EXPERTISE
Dupuytren Contracture
What is Dupuytren contracture?
This is a progressive disorder in genetically susceptible individual leading to flexion deformity of fingers.
These patients have inability to keep the fingers extended and may have associated pain and restriction in daily activities.
Case History
This 43-year-old patient presented with inability to fully extend the ring finger of both hands with severe involvement in right hand.
He underwent fasciotomy and subsequent supervised physiotherapy.
Two weeks post-surgery he has good finger extension.
He is waiting for the surgical correction of his contralateral finger flexion deformity.
Surgical correction in early stage will hamper the progression of disease and restore functional ability of the individual.
Flexion Deformity of Fingers
What is Flexion deformity of fingers?
It is a flexed atitude of tingers with lack of extension. It reduces the hand span and the extension of fingers.
It can be static or progessive.
Inspite of multitude of causes , volar skin contracture can be corrected by a special surgical technique ,”z” plasty where a normal tissue is transposed to break the contracture band.
This procedure reduces the chance of further recurrence of the deformity.
Case History
This 36 year old woman presented with flexion deformity of ring finger following an superficial abcess which burst open and healed secondarly leaving a flexion deformity of little finger for more than 4 years.
She underwent contracture release and multiple serial ‘z’ plasty for the correction of deformity.
Most important in correction of flexion deformity is preservation of vascular supply of the digit.
Flexor Tendon Reconstruction
How reconstruction differs from primary repair?
Reconstruction of flexor tendon can be done in single stage or multiple stage depending on the patency of flexor tendon sheath and pulley system.
If the patency of osseous fibrous sheath of fingers are intact, single stage reconstruction of flexor tendon is done using tendon graft or fascia lata.
If the patency of osseous fibrous sheath of fingers are lost, then stage 1 reconstruction of pulley system, followed by flexor tendon reconstruction.
Is post operative physiotheraphy is must?
Yes. Strict supervised physiotheraphy is most important.
Case History
18 year old girl presented 1 month after a knife cut injury with inability to flex the left middle finger, with a transverse scar at the base of the finger.
On exploration, proximal end has retracted upto the mid palm and the defect is about 8 cms.
Palmaris longus graft was harvested by multiple transverse incision over the volar aspect of the forearm.
Graft was tunnelled beneath the pulley system and reconstruction of the flexor digitorum profundus done.
At the end of surgery finger cascade was restored.
She underwent a strict flexor tendon reconstruction protocol for 3 months for the better function of her hand.
Flexor Tenosynovitis
Clinical features of flexor tenosynovitis
- Fusiform swelling of the digit
- Flexed attitude of the digit
- Pain on passive extension of the digit
- Limitation of finger flexion
Why it needs debridement?
In digits, the flexor tendons lie in a closed fibro osseous tunnel. Tenosynovitis will increase the intra compartment pressure of the digit and causes the ischemic necrosis of the flexor tendons. So early debridement will preserve the vascularity of the flexor tendon.
Why early post operative mobilisation?
To prevent tendon adhesion to the surrounding structures.Case History
38 yr old female nursing assistant presented with a swollen left index finger following a needle prick injury.
She was diagnosed to have flexor tenosynovitis.
She underwent emergency flexor tenosynovectomy.
On the 2nd post operative day she was started on finger mobilisation exercises.
At the end of 1 month she regained her full finger function.
Degloving Injury
What is a degloving injury?
Injury that causes the separation of the skin and subcutaneous tissues from the underlying fascia thereby causing vascular insult to the skin and subcutaneous tissues.
Why flap for volar aspect of hand?
Volar aspect of the hand with exposed flexor tendons and bones need a flap to preserve the hand function. Grafting these wound will create a stiff hand.
Success in these cases depends on the initial thorough debridement, early soft tissue cover in the form of groin flap and supervised physiotheraphy.
Case History
24 year old male had presented three days later ,with foul smelling discharge, a degloving injury to the right upper limb with gangrenous skin around arm & gangrenous little finger following a run over by a lorry.
He underwent a multi stage procedure for the salvage of his limb.
Emergency debridement under supraclavicular block done.
3 days later raw area over the arm was covered with split thickness skin graft.
Groin flap cover was done to cover the volar and ulnar palmar of the right hand.
Flap division done at the end of 1 month and mobilization started.
At the end of 3 months, patient is able to do all his activities and returned to his work.
Thumb Hypoplasia
- 1st web space contracture release
- Opponensplasty using FDS of ring finger along with ulnar collateral ligament reconstruction of 1st MCP joint
- Extensor indices proprius transfer for thumb extension.
3 year old boy presented with hypoplastic left thumb with inability to grasp objects using left thumb as it is in palm due to lack of extension.
He also had 1st web space contracture and lack of thenar muscles.
He had instability at 1st MCP joint.