Original Article

Distraction - A Minimally Invasive Technique for Treating

Camptodactyly and Clinodactyly
Lt Col R Ravishanker*, Col A S Bath+

Abstract
Camptodactyly and clinodactyly are relatively common congenital anomalies affecting about 1% to 2% of the general population.
Though functional impairment is uncommon other than in very severe cases, patients affected do present very often for correction.
The kind of surgeries available is as diverse as the aetiology of the conditions. It ranges from simple release of the flexor
digitorum sublimis (FDS) to more complex small muscle transfers, rebalance etc. In this short series a relatively easier, minimally
invasive technique of distraction has been used to correct these deformities with gratifying results.
MJAFI 2004; 60 : 227-230
Key Words : Common deformity; Minimally invasive procedure; Patient satisfaction

Introduction Camptodactyly
The youngest patient was a 6 year old girl, the oldest a 44
C amptodactyly (the congenital or developmental
antero-posterior flexion deformity of the proximal
interphalangeal joint of the fingers unrelated to trauma,
year old father of a soldier. The commonest digit affected was
the little finger in 6 cases, the ring in 1, and unusually the
systematic disease or neurological abnormality) and middle finger in 1 case.
clinodactyly (radio-ulnar deviation of the fingers) are Other than in two children, the distractors were applied
relatively common conditions found in about 1% - 2% under a digital block by the passing of two K-wires in radio-
of the population [1]. Both are complex conditions ulnar plane through the middle and the proximal phalanx. On
table distraction straightening was achieved by 10% to 15%
characterized by abnormal intrinsic and other muscle
without compromising the vascularity of the finger.
anatomy in case of camptodactyly and an abnormal Subsequently, distraction was started from the next day and
middle phalanx in clinodactyly [2]. Standard treatment done at the rate of 1mm per day till complete straightening
for the conditions has been complicated open surgery was achieved in 2-4 weeks. The operating surgeon did the
with release, re-insertion / transfer of tendons, different initial distraction. The patient / relatives were then trained to
types of wedge osteotomies etc. open the distractor at home and only come for weekly / bi-
The relatively minimally invasive technique of weekly review in out patient department (OPD). Once
distraction has been successfully applied in treating 11 completely straightened, the distractors were maintained in
cases of camptodactyly and clinodactyly. Though the place for 4 weeks. Following removal of the distractor,
splintage was maintained for 4-6 weeks. Active mobilization
series is small it represents a change in the concept of
with night splintage was then done for 4 weeks.
management of these conditions.
Clinodactyly
Material and Methods
Of the 3 patients, both the adult patients (females aged 18
There were 8 cases of camptodactyly, all congenital or
years and 19 years respectively) had presented for cosmetic
developmental (5 unilateral and 3 bilateral), and 3 cases of
correction for the deviated little fingers. Though the fingers
clinodactyly (2 unilateral and one bilateral) [Table 1].
were small in comparison to the other hand, simple soft tissue

Table 1

Ages Sex Side

0-10 10-20 20-40 >40 M F Unilateral Bilateral

Camptodactyly 2 4 1 1 7 1 5 3
Clinodactyly 1 2 - - 1 2 2 1

*
Classified Specialist (Surgery and Reconstructive Surgery), Command Hospital (Eastern Command), Calcutta-700 027, +Senior Advisor
(Surgery & Reconstructive Surgery), Army Hospital (R & R), Delhi Cantt- 110 010.
228 Ravishanker and Bath

