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Hand Surgery and Rehabilitation xxx (2018) xxx–xxx

Available online at

ScienceDirect
www.sciencedirect.com

1
2 Literature review

3 Management of posttraumatic finger contractures in adults

4 Traitement des raideurs post-traumatiques des doigts chez l’adulte
5 R. Michel
6 Chirurgie orthopédique-chirurgie de la main, institut locomoteur Pierre–Paul Riquet, hôpital Purpan, CHU de Toulouse, place Baylac, 31059 Toulouse cedex,
7 France

A R T I C L E I N F O A B S T R A C T

Article history: This lecture will focus on posttraumatic finger contractures affecting the metacarpophalangeal (MCP)
Received 17 July 2017 and proximal interphalangeal (PIP) joints in adults. The pathophysiology, main causes and essential
Received in revised form 18 May 2018 rehabilitation methods that can be used before resorting to surgical treatment are described, along with
Accepted 8 June 2018
the clinical examination. The goal is to define the surgical indications, even though the literature shows
Available online xxx
the functional outcomes are disappointing. While there is little to no change in a joint’s angular
amplitude, the functional range of motion can be improved. There is practically no functional
Keywords:
improvement except in cases of MCP extension contracture. For the PIP joint, the aim is to shift the range
Contracture
Stiffness
of motion into the functional range. Surgical approaches, surgical techniques and rehabilitation
Finger protocols are described in detail.
C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Proximal interphalangeal
Metacarpophalangeal
Arthrolysis
Tenoarthrolysis. R É S U M É

Les raideurs des doigts intéressant les articulations métacarpo-phalangiennes (MCP) et interphalan-
Mots clés : giennes proximales (IPP) d’origine post-traumatiques chez l’adulte sont développées dans cette
Raideurs conférence d’enseignement. Les aspects physiopathologiques, les causes principales et les méthodes de
Doigt rééducation indispensables à utiliser avant de proposer un geste chirurgical sont exposées, ainsi que
Interphalangienne proximale l’évaluation clinique. Le but poursuivi était de préciser les indications chirurgicales, sachant que la
Métacarpophalangienne littérature montre que les résultats fonctionnels sont décevants. Les gains angulaires sont nuls, seul le
Arthrolyse secteur de mobilité utile peut être amélioré. L’amélioration est quasi nulle sur le plan fonctionnel, sauf
Ténolyse pour les raideurs en extension des MCP ; pour les IPP, on déplace le secteur de mobilité vers un secteur
plus utile. Les voies d’abord, les techniques chirurgicales et la prise en charge par les rééducateurs sont
détaillées.
C 2018 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés.

8
9 1. Definitions and scope Metacarpophalangeal; Arthrolysis; Tenoarthrolysis’’. Recent publi- 17
cations were favored except for seminal works, in particular the 18
10 A finger contracture occurs when the active and passive range 1980 SoFCOT symposium on this topic [1]. 19
11 of motion (ROM) between two finger segments is reduced. The Contracture must be differentiated from finger deformity. This 20
12 scope of this lecture will be limited to posttraumatic finger excludes a locked trigger finger and PIP flexion deformity due to 21
13 contractures (excluding the thumb) in the metacarpophalangeal Dupuytren’s disease or skin adhesions (unless the joint itself is 22
14 (MCP) and proximal interphalangeal (PIP) joints in adults. stiff). Also excluded are contractures due to malunion or 23
15 A review of literature on Pubmed was done with the keywords posttraumatic osteoarthritis, which is where imaging comes into 24
16 ‘‘Contracture; Stiffness; Finger; Proximal interphalangeal; play, and fixed posttraumatic flexion contractures, which are very 25
challenging to treat. 26
Thus, finger contractures have a predominant articular compo- 27
E-mail address: rongieres.m@chu-toulouse.fr
nent and sometimes a tendinous one [1]. It is also important to 28

https://doi.org/10.1016/j.hansur.2018.06.003
2468-1229/ C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.

