Central Slip Attenuation in Dupuytren’s Contracture: A Cause of Persistent Flexion of the Proximal Interphalangeal Joint Paul Smith, FRCS, Corine Breed, MD, Middlesex, United Kingdom This paper stresses the importance of central slip attenuation in the management of Dupuytren’s contracture. Such attenuation occurs in patients who have had prolonged proximal interpha- langeal joint contractures and is a common problem when the flexion contracture exceeds 60”. The diagnosis can be made at the time of surgical correction by a tenodesis test. If central slip attenuation is confirmed, the postoperative regime described here will give a better correction of what at first might appear to be an intractable proximal interphalangeal joint flexion deformity. (J Hand Surg 1994; 19A:840-843) The proximal interphalangeal (PIP) joint is the most difficult area for the surgeon treating digital Dupuytren’s disease. In the past, attention has been focused on the release of the palmar plate and acces- sory collateral ligaments, but unrecognized and un- treated secondary attenuation of the central slip mechanism of the dorsal apparatus is a major cause of failure to correct the PIP joint. This study presents an analysis of patients with Dupuytren’s disease in an attempt to increase awareness of the problem, explain an intraoperative diagnostic test, and propose a method of treatment, involving careful, postoperative static extension splintage. Materials and Methods Between 1980 and 1992, all Dupuytren’s patients attending our clinic were analyzed by a modification of the International Federation of Societies for Sur- From the Mount Vernon Hospital, Northwood, Middlesex, United Kingdom. Supported by RAFT Institute of Plastic Surgery, Mount Ver- non Hospital, Northwood. Middlesex, United Kingdom. Received for publication Oct. 28. 1992; accepted in revised form Feb. 9, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the sub- ject of this article. Reprint requests: Paul Smith, FRCS, Westmoreland. Col- linswoodroad, Farnham Common. Bucks SL2 3LQ, UK. 840 The Journal of Hand Surgery gery of the Hand’s questionnaire, developed by the Committee on Dupuytren’s disease led by McFar- lane.’ A retrospective study of 75 PIP joints, all of which required further release of this joint following digital fasciectomy, revealed 54 PIP joints with cen- tral slip attenuation as a result of prolonged flexion deformity of the PIP joint, proven by tenodesis testing. All patients within this group had a standard digi- tal fasciectomy, in the manner described by McFar- lane,’ through a linear digital incision converted to multiple Z-plasties (Figs. l-3). In the palm, if in- volved, a resection of the diseased tissue was under- taken (limited fasciectomy). Digital skin shortening was compensated for by the open palm technique, when necessary, combined with Z-plasties. The op- eration was essentially a Skoog procedure, with McFarlane’s emphasis on resection of all diseased tissue in the digits. This usually produced a full pas- sive correction of the PIP joints, but all of our pa- tients spontaneously returned to a flexed position when not held in extension (Fig. 4). At this stage, a central slip tenodesis test was per- formed by fully flexing the wrist and the metacarpo- phalangeal joint of the involved finger (Fig. 5). This is a passive version of Carducci’s active test. Failure of the PIP joint to extend fully indicated central slip attenuation (Fig. 6). This was confirmed by explora- tion of the dorsal apparatus in the first 10 cases,
Transcript
Central Slip Attenuation in Dupuytren’s Contracture: A Cause of
Persistent Flexion of the Proximal Interphalangeal Joint
Paul Smith, FRCS, Corine Breed, MD, Middlesex, United Kingdom
This paper stresses the importance of central slip attenuation in the management of Dupuytren’s
contracture. Such attenuation occurs in patients who have had prolonged proximal interpha-
langeal joint contractures and is a common problem when the flexion contracture exceeds
60”. The diagnosis can be made at the time of surgical correction by a tenodesis test. If
central slip attenuation is confirmed, the postoperative regime described here will give a better
correction of what at first might appear to be an intractable proximal interphalangeal joint
flexion deformity. (J Hand Surg 1994; 19A:840-843)
The proximal interphalangeal (PIP) joint is the most difficult area for the surgeon treating digital Dupuytren’s disease. In the past, attention has been focused on the release of the palmar plate and acces- sory collateral ligaments, but unrecognized and un- treated secondary attenuation of the central slip mechanism of the dorsal apparatus is a major cause of failure to correct the PIP joint.
