Surgical technique and Up-to-date

management
Common Congenital Hand
anomalies - Part 2
Christian Dumontier, MD, PhD
FWI- Guadeloupe

Can be downloaded at: www.diuchirurgiemain.org

 The bent fingers
• Camptodactyly: 1846, Tamplin differentiated
campodactyly from Dupuytren's disease.

• Clinodactyly: Earliest report of clinodactyly is

probably by Smith, in 1896, who noted the
association between mongolism and clinodactyly

• Kirner’s deformity: Kirner described the deformity

which now bears his name (a flexion deformity of
the distal phalanx) in 1927.
 Camptodactyly

Christian Dumontier MD, PhD

Centre de la Main
Guadeloupe - FWI

Available at www.diuchirurgiemain.org
 Camptodactyly
• Camptodactyly = Bent finger [from
the greek κάµπτω (to bend) and
δάκτυλος (finger)]

• 1st description by Tamplin, 1846

• 1st use of the name by Landouzy-1906

• Nontraumatic finger PIP joint

flexion deformity, often occurring
bilaterally (≈ 2/3).

• Mostly the little finger (94% of cases -

Engber)

Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am
1977;2(3):216–24.
 Camptodactyly

• Camptodactyly is a clinical
sign, possibly part of a
syndrome, but is never a
disease in its own right
(Flatt).

• Its cause remains debatable to

date

Flatt AE: The care of congenital hand anomalies. St. Louis, 1977, The CV Mosby Co, pp 147-54
 Camptodactyly

• Unknown incidence but

probably less than 1% (0,83%
in 2000 newborn - Gnamey)

• Males = females or Females >

males according to series

• 45/46 were caucasians

( Engber)

Gnamey D. Fréquence des malformations congénitales et héréditaires des doigts. Lille Médical 1973;18(8):950–2.
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am
 Clinical presentation
• Most common: sporadic without family history

• Familial variant : autosomal dominant pattern of inheritance with

variable penetrance

• Association with clinodactyly, syndactyly, polydactyly,

brachydactyly, or longitudinal ray defects is a different form

• Associated with various syndromes including arthrogryposis,

mucopolysaccharidoses, Marfan syndrome, chromosomal trisomy
disorders, oculodentaldigital dysplasia, Freeman- Sheldon
syndrome, windblown hand, and camptomelic dysplasia..
 Camptodactyly
• Bimodal age distribution during
periods of rapid growth.

• < 2 years old, infantile

camptodactyly (M = F), ≈ 80% of Infantile presentation from Yannascoli 2018
cases.

• > 10 years old, adolescent

camptodactyly (F > M), ≈ 20% of
cases.

Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am
1977;2(3):216–24.
 Classification

• Many used
Type I Infantile
• Age at presentation
and associated Type II Adolescent
anomalies are more
frequently preferred Type III Syndromic

Benson LS, Waters PM, Kamil NI, et al. Camptodactyly: classification and results of nonoperative treatment. J Pediatr
Orthop 1994;14(6):814–9
 Causes suspected

• Tuberculosis and rheumatoid disorders - Landouzy

1906

• Sluggish peripheral circulation - Oldfield 1954

• Volar skin tightness + abnormal insertion of the 4th

lumbrical (2 out of 3 cases) - Courtemanche

Courtemanche AD. Campylodactyly: etiology and management. Plast Reconstr Surg 1969;44(5):451–4.
Oldfield MC. Campylodactyly: flexor contracture of the fingers in young girls. Br J Plast Surg 1956; 8(4):312–7.
 Cause: abnormal volar structures
• Abnormal lumbrical insertion (96% of his cases),
47% FDS anomaly -Mc Farlane

• Volar skin tightness and very few lumbrical

insertion anomaly (10%) - Siegert

• Hypoplastic FDS tendon in 5 out of 6 patients-

Ogino
McFarlane RM, Curry GI, Evans HB. Anomalies of the intrinsic muscles in camptodactyly. J Hand Surg Am 1983;8(5
Pt 1):531–44.
McFarlane RM, Classen DA, Porte AM, et al. The anatomy and treatment of camptodactyly of the small finger. J Hand
Surg Am 1992;17(1):35–44.
Siegert JJ, Cooney WP, Dobyns JH. Management of simple camptodactyly. J Hand Surg Br 1990;15(2): 181–9.
Ogino T, Kato H. Operative findings in camptodactyly of the little finger. J Hand Surg Br 1992;17(6): 661–4.
 Cause- abnormal dorsal structures

