British Journal of Plastic Surgery (2005) 58, 11481151

CASE REPORT

Correction of long term joint contractures of the

hand by distraction. A case report
P. Natividade da Silva*, R. Barbosa, P. Ferreira, A. Ferreira, E. Malheiro,
A. Silva, J. Reis, J. Amarante

o Joa
Department of Plastic and Reconstructive Surgery, Oporto Medical School, Sa o Hospital, Oporto,
Portugal

Received 5 August 2004; accepted 26 April 2005

KEYWORDS Summary Joint contractures are a common complication of hand trauma. The
Distraction; conventional treatment consists of arthrolysis, tenolysis and occasionally arthrod-
Hand; esis. Frequently, this does not achieve a good result, particularly when there has
Joint contracture been a long delay in presentation. Progressive lengthening of a joint by distraction
(joint distraction) allows the release of joint contractures even in cases of failure of
traditional methods.
We present a case of a delayed (20 years) work related traumatic flexion deformity
of the PIP joint of the left index and middle fingers. This was the result of a complete
division of both flexor tendons of both fingers.
The range of movements, both active and passive, was limited to 90/1008 in the
index finger and 95/1008 in the middle finger. Following joint distraction using our
lengthening device (Anta oe, Portugal) the patient was able to achieve an active and
passive range of movements of 10/1008 for the PIP joint of the index finger and
40/1008 of the middle.
This clinical case shows the simplicity and application of our technique for the
correction of joint contractures.
q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

