The Pathogenesis and

Tre a t m e n t o f t h e S t i ff
Finger
Eric D. Wang, MD, Paymon Rahgozar, MD*

KEYWORDS
 Stiff finger  Contracture  Metacarpophalangeal joint  Proximal interphalangeal joint
 Capsulotomy  Tenolysis  Progressive splinting  Dynamic splinting

KEY POINTS
 Evaluation and treatment of the stiff finger requires understanding of the complex periarticular anat-
omy surrounding the metacarpophalangeal and proximal interphalangeal joints.
 Finger joint stiffness is best avoided with appropriate splinting, therapy, and minimizing postinjury
swelling, edema, and pain. It is much more difficult to treat as a chronic problem.
 Nonoperative therapy is the mainstay of treatment, with targeted operative interventions reserved
for motivated patients who have either plateaued or have not responded to aggressive therapy.
 Surgery for contracted joints sequentially releases pathologic structures, including the joint capsule,
volar plate, collateral ligaments, and surrounding tendons, to achieve functional mobility.

INTRODUCTION healing with supple skin and soft tissue, and reso-
lution of edema.1
The metacarpophalangeal (MCP) joint, proximal Prevention of stiffness is a core tenet of hand
interphalangeal (PIP) joint, and distal interphalan- surgery and therapy. However, approaching the
geal (DIP) joint maintain a complementary relation- stiff digit requires a nuanced evaluation of the spe-
ship; injury at one joint may lead to dysfunction of cific pathologic situation in each case. This review
neighboring joints or digits. Many structures are addresses the pathogenesis of the stiff finger and
present within a tight joint space, pronouncing the selection, timing, execution, and expected
the effect of edema and inflammation from the outcomes of surgical treatment.
smallest of injuries.
The initial response to injury is inflammation,
ANATOMY
causing edema and pain. Within a week, proinflam-
The Metacarpophalangeal Joint
matory leukocytes and mediators surround the
injured digit resulting in a fibroblastic phase, which The MCP joint is a condylar joint with an arc of mo-
lasts for approximately 3 weeks. Collagen is depos- tion ranging from slight hyperextension to 90 of
ited in a disorganized manner, causing adhesions. flexion (Fig. 1). The volar plate is the thick, fibrous
Either inadequate or overzealous immobilization portion of the volar joint capsule that originates
at this juncture can be detrimental. The final stage proximally from the metacarpal head and inserts
of the response to injury is remodeling of disorga- on the base of the proximal phalanx. It primarily
nized collagen. Completion of this phase is marked limits hyperextension. The dorsal joint capsule is
plasticsurgery.theclinics.com

by the end of meaningful gains in therapy, complete closely associated with the extensor tendon. The

Disclosure Statement: Neither Dr E.D. Wang nor Dr P. Rahgozar has commercial relationships or conflicts of
interest to disclose.
Division of Plastic and Reconstructive Surgery, Department of Surgery, UC San Francisco Medical Center,
505 Parnassus Avenue, Suite M593, San Francisco, CA 94143, USA
* Corresponding author.
E-mail address: paymon.rahgozar@ucsf.edu

Clin Plastic Surg 46 (2019) 339–345

https://doi.org/10.1016/j.cps.2019.02.007
0094-1298/19/Ó 2019 Elsevier Inc. All rights reserved.
340 Wang & Rahgozar