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29 consider—both in terms of causes and surgical technique—the contracture is very rare. However, PIP flexion contracture of 808 is 89
30 trophicity and tissue balance, hence the health of the skin, blood very disabling, as is a severe extension contracture that prevents 90
31 vessels and nerves in the affected finger, along with bone structures. any and all movement. It is well known in rheumatoid arthritis 91
32 Very few new or innovative ideas have been introduced since cases that a finger set in the boutonniere position is better than a 92
33 the 1980 SoFCOT symposium [1]. finger contracture with a swan neck deformity. 93
Thus simple cases of contracture—the most common are purely 94
articular with occasional tendon involvement—must be differen- 95
34 2. Pathophysiology and anatomical pathology
tiated from complex cases that are the sequelae of severe trauma 96
involve the bone, joints, tendons, nerves and blood vessels. This 97
35 From simple PIP sprains to crush injuries, the sequence of
latter condition will not be addressed here (see SoFCOT sympo- 98
36 events is the same. The injured hand and fingers bathe in a fluid
sium) [1]. 99
37 rich in proteins and macrophages that encompasses not only the
The type of contracture is defined based on the position in 100
38 injured structure, but the adjacent uninjured structures. The
which the finger has become stiff (not the residual angular sector): 101
39 edema and hematoma infiltrate the tendon sheaths, ligaments,
40 capsule and synovial spaces, which limits finger movement. Edema
 extension contracture: the finger has good extension (for 103
41 settles in and the swollen hand settles into a pain-free position due
example PIP or MCP with 108 extension), but its flexion does 104
42 to filling of the soft tissues. Contrary to the functional balanced
not exceed 408. 105
43 position (intrinsic-plus), the hand is in a position in which the
 flexion contracture: the joint can be flexed actively beyond 908, 106
44 MCPs are slightly flexed and the PIPs are in subtotal extension at
but its extension is limited to 608. 107
45 108. The hand is held up by the contralateral arm. What we see in
46 our offices is a stiff patient, not an isolated case of finger
The injury mechanism, treatments applied urgently and 108
47 contracture.
secondarily, rehabilitation and splint use are documented. A 109
48 Studies on stretching of the dorsal skin have shown the PIP only
clinical examination is used to specify the type and extent of the 110
49 needs 12 mm lengthening to flex 908. In the case of dorsal
contracture. This examination starts by evaluating the skin. An 111
50 edematous thickening, 19 mm of skin lengthening is required to
analysis of scars, gliding areas, burn sequelae and flexibility is 112
51 achieve 908 flexion, which is impossible. Thus the intrinsic-plus
important to choosing a surgical approach and/or thermoplastic 113
52 position is useful not only for preventing MCP extension
splints needed to shorten but not restrain the movement. X-rays 114
53 contracture, but also for keeping the PIP extended since the
are done to rule out intra-articular malunion, which would require 115
54 extensor mechanism is stretched by the tenodesis effect. The
an additional procedure (one or two phases) and that bone fixation 116
55 opposite can lead to MCP extension and PIP flexion contracture
material be left in place. 117
56 [2,3]. These events are also associated with pain.
It is essential for the finger to have good sensation, good 118
57 Mansat and Delprat [4] described three factors responsible for
vascularization and good metabolism. Everything possible must be 119