• Anomalies of the extensor mechanism

• Absence of lateral bands- Smith

• Absence of extensor mechanism - Carneiro

• Extensor mechanism anomalies- Koman

Smith PJ, Grobbelaar AO. Camptodactyly: a unifying theory and approach to surgical treatment. J Hand Surg Am
1998;23(1):14–9.
Carneiro RS. Congenital attenuation of the extensor tendon central slip. J Hand Surg Am 1993;18(6): 1004–7.
Koman LA, Toby EB, Poehling GG. Congenital flexion deformities of the proximal interphalangeal joint in children: a
subgroup of camptodactyly. J Hand Surg Am 1990;15(4):582–6.
 As a consequence
• If surgery is considered

• « We believe that rather than

isolated anatomic factors that
differ in each individual, it is
involvement of all the anatomic
factors previously discussed to
a variable degree that occurs in
all patients » (Smith) from Smith and Grobbelaar

Smith PJ, Grobbelaar AO. Camptodactyly: a unifying theory and approach to surgical treatment. J Hand Surg Am
1998;23(1):14–9.
 Most authors now favor a stepwise surgery

• Stepwise assessment of all potentially involved

structures (skin, fascia, the FDS tendon,
lumbricals, interossei, lateral bands, volar plate,
accessory collateral ligaments, joint surfaces, and
central slip insertion) is necessary

• And treatment is tailored to the involved structures

diagnosed pre-op and/or found at surgery
Foucher G, Lorea P, Khouri RK, et al. Camptodactyly as a spectrum of congenital deficiencies: a treatment algorithm
based on clinical examination. Plast Reconstr Surg 2006;117(6): 1897–905.
Hamilton KL, Netscher DT. Evaluation of a stepwise surgical approach to camptodactyly. Plast Reconstr Surg
2015;135(3):568–76.
Netscher DT, Hamilton KL, Paz L. Soft-tissue surgery for camptodactyly corrects skeletal changes. Plast Reconstr Surg
2015;136(5):1028–35.
 Physical examination

• Eliminate differential diagnosis (trigger finger and

distal arthrogryposis are the main diagnosis)

• Identify all structures that can be involved in the

deformity in order to address them
 Physical examination steps

May require Z-plasty, skin graft or

Skin tightness or a pterygium
rotational flap

Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
 Physical examination steps
PIP contracture with MCP and
wrist flexion to assess volar plate
and intrinsic joint structures
 Physical examination steps
May require Z-plasty, skin graft or
Skin tightness or a pterygium
rotational flap
PIP contracture with MCP and wrist flexion to
assess volar plate and intrinsic joint structures

PIP passive extension with the wrist
in extension
Bouvier’s maneuver (active PIP
extension with the MP flexed)
DIP hyperextension ?
any change during wrist extension
indicates tightness of flexor tendons
To identify attenuation of the central
slip of the extensor mechanism

if planning to divide the FDS, FDP

FDP strength
must be intact and strong
FDS function of the small finger ? Testing of FDS V

Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018)
237–249
 Radiographic evaluation

• Flattening and beaking of the

P1 head

• Indentation of P2 phalangeal
base
 Radiographic evaluation

• Present in 29% of Foucher’s

series (up to 58% if the
contracture was fixed) and
68% in Ogino’s series

Foucher G, Lorea P, Khouri RK, et al. Camptodactyly as a spectrum of congenital deficiencies: a treatment algorithm
based on clinical examination. Plast Reconstr Surg 2006;117(6): 1897–905.
Ogino T, Kato H. Operative findings in camptodactyly of the little finger. J Hand Surg Br 1992;17(6): 661–4.
 Treatment

Patients (and parents) should be

• Abstention aware
To accept mild deformity
To strictly adhere to therapy
• Non operative protocol often sufficient with
treatment acceptable results
That a normal finger are not the
• Surgery goal of surgical correction and
that surgery can be delayed
 Abstention
• Easy to perform

• No cost

• No complication

• No functional impairment

Possible aggravation
with time
 Non-operative treatment

• Of 62 patients, only 5 failed

conservative treatment

• Capener-type splint worn day

& night until regaining
complete extension, then 8
hours/night until late teenage

Miura T, Nakamura R, Tamura Y. Long-standing extended dynamic splintage and release of an abnormal restraining
structure in camptodactyly. J Hand Surg Br 1992;17B:665-672.
 Non-operative treatment
• Passive stretching protocols
( 4 times / day, 5 minutes)

• Active extension
strentghening
FromYannascoli
• Static splinting at night
(sometimes dynamic splinting
at day)

A lack of motivation from the patient or family to comply with these

regimens excludes the patient as a surgical candidate
 Non-operative treatment

• Passive manipulation: 5
minutes, 20 times a day to
take advantage of the creep
phenomenon,

• The stretching force should

be maintained for a prolonged
time.