The Proximal Interphalangeal Joint

The PIP joint is a hinge joint, with an arc of motion
ranging from slight hyperextension to 110 of
flexion. Unlike the MCP joint, it does not permit
motion in the coronal plane. This stability arises
from the bicondylar geometry of the articular sur-
faces as well as the thick volar plate and collateral
ligaments.4
The proper collateral ligaments originate from
the lateral portion of the proximal phalanx head
and insert on the volar portion of the middle pha-
lanx base and volar plate. Accessory collateral
ligaments originate volar to the proper collateral
Fig. 1. The metacarpophalangeal joint. (From Chung
ligaments and insert laterally onto the volar
KC. Operative techniques: hand and wrist surgery. 3rd plate.5 The proximal aspect of the volar plate
edition. Elsevier: Philadelphia; 2018; with permission.) forms 2 projections known as checkrein liga-
ments that extend over the transverse digital
sagittal bands of the extensor tendon originate artery and insert onto the volar aspect of the
from the volar plate, wrap around the joint capsule, proximal phalanx (Fig. 2A, B). Dorsally, the
and insert on the extensor hood. extensor tendon lies in close association with
Paired proper collateral ligaments originate the joint capsule.
from the ulnar and radial boundaries of the meta- In contrast to the MCP joint, the injured PIP joint
carpal and insert on the base of the proximal pha- adopts a flexed position. Without therapy, fibrosis
lanx. Accessory collateral ligaments arise volar to of the volar plate, shortening of the checkrein
the proper collateral ligaments and insert on the ligaments, and contracture of the periarticular
volar plate.2 In extension, the cam-shaped meta- soft tissues quickly leads to a flexion deformity.
carpal head creates redundancy in the collateral
ligaments and the dorsal capsule, permitting a EVALUATION AND TREATMENT ALGORITHM
limited degree of radial and ulnar deviation. The
collateral ligaments are on maximal stretch at The treatment of a stiff digit requires an educated
70 of flexion.3 In the setting of postinjury swelling and motivated patient who is medically and psy-
without appropriate splinting, the MCP joint chologically prepared for treatment and therapy.
assumes a position of extension, with laxity of Persistent hypersensitivity and regional pain syn-
the dorsal capsule and the collateral ligaments. drome should be controlled, and scars should be
This results in shortening of the collateral liga- matured. Functional goals are tailored to the pa-
ments, scarring of the joint capsule, and stiffness tient’s needs, occupation, and expectations.6 A
of the joint. hand therapist should be involved to maximize

Fig. 2. (A) Anatomy of the proximal interphalangeal joint. (B) Volar plate and checkrein ligaments. (From Chung
KC. Operative techniques: hand and wrist surgery. 3rd edition. Elsevier: Philadelphia; 2018; with permission.)
 Pathogenesis and Treatment of the Stiff Finger 341

passive joint motion and to treat scars, hypersensi-

tivity, and edema.
The goal of the patient examination is to identify
the source of the stiffness, which may include pa-
thology of one or more of the following structures:
1. Osseous and articular: metacarpals, phalanges,
and joint surface
2. Capsuloligamentous: proper and accessory
collateral ligaments, volar plate, and joint capsule
3. Musculotendinous units: extensor mechanism,
flexor tendons, intrinsic contributions, and
tenosynovium
4. Soft tissue and fascia: skin, subcutaneous
tissue, neurovascular structures, and superfi- Fig. 3. The intrinsic plus “safe” position.
cial fascia
mechanical force to the joint at its end point of mo-
Radiographs are helpful in identifying a bony tion to encourage stretching of contracted tissues.
block to motion. The stability and compliance of Static and static-progressive splinting apply in-
skin, fascial, and neurovascular structures should elastic forces to the joint to position it at maximal
be assessed. Passive and active motion of each stretch, but need to be refabricated or adjusted
joint is evaluated. Passive motion that exceeds in intervals. Dynamic splints apply a preset force
active motion suggests musculotendinous unit across the joint using springs or elastics to posi-
disruption, subluxation, or adhesions. However, tion the joint at maximal stretch. Either type of
if active and passive motion are equivalent, the splinting regimen has been demonstrated to be
cause of the stiffness is most likely related to equally effective.13
intra-articular disorder or capsuloligamentous In a series of 212 stiff joints, therapy alone suc-
fibrosis.6,7 cessfully treated 87% of PIP joint and MCP joint
Decreased passive finger extension with the contractures.14 The groups of Flowers and Glas-
wrist in maximal extension suggests extrinsic gow15–17 demonstrated that passive ROM gains
flexor muscle-tendon shortening or adhesions. In are a function of increasing splint time and force
cases of extension contracture, the Bunnell test applied. However, the optimal intensity and dura-
can help determine whether intrinsic muscle tight- tion of therapy is not well defined. Excessive
ness is present. The test is positive if there is less external force can cause damage from tearing of
PIP joint flexion with MCP joint extension when soft tissues and ligaments or articular subluxation.
compared with MCP joint flexion.8,9 Time spent splinting reaches a practical maximum
based on the limits of patient tolerance and dimin-
Prevention ishing returns.15,17
Numerous researchers have investigated external
Secondary dysfunction and deformities can often
devices for mobilizing a PIP joint flexion contrac-
be prevented if initial care follows the principles
ture.18–21 Placed surgically, these devices apply
of hand surgery. This treatment includes repair
skeletal traction across the PIP joint in the form of
or replacement of normal anatomy, elevation to
gradual extension or distraction as the device is
control edema, immobilization in the protective
adjusted. These devices stretch not only the deeper
“intrinsic plus” position (30 wrist extension, 90
capsuloligamentous tissues and musculotendinous
of MCP joint flexion, and full extension of PIP
units but also stretch the soft tissue and fascia, as
joint and DIP joint; Fig. 3), and early motion pro-
in Dupuytren contracture. Institutional results from
tocols when appropriate to prevent fibrosis and
these devices have shown promising improvements
adhesions.6,10
in PIP joint arc of motion, with a mean of 67 over
long-term follow-up.20
NONOPERATIVE INTERVENTION
SURGICAL INTERVENTIONS
The initial treatment of the stiff finger consists of a
therapy program aimed at softening and stretching The end point for nonoperative therapy is poorly
scar tissue as well as maximizing passive range of defined. However, the consensus among most
motion (ROM).11–13 Exercises are supplemented hand surgeons6,7,22 is to offer operative inter-
with splinting: dynamic, static-progressive, or se- vention when nonoperative therapy has failed
rial static splints. All types of splinting apply to produce additional desired gains. The focus
342 Wang & Rahgozar