58 PIP contracture—pain, edema and prolonged immobilization in the
done to restore these functions. Smoking habits, the ability to 120
59 wrong position—which contribute to creating adhesions between
participate in the orthotic and surgical treatment, and the patient’s 121
60 the ligaments and bones. This results in a vicious circle of ‘‘pain,
psychological profile must be evaluated. While a splint treats the 122
61 edema, pain-free position, stiffness, pain, etc.’’
hand, it takes the patient ‘‘in hand’’ at the same time. The surgeon’s 123
62 The ligament and capsule structures are always affected, which
role as a therapist is to ‘‘tame’’ the hand. 124
63 means that a finger contracture is first and foremost a joint
Grip strength and ROM (active and passive) are measured 125
64 contracture. The specific anatomy of the fingers can explain the
preoperatively. This will help determine the best time for a surgical 126
65 contracture and can be used as a basis to infer treatments.
intervention if the rehabilitation fails. If the passive ROM is better 127
66 In the study presented at the 1980 SoFCOT symposium [1], the
than the active one, the muscle-tendon unit is implicated, and the 128
67 contributing elements were identified:
cause is extrinsic. If passive and active ROMs are equal, there is 129
likely a ligament, capsule or bone problem and the cause is 130
69  skin: particularly the dorsal aspect after deep wounds, leading to
intrinsic. 131
70 restrictive skin–tendon–bone adhesions; this situation was
The following clinical tests can be used for each type of 132
71 found in only 12% of cases; however, it is essential to consider
contracture: 133
72 the skin when selecting the surgical approach, especially when
73 bone needs to be exposed;
 for PIP in extension, the standard Finochietto–Bunnell (intrinsic 135
74  extensor mechanism: this was involved in 25% of PIP contracture
tightness) test is used. The PIP is easier to flex if the interosseous 136
75 and 20% of MCP extension contracture cases; however joint
muscles are relaxed, thus with the MCP flexed, and it will be 137
76 involvement was responsible for more than 70% of contracture
harder to flex when the MCP is extended. If the PIP joint does not 138
77 cases;
flex in this position, a procedure is required on the interossei 139
78  flexor tendons: PIP flexion contracture was implicated in 20% of
muscles; 140
79 cases and should always be evaluated.
 the Colditz lumbrical tightness test determines whether the 141
lumbricals are also involved because distal interphalangeal (DIP) 142
80 Contracture following complex regional pain syndrome is often
joint flexion is also limited by extending the MCP. 143
81 extensive and affects multiple fingers. The treatment strategy is
 the Haines–Zancolli test identifies tightness of the oblique 144
82 completely different to posttraumatic contracture and surgery
retinacular ligament in PIP flexion contracture cases when 145
83 should be delayed until the acute stage is over.
extending the PIP prevents DIP flexion. 146
 the Kilgore extrinsic test is positive when the extensor tendons 147
84 3. Clinical and imaging assessments are involved and adhered: flexing the wrist and MCP prevents 148
PIP extension. 149
85 Like in the wrist and elbow, the functional ROM for the MCP and
86 PIP joints has been defined as 338 to 738 flexion for the MCP, and With a significant flexion contracture, it is important to rule out 150
87 368 to 868 flexion for the PIP [5]. MCP extension contracture may damage to the central slip of the extensor apparatus resulting in 151
88 not be very problematic if some flexion is still present; a flexion chronic boutonniere deformity, which is more difficult to treat. A 152

