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Swan Neck Deformity

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Z deformity Pathophysiology In ... Correct PIPJ hyperextension Restore DIPJ extension Type1 Silver ring splint to flex PIPJ Volar dermatodesis Correction of any MCPJ ... – PowerPoint PPT presentation

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Title: Swan Neck Deformity


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Swan Neck Deformity

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Swan neck deformity. The volar plate is torn,
causing the joint to open abnormally under the
pull of the extensor ligaments.
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Swan-Neck Deformity
  • Typically defined as
  • proximal interphalangeal (PIP) joint
    hyperextension
  • with concurrent distal interphalangeal (DIP)
    joint flexion
  • Not necessarily unique to RA but rather an end
    result of muscle and tendon imbalance caused by
    RA.

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Swan-Neck Deformity
  • Not necessarily unique to RA but rather an end
    result of muscle and tendon imbalance caused by RA

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Nalebuff Classification1989
  • Type I - PIP joints flexible in all positions
  • No intrinsic tightness or functional loss
  • Type II - PIP joint flexion limited in certain
    positions
  • Intrinsic tightness
  • Limited PIP motion with extended MCP with ulnar
    deviation
  • Type III - PIP joint flexion limited in all
    positions
  • Near normal radiograph
  • Type IV - PIP joints stiff with poor radiographic
    appearance

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Pathophysiology
  • The intercalated joint collapse concept of
    Landsmeer means that collapse of a joint in one
    direction will result in deformity of the next
    distal joint in the opposite direction.
  • Z deformity

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Pathophysiology
  • In a normal finger, intrinsic muscles serve as
  • flexors of the MCP joint
  • extensors of the PIP and DIP joints
  • By being located volar to the MCP joint axis and
    dorsal to the PIP and DIP joint axes

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Pathophysiology
  • Intrinsic tightness increases the flexor pull on
    the MCP joint and hyperextension of PIPJ
  • Weak flexor power aggravates this by being
    unable to pull the middle phalanx.
  • DIPJ and MCPJ hyperextension follows
  • Constant efforts to extend the finger against
    this pull then leads to stretching of the
    collateral ligaments and weakening of the volar
    plate at the PIPJ.

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Pathophysiology
  • the lateral bands are constrained in their dorsal
    position with the extensor apparatus migrating
    proximally
  • therefore upsetting the flexor-extensor balance,
  • The lateral bands in this position act to
    increase the pull of the central slip that
    attaches to the dorsal base of the middle
    phalanx.
  • Leading to hyperextension of PIPJ

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Pathophysiology
  • The increase of FPL tension resulting from
    hyperextension of the PIP joint leads to a
    reciprocal flexion of the DIP joint.
  • DIP mallet deformity also from
  • Joint erosion
  • Extensor tendon attentuation or rupture
  • Progressive disease leads to joint destruction
    and fixed contracture.

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Hashemi-Nejad and Goddard (1994)
  • -multidisciplinary approach is best
  • -an affected joint will affect other joints
  • -early synovectomy is worthwhile after a 6-month
    trial of non-operative treatment
  • -tenosynovectomy decreases the risk of tendon
    rupture,
  • -the wrist is the key in the RA hand
  • -the thumb is a very important source of
    disability
  • -silastic MCPJ arthroplasty is successful in
    reducing pain and improving function

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Feldon (1993) lists the aims of surgery in the RA
hand
  • 1. pain relief
  • 2. functional improvement
  • 3. preventing disease progression
  • 4. cosmetic improvement
  • Note that the presence of a painless deformity
    with minimal function deficit is not an
    indication for surgery.