Rhee SH et al. Effect of Passive Stretching on Simple Camptodactyly in Children Younger Than Three Years of Age. J
Hand Surg 2010;35A:1768–1773
 Non-operative treatment
Before TTT
After

• Only passive manipulation

• 61 digits in 22 patients Mild

• < 3 years of age: long finger Moderate

in 27 cases, little finger in 15
cases, ring finger in 14 cases,
and the index finger in 5 Severe
cases.
0 17,5 35 52,5 70

Rhee SH et al. Effect of Passive Stretching on Simple Camptodactyly in Children Younger Than Three Years of Age. J
Hand Surg 2010;35A:1768–1773
 Non-operative treatment may
improve bone remodeling

• 48 fingers in 20 patients

• Statistically significant
radiological parameters
improvement

• PIP contracture improved

from 34° +/- 13° to 6° +/- 7°

Hong SW et al. Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With
Camptodactyly . J Hand Surg Am. 2019 (in Press)
Surgery : Contra-indications ?

• Non-motivated/compliant
patient

• No functional impairement

• Contracture less than 30-60°

• Long-standing articular
deformity ?
 Operative treatment
• Skin tightness ➠ Zplasty, rotational
flaps, FTSG,…

• As all different • Lumbrical insertion ➠ excision +/- re-

anatomical structures insertion onto the extensor mechanism
have been involved, so • FDS ➠ FDS tenotomy +/- transfer
techniques have been
onto the extensor mechanism
designed to treat the
suspect anatomical • PIP contracture ➠ volar plate release
anomaly +/- temporary K-wire

• Extensor weakness ➠ FDS transfer,

Lasso,…or postop splinting
 Limited expected outcomes
• In 18 patients, improvement in 35%, no difference in 30%, and worse results in
35% (Engber). Worse results associated with phalangeal joint recontouring

• 0 excellent, 7 good, 6 fair, and 25 poor results (Siegert). 50% of patients

considered worsened by surgery. Results deteriorate with longer follow-up.

• With FDS sectioning without transfer ➠ Patients improved in active extension

but noted a loss of flexion (Ogino), ➠ no improvement in 8 digits, but
improvement if transfer was done in 12 cases (Koman) .

• In 35 cases of isolated small finger camptodactyly, only 50% had less than 15°
flexion deformity with 33% unable to regain full flexion, average dpc1.8 cm (Mc
Farlane).

Engber WD, Flatt AE. Camptodactyly: an analysis of sixty-six patients and twenty-four operations. J Hand Surg Am 1977;2(3):216–24.
Siegert JJ, Cooney WP, Dobyns JH. Management of simple camptodactyly. J Hand Surg Br 1990;15(2): 181–9.
Ogino T, Kato H. Operative findings in camptodactyly of the little finger. J Hand Surg Br 1992;17(6): 661–4.
McFarlane RM, Classen DA, Porte AM, et al. The anatomy and treatment of camptodactyly of the small finger. J Hand Surg Am 1992;17(1):35–44.
Koman LA, Toby EB, Poehling GG. Congenital flexion deformities of the proximal interphalangeal joint in children: a subgroup of camptodactyly. J
Hand Surg Am 1990;15(4):582–6.
 Operative treatment

• Adverse results such as loss of flexion and scar

formation have been commonly reported
• « Surgical correction does not improve overall arc of
motion but places the existing arc of motion in a more
functional, hygienic position for improved large-object
grasp ».

Evans BT, Waters PM, Bae DS. Early results of surgical management of camptodactyly. J Pediatr Orthop 2017;37(5):
317–20.
 Stepwise approach
• 83% good to excellent results (Smith)

• Radiographic improvement in 15/16 patients, a

decrease deformity from 62° to 4° post, 83% had
full active extension (Netscher)

• Foucher improved his results from 55% to 86%

using a stepwise approach
Smith PJ, Grobbelaar AO. Camptodactyly: a unifying theory and approach to surgical treatment. J Hand Surg Am
1998;23(1):14–9.
Netscher DT, Hamilton KL, Paz L. Soft-tissue surgery for camptodactyly corrects skeletal changes. Plast Reconstr Surg
2015;136(5):1028–35.
Foucher G, Lorea P, Khouri RK, et al. Camptodactyly as a spectrum of congenital deficiencies: a treatment algorithm
based on clinical examination. Plast Reconstr Surg 2006;117(6): 1897–905. 

