SWAN NECK DEFORMITY

DEFINITION

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

ANATOMY

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4l) .Intrinsic Muscle    Lumbricals (ulnar two B. 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 .

g. due to intrinsic muscle spasm or contracture.PATHOMECHANISM   Proximal interphalangeal extensors overact (e. 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) .

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

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 .

Finger Deformities. In : Wolfe : Green’s Operative Hand Surgery 6th edition II III IV .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.

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. Arthrodesis . Lateral band release from the central slip may be needed.

TREATMENT TYPE I DESCRIPTION PIP supple in all MCPJ positions TREATMENT Proximal Fowler’s tenotomy. 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 . sublimis tenodesis.

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 .

028. A transverse stab wound is made where the Kirschner wire exits.035-inch Kirschner wire parallel to the screw. The DIP joint is exposed and the joint surfaces are prepared as described previously. The wire is driven distally and exits on the tip of the finger just below the hyponychium. Rotatory stability can be augmented by inserting a 0. 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. The trailing threads of the screw are recessed into the tuft. into the tuft of the distal phalanx. The appropriate length of screw is inserted and advanced until it emerges at the base of the distal phalanx. A Kirschner wire is inserted through the base of the distal phalanx and into the medullary canal. Intraoperative radiographs are obtained to confirm proper placement and length of the screw . The wire is withdrawn. If a Herbert-type screw is used and the screw is too long.or 0. and advanced proximally until it emerges at the base of the phalanx. The canal is prepared with either a larger Kirschner wire or the appropriate drill/reamer. depending on the type of screw system selected. 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.DIP FUSION WITH A SCREW  Before beginning this procedure. The medullary canal of the middle phalanx is located with a Kirschner wire. and the appropriate drill/tap is inserted through the stab wound. 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.

DIP FUSION WITH A SCREW .

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

or it can be made at the thickened  . One slip of the FDS is divided approximately 1. This portion is separated from its corresponding slip but is left attached distally.5 cm proximal to the joint. The proximal attachment can be made directly into the bone by using a bone anchor or pull-out wire. These patients require restoration of strong volar support to the joint. the detached slip is fixed proximally to act as a checkrein against extension. as the hyperextension increases. We prefer the use of FDS tenodesis to prevent PIP joint hyperextension. begin to have difficulty initiating active flexion. With the joint in 20 to 30 degrees of flexion. A volar zigzag incision is made over the PIP joint to expose the flexor tendon sheath. and care is taken to avoid injury to the vincula passing between the FDS and FDP tendons.Flexor Tendon Tenodesis (“Sublimis Sling”)  Patients with PIP joint hyperextension maintain full passive motion but. The thin portions of the sheath on either side of the A3 pulley are excised while preserving the pulley. The flexor tendons are exposed.

Sublimis Sling .

the ulnar lateral band is freed from the extensor mechanism proximally but left attached distally. no amount of tension applied to the relocated lateral band will restore DIP joint extension. In theory. the net result of this procedure is restriction of PIP joint hyperextension. in a rheumatoid patient who has a primary mallet deformity with destruction of the terminal tendon. It is passed volar to Cleland's fibers to bring it volar to the axis of PIP joint motion. Thus. However.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. . it is an alternative to dermadesis or flexor tenodesis. In patients with rheumatoid arthritis. 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. this approach should solve both the DIP and PIP joint problems simultaneously. In this procedure.

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

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

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

If this blanching is not relieved. skin necrosis occurs directly over the joint. the dorsal skin blanches. In fact. 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. At some point during the manipulation of long-standing fixed deformities into flexion. satisfactory healing by secondary intention has convinced us that grafts are not needed. Dorsal skin tension can be minimized with an oblique incision just distal to the PIP joint. It is important that the skin be released distal to the joint so that the extensor mechanism overlying the joint is covered.SKIN RELEASE   The dorsal skin may limit the amount of passive flexion that can be achieved by manipulation. leaving this portion of the wound open allows drainage and reduces postoperative swelling and pain. which allows the skin edges to spread. .

SKIN RELEASE .

the lateral bands are displaced dorsally. and the finger has limited flexion. Full passive flexion can often be achieved by this method. 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. When the procedure is performed under local anesthesia. Their normal volar shift is lost.LATERAL BAND MOBILIZATION  In established swan neck deformities. . shifting of the lateral bands volarward on flexion and relocation of them dorsally on extension can be observed during active motion.

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. Swanson's single-piece polymeric silicone spacer has been the arthroplasty implant of choice for several decades. and we now find the procedure most useful with degenerative arthritis and certain cases of traumatic arthritis. Over the years the indications have changed. 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.PIP ARTHROPLASTY   PIP silicone arthroplasty was originally used in 1966 in conjunction with silicone implants for the MP joints in rheumatoid arthritis.

INDICATION Persistent PIP joint pain CONTRAINDICATI ON Infection Bone loss Swan neck deformity with joint destruction Unstable joint Severe flexion deformity .

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