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Management
  • Millender and Nalebuff staging system (1975) is a
    good guideline for identifying treatment options
    in RA

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Principles
  • Prevention
  • Correct PIPJ hyperextension
  • Restore DIPJ extension

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Type1
  • Silver ring splint to flex PIPJ
  • Volar dermatodesis
  • Correction of any MCPJ abnormality first
  • Flexor tenosynovectomy (if synovitis is present)
  • Flexor tenodesis - FDS slip through A2 pulley
    then looped back to itself
  • Retinacular ligament reconstruction
  • Release ulnar lateral band proximally and pass
    volar to PIPJ axis ? sheath

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Silver Ring Splint
  • Permit active PIP flexion and limit
    hyperextension of the PIP joint

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DIP Fusion
  • Difficult and unreliable to restore the extensor
    apparatus at DIP level cause underlying RA
    disease will destroy the repair
  • Also secondary arthritis within DIP may make
    attempts to mobilise joint unwise

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Dermadesis
  • Used to prevent PIP hyperextension bu creating a
    skin shortage volarly
  • Elliptical skin wedge (4-5mm at widest) is
    removed from volar aspect of PIP
  • Care not too disturb venous drainage or violate
    the flexor sheath
  • Skin closed with PIP in flexion
  • Only useful if done in conjunction with other
    procedures ie DIP fusion

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Flexor Tendon Tenodesissublimis sling
  • Used as checkrein against hyperextension ie
    restoration of strong volar support
  • One slip of FDS is divided 1.5cm proximal to PIP
  • This is then separated from its corresponding
    slip bit left attached distally
  • With joint at 20-30 degrees the detached slip is
    fixed proximally
  • Anchored to thickened margin of sheath, distal
    edge of A2 or Mitek
  • Nalebuff did simpler procedure whereby he passed
    split tendon around A1 pulley

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Reticular Ligament Reconstruction
  • Credited to Littler
  • Ulnar lateral band is freed from extensor
    mechanism proximally but left attached distally
  • Passed volar to Clelands fibres to bring it
    volar to axis of PIP
  • Band is sutured to the fibrous tendon sheath
    under enough tension to restore DIP extension
    and prevent hyperextension at PIP
  • However, in RA may have destruction of terminal
    tendon so no amount of tension applied to the
    relocated tendon will achieve DIP extension

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Type 2
  • Looks like Type 1 but PIP movement is limited in
    certain positions related to position of MCPJ
  • MCPJ extended/radial deviation then limited
    passive PIP ROM
  • MCPJ flexed/ulnar deviated then PIP ROM increased
  • As MCPJ subluxates and the intrinsics get tight a
    secondary swan neck develops as a result of
    muscular imbalance
  • Not sufficient to restrict PIPJ hyperextension,
    intrinsics must be released plus MCPJ subluxation
    must be corrected /- arthroplasty

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Intrinsic Release
  • Photo on camera
  • A rhomboid portion of the ulnar extensor
    aponeurosis is then resected
  • This procedure resects the lateral band through
    which the abnormally tight intrinsics have caused
    MP flexion and PIP hyperextension

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Type 3
  • unlike type 1 2 have significant functional
    disability due to inability to grasp objects
  • Not joint destruction but restriction due to
  • Extensor mechanism
  • Collateral ligaments
  • Skin
  • First goal is to restore passive ROM
  • PIPJ manipulation
  • Skin release
  • Lateral band mobilisation
  • Then correction of deformity after motion restored

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PIPJ Manipulation
  • MUA possible up to 80-90 degrees
  • Usually in conjunction with intrinsic release,
    arthroplasty or tenosynovectomy

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Skin Release
  • Dorsal skin may limit the amount of passive
    flexion that is achieved during manipulation
  • Tension minimised with an oblique incision just
    distal to the PIPJ
  • Allowing skin edges to spread
  • Closes 2-3 weeks by secondary intention
  • PHOTO 2112

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Lateral Band Mobilisation
  • Lateral bands are displaced dorsally
  • Free lateral bands from central slip using 2
    parallel incisions allows flexion without
    releasing lateral bands or lengthening central
    slip
  • PHOTO 2113

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Type 4
  • Patients with stiff PIPJ and radiographic
    evidence of advanced intra-articular changes
    require salvage procedure
  • Fusion or arthroplasty
  • PHOTO 2114
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