SWAN NECK DEFORMITY

DEFINITION

Reverse boutoniere deformity; the proximal interphalangeal joint is hyperexetended and the distal interphalangeal joint flexed.

ANATOMY

Intrinsic Muscle

Lumbricals (ulnar two B,4l) . Dorsal interossei (Dl0) Palmar (volar) interossei (Vl0)

INTRINSIC MUSCLE

INTRINSIC MUSCLE

ETIOLOGY

Reproduced voluntarily by lax jointed individuals Imbalance of extensor versus flexor action at the proximal interpahalangeal joint Laxity of the palmar plate

PATHOMECHANISM

Proximal interphalangeal extensors overact (e.g. due to intrinsic muscle spasm or contracture, after disruption of the distal extensor attachment or following volar subluxation of the metacarpophalangeal joint) Proximal interphalangeal flexors are inadequate (inhibition or division of the flexor superficialis)

PATHOMECHANISM

If the palmar plate fails ( in rheumatoid arthritis, lax-jointed individuals or trauma)

ASSOCIATED DISORDERS
Swan-Neck Deformity

Trauma

NonTrauma

ASSOCIATED DISORDER
Trauma Mallet finger Non-Trauma Rheumatoid arthritis Cerebral palsy Congenital joint laxity Ehlers-Danlos syndrome

RHEUMATOID ARTHRITIS
Stage I ( Proliferative) Synovitis of MCP & PIP joints Stage II (Destructive) Joint & tendon erosions Stage III (Reparative) Joints Instability and tendon rupture

Failure of the palmar plate of the PIP Joint Rupture of the flexor digitorum superficialis Dislocation/subluxation of MCP joint & consequent tightening of intrinsic muscles

SWAN NECK DEFORMITY

MALLET FINGER
The finger tip is forcibly bent during active extension

Direct trauma

Avulsion of extensor tendon from its insertion in the base of the terminal phalanx A tiny flake of bone is pulled of with the tendon A comparatively large fragment of bone is avulsed

CLINICAL MANIFESTATION

CLASSIFICATION
Type I Characteristics Full range of motion No intrinsic tightness No functional limitations Intrinsic tightness Limited PIP motion and an extended MP joint with ulnar deviation corrected Stiff PIP in all positions of the MP joint Radiograph good Severe arthritic changes
Wolfe et al. Finger Deformities. In : Wolfe : Greens Operative Hand Surgery 6th edition

II

III IV

TREATMENT

If deformity correct passively, then a simple ring splint to maintain the proximal interphalangeal joint in a few degrees of flexion may be required. Tenodesis of the proximal interphalangeal joint with a slip of flexor digitorum superficialis stops the hyperextension Temporary K-wire fixation in a few degrees of flexion. Lateral band release from the central slip may be needed. Arthrodesis

TREATMENT
TYPE I DESCRIPTION PIP supple in all MCPJ positions TREATMENT Proximal Fowlers tenotomy, sublimis tenodesis, SORL reconstruction Intrinsic release and/or reconstruction MCPJ Closed manipulation with or without pinning

II III

PIP flexion limited with MCPJ hyperextension PIP flexion limited in al MCPJ positions

IV

Rigid deformity with ankylosis on radiograph

Arthrodesis

TREATMENT
Type I MP Joint PIP Joint Splint Dermadesis FDS sling Littler's ORL reconstruction II III Intrinsic release As for type II MP joint reconstruction as needed As for type I As for type II PIP joint manipulation Skin release Lateral band mobilization Check flexor tendons IV As for type III As for type III Arthroplasty Fusion Fusion Fusion Fusion DIP Joint Fusion

