Nonoperative treatment of camptodactyly

Camptodactyly: From Embryological Basis to Surgical Treatment

Camptodactyly is a relatively rare hand deformity presenting as the proximal interphalangeal joint's nontraumatic and progressive flexion contracture. Most cases are limited to the fifth finger. The severity and type of camptodactyly should be considered to optimize treatment. Since many structures at the finger base can be involved in the pathogenesis of the deformity, surgical treatment for this particular type of deformity is challenging. This paper aims to bring insight into camptodactyly's pathogenesis and treatment options. We discuss the indication and pitfalls of surgical treatment options for particular camptodactyly types and present a case of a fourteen-year-old boy who was admitted to our department with proximal interphalangeal joint flexion contracture of the left fifth digit.

Surgical Treatment of Camptodactyly with Malek Cutaneous Approach and Stepwise Release: A Retrospective Multi-centre Study

Background: Clinical manifestations of camptodactyly are varied and no official consensus on the etiopathogenesis or best treatment is available. Conservative treatment is generally preferred and, in refractory patients, surgery might be considered. However, reported results of surgery are often unsatisfactory and it is difficult to compare outcomes as different classification systems are adopted. We reported the outcomes of surgical treatment of camptodactyly with the Malek cutaneous approach and stepwise release, assessed using the Siegert classification. Methods: A retrospective analysis of paediatric patients (≥1 and ≤18 years) with congenital camptodactyly refractory to conservative management (flexion contracture >30°), treated with Malek cutaneous approach and stepwise release surgery between June 2009 and June 2019 with at least 1 year of follow-up was performed. Pre- and post-operative clinical and radiographic assessments were evaluated for degrees of flexion contractures and early (<30 days) or late (>30 days) complications were recorded. Results: A total of 59 patients underwent surgery, of whom 38 (64%), including 42 fingers, were enrolled; mean patient age was 8 years (range 1-18). Post-operative mean flexion contracture was significantly improved (p > 0.001) and no infections were recorded. Mean follow-up was 6 years (range 1-10) and proximal interphalangeal joint extension deficits were rated according to Siegert classification as excellent (69%), good (12%), or fair (9.5%) and poor (9.5%). Conclusions: The Malek cutaneous approach and stepwise release of the retracting soft tissues allow prompt evaluation of the anatomical structures involved in the deformity and seem to be an effective surgical correction in the long term. Level of Evidence: Level IV (Therapeutic).

Estratégia para o tratamento conservador da camptodactilia de tipo III em criança com síndrome de Beals-Hecht

Os autores apresentam um caso bem-sucedido no tratamento conservador da camptodactilia de tipo III em paciente com síndrome de Beals-Hecht. A camptodactilia é uma deformidade em flexão da articulação interfalangeana proximal (IFP), no sentido anteroposterior, indolor, e bilateral em 2/3 dos casos. A de tipo III é a forma mais grave e incapacitante, pois geralmente acomete vários dedos e está associada a síndromes e outras malformações. O caso apresentado teve a correção alcançada com o uso sistemático de órteses estáticas iniciado aos 7 meses de idade e concluído após 23 meses e meio de intervenção.

Surgery and Conservative Management of Camptodactyly in Pediatric Patients: A Systematic Review

Camptodactyly is a pediatric hand condition, the treatment of which remains controversial. The authors' aim was to improve patient care through clarifying the definition of camptodactyly and indications for surgical and/or conservative management, summarizing outcomes, and defining risks. A systematic review was conducted of articles in all languages on outcomes following surgical and/or conservative management of idiopathic camptodactyly in children using MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, EMBASE (Excerpta Medica database), AMED (Allied and Complementary Medicine), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) (until January 2017). The primary outcome was posttreatment flexion contracture, and the secondary outcomes were indications for surgery, complications, and patient satisfaction. Database searching generated 16 final articles, with 7 case series and 9 retrospective cohort studies. There was a lack of consistency on the definition of camptodactyly and in outcome reporting. All 16 studies received a "Weak" global rating and demonstrated low-quality evidence, suggesting that treatment of camptodactyly with operative or nonoperative measures reduces the degree of flexion contracture in most patients (from pretreatment averages of 20°-85° to posttreatment averages of 5°-37°). There was general agreement that surgery should be reserved for contracture >30° or failure to respond to conservative management. Surgery generally led to more complications compared with conservative management. Only one study reported on functional limitations, and another reported on patient-reported outcomes. Current evidence of the effectiveness of camptodactyly treatment in addressing both joint-specific deformity and patient-perceived function and appearance is insufficient to guide patient care. Future research may consider the development of decision aids to guide patients and families through selecting management strategies and to promote shared decision making.

Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With Camptodactyly

PURPOSE

The aims of this study were to verify proximal phalangeal head normalization after a stretching exercise in patients with infantile-type camptodactyly and to propose radiographic indices for quantifying bony deformities.

METHODS

Forty-eight fingers of 20 patients with camptodactyly were enrolled in this study. All patients and their parents received instruction on how to perform the stretching exercise. The qualitative assessments of proximal phalangeal head remodeling were conducted by consensus of 2 hand surgeons. Two radiographic parameters, head triangle ratio (HTR) and head angle (HA), were measured on finger lateral radiographs taken at the initial visit and at 12-month follow-up. The intra- and interobserver reliability of both parameters was assessed. Those parameters of the patients were compared with those of 177 fingers of 80 children without camptodactyly. The extent of proximal interphalangeal (PIP) joint flexion contracture was used to evaluate clinical outcomes resulting from nonsurgical treatment.

RESULTS

Qualitative assessments of proximal phalangeal head remodeling exhibited meaningful improvements. Both radiographic parameters showed significant change between their status before and after intervention and had excellent intra- and interobserver reliability. Average PIP joint flexion contracture significantly improved. In the noncamptodactyly group, neither parameter showed significant differences in accordance with finger types and age ranges.

CONCLUSIONS

Stretching improved movement within the proximal phalangeal joint and helped to restore proximal phalangeal head roundness and concentricity in patients with infantile-type camptodactyly. The HTR and HA would be useful indices for objectively assessing the degree of bony deformity in patients with camptodactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treating Congenital Proximal Interphalangeal Joint Contracture

The management of congenital proximal interphalangeal joint deformity, also known as camptodactyly, is challenging. There are numerous theories on the cause of this abnormal finger posture, leading to variations in classification, definition, and treatment approaches. This article assesses the previous literature and provides clarity and guidance for the practical treatment of camptodactyly.

Early Results of Surgical Management of Camptodactyly

BACKGROUND

We hypothesize that surgery for moderate-to-severe camptodactyly (>50 degrees) results in modest gains in range of motion and improved digital position.

METHODS

A retrospective analysis of patients undergoing surgery for camptodactyly at a tertiary children's hospital between 2000 and 2014 was performed. Surgery was indicated for patients with persistent, functionally limiting flexion contractures despite observation, therapy, and splinting. Data were collected on demographics, clinical history and presentation, nonoperative management, surgery, and clinical follow-up, focusing on range of motion at the involved joint. Total passive motion (TPM) and total active motion (TAM) at the proximal interphalangeal (PIP) joint was calculated at presentation, preoperative visit, first postoperative visit out of the cast, and last follow-up visit. Average postoperative follow-up was 1.4 years.

RESULTS

In total, 31 digits in 22 patients were reviewed. There were 13 males; average age at surgery was 9.6 years. There were 7 type I (infantile), 8 type II (adolescent), and 7 type III (syndromic) patients. All cases involved the PIP joint; 55% involved the small finger. All patients underwent sequential release of contracted structures until maximal extension without compromising vascularity or joint stability was obtained. Z-plasty of the volar skin was performed in 68% of digits, flexor digitorum superficialis tenotomy in 77%, volar plate release in 58%, and collateral ligament release in 48%. All patients were casted postoperatively for an average of 31 days, and 71% of digits had temporary transarticular pin fixation. At initial presentation, mean TPM and TAM were 34 and 24 degrees, respectively. TPM and TAM were 32 and 19 degrees immediately preoperatively, 30 and 13 at the first postoperative visit, and 35 and 25 at the final follow-up. Furthermore, the position of PIP arc of motion was in a more extended position postoperatively. Average TPM arc of motion was from 50 to 82 degrees preoperatively and 28 to 63 degrees at final follow-up; average TAM arc of motion was 62 to 81 degrees preoperatively and 30 to 55 degrees at final follow-up. There were no clinically meaningful differences in results based on camptodactyly type, preoperative motion, or age at surgery. There were no cases of wound infection or dehiscence. Two patients with recurrent contractures opted for subsequent PIP arthrodesis.