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153 simple arthrolysis procedure is doomed to fail if the central slip of understand how to use it, its purpose, when to use it, and the risk of 213
154 the extensor is not repaired. In this scenario, the flexion problems where it touches the skin. The splint should not be worn 214
155 contracture is associated with DIP hyperextension. at night, except for postural night braces. The prescription must be 215
clearly explained and in written form. 216

156 4. Surgical approaches and treatment indications 4.2.2. Joint positions 217
The goal is to place tension on the entire finger chain for intra- 218
157 4.1. Rehabilitation and progress report articular contractures due to fibrosis of peri-articular tissues. 219
The following positions are recommended for the MCP joint: 220
158 It can be difficult to decide the exact point in time when surgery
159 should take the relay from splinting in order to avoid drawing out  intra-articular flexion contracture: wrist straight (wrist flexion 222
160 this treatment unnecessarily, which would damage the patient’s would be more effective, but it can be painful); 223
161 moral and physical capacities. It appears that the 11-week  extra-articular flexion contracture: wrist extended; 224
162 threshold is an important point beyond which the hope of further  intra-articular extension contracture: wrist extended; 225
163 improvement is very small. Hence, it is vital to carefully follow the  extra-articular extension contracture: wrist straight. 226
164 patients between weeks 4 and 11 [1,6].
165 In cases of complex multifinger contracture, it is recommended The following positions are recommended for the PIP joints: 227
166 to send these patients to specialized centers where doctors can
167 perform repeated local anesthesia to facilitate therapy and splint  intra-articular flexion contracture: wrist free or straight, MCP 229
168 adjustments. free, straight or in slight flexion; 230
169 Occupational therapy and the chronicity of the injury and  extra-articular flexion contracture: wrist and MCP extended; 231
170 immobilization must also be taken into consideration. A finger  intra-articular extension contracture: wrist free or extended; 232
171 (especially the index) can easily be excluded from the body image. MCP free or straight; 233
172 This makes rehabilitation pointless since, although good passive  extra-articular extension contracture: wrist straight, MCP 234
173 motion can be achieved, the activation will be insufficient [1]. The flexed. 235
174 intake of analgesics and the patient being pain-free contribute to
175 rehabilitation. The results of this treatment are communicated to the surgeon 236
176 This treatment must always be proposed to a patient with a who must see the patient regularly. If the contracture no longer 237
177 chronic contracture, while taking into account the causes and improves from a severe non-functional condition to a functional 238
178 associated injuries. While hand therapy has a circulatory and pain- ROM, the decision to perform surgery is made and discussed with 239
179 relieving effect, it also provides the patient with continuous the patient. At this point, the patient’s participation, motivation 240
180 reassurance about their progress and condition [6]. It is important and psychological context must be re-evaluated since postopera- 241
181 not to strain and to avoid pain at night and the next day, to start tive rehabilitation must be understood and accepted. Everything 242
182 with pain-relieving therapy modalities and to combine assisted must be explained and provided in writing. If physical therapy 243
183 passive work and active work. This treatment requires that the achieves an intermediate but functional ROM, there is no need to 244
184 patient wear a splint tailored to the type of contracture. Thus, the go further or to try surgery. 245
185 treatment will evolve through a close collaboration between the
186 surgeon and hand therapist by tracking the changes in passive and 4.3. Surgical treatment: arthrolysis and tenoarthrolysis [1,10–12] 246
187 active ROMs. The splints themselves are a treatment modality that
188 must be re-evaluated regularly and adjusted based on the patient’s 4.3.1. MCP extension contracture 247
189 progress. The patient must be educated on how to use them
190 correctly. 4.3.1.1. MCP joint anatomy. The MCP joint is an asymmetric 248
191 The next treatment steps consist of active motion using simple condyloid joint, although some authors see it as a ball-and-socket 249
192 devices and the therapist’s assistance. Splints are used for multiple joint. The collateral ligaments are not isometric. They insert above 250
193 short periods during the day. Well-controlled electrical stimula- the joint’s flexion axis, which explains why they are taut in flexion 251
194 tion therapy and skin gliding work are also used. Continuous and slack in extension. This is what we observe when it is 252
195 passive motion techniques are used in some cases, but do not impossible to abduct the fingers in full flexion. Thus, the hand must 253
196 appear to lead to any improvement when compared to classic be immobilized with the MCP flexed. 254
197 rehabilitation techniques [7]. The volar plate prevents hyperextension; however, this can still 255
198 Occupational therapy is essential for reintegrating movement occur in patients with hypermobility. This is a fibrocartilage 256
199 of the stiff finger(s) in the overall hand motions. A schedule will be structure that slides on the volar side of the metacarpal head and 257
200 established jointly by the surgeon, therapist and orthotist. A disappears along the metaphysis without restraining the flexion 258
201 summary of each step is written with the exercises performed, movement. The synovial cul-de-sac is important and should be 259
202 ROM achieved, pain triggered, and recovery of sensibility if the released in contractures to allow proper gliding of the phalanx on 260
203 involved fingers had nerve defects. the head and to prevent false flexion due to a rocking chair effect 261
and to encourage gliding. The interossei muscles must also be 262
204 4.2. Splinting considered. 263