 1.Skin Stepwise approach:
2.Subcutaneous and fascia Goldfarb proposal
3.Lumbrical and FDS

4.FDS tenotomy
Step 1 to 4, and step 9
5.Release of PIP joint contracture always performed
6.Correction of PIP extension lag
Step 5 to 8 are
7.PIP joint pinning
performed according to
8.Terminal tenotomy prep examination and
9.Release of the tourniquet intraoperative findings
Yannascoli SM, Goldfarb CA. Treating Congenital Proximal Interphalangeal Joint Contracture. Hand Clin 34 (2018) 237–249
Wall LB, Ezaki M, Goldfarb CA. Camptodactyly Treatment for the Lesser Digits. J Hand Surg Am. 2018;43(9):874.e1-e4.
 Skin and subcutaneous release

• Z-plasty may be insufficient

in severe deformities and a
flap should be preferred
Skin and subcutaneous release

• Then release subcutaneous

tissues and fascia
 Assessment of lumbricals and FDS anatomy

• Trace lumbricals distally and

remove any abnormal
insertion

Kamnerdnakta S, Brown M, Chung KC. Camptodactyly Correction. Operative Techniques in Hand and Wrist Surgery,
Chund KC (eds). 2018. pp842-849
 Assessment of lumbricals and FDS anatomy

• FDS division at Chiasma camper (if FDP has enough strength

preop)

Kamnerdnakta S, Brown M, Chung KC. Camptodactyly Correction. Operative Techniques in Hand and Wrist Surgery,
Chund KC (eds). 2018. pp842-849
 Release of PIP contracture

• Done if no full extension is

made possible preoperatively
with wrist and MP flexion

• Cave !: preserve the arterial

arch (Edwards) for the
vincula and the
vascularisation of the PIP +++
Correction of PIP extension lag
• If preop Bouvier maneuver shows
a mild extension lag (<60°), the
patient receives a postoperative
splint for 4 weeks.

• If the preoperative Bouvier

maneuver shows a severe extension
lag (>70°), a tendon transfer using
the released FDS to the extensor
mechanism is performed.

• A K-wire is inserted for 7-10 days

to maintain the correction
 Tendon transfer

• Few authors recommend it actually

• McFarlane used the FDS IV

• Gupta suggested the use of EIP

Gupta A, Burke FD. Correction of camptodactyly. J Hand Surg 1990;15B:168-170.

 Release of the tourniquet

• Release tourniquet before the

end of the procedure to assess
digit perfusion

• Sometimes the neurovascular

bundles will not allow full
extension
 Postop regimen
• Permanent splint except for hourly exercices:

• Active and passive MCP joint range of motion.

• Active PIP joint extension with MCP held in flexion.

• Ranges of motion for the PIP joint and DIP joint are initiated via proximal and
middle phalanx blocking exercises.

• Passive PIP joint flexion is avoided if an extension transfer has been performed.

• Four weeks postoperative : start to remove the splint

• Six weeks postoperative : passive flexion of the PIP joint for patients with tendon
transfer. A dynamic finger extension splint may be initiated. The static extension splint
is now worn only at night.

• Twelve weeks postoperative: splint are discontinued

Netscher DT, Staines KG, Hamilton KL. Severe camptodactyly: A systematic surgeon and therapist collaboration
Journal of Hand Therapy 28 (2015) 167-175
 Conclusion
• Camptodactyly is a clinical sign, not a symptom

• Most patient are no or little impairment

• Non surgical treatment has proven effective but parents’

adhesion to the treatment plan is the key to success.