This study presents an analysis of patients with Dupuytren’s disease in an attempt to increase awareness of the problem, explain an intraoperative diagnostic test, and propose a method of treatment, involving careful, postoperative static extension splintage.
Materials and Methods
Between 1980 and 1992, all Dupuytren’s patients attending our clinic were analyzed by a modification of the International Federation of Societies for Sur-
From the Mount Vernon Hospital, Northwood, Middlesex, United Kingdom.
Supported by RAFT Institute of Plastic Surgery, Mount Ver- non Hospital, Northwood. Middlesex, United Kingdom.
Received for publication Oct. 28. 1992; accepted in revised form Feb. 9, 1994.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the sub- ject of this article.
gery of the Hand’s questionnaire, developed by the Committee on Dupuytren’s disease led by McFar- lane.’ A retrospective study of 75 PIP joints, all of which required further release of this joint following digital fasciectomy, revealed 54 PIP joints with cen- tral slip attenuation as a result of prolonged flexion deformity of the PIP joint, proven by tenodesis testing.
All patients within this group had a standard digi- tal fasciectomy, in the manner described by McFar- lane,’ through a linear digital incision converted to multiple Z-plasties (Figs. l-3). In the palm, if in- volved, a resection of the diseased tissue was under- taken (limited fasciectomy). Digital skin shortening was compensated for by the open palm technique, when necessary, combined with Z-plasties. The op- eration was essentially a Skoog procedure, with McFarlane’s emphasis on resection of all diseased tissue in the digits. This usually produced a full pas- sive correction of the PIP joints, but all of our pa- tients spontaneously returned to a flexed position when not held in extension (Fig. 4).
At this stage, a central slip tenodesis test was per- formed by fully flexing the wrist and the metacarpo- phalangeal joint of the involved finger (Fig. 5). This is a passive version of Carducci’s active test. Failure of the PIP joint to extend fully indicated central slip attenuation (Fig. 6). This was confirmed by explora- tion of the dorsal apparatus in the first 10 cases,
The Journal of Hand Surgery I Vol. 19A No. 5 September 1994 841
Figure 1. A patient with long-standingflexion contracture of the proximal interphalangeal joint.
Figure 2. Dotted outline shows the extent of Dupuytren’s tissue. The linear incision can be clearly seen. and a dia- mond knife is used for dissection.
Figure 3. Full extension possible following excision of all Dupuytren’s tissue and conversion of the linear incision into multiple Z-plasties.
Figure 4. On release of forcible extension, the finger im- mediately reverts to flexion. This is due to lack of extensor tone.
but later in the series, a positive tenodesis test was accepted as evidence of central attenuation.
These patients underwent 3 weeks of static splint- age with the PIP joint in extension, but distal inter- phalangeal joint movement was allowed to encour- age lateral band mobility. We would prefer to under- take immediate dynamic extension splintage, but problems with patient compliance have prevented us from pursuing this. The 3 weeks of static splintage ensures compliance, and on removal of the splint, the open palm has healed, allowing active mobiliza- tion within a soft Capener splint for a further 3 weeks This splint cannot be used earlier because the proximal end would impinge upon the open pal-
Figure 5. After release of Dupuytren’s tissue. a tenodesis test is performed by fully flexing the wrist and the meta- carpophalangeal joints. Note that the ring, finger shows extension at the proximal interphalangeal joint due to the tenodesis action of the central slip, which is intact. The little finger. however. does not show any extension, and consequently, one can diagnose central slip attenuation. Patients who display this particular sign are then immobi- lized in plaster for 3 weeks.
842 Smith and Breed / Central Slip Attenuation in Dupuytren’s Contracture
Figure 6. Another patient with a similar problem, is in Figure 5, where the dorsum of the finger has been ex- plored. Note the punched out area of the central slip mechanism.
mar wound. This was followed by active daytime mobilization associated with nighttime PIP exten- sion splintage for 4-6 months.
In 21 PIP joints with no central slip attenuation, the patients were immediately mobilized, following standard Dupuytren’s protocol of full daytime activ- ity with nighttime extension splintage (4-6 months). All patients were reviewed and their postoperative results were analyzed (Figs. 7,8). The follow-up pe- riod averaged 4 years at review (SD, 2.6 years; range, OS-10 years) from the time of cessation of splintage.