CONCLUSIONS

Total motion of the PIP joint was similar both preoperatively and postoperatively following surgical release of camptodactyly. However postoperatively, the digit was in a more extended position over this arc of motion. For patients with functionally limiting flexion contractures, surgical release may be beneficial by providing a more extended position, for improved digital release, hygiene, and esthetics.

LEVEL OF EVIDENCE

Level IV.

Management of complications of congenital hand disorders

This article reviews treatment and presents complications seen in the treatment of 7 common congenital hand differences, including syndactyly, camptodactyly, ulnar and radial polydactyly, thumb hypoplasia, radial longitudinal deficiency, and epidermolysis bullosa. The management of these conditions is challenging but has evolved over the last several decades with refined understanding of the disease processes and treatments. The goal of this article is to synthesize prior knowledge and provide further insights into these conditions that will help the surgeon avoid treatment complications.

A review of conservative management of camptodactyly in children and adolescents

Introduction

The purpose of this review was to systematically evaluate the best available evidence for the conservative management of children and adolescents diagnosed with camptodactyly and propose recommendations to guide clinical practice.

Methods

A search of six electronic databases and manual searches were carried out in January 2014. The search strategy aimed to identify any published clinical practice guidelines as well as articles on the conservative management of camptodactyly for children and adolescents. Included articles were appraised using the McMaster Critical Review Forms for quantitative studies and assigned a level of evidence according to the National Health and Medical Research Council guidelines.

Results

No published clinical practice guidelines were located; however, five quantitative articles met the inclusion criteria from the 31 articles identified. The evidence from all included studies was classified according to the National Health and Medical Research Council guidelines as level IV, pre–post study design. All were retrospective. Included studies demonstrate clinically significant changes in passive joint range of motion following conservative treatment protocols. The results of the literature review, combined with clinical experience, were used to develop recommendations to guide clinical practice in the conservative management of children and adolescents with camptodactyly.

Discussion

The effectiveness of conservative therapy for camptodactyly is promising but evidence remains weak. More rigorous research is needed and the proposed recommendations could be used to inform future research for the conservative treatment of camptodactyly in children and adolescents.

Multidigit camptodactyly of the hands and feet: A case study

A clinical case of a 12-year-old boy who presented with multidigit, nonsyndromal, progressive camptodactyly is discussed. While bilateral little finger camptodactyly is well described, there is no documentation of camptodactyly involving all fingers and many toes as well as both proximal (PIP) and distal interphalangeal (DIP) joints. This patient responded well to surgery, which was performed on four toes and seven fingers, despite having established radiographic changes of camptodactyly in the PIP joints as well as two DIP joints. This case illustrates that in the skeletally immature patient, successful surgical outcomes can occur even in patients with radiographic bone changes, which themselves may be reversible following PIP contracture release. This patient's separate fingers presented with deformity at different stages. A single patient with multiple digit involvement is illustrative of the range of clinical presentations and treatment options for camptodactyly. This article serves to inform hand surgeons about the potential consequences of avoiding surgical treatment, the need for a severity staging system, and the breadth of presentations in camptodactyly.

Effect of passive stretching on simple camptodactyly in children younger than three years of age

PURPOSE

To present the effectiveness of passive stretching as a treatment for camptodactyly, without any other form of physiotherapy or splinting.

METHODS

From May 2003 to August 2008, 61 digits of 22 patients were treated conservatively using passive stretching exercises. All children were less than 3 years old and had no other anomalies. Flexion contractures before and after treatment in mild, moderate, and severe groups were measured and changes were analyzed statistically. The correlations between various clinical factors and treatment outcome were also analyzed statistically. The average follow-up period was 26 months (range, 12-47 mo).

RESULTS

Mean flexion contracture improved from 20° to 1° in the mild group (p < .001), from 39° to 12° in the moderate group (p < .001), and from 75° to 28° in the severe group (p < .001). Of the clinical factors examined, only initial flexion contracture was found to be significantly correlated with treatment outcome (r = -0.287, p = .0025).

CONCLUSIONS

Passive stretching can effectively improve flexion deformity in camptodactyly in infants and young children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Failure of differentiation: Part II (arthrogryposis, camptodactyly, clinodactyly, madelung deformity, trigger finger, and trigger thumb)

The term "failure of differentiation" describes the phenotypes of a large number of otherwise unrelated conditions. The six conditions described here (arthrogryposis, camptodactyly, clinodactyly, Madelung deformity, trigger finger, and trigger thumb) are believed to occur because various structures failed to differentiate normally; however, they have neither common features nor a common cause. We have included information about the history and diagnosis of these conditions, the cause (if known), and the current concepts of treatment and expected outcomes.