• Surgery can improve patients but will not give a normal finger,
and can sometimes aggravate the symptoms

• If surgery is performed, a stepwise approach seems logical as not

a single anomaly can be expected to be the cause of the deformity
 Clinodactyly
Christian Dumontier MD, PhD
Centre de la Main- Guadeloupe- FWI
• Clinodactyly is a physical sign, not a disease, and
may be found at birth, may gradually develop, or
may result from a variety of pathological processes.
 Clinodactyly

• From the Latin -clīn(āre) (cognate with Greek klī́nein to cause

to lean) and the Greek daktylos = finger

• A bent finger: clinodactyly is defined as angulation of a digit in

the radio-ulnar plane

• Earliest report of clinodactyly is probably by Smith, in 1896,

who noted the association between mongolism and
clinodactyly
 Incidence

• In the literature between 10,7-19.5%

• 1/1,000 in America (Hersch)

• 3-5% of Japanese children (geographical variations ? Fujita)

• Gender distribution in the USA to be 15% among boys and 8%

among girls for the little finger and 2% for index finger

Hersch, AH, De Marinus, F, Stecher R. On the inheritance and development of clinodaclyly. Am. J Human Gen., 1953;
5: 257-268.
Fujita H, Iio K, Yamamoto K. Brachymesophalangea and clinodac- tyly of the fifth finger in Japanese children. Acta
Paediatr Jpn 1964; 31:26 –30.

 Classification
• 3 types

• Familial clinodactyly with a

dominant inheritance

• Clinodactyly in association with

other (> 60) syndromes; Marked
clinodactyly often indicates
mental retardation.

• Clinodactyly secondary to
epiphyseal injury (fracture,
frostbite…)
Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Poznanski AK et al. Clinodactyly, Camptodactyly, Kirner’s Deformity, and Other Crooked Fingers. Radiology 1969; 93:
573-582.
 Clinodactyly in Apert Clinodactyly in a tri-
Syndrome phalangeal thumb

Norat F et al. Les clinodactylies : phalange delta et déformation de Kirner. Chirurgie de la main 27S (2008) S165–S173
 « Familial » clinodactyly

• Minor angulation, particularly in the little finger, is a normal

finding and an angulation of 10° is commonly regarded as the
upper limit of normal.

• Inherited as an autosomal dominant trait with slight lack of

penetrance (Hersch, 1953)
•

Hersch, AH, De Marinus, F, Stecher R. On the inheritance and development of clinodaclyly. Am. J Human Gen., 1953;
5: 257-268.
 Clinodactyly in art

François Ier, French king,

1494-1547 (painting from Jean Marguerite de Valois, « la reine Margot »,
Clouet, Musée du Louvre) 1553-1615 his grand daughter (painting from
François Clouet, Musée Condé-Chantilly)
 Clinodactyly - Pathophysiology
• Skeletal basis is a delta-shaped
middle phalanx (in most cases)

• Characterized by an anomalous
epiphysis (C-shaped) that is
oriented longitudinally along the
short side of the affected bone
leading to progressive angulation
of the digit toward the convex side

• Blundell Jones suggested the term

“delta phalanx” to describe the
abnormal triangular bone, but it
could be a trapezoidal phalanx.

Blundell Jones G. Delta Phalanx. JBJS Br 1964, 46B(2): 226-228

Delta phalanx
Trapezoidal shape
 Clinodactyly

• In young children without visible

epiphysis, the C-shape is not visible
 Flatt’s series of 50 cases
• 28 females, 22 males

• 32 had familial history

• 18 isolated (mostly familial

history), 30 had a syndrome

• 24 patients with P2 involvement,

4 P1 (2 thumb, 2 ring) had a
radiological appearance of delta
phalanx (17 too old without
•
cartilage left to conclude).

Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
 Clinical presentation

• Radial deviation of the DIP

of the little finger

• Most cases of true

clinodactyly are a cosmetic
rather than a functional
problem.

Burke F, Flatt AE. Clinodactyly. A Review of a Series of Cases. The Hand 1979; 11(3):269-280
Poznanski AK et al. Clinodactyly, Camptodactyly, Kirner’s Deformity, and Other Crooked Fingers. Radiology 1969; 93:
573-582.
 Indications for treatment

• « …The majority of patients with clinodactyly have little

in the way of functional problems and therefore require no
treatment. A minority will require surgical intervention,
either from a functional or a cosmetic point of view, usually
the latter… »( Flatt)

• It also depends of the phalanx involved

 Abstention

• Minor deformity

• May reveal psychological

problems
 Indications according to the
phalanx involved
• Middle Phalanx. Few of these merit surgery (according to Flatt) as
longitudinal growth of the affected middle phalanx is moderately reduced.

• Those with marked angulation of the small finger at the DIP joint can
accommodate by abduction of the metacarpophalangeal joint.