205 4.2.1. Guiding principles [8] 4.3.1.2. Technique [1]. An S-shaped dorsal incision is made on the 264
206 Splints must have the following features: early adaptation after lateral side of the finger. If adjacent fingers are involved, it is best to 265
207 the injury; trouble-free construction; easy to apply and maintain; place the incision in the intermetacarpal valley, since these 266
208 simple shape; light; esthetic; comfortable; no pressure points. contractures are also associated with difficulty closing skin 267
209 The splints may be postural braces made of cast material [9] or deficiencies. For this reason, a large transverse incision is not 268
210 elastic deformable splints with a proximal fixation system and a recommended because it will be impossible to close in these 269
211 distal force application point that can be adjusted. The splint is circumstances. Weeks et al. proposed a volar approach that leads to 270
212 worn for 10 to 60 minutes, 4 to 6 times per day. The patient must better functional outcomes than the dorsal approach but only in 271

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272 very specific conditions: tenolysis of flexor tendons is required, movement. Edema, hematoma and soft tissue injuries contribute 317
273 minimally retracted dorsal skin, possibility of early rehabilitation, to making the contracture even worse. 318
274 and secondary procedures on the flexor tendons to be done later on The treatment is a one-stage surgery when possible: restore the 319
275 [13]. skin elements, reconstruct the tendons and bone elements, 320
276 To access the joint, we do not pass through the extensor tendon particularly the PIP joint. Bone fixation contributes to restoring 321
277 like Shin and Amadio [10] in order to preserve the extensor the anatomy as long as the hardware is not too bulky. Page and 322
278 aponeurosis on the dorsal side of the MCP. Instead, we take a lateral Stern advise against using plates for open fractures and phalanx 323
279 path by making an incision in the sagittal slip in the inter- fractures but suggest using them for the metacarpals. While 324
280 metacarpal valley, or even by opening the proximal portion of the modern hardware is much better than the type used in their study, 325
281 dorsal aponeurosis. For the index and little finger, we pass between we share their cautious views [17]. 326
282 the two extensor tendons (proper, common). The release starts by
283 excising the dorsal capsule. A flexion test is carried out. If the result 4.3.2.3. Technique. For isolated, moderate contractures, three 327
284 is not satisfactory, a thin spatula is passed between the capsule, techniques have been described: resection of the check reins 328
285 ligaments and metacarpal head to break down any retraction of the [18], anterior arthrolysis as described by Curtis [19,20] and 329
286 synovial recesses. The flexion test is repeated a second time. If the complete resection of the lateral ligaments [21,22]. 330
287 results are not satisfactory, the main phalangeal bundle of the A mediolateral or Bruner anterior approach can be used. A Z- 331
288 collateral ligaments is gradually detached from its metacarpal shaped incision (Bruner) will make it difficult to use Capener 332
289 attachment. The flexion test is repeated a third time. The goal is to splints. Nevertheless, Bruser et al. [23] and Levaro et al. [24] use a 333
290 achieve resistance-free flexion with normal gliding of the articular mediolateral approach on the finger’s non-dominant side and have 334
291 surfaces without dorsal gaping; this is the role of palmar cul-de-sac reported better results than with the anterior approach. We use 335
292 release. For the index, it is preferable to preserve the bundle on the this approach, which can be supplemented by another shorter 336
293 radial ligament. The extensor tendon must be released if there are lateral incision, solely to access the collateral ligaments. This is the 337
294 any adhesions. The aim is to place the hand in the intrinsic-plus primary approach to access the volar plate, capsule and ipsilateral 338
295 position (Fig. 1). collateral ligament. 339
Release of the flexion deformity is done gradually. It is vital for 340
296 4.3.2. Flexion contracture of the PIP joint the pulleys (especially A2) to be preserved, which allows access to 341
297 Flexion contracture is the most common type and the most the checkreins and allows the PIP to be tested after each step. If the 342
298 difficult condition to treat. The results are disappointing. result is not satisfactory, anterior release is done gradually to the 343
base of the middle phalanx. Resection of the collateral ligaments 344
299 4.3.2.1. PIP anatomy. PIP joint motion represents 85% of the must be limited as it is often useless [25–40]. 345
300 finger’s total motion [14,15]. The PIP is a hinge joint; it is The hand and then the treated finger(s) must be moved into 346
301 inherently stable because of the shape of its congruent bone position alternatively. Coiling splints must be worn several times 347
302 surfaces. It is reinforced by isometric insertion of the collateral per day in combination with rehabilitation (Fig. 2). 348
303 ligaments, which prevents lateral motion, except in deep flexion
304 where the accessory bundles are slack and may be retracted due to 4.3.3. Extension contracture of the PIP joint [41,42] 349
305 adhesions. The PIP is protected against hyperextension by the volar Contrary to flexion contractures, extension contractures are 350
306 plate, which is a fibrocartilaginous structure that inserts at the base considered a sure-bet, as long as the dorsal aponeurosis (extensor 351
307 of the middle phalanx and is reinforced on its side by checkrein expansion) is also released. The best-case scenario is to perform this 352
308 ligaments. Lastly, the dorsal structures are thin and weak and made procedure under location anesthesia and sedation, while asking the 353
309 up of the slack dorsal capsule, the central slip of the extensor patient to flex his PIP joint to verify the flexion motion achieved. 354
310 tendon and the lateral slips that spread around it; all these
311 structures are stabilized by the transverse retinacular ligament. 4.3.3.1. Surgical technique. Either a dorsal or lateral approach is 355
used, depending on previous scars and underlying lesions. 356
312 4.3.2.2. Preoperative planning [16]. The bone anatomy must be Extensor tenolysis is always needed. This release must be extended 357
313 analyzed carefully in case of incongruity or even osteoarthritis. In proximally and also distally if needed. The reason for the 358
314 fracture cases, the chosen treatment must restore the articular contracture provides insight into why this procedure is needed. 359
315 congruency of the base of the middle phalanx and the head of the The dorsal aponeurosis is elevated and the transverse retinacular 360
316 proximal phalanx so that it is sufficiently stable to allow early joint ligaments are transected, and then marked for future repair if they 361
can be individualized. 362