Camptodactyly as a Spectrum of Congenital Deficiencies: A Treatment Algorithm Based on Clinical Examination

BACKGROUND

Camptodactyly is a frequent congenital hand disorder, but its cause and treatment remain a matter of controversy. Although it is difficult to establish the primary cause of camptodactyly, careful clinical examination allows the assessment of all the structures involved (e.g., skin, subcutaneous fascia, flexor tendons, extensor tendon, intrinsic muscles, and joints). The purpose of the study was to assess the validity of an algorithm based on the clinical examination in planning the operation.

METHODS

An algorithm based on clinical examination and the authors' 27-year experience was designed to determine and customize the surgery for each case according to the function of the anatomical structures involved. The authors compared the results of surgical treatment in two groups of patients with camptodactyly of the fifth finger operated on before (group 1, 33 patients) or after use of the algorithm (group 2, 35 patients). All patients had more than 1 year of follow-up (range, 21 to 47 months).

RESULTS

There were significantly fewer failures in group 2 (14 percent versus 45.5 percent, p < 0.01). The improvement, after an extensive liberation in stiff early cases (type Ia), gave better results than previous attempts but did not reach significance (84 percent versus 66 percent). Similarly, for types Ib (early and correctable) and IIb (late and correctable) camptodactyly, the surgical results were improved, with 91 percent and 90 percent improvement, respectively, in group 2 versus 50 percent and 44 percent in group 1 (not significant).

CONCLUSION

A selective surgical indication, based on careful clinical examination, improves the results of camptodactyly treatment by correcting the involved anatomical components.

Distraction - A Minimally Invasive Technique for Treating Camptodactyly and Clinodactyly

Camptodactyly and clinodactyly are relatively common congenital anomalies affecting about 1% to 2% of the general population. Though functional impairment is uncommon other than in very severe cases, patients affected do present very often for correction. The kind of surgeries available is as diverse as the aetiology of the conditions. It ranges from simple release of the flexor digitorum sublimis (FDS) to more complex small muscle transfers, rebalance etc. In this short series a relatively easier, minimally invasive technique of distraction has been used to correct these deformities with gratifying results.

[Camptodactylies]

Camptodactyly is a permanent non-traumatic flexion contracture at the proximal interphalangeal joint, involving most of the time the fifth finger. This condition is rare (incidence is inferior to 1%). Most of the cases are sporadic, although some authors have traced the transmission through several generations. Two types of camptodactyly have been described, depending on the age of onset (within the first year of age or in adolescent). This condition can also be described as "static" or "dynamic", depending on the effect of MP flexion on the PIP extension lag. Many anatomical abnormalities have been evoked as potential aetiology for camptodactyly, including variations in the lumbrical or flexor superficialis origin or distal insertions. However, after a few years without treatment, permanent flexion position of the joint adds its own effects and leads to joint contracture, regardless of the aetiology of camptodactyly. Treatment is required for this condition for extension deficit greater than 30 degrees. The first step will always consists of dynamic splinting of the PIP joint. If improvement is not obtained through dynamic splinting alone, surgery can be considered. Correction of a well defined anatomical abnormality is part of the treatment. When required, it will be associated to correction of joint and soft tissue contracture.

Camptodactyly: a unifying theory and approach to surgical treatment

Camptodactyly is an isolated congenital flexion deformity of the proximal interphalangeal (PIP) joint. Surgical experience with 16 patients (18 fingers) between June 1983 and December 1994 is reported. Skin, fascia (retinaculum cutis), tendon sheaths, flexor digitorum superficialis tendon, lumbricals and interossei (particularly the lateral bands), joint surfaces, neck of the proximal phalanx, and central slip insertion were involved in all cases, although the degree of involvement can vary. Surgery must address all of these structures. Postoperative splinting is important. Fifteen patients had good or excellent results after surgery, with a mean gain in motion of 57 degrees (range, 0 degrees-90 degrees). Surgery should be aimed at prevention of progressive deterioration and is probably not indicated in minor degrees of the deformity. Surgery should be reserved for patients with a preoperative PIP joint contracture of more than 60 degrees.