• It is advisable to allow the middle phalanx to achieve maximal length before

surgery is attempted ( await skeletal maturity before performing surgery)

• Proximal Phalanx. Angulation of a significant degree tends to occur early and

early intervention is indicated

• Congenital triangular bone in the tri-phalangeal thumb should be excise early

in life, for increasing instability and angulation will occur.
 Surgical techniques
+/- Bone graft

• Closing wedge osteotomy (Wood)

• Opening wedge osteotomy (Jones)

• Reverse wedge osteotomy (Carstam)

Carstam N, Theander G. Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis (‘‘delta
phalanx’’). Scand J Plast Reconstr Surg 1975;9:199–202.
Jones GB. Delta phalanx. J Bone Joint Surg Br 1964;46:226–8.
Wood VE, Flatt AE. Congenital triangular bones in the hand. J Hand Surg Am 1977;2:179–93.
 Closing wedge osteotomy

• 25 fingers (17 patients): small finger

(20 digits), index finger (4 digits), and
middle finger (1 digit)

• Age 1-15 years (mean, 9 years).

• Family history was positive for

clinodactyly only in 4 patients. Fifteen
patients had isolated clinodactyly.

Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
 Closing wedge osteotomy
• Dorsolateral longitudinal incision over the
convex side of the finger.

• Remove a 2- to 3-mm bony wedge (or the kerf

of the blade)

• One or two K-wires (1.4 mm or 0.9 mm) from

the pulp, across the osteotomy, transfixing the
PIP joint.

• K-wires are removed after 4 or 6 weeks

Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
 Closing wedge osteotomy
• Angular deformity improve
from 33° preop to 9° postop
(X-rays correction from 29°
to 5°)
6 years old boy, 6 months FU
• DIP joint arc of motion
decreased from 84° prior to
surgery to 81° after surgery,

• PIP joint arc of motion was

unchanged.
Ali M, Jackson T, Rayan GM. Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. J Hand Surg
2009;34A:914–918
Opening wedge osteotomy

• Dorsal V-shaped incision that

can be close in a VY fashion

Goldfarb CA, Wall LB. Osteotomy for clinodactyly. J Hand Surg Am. 2015;40(6):1220-1224
Opening wedge osteotomy
• A single 0.045-inch Kirschner
wire is placed retrograde in the
distal phalanx, slightly radial to
midline.

• It crosses the DIP joint to

stabilize it during the osteotomy

• A second, temporary 0.035-inch

Kirschner wire is placed across
the PIP joint to avoid deviation
through the joint when “opening”
the osteotomy

Goldfarb CA, Wall LB. Osteotomy for clinodactyly. J Hand Surg Am. 2015;40(6):1220-1224
 Opening wedge osteotomy
• 13 fingers in 9 patients treated Preop Postop
between 2003 and 2011.
Clinical 34°
• Average age at surgery was 7° (0-35°)
angle (20-45°)
nine years. FU was 25 months

• 2 complications (non-unions X-rays 35°

7° (0-30°)
angle (27-45°)
with recurrent deformity)-
they now use bone grafts from
259,3° 234,5°
the radius TAM
(225-270) (110-270°)

Piper SL, Goldfarb CA, Wall LB. Outcomes of Opening Wedge Osteotomy to Correct Angular Deformity in little finger
Clinodactyly J Hand Surg Am. 2015;40(5):908-913
 Others

• Realignement

• Reverse wedge osteotomy

(Carstam)

Carstam N, Theander G. Surgical treatment of clinodactyly caused by longitudinally bracketed diaphysis (‘‘delta
phalanx’’). Scand J Plast Reconstr Surg 1975;9:199–202.
 Surgical techniques
The limiting factor is tightness of all the soft tissues, and Z-
plasty of the skin does little to help (Jones, 1964).
The extensor mechanism and the neurovascular structures
are at risk

• Physiolysis (Vickers)

Vickers D. Clinodactyly of the little finger: a simple operative technique for reversal of the growth abnormality. J Hand
Surg Br 1987;12:335–42.
 Physiolysis

• Vickers removes the proximal

bone metaphysis up to the
growth plate and add a fat
graft
Radiographic evolution over a 5 years period
• He reported (progressive)
improvement in 12 patients

Vickers D. Clinodactyly of the little finger. A simple operative technique for reversal of the growth abnormality. J Hand
Surg Br 1987; 12B(3):335-342
 Vickers’s Physiolysis
• 22 patients (27 fingers) over a 13 years period with 7,4 years FU

• 14 boys, 8 girls Mean age 3,9

• 1 index, 1 middle, 24 little fingers

• Fat graft from the hypothenar

• No K-wire, only the skin is sutured. 2 weeks immobilisation.