Fig. 1. Positional brace after arthrolysis for MCP extension contracture. Fig. 2. Adjustable full finger curl splint.

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363 The joint is exposed, the dorsal capsule is excised, and the
364 collateral ligaments are transected minimally, very proximally and
365 gradually depending on the how well the flexion is restored. A thin
366 scalpel blade is slid between the phalanx and the accessory bundle
367 in order to transect the main bundle high up.
368 The patient is asked to active flex his finger. If this is impossible
369 under regional anesthesia, a high counter-incision is made at the
370 palm or forearm, and then the flexor tendons are pulled on to
371 ensure they move freely.
372 The interossei muscles often play a role in this type of
373 contracture, thus the Bunnel–Finochietto test must be done before
374 closing the incision. If it is positive, triangular resection removing
375 part of the interosseous aponeurosis must be done, and the finger’s
376 flexion tested again.
377 Retinacular structures are sutured and the finger is immobilized
378 at 458 without pinning for up to 15 days.
Fig. 5. Capener PIP dynamic extension splint.
379 4.3.3.2. Postoperative course [16]. Rehabilitation starts with a
380 dynamic splint, wrist in a neutral position, MCP extended and
381 under the proximal phalanx (Fig. 3). Active PIP flexion is performed
382 by recoil on the middle phalanx and completed by the hand
383 therapist. In cases of severe flexion deformity, postural braces or
384 extension casts can be used preoperatively (Fig. 4). The next step is
385 to use a Capener-like spring coil finger extension assist splint
386 (Fig. 5). Positional splints with passive extension recoil and active
387 DIP motion perform an active Haines maneuver (Fig. 6).
388 Adjuvant techniques are needed such as electric stimulation of
389 resting muscles. Movements against resistance must be avoided
390 during the first weeks.

391 5. Results

392 The results of arthrolysis procedures are disappointing overall.

393 For PIP flexion contractures, the maximum improvement is about Fig. 6. Extension recoil splint under the middle phalanx.

