A M E T H O D OF T R E A T I N G C H R O N I C F L E X I O N C O N T R A C T U R E S

OF T H E F I N G E R S

By IAN T. JACKSON,F.R.C.S.Glas., F.R.C.S.Ed.

West of Scotland Regional Plastic Surgery Service, Canniesburn Hospitai,
Bearsden, Glasgow
and G. EARLED. BROWN,F.R.C.S.
Plastic Surgery Unit, Middlemore Hospital, Otahuhu, Auckland, New Zealand

LONG-STANDING volar flexion contractures of the fingers, whether they be post-burn or

post-traumatic, present a considerable therapeutic problem. In addition to skin short-
age, there is contracture of the tendon sheath, volar plate adhesion to the phalangeal
head and contracture of the collateral ligaments, due partly to initial deep damage and
partly to chronic shortening of these structures. If all these factors are to be corrected,
then tendon and occasionally bone will be exposed, necessitating flap cover ; the most
convenient is usually the cross finger flap. This has the additional advantage that it is
possible to obtain secure cover of relatively large scarred areas and obviate the likeli-
hood of later skin contractures developing. However, this by itself is not enough to
maintain permanent correction.
In post-burn or post-traumatic flexion contractures involving the metacarpophalan-
geal joint area and causing associated collateral ligament tightness, satisfactory correction
can be obtained by excision of collateral ligaments, volar plate mobilisation from the
metacarpal heads and resurfacing as required.
When the area involved is in relation to the proximal or distal interphalangeal joints,
as is commonly found with electric burns, the problem is more complex. To excise the
collateral ligaments of these joints would result in disastrous instability. Alternatively,
to disregard these structures would prejudice the chance of a satisfactory result. The
method described is an attempt to deal with this compound problem.

M e t h o d . - - A complete excision of the scarred area (Fig. ia), or as much as is

feasible, is performed, down to the tendon sheath. Should this prove a block to full
extension, it is also excised as required (Fig. ib). Where the initial injury has been crush-
hag as opposed to thermal trauma there are additional problems of bone and joint damage :
the volar plate may also have been traumatised initially or have become subsequently
adherent to the phalangeal area, just proximal to the condyles. This latter problem may
be encountered in long-standing contractures resulting from burns and is always a most
potent opposition force to full extension. It is best dealt with by excision of the volar
plate, should freeing from the phalanx be unsuccessful. At this point full extension can
only be obtained, in many cases, by exerting a force sufficient to overcome the remaining
opposing forces. These are inherent in the tightness of collateral ligaments, flexor
tendons and neuro-vascular bundles. To maintain full extension (Fig. ib), a Kirschner
wire is inserted into the digital pulp and along the length of the phalanges using a Bunnell
drill. It will usually traverse both the distal and proximal interphalangeal joints since
the corttracture is commonly ha the region of the latter joint (Fig. id).
The complete area to be resurfaced is now displayed. A cross finger flap from the
dorsum of an adjacent finger is used ha the conventional fashion (Fig. Ic). In one case
of thumb contracture, it proved necessary to use a chest flap for resurfacing. A " fluffed
373
374 BRITISH JOURNAL OF PLASTIC SURGERY

gauze " dressing and plaster of Paris is applied, the hand being immobilised for two
weeks. At this time the pedicle is divided, the Kirschner wire is withdrawn and early
active and passive exercises are commenced.

FIG. I
This illustrates a case of simple laceration over the proximal interphalangeal
joint of the index finger sustained two years previously. Subsequently the
finger was voluntarily held in flexion for many weeks ; a flexion contracture
developed. A, The area of skin to be excised. B, Skin and tendon sheath
excised to obtain full extension. Kirschner wire being inserted. C, Cross finger
flap. D, X-ray showing Kirschner wire in position.

Results.--Fifteen cases have been treated by this method. These have ranged in
age from 2I months to 32 years. Most contractures have resulted from burns caused
by grasping the element of an electric fire. Others were due to various types of trauma
such as crush injuries, a sodium chlorate bomb explosion and a simple laceration. This
last case is of some interest in that the contracture appeared to have resulted from the
patient voluntarily maintaining his finger in flexion for several weeks after having sus-
tained the laceration ; there was no history of tendon sheath damage at that time (case
illustrated in Fig. I). The contractures have on the whole been of long duration, the
shortest being three months, the longest eight years, with an average of time since
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376 BRITISH JOURNAL OF PLASTIC SURGERY

TABLE I I
Cases t r e a t e d w i t h Cross F i n g e r F l a p a n d K i r s c h n e r W i r e s - - U n a b l e to be R e v i e w e d