SPLINT

DIP FUSION WITH A SCREW

Before beginning this procedure, the lateral radiograph of the finger should be checked to be sure that the width of the medullary canal of the distal phalanx is sufficient to accept the screw. The DIP joint is exposed and the joint surfaces are prepared as described previously. The medullary canal of the middle phalanx is located with a Kirschner wire. The canal is prepared with either a larger Kirschner wire or the appropriate drill/reamer, depending on the type of screw system selected. A Kirschner wire is inserted through the base of the distal phalanx and into the medullary canal. The wire is driven distally and exits on the tip of the finger just below the hyponychium. A transverse stab wound is made where the Kirschner wire exits. The wire is withdrawn, and the appropriate drill/tap is inserted through the stab wound, into the tuft of the distal phalanx, and advanced proximally until it emerges at the base of the phalanx. The appropriate length of screw is inserted and advanced until it emerges at the base of the distal phalanx. The screw tip is aligned with the hole in the middle phalanx under direct vision and then advanced with the fusion surfaces held tightly together. The trailing threads of the screw are recessed into the tuft. If a Herbert-type screw is used and the screw is too long, there may be a sudden loss of fixation as the leading thread passes through the isthmus into the softer and wider portion of the phalanx. Rotatory stability can be augmented by inserting a 0.028- or 0.035-inch Kirschner wire parallel to the screw. Intraoperative radiographs are obtained to confirm proper placement and length of the screw

DIP FUSION WITH A SCREW

DERMADESIS

Dermadesis is an operative approach that is used rarely in patients with type I swan neck deformities. This procedure attempts to prevent PIP joint hyperextension by creating a skin shortage volarly. An elliptic wedge of skin (4 to 5 mm at its widest point) is removed from the volar aspect of the PIP joint. Care is taken to preserve the venous network just under the skin and to not open or disturb the underlying flexor tendon sheath. The skin is closed with the PIP joint in flexion. This technique is helpful only in mild cases and usually fails unless it is done in conjunction with other procedures, such as DIP joint fusion. When the PIP joint hyperextension is primary, we prefer to use a stronger checkrein against hyperextension.

Flexor Tendon Tenodesis (Sublimis Sling)

Patients with PIP joint hyperextension maintain full passive motion but, as the hyperextension increases, begin to have difficulty initiating active flexion. These patients require restoration of strong volar support to the joint. We prefer the use of FDS tenodesis to prevent PIP joint hyperextension. A volar zigzag incision is made over the PIP joint to expose the flexor tendon sheath. The thin portions of the sheath on either side of the A3 pulley are excised while preserving the pulley. The flexor tendons are exposed, and care is taken to avoid injury to the vincula passing between the FDS and FDP tendons. One slip of the FDS is divided approximately 1.5 cm proximal to the joint. This portion is separated from its corresponding slip but is left attached distally. With the joint in 20 to 30 degrees of flexion, the detached slip is fixed proximally to act as a checkrein against extension. The proximal attachment can be made directly into the bone by using a bone anchor or pull-out wire, or it can be made at the thickened

Sublimis Sling

RETINACULAR LIGAMENT RECONSTRUCTION

Littler devised a clever technique to prevent hyperextension while restoring DIP joint extension by reconstructing an oblique retinacular ligament with the ulnar lateral band. In this procedure, the ulnar lateral band is freed from the extensor mechanism proximally but left attached distally. It is passed volar to Cleland's fibers to bring it volar to the axis of PIP joint motion. We pass the tendon slip to the opposite side of the finger and suture it to the fibrous tendon sheath under enough tension to restore DIP joint extension and prevent PIP hyperextension. In theory, this approach should solve both the DIP and PIP joint problems simultaneously. However, in a rheumatoid patient who has a primary mallet deformity with destruction of the terminal tendon, no amount of tension applied to the relocated lateral band will restore DIP joint extension. Thus, the net result of this procedure is restriction of PIP joint hyperextension. In patients with rheumatoid arthritis, it is an alternative to dermadesis or flexor tenodesis.