Results
Between 1980 and 1992, 75 PIP joints required release following digital fasciectomy. During the early part of this series, it became apparent that sec-
Figure 8. Full extension.
ondary attenuation of the dorsal apparatus at the site of the central slip was responsible for failure to correct the flexion deformity in some patients with Dupuytren’s disease. Fifty-four joints were diag- nosed as having central slip attenuation following the tenodesis test.In this series, this was present in 80% of the patients with PIP joint contractures over 60”.
Preoperative analysis of the 54 joints with central slip attenuation showed an average PIP joint con- tracture of 87”. After surgery, this was reduced to 27”, an improvement of 70% (Table I). The 21 PIP joints with intact central slips showed a less severe preoperative contracture of 63” (Table 2). The de- scribed treatment regime applied to the central slip attenuation group produced results that were at least as good (70% improvement) as those achieved in the less severely affected group (66% improvement).
Discussion
McFarlane’ made the important point that Dupuy- tren’s cords produce a primary contracture, empha-
Figure 7. Full flexion following conservative treatment of the central slip attenuation with splintage and then mobili- zation in a Capener splint.
Table 1. Results of 54 PIP Joints That Underwent PIP Joint Release and Were Found
to Have Attenuation of the Central Slip of Their Extensor Apparatus
sizing that secondary contractures resulted from ad- herence and contraction of structures held in a shortened position but not directly infiltrated by DU- puytren’s disease. Most reports have emphasized the flexor aspect of the finger, and little reference has been made to the dorsal apparatus. Even Cur- tis’s’ comprehensive analysis of the reasons for lack of complete extension at the PIP joint did not men- tion lack of extensor tone. Hueston reported the problem of persistent PIPjoint flexion “despite total release of all fascial contracture.” He emphasized that these were secondary changes in the extensor apparatus and suggested the use of a lively splint after surgery. He recommended Fowler’s extensor tenotomy to regain distal interphalangeal joint flex- ion. Tonkin and Lennon in 1985, pointed to the failure of PIP joint extension following an arthroplasty.
The role of the dorsal apparatus in Dupuytren’s contracture was first presented to the British Soci- ety for Surgery of the Hand in 1985 (Smith) and quoted by Burke et al.’ and McFarlane et al.‘j in 1990.
Andrew’ undertook an anatomic study of con- tracted PIP joints recovered from eight patients who underwent elective amputations. He documented
the ballooning of the central slip previously alluded to, but did not advocate any treatment.
Throughout these studies there is an awareness of an additional problem once Dupuytren’s cord has been removed by fasciectomy and any secondary contractures have been handled, but there has been a failure to recognize the importance of central slip attenuation. This is surprising since hand surgeons have long recognized the importance of the BouvierX test in long-standing ulnar nerve palsies with claw deformities.
Since 1980, all of our patients have undergone the central slip tenodesis test after fasciectomy and PIP joint procedures have produced complete correction of the extension. The tenodesis test will diagnose central slip attenuation. The recurrent flexion in a digit that can be passively extended is due to lack of extensor action.
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References
McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture. Plast Reconstr Surg 1974;54:31-44. Curtis RM. Surgical restoration of motion in the stiff interphalangeal joints of the hand. Bull Hosp J Dis 1970;31:1-6. Hueston JT. The extensor apparatus in Dupuytren’s disease. Ann Chir Main 1985;4:7-IO. Tonkin MA, Lennon WP. Dermofasciectomy and proximal interphalangeal joint replacement in Dupuy- tren’s disease. J Hand Surg 1985:10B:351-2. Burke FD, McGrouther DA, Smith PJ. Principles of hand surgery. 1st ed. New York: Churchill Living- stone, 1990:308. McFarlane RM, McGrouther DA. Flint MH. Dupuy- tren’s disease: biology and treatment. 1st ed. New York: Churchill Livingstone, 1990:310. Andrew JG. Contracture of the proximal interphalan- geal joint in Dupuytren’s disease. J Hand Surg 1991: 16B:446-8. Bouvier M. Note sur une paralysie partielle des mus- cles de la main. Bull Acad Nat Med (Paris) 18:125: 1851.
