volar plate lesions can allow hyperextension or, more frequently because of the retraction and adhesions, a flexion contracture of the proximal interphalangeal joint. Hyperextension deformity can be treated by using one of the procedures proposed for the swan-neck deformity. Flexion deformity must be treated releasing the adhesions a n d excising the volar plate and, if necessary, the accessory collateral ligament (Curtis, 1954).
REFERENCES CURTIS, R. M. (1954) Capsulectomy of the Interphalangeal Joints of the Fingers. Journal of Bone and Joint Surgery, 36A: 1219-1232. ISELIN, F. (1971) Traitement des Entorses et Luxations R6centes des Doigts Monographie du G.E.M. No. 4 Traumatismes Osteoarticulaires de la Main 67-70. Paris. L'Expansion Ed. REDLER, I. and WILLIAMS, J. T. (1967) Rupture of the Collateral Ligaments of the Proximal Interphalangeal Joint of the Fingers. Journal of Bone and Joint Surgery, 49A: 322-326. RODRIGUEZ, A. L. (1973) Injuries to the Collateral Ligaments of the Proximal Interphalangeal Joints. The Hand 5: 55-57. STENER, B. (1962) Displacement of the Ruptured Ulnar Collateral Ligament of the Metacarpo-phalangeal Joint of the Thumb. Journal of Bone and Joint Surgery 44-B: 869-879. VAN DER MEULEN, J. C. (1972) Causes of Prolapse and Collapse of the Proximal Interphalangeal Joint. The Hand 4: 147-153.
The H a n d ~ V o l . 7
No. 1
1975
45