The treatment of prolapse and collapse of the proximal interphalangeal joint

Extensor tendon: anatomy, injury, and reconstruction

Although seemingly simple in its anatomy and function, the extensor mechanism of the hand is actually a complex set of interlinked muscles, tendons, and ligaments. A thorough understanding of the extensor anatomy is required to understand the consequences of injury at various levels. Reconstructive options must restore normal function. Whereas primary repair of anatomic structures is frequently possible in acute injury, it is rarely possible in chronic situations. Technically exacting procedures may be necessary to restore function.

Biomechanical evaluation of chronic boutonnière reconstructions

The magnitudes of the extensor forces generated across the proximal interphalangeal joint by the Littler-Eaton, Matev, Hellmann, and Fowler reconstructive procedures for posttraumatic chronic boutonnière deformity were measured in a laboratory study. The purpose of the experiment was to determine whether the mechanical design of a procedure had a significant impact on biomechanical performance. Results showed that each method produced adequate extensor forces and restored full proximal interphalangeal joint extension. There were few statistically significant differences among the procedures for the different joint angles and load conditions tested. The data suggest that the mechanical designs of these reconstructions are satisfactory for correction of the extensor deficit of the deformity. The preoperative condition of the finger is probably responsible for the variations seen in clinical results.

A staged technique for the repair of the traumatic boutonniere deformity

A step-by-step approach to the systematic management of chronic boutonniere deformity due to trauma is presented. If surgical intervention is necessary, the problem should be approached one step at a time. The following stages are described: stage I, tendolysis of the extensor tendon and freeing of the transverse retinacular ligament; stage II, sectioning of the transverse retinacular ligament; stage III, tendon lengthening of the lateral bands over the middle phalanx; and stage IV, repair of the central extensor tendon. After managing 23 patients according to this plan, we have concluded that it is frequently unnecessary to automatically go through all four stages in treating chronic traumatic boutonniere deformity. We found that 17 patients were successfully managed by some combination of stages I, II, and III, and six patients received adequate treatment with stages I, II, and IV.

Repair of the established post traumatic boutonnière deformity

A technique is described for the repair of the chronic, post traumatic, uncomplicated boutonnière deformity which has given consistently good results. The fundamental steps are: Mobilisation and reefing of the lengthened middle slip; Kirschner wire fixation of the proximal joint in full extension and replacement of the mobilised lateral slips with the distal joint flexed approximately 45 degrees.

The spiral oblique retinacular ligament (SORL)

A procedure is described for reconstruction of the oblique retinacular ligament using a small tendon graft in a spiral fashion to act as a dynamic tenodesis to restore distal interphalangeal extension and to restrain proximal interphalangeal hyperextension. The method has been uniformly successful in the treatment of post-traumatic "swan-neck" or "mallet" deformity. Although the concept is simple, the procedure demands thorough understanding of digital anatomy for successful completion.