No. Age Area Involved Cause of Injury Follow-up Recorded or Postal Comments
I I5 Index p.i.p. Laceration 7months Requires tenolysis
2 9 Index p.i.p. Thermal burn 2 years Very satisfactory--full function
3 5 Index p.i.p. Crush injury I year Greatly improved
4 2I Index d.i.p. Crush injury 3 years Satisfactory--full function
5 3 Thumb i.p. Electrical burn I½ years Satisfactory--full function
6 8 Little p.i.p. Thermal burn 3 years Satisfactory
7 3o Little p.i.p. Crush injury 2 years Satisfactory--minimal flexion
deformity
8 I9/I2 Index p.i.p. Electrical burn 3 years Straight--good function
 C H R O N I C F L E X I O N C O N T R A C T U R E S OF T H E F I N G E R S 377
injury of two years. The period of follow-up has varied from three months to seven and
a half years with an average of three years.
It was only possible to review seven cases, the others having moved from the area or
being lost in redevelopment. The results obtained in the patients interviewed are shown
in Table I. Results have been assessed for those not interviewed on the basis of the
follow-up reports in the patients' case notes and postal review (Table II). This latter

FIG. 3
C r u s h injury of right
index finger resulting
in flexion contracture.
A, Pre-operative flex-
ion contracture. B,
Post - operative flex-
ion. C, P o s t - o p e r a -
tive extension.

group have all been discharged from follow-up and have not returned for further advice
or treatment.
It will be seen that in six of seven cases reviewed a full range of movement was
obtained with complete and permanent correction of contracture. It is of considerable
importance to note that there have been no damaging sequelae to the donor finger. In
the case where some contracture remained the period of follow-up was only three months
and both the flap and the grafted area on the donor finger showed considerable indura-
tion (Case i, Table I).
An example of a severe electrical burn which necessitated earlier amputation of the
index finger and was later treated by this method is illustrated in Figure 2 (Case 3,
378 BRITISH JOURNAL OF PLASTIC SURGERY
Table I). Figure 3 on the other hand shows a 32-year-old man, who sustained a crush
injury five months previously. This had caused a compound fracture into the proximal
interphalangeal joint. He was referred to us with a volar flexion contracture which
interfered so much with his work as to make him consider amputation. As can be
seen, complete function was regained after skin, tendon sheath and volar plate excision,
with subsequent management as described above (Case 7, Table I).

DISCUSSION
Kirschner wires have been used by ourselves and others (Smith, 1966) to stabilise
fingers when grafts are applied following excision of mild skin contractures. This can

FIG. 4
X-ray of index finger A, pre-operative and B, post-
operative to illustrate the absence of joint damage
one year after a flexion contracture had been treated
by the method described in the text.

only be done provided the underlying tendon is not exposed, although Simonetta (1968)
has been applying what he calls une greffe supra totale, i.e. leaving the dermal vascular
plexus intact, in such a situation and he reports successful graft take. This in fact has
not been our experience in a small number of cases.
The insertion of Kirschner wires for fixation in association with cross finger flap
cover after the excision of scarred digital skin is mentioned by Bunnell (I956) and
Hanna (I96O). Where tendon is exposed and full correction of chronic contracture is
performed, a cross finger flap is necessary. The insertion of a Kirschner wire, as
described, allows stretching of collateral ligaments, flexor tendons and neuro-vascular
bundles, and obviates later tendency to recurrence. There is no other method of dealing
with these structures in a satisfactory fashion. It is pertinent at this point to introduce
a word of caution. We think it would be inadvisable to extend chronic contractures
completely if the neuro-vascular bundles seem very tight, as this could well result in
 CHRONIC FLEXION CONTRACTURES OF THE FINGERS 379

thrombosis, ischaemia and possibly loss of parts of the finger. The neuro-vascular
bundle should in fact be regarded as the limiting factor in extension.
One initially worrying factor was the possibility of joint damage resulting from the
trauma of the Kirschner wire as it passed through the epiphyscal plate and the articular
cartilage. This was augmented by the scan electron microscope studies of McCall
(1968) on the healing phenomena in articular cartilage. His findings suggested that
healing was by fibrosis and scarring was permanent. Our fears have proved to be un-
founded since radiographic examination has failed to show any damage to joints and
clinically there has been no suggestion of this (Fig. 4). In patients in the growing age,
no abnormalities of digital growth have been noted. This is in accordance with experi-
ence gained from treating other injuries in this age group, with Kirschner wire fixation
(McGregor and Jackson, 1969). We conclude from our findings in this group of
patients that this is a reliable, safe method of treating chronic Polar flexion contractures
of the digits, which is otherwise a most difficult condition to manage.

SUMMARY

A method is described of treating chronic volar flexion contractures of the digits,

following burns and trauma. Basically this involves excision of scarred skin, flexor
tendon sheath and volar plate as required with subsequent immobilisation by Kirschner
wires and resurfacing with cross finger flaps.
Fifteen cases are presented and the results studied.

REFERENCES
AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS (1965). " Joint Motion, Method of
Measuring and Recording." Edinburgh : Livingstone.
BUNNELL, S. (1956). " Surgery of the Hand," 3rd ed., p. 165. Philadelphia : Lippincott.
HANNA, D. C. (196o). Resurfacing the hand in acute injuries. Surg. Clins N. Am. 4 o, 333.
MCCALL, J. (1968). Ph.D. Thesis. University of Strathclyde.
McGREGOR, I. A. and JACKSON, I. T. (1969). Sodium chlorate bomb injuries of the hand.
Br. J. plast. Surg. 22, 16.
SIMONETTA, C. (I968). Personal communication.
SMITH, J. W. (1966). Burned hands in children. Am. J. Surg. 112, 58.