of these interventions is the MCP joint and the effective therapy because of excessive postopera-
PIP joint. tive pain and edema.6,7

Osseous and Articular Pathology Proximal Interphalangeal Joint Flexion

Contracture Release
Bone and joint pathology is addressed first. A
fracture malunion, rotational malunion greater PIP joint flexion contractures are treated through
than 10 , or presence of exostoses may cause a either a volar or midlateral approach.36 The authors
fixed block to joint motion and is corrected with prefer a midlateral incision dorsal to the neurovas-
an osteotomy.23–26 Joint replacement of the cular bundle (Fig. 4). The transverse retinacular lig-
MCP and PIP joints has also been described as ament and A3 pulley are divided. The flexor tendon
a potential treatment. However, multiple reviews is retracted in a volar direction, providing exposure
have not demonstrated significant improvement to the proper collateral, accessory collateral, and
in ROM.20,27–32 Therefore, joint replacement may checkrein ligaments. The volar plate is dissected
be more applicable for treatment of pain rather subperiosteally and the checkrein ligaments are
than stiffness. incised, taking care to avoid the transverse digital
artery. The volar accessory collateral ligaments
Skin and Fascia are then partially incised. The proper collateral liga-
ments are also released if necessary. Tenolysis is
A stable, compliant soft-tissue covering is neces-
performed if flexor tendon adhesions are further
sary for surgical recovery and early rehabilitation.
limiting passive extension. The patient should begin
Contracted scar and prior skin grafts may require
aggressive ROM exercises within 48 to 72 hours
excision and reconstruction with vascularized tis-
after surgery.
sue in the form of local or distant flaps. Restricted
Brüser and colleagues38 compared the midlat-
passive motion caused by skin or fascial contrac-
eral with the palmar approach and found that at a
ture is treated with release, fasciotomy, and/or
minimum of 1.5 years of follow-up, the midlateral
resurfacing.
technique had a greater improvement in the arc
of motion. These investigators concluded that
Tendon Tenolysis/Reconstruction
quicker healing with this approach facilitated
Fingers with normal passive extension but limited earlier therapy and superior outcomes.
active extension may have disruption or incompe- Overall, reported outcomes in surgical PIP joint
tence of the extensor mechanism, which can be cor- flexion contracture release are mixed among se-
rected with an extensor tenolysis, rebalancing, or ries. In contrast to the 30 to 50 gain in extension
reconstruction. When active flexion is diminished, reported by Brüser and colleagues38 and the 25
flexor tendon adhesions can be treated with tenoly- to 30 gain reported by Hogan and Nunley,39
sis, but flexor incompetence may require a staged Ghidella and coworkers40 found that improve-
tendon reconstruction. These procedures can be ments were modest at 2-year follow-up, with an
performed in combination with capsuloligamentous average of only 5.8 improvement in extension
releases.33 and a 31% reoperation rate. Older patients experi-
enced the worst outcomes in the Ghidella series,
Sequencing of Procedures emphasizing the importance of surgical patient
selection.
Operations are performed in a stepwise sequence
designed to facilitate joint mobility during recovery
Proximal Interphalangeal Joint Extension
and minimize the need for protective immobiliza-
Contracture Release
tion.34–36 Motion is reassessed after each step
until functional goals are achieved. Performing PIP joint extension contracture release is per-
the procedure with local anesthetic, minimal seda- formed through a dorsal curvilinear incision.
tion, and no tourniquet permits immediate intrao- Once the extensor apparatus is exposed, an inci-
perative assessment of improvements in active sion is made on either side of the extensor tendon
ROM.37 A counter-incision at the wrist may be to separate it from the lateral bands. A tenolysis is
used to simulate active tendon excursion if the performed, ensuring that the central slip insertion
patient is under general anesthesia. is not violated. A dorsal capsulotomy or capsu-
In cases of both extension and flexion contrac- lectomy is performed. If full passive flexion is
ture, a staged approach is recommended, with not obtained, the proper and accessory collateral
immediate postoperative therapy after the first ligament fibers are sequentially released from
stage to maximize passive ROM. Simultaneous sur- their origin on the proximal phalanx beginning
gery on dorsal and volar structures compromises dorsally (Fig. 5C). Active flexion of the PIP joint
 Pathogenesis and Treatment of the Stiff Finger 343