INTRINSIC RELEASE

Intrinsic muscle release is performed through a dorsal ulnar longitudinal incision over the proximal phalanx, as described earlier. After release, PIP joint flexion with the MP joint extended or radially deviated should be improved. Intrinsic release can be combined with DIP or PIP joint procedures (or both) to restore balance. In patients with associated MP joint disease, MP joint alignment is corrected by implant arthroplasty. Although MP joint arthroplasty (Swanson) with resection of the metacarpal heads does lengthen the intrinsic tendon, we prefer to resect the ulnar intrinsic tendon as well to reduce the risk for recurrent intrinsic tightness and ulnar drift of the fingers

PROXIMAL INTERPHALANGEAL JOINT MANIPULATION

In patients with stiff swan neck deformities, the soft tissues have contracted about the joint. However, with the patient under anesthesia, it is sometimes possible to obtain 80 to 90 degrees of PIP joint flexion by gentle manipulation. PIP joint manipulation is rarely performed alone; it is usually done in conjunction with intrinsic release, MP arthroplasty, or flexor tenosynovectomy. If the joint is splinted in the flexed position, the tight soft tissues will stretch. After several weeks, the passive motion obtained by manipulation and splinting can be maintained as active motion, provided that the flexor tendons have not become adherent. When done in conjunction with MP arthroplasty, temporary Kirschner wire fixation is used to hold the PIP joint in flexion. This concentrates the postoperative exercises on MP joint motion. After 10 days, the pins are removed and therapy is directed toward increasing PIP joint motion by using an extension block splint to prevent full extension of the joints. As stated previously, this method has restored 80 to 90 degrees of PIP joint flexion in joints that had been stiff.

When PIP joint manipulation is performed in conjunction with flexor tenosynovectomy, the joints are not pinned but are splinted in the flexed position postoperatively. Usually, after 24 to 48 hours of splinting, therapy can be initiated with extension block splints. Therapy includes active PIP range of motion exercises, with careful splinting in flexion between exercise periods. Initially, exercises are done for 5 minutes, four to six times daily, and increased as pain and endurance allow. Splinting is continued for 2 to 4 weeks, depending on the range of motion obtained. If an extensor lag of the PIP joint develops, extension splinting may be necessary

SKIN RELEASE

The dorsal skin may limit the amount of passive flexion that can be achieved by manipulation. At some point during the manipulation of long-standing fixed deformities into flexion, the dorsal skin blanches. If this blanching is not relieved, skin necrosis occurs directly over the joint. Dorsal skin tension can be minimized with an oblique incision just distal to the PIP joint, which allows the skin edges to spread. The defect created is the result of skin contracture (not loss) and closes gradually in 2 to 3 weeks. Although initially we used skin grafts to cover these defects, satisfactory healing by secondary intention has convinced us that grafts are not needed. In fact, leaving this portion of the wound open allows drainage and reduces postoperative swelling and pain. It is important that the skin be released distal to the joint so that the extensor mechanism overlying the joint is covered.

SKIN RELEASE

LATERAL BAND MOBILIZATION

In established swan neck deformities, the lateral bands are displaced dorsally. Their normal volar shift is lost, and the finger has limited flexion. We have found that freeing the lateral bands from the central slip with two parallel longitudinal incisions in the extensor mechanism allows the joint to be manipulated gently into full flexion without releasing the collateral ligaments or lengthening the central slip. Full passive flexion can often be achieved by this method. When the procedure is performed under local anesthesia, shifting of the lateral bands volarward on flexion and relocation of them dorsally on extension can be observed during active motion.

PIP ARTHROPLASTY

PIP silicone arthroplasty was originally used in 1966 in conjunction with silicone implants for the MP joints in rheumatoid arthritis. Over the years the indications have changed, and we now find the procedure most useful with degenerative arthritis and certain cases of traumatic arthritis. Swanson's single-piece polymeric silicone spacer has been the arthroplasty implant of choice for several decades. Use of the flexible silicone spacer was designed to facilitate the development of a fibrous capsule that would provide a pain-free and functional PIP joint.

INDICATION Persistent PIP joint pain

CONTRAINDICATI ON
Infection

Bone loss Swan neck deformity with joint destruction

Unstable joint

Severe flexion deformity