FINGER CONTRACTURE

Presented by :
Rosita Alifa Pranabakti G99152090
Aprillio Bagas Sriwisnu G99152099
 DEFINITION

Contracture is a persistent contraction of the

skin and / or tissue beneath which causes
deformity and limitation of motion.
This disorder is caused by the pull of abnormal
scar post wound healing, congenital
abnormalities and degenerative processes. The
most common contractures are burns.
 CAUSES
1. External immobilization

Occurs when the joint is in stationary position for a long

period of time, adhesion occurs between the connective
tissue.
2. Traumatic injury

the connective tissue around the joint is pulled or torn

3. Joint disease

For example: rheumatoid arthritis

4. Neurologic defect

In the central and peripheral nervous system can produce

abnormal impulses that result in restriction in joint tissue.
 MECHANISM
Muscles and connective tissue affect the
occurrence of contractures. The loss of the
sarcomer at the end of myofibril and the
shortening and loss of connective tissue
elasticity leads to contractures. If the
connective tissue and muscle are maintained
in a shortened position for long periods of time,
muscle fibers and connective tissue will adjust
shortens and cause joint contractures.
Retained muscles shorten within 5-7 days will
result in shortening of the muscular abdomen
causing contraction of collagen tissue and
reduction of muscle sarcoma tissue. When this
position continues for up to 3 weeks or more,
the connective tissue around the joints and
muscles will thicken and cause contractures. In
joint contractures, immobilization, muscle
weakness and muscle stiffness are major
factors in the occurrence of contractures.
 CLASSIFICATION
1. DERMATOGEN CONTRACTURE
 Contractures caused by the process of occurrence in the skin, it can occur due to loss of
extensive skin tissue such as deep burns and broad, loss of skin / tissue in accidents and
infections.
2. TENDOGEN CONTRACTURE
 ontractures that occur due to muscle shortening and tendons. May occur by prolonged
ischaemia, connective tissue and atrophy, eg in neuromuscular disease, extensive burns,
trauma, degeneration and inflammatory diseases.
 Dupuytren contractures, Volkman contractures, Tendo Achiles contractures, Trigger Finger
3. ARTHROGEN CONTRACTURE
 Contractures that occur due to the process within the joints, this process can even occur
until ankylosis. Such contractures are the result of long and continuous immobilization,
resulting in shortening of joint capsules and ligaments, eg bursitis, tendinitis, congenital
diseases and pain.
 PHYSICAL EXAMINATION

1. GONIOMETER
2. ALLEN’S TEST
3. BUNNEL-LITTLER TEST
4. FINKELSTEIN TEST
5. FROMENT’S SIGN
6. INTRINSIC-PLUS TEST
7. PHALEN’S TEST
 ALLEN’S TEST

A test designed to determine the patency of vascular

anastomosis in the hand. The examiner first palpates
pressing the radial and ulnar arteries. The patient is
then asked to open and close the finger three to five
times quickly until the skin of the palm is swollen. The
pressure is then released as either a radial or ulnar
artery, the speed at which the normal hand color
returns is recorded
 BUNNEL-LITTLER TEST

A test designed to identify intrinsic muscle

contractures or joint contractures in PIP joints (Proximal
Inter Phalang). The examiner modifies PIP to the
maximum while previously slightly extending the
metacarpophalang (MCP) joints. Positive test results
for joint capsule contractures if PIP joints can not be
reflected. This test is positive for intrinsic muscle
contractures if MCP is slightly flexed and PIP can be
fully flexed.
 FINKELSTEIN TEST

FA test designed to determine the presence of

tenosynovitis tendo abductor pollicis longus and
extensor pollicis brevis. This test is usually used to
determine de Quervain's disease. The patient makes a
fist with the thumb bent in the other four fingers. The
patient then deviates the first metacarpal (bone) into
the ulnar and lengthens the proximal joint of the
thumb (ie by bending the fist towards the ulnar). If the
patient experiences pain, then it is said to be a
positive test result.
 FROMENT’S SIGN

A test designed to determine the presence of

adductor policis muscle weakness due to ulnar nerve
paralysis. The patient is asked to hold a piece of
paper using the tip of the thumb and the radial side of
the index finger. The test results are positive if when
the examiner pulls the paper from the handle of the
patient the phalanx of the patient's thumb terminal
will be reflected or if the MCP joint in the thumb
becomes very elongated (Jeanne's sign).
 INTRINSIC-PLUS TEST
 A test designed to identify the shortening of the intrinsic
muscles of the hand. This test becomes specific in the hands of
patients with rheumatoid arthritis, especially in the early stages
before any damage or hand defects. In this test, the MCP joint
of the finger under test in hyperextension. Thus the finger joints
in the middle and distal will be slightly flexed due to passive pull
of tissue. The examiner then tries to facilitate the PIP joint of the
finger. If there are obstacles in reflecting the finger it is
considered a positive sign.
 PHALEN’S TEST

A test designed to determine the presence of carpal

tunnel syndrome. the patient's wrist is maximized by
the examiner, then the patient maintains this position
by holding one wrist with the other wrist for 1 minute.
The test results are positive if there is paresthesias in
the thumb, index finger, and ½ lateral ring finger
 TIGHT RETINACULAR LIGAMENT TEST

A test designed to determine the presence of

retinacular ligament shortening or presence of a bond
on the distal interphalangeal joint capsule (DIP). The
examiner holds the patient's PIP joint in full extension
position while reflecting the DIP joint. If the DIP joint
can not be reflected, the test is considered positive
(either due to ligamencollateral contracture or joint
capsule contracture). To distinguish it, the PIP joint is
reflected and if the DIP joints can be flexed easily the
joint capsule is considered normal.
 TINEL’S SIGN

A test designed to detect carpal tunnel

syndrome. The examiner taps on the carpal
tunnel on the wrist. The test results are positive if
the patient feels paresthesia distal from the
wrist.
 OTHER EXAMINATION
1. RONTGEN
 X-rays can be useful for diagnosing contractures due to the narrowing of joint space that
appears to indicate tight and contraction joints, as well as physical examinations involving
physical and manual tests to test joint motion.
2. USG
 Ultrasound is one of the investigations for contractures, especially Dupuytren contractures.
Ultrasound produces a picture of the position between the bone, the artery, and the
nodule. In addition, from ultrasound also obtained differences echo the structure of
nodules and surrounding tissues. Early nodules on Dupuytren contractures look more
hipoechoic than with tendons. While nodules that have long been seen isoechoic or
hiperechoic.
 PREVENTION
1. PREVENT INFECTION

Care the wound, examine the necrotic tissue and

necrotomy if needed.
2. SKIN GRAFT OR SKIN FLAP

Widespread injuries and extensive tissue loss are attempted

to close as early as possible, if necessary, skin closure with
skin graft or flap.
3. PHYSIOTHERAPY

Proper positioning
Exercise / Stretching
Splinting / bracing
Mobilization
 TREATMENT

1. DERMATOGEN CONTRACTURE (BECAUSE OF LOSS

TISSUE)
a. Linear scar -> release with Z plasty / W plasty if
needed with skin graft
b. Half rounded scar -> multipleZ plasty
c. Wide and deep scar -> scar excition, skin graft with
skin around the scar / transpotition flap
 TREATMENT

2. TENDOGEN CONTRACTURE
a. Volkman contracture -> it’s difficult and not
adequate for treatment. The only way is to
maintain the function of the hand with :
arthroplasty, arthrodese, tendon transplatation
b. Dupuytren contracture -> excision in many places,
fasciestomy, Z plasty