258 with a risk of shifting the functional ROM [15,19–21,24]. For 394
PIP extension contractures, the results are better, but do not exceed 395
a 348 improvement [1,43]. 396

5.1. Other techniques for treating severe contractures 397

5.1.1. External fixators in distraction 398

Alternative solutions have been proposed such as 7 to 14 days 399
progressive distraction with external fixator until a satisfactory 400
flexion–extension arc is achieved, or a 3 mm to 6 mm interpha- 401
langeal gap, which would lead to good outcomes according to 402
Houshian et al. [44–47]. 403
Fig. 3. MCP-stop extension position with PIP extension.

5.1.2. Total anterior tenoarthrolysis (TATA) 404

We excluded fixed posttraumatic flexion contracture from this 405
lecture, which is the target of this delicate technique described by 406
Saffar in 1983. It is aimed at fingers with PIP and DIP flexion 407
contractures. The surgeons who pioneered this technique achieved 408
a large 568 shift in the PIP functional ROM and 868 overall [48–50]. 409

6. Conclusion 410

The general context (follow-up, patient’s psychological state, 411

work-related injury, commitment to the treatment), functional 412
ROM (PIP) and tissue health must be assessed. Collaboration 413
between the surgeon and hand therapist is vital. The treatment 414
must be comprehensive, with regular feedback provided. Curves 415
Fig. 4. Finger gutter splint with PIP extension for flexion contracture. describing the change in active and passive ROM are very useful. 416

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417 Splints are a treatment modality, not an accessory. The [21] Eaton RG, Sunde D, Pang D, Singson R. Evaluation of ‘‘neocollateral’’ ligament 474
formation by magnetic resonance imaging after total excision of the proximal 475
418 treatment is gradual, controlled and adapted to the patient’s interphalangeal collateral ligaments. J Hand Surg Am 1998;23:322–7. 476
419 progress. The splints must be adjusted constantly. [22] Diao E, Eaton RG. Total collateral ligament excision for contractures of the 477
420 Surgical indications are made after discussion between the proximal interphalangeal joint. J Hand Surg Am 1993;18:395–402. 478
[23] - Bruser P, Poss T, Larkin G. Results of proximal interphalangeal joint release 479
421 patient, therapist and surgeon to determine the optimal date for for flexion contractures: midlateral versus palmar incision. J Hand Surg Am 480
422 surgical treatment if rehabilitation has not been successful. 1999;24:288–94. 481
423 Arthrolysis with or without tenoarthrolysis is a sequential, [24] Levaro F, Henry M, Masson M. Management of the stiff proximal interphalan- 482
geal joint. J Am Soc Surg Hand 2003;3:78–87. 483
424 selective, progressive treatment that is as least aggressive as [25] Schneider LH. Tenolysis and capsulectomy after hand fractures. Clin Orthop 484
425 possible (stability/mobility) after intraoperative verification of the Relat Res 1996;327:72–8. 485
426 musculotendinous motor unit, with appropriate instrumentation, [26] Harrison DH. The stiff proximal interphalangeal joint. Hand 1977;9:102–8. 486
427 if possible under sensory nerve block or even local anesthesia. [27] Ghidella SD, Segalman KA, Murphey MS. Long-term results of surgical man- 487
agement of proximal interphalangeal joint contracture. J Hand Surg Am 488
428 Postoperative rehabilitation is essential. 2002;27:799–805. 489
[28] Foucher G, Lenoble E, Ben Youssef K, Sammut D. A postoperative regime after 490
digital flexor tenolysis. A series of 72 patients. J Hand Surg Br 1993;18:35–40. 491
429 Disclosure of interest [29] Stanley JK, Jones WA, Lynch MC. Percutaneous accessory collateral ligament 492
release in the treatment of proximal interphalangeal joint flexion contracture. 493
J Hand Surg Br 1986;11:360–3. 494
430 The author declares that he has no competing interest. [30] Bailie DS, Benson LS, Marymont JV. Proximal interphalangeal joint injuries of 495
the hand. Part I: anatomy and diagnosis. Am J Orthop 1996;25:474–7. 496
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Please cite this article in press as: Michel R. Management of posttraumatic finger contractures in adults. Hand Surg Rehab (2018),
https://doi.org/10.1016/j.hansur.2018.06.003