Joint contractures are a common complication of
hand trauma and can have several causes related to
contractions or adhesions of the tendons, thicken-
ing of the synovium, contracture of the ligaments or
* Corresponding author. Address: Av. Visconde Barreiros, 288-
48 Dt8 Sul, 4470-151 Maia, Portugal. Tel.: C351 91 9009956; fax:
C351 22 5506272.
E-mail address: pedrosilva@portugalmail.pt (P.N. da Silva).
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.04.028
joint capsule, insufficient skin cover or scarring and
bone block or exostosis within the joint.1
The conventional treatment consists of perform-
ing a combination of arthrolysis, tenolysis and
occasionally, as a last resort, arthrodesis or
replacement. Frequently this does not achieve a
good result,2,3 particularly when there is a long
delay since the injury.
The surgical release of a digital joint contracture
can cause excessive stretching of the neurovascular
Correction of long term joint contractures of the hand by distraction
structures resulting in damage to these elements. In
addition there can be a lack of skin cover.
Progressive lengthening by distraction can prevent
such complications, and does not result in perma-
nent tissue modifications,4 allowing the release of
joint contractures even in cases of failure of
traditional methods.
The use of such techniques for the release of
post-traumatic joint contractures (not as sequelae
of burn) has not been widely reported in western
literature.6,7 Joint distraction techniques were first
reported by Kolontay and Miloslavskii5 in 1987 in the
former Soviet Union.
This paper shows the efficacy of a technique of
joint distraction, employed by the authors, through
the presentation of a clinical case.
Surgical technique
With the patient in the supine position and under
loco-regional anaesthesia, a threaded, self-tapping
half-pin is inserted bicortically into the bone,
proximal to the joint(s) to be distracted and
another distal to the joint(s), using a drill. The
pins should be passed perpendicular to the axis of
joint movements and should have a diameter of at
least 1.5 mm.
When the goal is to lengthen a proximal inter-
phalangeal (PIP) joint, stabilisation of the distal
interphalangeal (DIP) joint should be performed
with a Kirschner wire, to avoid contracture of this
joint.
The lengthening device (Anta oe, Portugal) is
assembled onto the two previously applied pins.
The lengthening of the device starts immediately. It
should be adjusted daily, up to the maximum
tolerated length, which is determined by the
appearance of moderate pain and pale skin.
Once the desired length has been achieved, the
device and the pins are removed. This is usually
done in the outpatient clinic and without the need
for any anaesthesia. The patient should initiate
mobilisation of the lengthened joint immediately.
Case report
A 40-year-old male was admitted to the emergency
service because of a full-thickness flame burn of the
dorsum of the right hand. Besides the burn, the
physical examination revealed the presence of a
flexion deformity of the PIP joints of the index and
middle fingers of the left hand, secondary to a
flexor tendon injury 20 years previously (a work-
1149
related accident). Primary repair was performed at
that time. The patient developed a flexion deform-
ity post-operatively and underwent tenolysis 6
months after the repair, without improvement.
The range of both active and passive motion was
90/1008 at the index finger and 95/1008 at the
middle finger, with restriction of some basic
activities (Fig. 1). The DIP joints had an active and
passive range of 0/708 at the index finger and 0/408
at the middle finger. The superficial and deep flexor
tendons of both fingers functioned independently.
The clinical and radiographic (Fig. 2) examin-
ation excluded the existence of a true ankylosis
from bony fusion or block. We treated him with our
technique of joint distraction and lengthened the
PIP joint of both fingers simultaneously (Fig. 3). The
degree of lengthening achieved on a day-to-day
basis was limited by pain rather then skin perfusion.
After 20 days the device was removed and the
patient began active and passive mobilisation. The
range of motion achieved, both active and passive,
was 10/1008, for the PIP joint of the index finger
and 30/1008 for the middle finger. A decrease in the
range of motion of the DIP joints of both fingers was
noted and was probably related to the immobilis-
ation period of this joint with the K-wire.
The patient was reviewed at 3, 6 and 9 months
after surgery. He maintained an improved range of
motion, both active and passive, of the PIP joints of
10/1008 in the index finger and 40/1008 in the
middle finger (Figs. 46). The DIP joint of the index
finger recovered to the previous range of 0/708,
both active and passive, but the DIP joint of the
middle finger remained limited to 0/158, both
active and passive. The independent function of
the superficial and deep flexor tendons of both
fingers was maintained. The patient reported
improvement of his functional ability, as well as
better aesthetic appearance.
Figure 1 Pre-operative viewextension.
1150
Figure 2 Pre-operative radiographic study.
Lengthening techniques for the soft tissues of the
hand appear sporadically in the literature and have
mostly been used for the correction of burn
contractures. Description of such techniques for
the correction of tendon and joint contractures is
rare.59
There are many mechanical factors that may limit
the excursion of a joint; it is, therefore, important to
perform an accurate clinical10 and radiographic
examination of the hand to determine the precise
cause. In our opinion, the technique presented here is
useful for the release of joint contractures related to
contractions or adhesions of the tendons, contrac-
ture of the ligaments or the joint capsule, inadequate
skin cover or scarring. When the joint contracture is
related to bony block or exostosis within the joint,
other techniques should be employed.
In the presented case the limitation of motion
was attributed to adhesions of the flexor tendons
and contracture of the ligaments and capsule of the
affected joints. The progressive distraction of the
Figure 3 Pre-operative viewdevices assembled.
P.N. da Silva et al.
Figure 4 Result. Six months post-operatively.
joint allowed the lengthening of the contracted
structures and at the same time caused the rupture
of the flexor tendon adhesions, without causing any
damage to neural or vascular structures.
The patient presented 20 years after his injury
and after the conclusion of his case by the insurance
company, having received due compensation. He
recovered a very good range of motion of the index
finger and only a good range of motion of the middle
finger because of residual flexion deformity at the
PIP joint. It is important to stress that the range of
motion was almost the same at 3, 6 and 9 months
after surgery, which confirms the durability of the
technique in the short and medium term. Special
attention should be paid to early movement of the
DIP joints in order to avoid loss of range due to the
immobilisation period.
The technique we present here uses a simple
distraction device that is easy to assemble and
adjust, as well as being relatively cheap (approxi-
mately 75V) compared to other devices usually
employed.
Figure 5 Result. Six months post-operatively.
Correction of long term joint contractures of the hand by distraction
Figure 6 Result. Six months post-operatively.
The low cost, low morbidity and simplicity of
application under loco-regional anaesthesia make
this an alternative to the classic techniques used,
either as a first line therapeutic option or as a last
resort when other techniques have failed.
Acknowledgements
The authors wish to thank Dr Martin Vesely and Dr
Dylan Murray for their help with the manuscript.
1151
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