• No immediate correction of the clinodactyly; the response to surgery is seen

only with the child’s growth +++

• No complications, normal finger motion

• Final angulation was 8° (79% correction) obtained in most cases within 1 year

Medina J, Lorea P, Elliot D,Foucher G. Correction of Clinodactyly by Early Physiolysis: 6-Year Results. J Hand Surg
Am. 2016;41(6):123-127
 Vickers’s Physiolysis
• 14 patients (24 fingers) over a 6
years period with 54 months FU

• Mean age 4,3 years at surgery

• Correction rate was 49% at 1 year

and 70% at 2 years

• 2 premature growth plate closure

• No difference if performed after 6

years of age

El Sayed L, Salon A, Glorion C, Guéro S. Physiolysis for correction of clinodactyly with delta phalanx: Early
improvement. Hand Surgery and Rehabilitation 38 (2019) 125–128
 Conclusion

• Rarely a functional impairment

• Vicker’s physiolysis is safe, effective if performed in

the early ages (but complete removal of the
abnormal epiphysis is required)

• Ostotomies can be performed later when sufficient

bone is available
Pediatric trigger
thumb
Christian Dumontier MD, PhD
Centre de la Main, Guadeloupe, FWI
 Pediatric not congenital

• 4,719 consecutive newborns and no cases of

“congenital” trigger thumb - Slakey

• 1116 new borns, no cases of “congenital” trigger

thumb - Kikucki

• 1016 new borns, no cases of “congenital” trigger

thumb - Rodgers

Slakey JB, Hennrikus WL. Acquired thumb flexion contracture in children. J Bone Joint Surg 1996;78B:481–483.
Kikuchi N, Ogino T. Incidence and development of trigger thumb in children. J Hand Surg 2006;31A:541–543. Rodgers
WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg 1994;19A:364–368.
 Pediatric trigger thumb
• Prevalence at 1 year is approximately
3,3 per 1,000 live birth.

• 1,187 patients with 1,449 PTT assessed.

• 50% girls, 50% boys.

• Right side 55%.

• Bilateral involvement 25% of cases.

• Mean age at first presentation was 26

months, with 19% of patients
presenting before 6 months of age.

Bae DS. Pediatric trigger thumb. JHS 2008; 33A:1189-1191

Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
Pediatric trigger thumb- Pathology

• Triggering is caused by a size

mismatch between the flexor
pollicis longus tendon and
flexor tendon sheath.

• At present, the exact etiology

remains unknown.

• Notta nodule (thickening of

the flexor pollicis longus
tendon at the base of the
MPJ) was described in 1850

Bae DS. Pediatric trigger thumb. JHS 2008; 33A:1189-1191

 Pediatric trigger thumb
• Thumb in fixed flexion at the IP
joint,

• Rarely (10%), Intermittent, painful

catching of the interphalangeal joint.

• A palpable nodule (Notta’s node) at

the A1 pulley
 Natural history
• Spontaneous resolution has been described in 0 to 60% of
cases !

• 19/ 26 thumbs (73%) demonstrated spontaneous recovery

within 1 year after presentation. 30% for patients presenting
soon after birth versus 12% for the whole group [Dinham].

• 71 thumbs in 55 patients followed at least 2 years. At 4-year

follow-up, the average pretreatment 26° flexion posture
resolved in 45 thumbs (63%) and improved in most of the
rest [Baek].

Dinham JM, Meggitt BF. Trigger thumbs in children. J Bone Joint Surg 1974;56B:153–155.
Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of pediatric trigger thumb. J Bone
Joint Surg 2008; 90A:980 –985.
 Natural history

• Rate of spontaneous recovery in Southeast Asian

papers is close to 50% and that in Western papers is
about 10%.
Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
 Non-operative treatment

• Stretching with approximately 50% of children demonstrating

resolution at 6 months (Tan, Dunsmuir)

• 58 thumbs in 46 children treated with daily parent-supervised

passive extension exercises( Watanbe).

• 96% of thumbs had a “satisfactory result,”but final motion was

abnormal in 34 of 59 thumbs (59%).

Tan AH, Lam KS, Lee EH. The treatment outcome of trigger thumb in children. J Pediatr Orthop B 2002;11:256–259.
Dunsmuir RA, Sherlock DA. The outcome of treatment of trigger thumb in children. J Bone Joint Surg 2000;82B:736–
738.
Watanbe H, Hamada Y, Toshima T, Nagasawa K. Conservative treatment for trigger thumb in children. Arch Orthop
Trauma Surg 2001;121:388 –390.
 Non-operative treatment: splinting
• Nighttime IP joint extension splinting in 40 trigger thumbs for
an average of 10 months.