[Camptodactyly: classification and therapeutic results. Apropos of a series of 50 cases]

Fifty patients with camptodactyly of one or several fingers were seen in the Strasbourg SOS Main unit between 1980 and 1988. Classification of these lesions was based on the mobile or fixed nature of the deformity in flexion of the interphalangeal joint. This classification is useful for the therapeutic management. Treatment by dynamic splint for a mean duration of 20 months gives good results in fixed or mobile camptodactylies of small children, provided that this treatment is commenced as soon possible. This splint treatment also obtains favorable results in patients reaching the end of the growth period, whether their camptodactyly is mobile or even, in some cases, fixed. In every case, treatment by dynamic splint constitutes a therapeutic test (safety of the apparatus, patient's cooperation) and only forms of camptodactyly resistant to conservative treatments benefit from Malek's type of surgical correction. It must be remembered that a certain number of cases of camptodactyly have a potential for severity with time, progressing towards irreducible forms which can only be corrected by surgical treatment. Camptodactyly in adults must be analysed meticulously and only major deformities causing functional discomfort or major aesthetic prejudice should be operated.

Long-standing extended dynamic splintage and release of an abnormal restraining structure in camptodactyly

62 patients with camptodactyly of the little finger have been reviewed, and only five cases failed to respond to conservative treatment. These cases are reported. One patient could straighten the deformed PIP joint with snapping, and the other two were resistant to conservative treatment and were found to have a restraining structure requiring release. These findings are in keeping with an imbalance between flexion and extension forces due to long-standing malposition of the extensor lateral bands. Operative treatment should be reversed for cases of failed conservative treatment, which should be started as early as possible.

The anatomy and treatment of camptodactyly of the small finger

Having observed an anomalous insertion of the lumbrical muscle in 74 consecutive operations for correction of camptodactyly of the small finger, we have concluded that the loss of normal lumbrical action is the principal cause of the intrinsic minus deformity seen in this condition. Other anatomic abnormalities observed in this series of patients are those of the superficial tendon in 47%, the x-ray appearance of the proximal interphalangeal (PIP) joint in 15%, and a fixed flexion contracture of the PIP joint in 66%. Fifty-seven percent of our patients had PIP flexion contracture of more than 45 degrees. To determine the contribution of these anomalies to this deformity, we analyzed a series of 53 patients who had been followed up for at least 1 year. The study revealed that these conditions are interdependent and that each had an adverse effect on the final operative results. Treatment included a transfer of the superficial tendon of the ring or little finger to the extensor mechanism of the little finger in all cases and other procedures as dictated by the individual situation. Overall, the joint contracture was reduced from 49 degrees to 25 degrees, but only 33% of the patients regained full flexion of the small finger.

Correction of Camptodactyly

Extensor indicis proprius has been used as a transfer to overcome passively correctable camptodactyly. The transferred tendon is accessible, expendable and synchronous. Early results are encouraging.

Cloward technique for obtaining iliac crest bone graft in hand surgery

From a review of 57 patients with flexion deformity of the fingers (camptodactyly), 21 patients with 38 digits treated operatively had 18% good or excellent results, whereas 14 patients (41 digits) treated conservatively had 66% good or excellent results. Mild deformities responded well to splints and stretching. Moderate deformities treated operatively gained extension but at the loss of finger flexion. Severe deformities had improvement in extension (averaging 19° in operative cases and 27° in conservative), but there was significant loss of flexion in the operative group. Overall, 16 of 21 patients had loss of flexion after operative treatment. Conservative treatment of camptodactyly is recommended for digits with less than 60° lack of extension. Operative treatment should be reserved for failed conservative treatment. Early joint motion post-operatively appears essential and surgical procedures that immobilise the P.I.P. joints should be avoided.

Improvement in the surgical results of treatment of duplicated thumb by preoperative splinting

Seven patients with an angular deformity of their duplicated thumb were treated by splinting and taping before operation. In all patients, the angular deformity of the interphalangeal joint improved within a few months, and surgical centralization and osteotomy were not necessary. Furthermore the design of the fillet flap was easier and more accurate as was the adjustment of the joint ligament tension. After operation there was no recurrence of angular deformity, and the range of motion of the interphalangeal joint was good. We believe that this procedure simplifies the operative approach, making it more precise and helping to prevent postoperative complications in patients with angular deformity.