differential lengthening on the ulnar side was adequate to There were no pin tract infections as the selected patients
correct the deformity. were intelligent enough to maintain good local hygiene.
In the 10 year boy with a bilateral deformity and the Discussion
classical delta phalanx an opening osteotomy was performed
on the radial aspect of the middle phalanx. Then 0.8 mm K- “Camptodactyly” was coined in 1846 by Tamplin to
wires were passed through the middle phalanx proximal to describe a flexion deformity of the PIP joint of the little
the osteotomy, and the distal phalanx as there was not finger in an antero-posterior direction [3]. Though
adequate length in the middle phalanx to get a purchase with documented studies show it to account for 5% of
the K-wire. Differential distraction was then done on the radial congenital hand anomalies and 1% of general congenital
aspect. Distraction was done again at the rate of 0.5mm twice anomalies [1, 2], the true incidence is probably higher
a day till adequate straightening and lengthening was as contractures of less than 20% are rarely symptomatic
achieved. The distractors were then maintained in place for 6 and hence not recorded. Though initially used to describe
weeks till callostasis and bony consolidation was complete. the deformity for the little finger it is now used to describe
The distractors were then further retained for two weeks, the deformity in all fingers [4, 5]. Functional impairment
removed and followed by splintage to the fingers for 4 weeks.
in this condition is rare, other than in the very severe
This was followed by active mobilization and night splintage
for 4 weeks.
cases. Aetiologically the condition has been postulated
to be due to a dynamic imbalance caused by abnormal
Results intrinsic anatomy. An abnormal lumbrical insertion is the
Camptodactyly commonest cause [6]; shortening of the FDS in other
The results of distraction for camptodactyly have been cases [6,7]; the central slip of the extensor tendon has
extremely gratifying. 100% straightening was achieved in all been implicated by some authors [8]. As numerous and
patients who completed treatment (Fig 3). Subluxation of the conflicting the aetiologies are, so too the myriads of
proximal interphalangeal joint (PIP) took place in one initial surgical treatment advocated. Splinting was advised for
case where the axis of distraction was not in the correct plane. the very young and where the deformity is less than 60°
Early detection and re-insertion of the K-wires corrected the and reducible [9,10,11]. Surgery ranges from the simple
subluxation and the deformity. Following active and passive release of the FDS [6] or a tight lumbrical [7] to more
physiotherapy good function returned in the finger. Due to complicated procedures of release of collateral ligaments
the anatomical abnormality caused by the chisel shaped head and rebalance with tendon transfers [6-12]. Most of
of the proximal phalanx and the broadened or indented base these procedures involve complicated and delicate
of the middle phalanx on straightening the finger, in some
surgeries including skin cover with full thickness graft
patients the PIP joint used to look swollen and deformed.
(FTGs) for defects created. Results from the procedures
The only recurrence took place in a 44 year patient due to reported, range from good to poor [6-12], the best results
poor compliance with post-operative splintage. It was then
having been where FDS was independent, contracture
realized that splintage after removal of the distractors had to
be rigorously followed especially in adults. In the follow up
was less than 45°, and the PIP was not clinically fixed.
of the other patients, the longest being for over 2 years, there There is no reported literature on the use of distractors
has been no recurrence. for treating camptodactyly. Though our series using this
Clinodactyly
innovative technique is a short one, the results have been
very gratifying.
The result of distraction in the teenagers with cosmetic
deformity was extremely gratifying as the aim of cosmetic “Clinodactyly” or radio-ulnar deviation of the digits is
and functional correction was achieved and the patient a common congenital anomaly of the hand with a
satisfaction level was high. reported incidence of 19.5% in a non-Caucasian
In the boy treated with wedge osteotomy and distraction population [2]. It is reported in about 1% of normal
the results were gratifying (Figs 4,5,6,7). Functional results newborns and 10% of abnormal newborns [13]. The
were good - the major advantage was that the length of the most commonly affected digit is the little finger; the
digit was increased unlike in a closing wedge osteotomy proximal phalanx of the thumb is the second most
where there is shortening. Callostasis achieved was good common site of occurrence. An inherited disorder with
and in the follow up done for over 6 months there has been a dominant trait [13,14], the condition is usually bilateral
no recurrence or growth deformity. [13,14]. It usually results from an angulated short tubular
Complications bone - the “delta” phalanx - the middle phalanx
There were relatively very few complications. Subluxation commonly as the middle phalanx is the last bone in the
took place in one of the earlier cases, but was easily corrected. hand to ossify [14,15]. However, not all cases of
Thickening and swelling of the PIP joint due to ossification clinodactyly are caused by bony abnormalities; some
of the collateral ligaments took place in one case. With good involve soft tissue deficiencies only. Even in more severe
physiotherapy the function in the digit was not impaired.
MJAFI, Vol. 60, No. 3, 2004
Distraction in Camptodactyly, Clinodactyly 229

to indicate figure position of these figures ...

Fig. 1 : Camptodactyly of the middle finger

Fig. 2 : Straightening as obtained on the table under digital block

after application of the distractor
Fig. 5 : X-ray of opening wedge osteotomy and distraction in
progress

Fig. 6 : Correction in progress

Fig. 3 : On completion and removal of distraction

Fig. 4 : Bilateral clinodactyly of the little finger Fig. 7 : Correction in progress

MJAFI, Vol. 60, No. 3, 2004

230 Ravishanker and Bath

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