• “success rate” of 73% is reported, with a number of patients

who had incomplete improvement,

• Full-time hyperextension splinting for 6 to 12 weeks followed

by nighttime splinting in 31 locked thumbs.

• 71% of thumbs demonstrated improvement, although normal

motion was not restored in all patients.
Nemoto K, Nemoto T, Terada N, Amako M, Kawaguchi M. Splint therapy for trigger thumb and finger in children. J
Hand Surg 1996;21B:416 – 418.
Lee ZL, Change CH, Yang WY, Hung SS, Shih CH. Extension splint for trigger thumb in children. J Pediatr Orthop
2006;26: 785–787.
 Non-operative treatment
• Probably worth to try

• However due to the length of treatment (many

months), the difficult to employ splinting in young
children, the natural of the disease and the
incomplete return of full IP range of motion with
persistent MP joint hyperextension

• Stretching is probably all that is needed

 Surgical release

• Favored by many authors

• Release of the A1 pulley is a

reliable procedure with
minimal morbidity; long-term
outcome is satisfactory.
 Surgery for pediatric trigger thumb
• Transverse incision
(longitudinal incision
are less esthetic)

• A1 pulley release

• Check for complete IP

extension

• If necessary, enlarge the

release: any proximal
bands of tissue (an A0
pulley), the proximal
part of the oblique
pulley.

McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
 When to perform surgery ?
• Children who had surgery after the age of 3 years took
longer (many months) to correct the contracture - Ger.

• Residual flexion contracture of 10° to 15° in 23% of the

patients when surgery was performed after 3 years of
age - Mac Adams.

• Residual flexion contractures on patients treated after

the age of 4 years - Dinham.

Ger E, Kupcha P, Ger D. The management of trigger thumb in children. J Hand Surg 1991;16A:944–947.
Dinham JM, Meggitt BF. Trigger thumbs in children. A review of the natural history and indications for treatment in 105
patients. J Bone Joint Surg 1974;56B:153–155.

McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
 Outcomes of surgical release
• Overall, favorable results may be expected after surgical release.

• 30 thumbs in 21 patients with mean follow-up of 15 years. No recurrence

or functional compromise. 23% had mild loss of IP joint extension and
18% had metacarpophalangeal joint hyperextension -Mc Adams.

• 40 thumbs in 37 patients with a mean follow-up of 69 months. All had full

range of motion, and there were no neurological or scar-related
complications. 25% had mild (asymptomatic) tendon bowstringing of 1–2
mm - Skov.

• All 217 thumbs achieved full extension and 6 thumbs hyperextended.

Four minor complications (superficial infection and wound dehiscence)
No major complications. No secondary surgeries - Marek.
McAdams TR, Moneim MS, Omer GE Jr. Long-term follow-up of surgical release of the A(1) pulley in childhood trigger
thumb. J Pediatr Orthop 2002;22:41–43.
Skov O, Bach A, Hammer A. Trigger thumbs in children: a follow-up study of 37 children below 15 years of age. J Hand
Surg 1990;15B:466 – 467.
Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
 Complications
• Rate of complications from the literature is 1% (0.7% minor
and 0.3% major).

• Six minor wound infection that responded to oral antibiotics.

• Two deep infection that required incision and drainage.

• No case of digital nerve or artery injury reported.

• Literature showed a success rate of 99% with 1% recurrence,

mainly owing to inadequate surgical release.

Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
 Questionnaire
• For treatment of a 2-year-old with a 6-month
history of a locked trigger thumb,

• 85% of surgeons would recommend surgical

release as the treatment of choice.

• For the same patient who presented with an

intermittently triggering thumb, 52% would Forget about approaching a
choose to continue observation if the young child with a needle for
a steroid injection in your
triggering thumb was not painful, with the office !
remainder of surgeons split among splinting,
surgery, and injection.

Marek DJ et al.Surgical Release of the Pediatric Trigger Thumb. J Hand Surg 2011;36A:647–652
 Conclusion

• Pediatric trigger thumb is not rare

• Stretching by parents is recommended as the first

treatment as natural history if favorable

• If no resolution is observed by the age of 2-3,

surgical release is recommended.
Surgical technique and Up-to-date management
Common Congenital Hand anomalies

Choukran