Fig. 4. (A) Preferred midlateral approach for index finger PIP joint flexion contracture capsuloligamentous
release. (B) Exposure of the flexor tendons after retraction of the neurovascular bundles, division of transverse
retinacular fibers, and division of A3 pulley. (C) Volar retraction of the flexor tendon provides exposure to incise
proper and accessory collateral ligaments at their origin. Photo shows subperiosteal dissection of the volar plate
and release of checkrein ligaments. (D) Immediate correction of PIP flexion contracture. Bilateral incisions can
be used to improve exposure. (Courtesy of Kevin C. Chung, MD, Ann Arbor, MI.)

is then tested. If incomplete, a flexor tenolysis fibers) are divided in a distal intrinsic release.9,43
is performed.41 Alternatively, adhesions between If the MCP joints are also affected with a flexion
the central extensor tendon, lateral bands, and deformity caused by interosseous fibrosis, the
dorsal capsule are divided and the finger flexed intrinsic tendons are divided proximally.9
under anesthesia with placement of a dorsal Mansat and Delprat44 described results of PIP
blocking Kirschner wire.42 joint contracture release in a multicenter study.
If the cause of PIP joint extension contracture is Among their cohort of extension contractures, a
intrinsic tightness, the intrinsic contributions to the 28 improvement in arc of motion was maintained
extensor aponeurosis (lateral band and oblique over long-term follow-up.

Fig. 5. (A) Preoperative extension contracture of left hand PIP joint and MCP joint. (B) Dorsal skin incisions for
approach to MCP joint and PIP joint extension contracture release, and release of sagittal bands for exposure
to dorsal MCP joint capsule and collateral ligaments. (C) Intraoperative MCP joint flexion following tenolysis, dor-
sal capsulotomy, and sequential release of collateral ligaments. (D) Intraoperative PIP joint flexion following
extensor tenolysis, dorsal capsulotomy, and release of proper and accessory collateral ligaments. (Courtesy of
Kevin C. Chung, MD, Ann Arbor, MI.)
344 Wang & Rahgozar

Metacarpophalangeal Joint Extension based on restoration of normal bony anatomy and

Contracture Release articular alignment, release of soft-tissue contrac-
tures, and therapy to achieve passive mobilization.
The MCP joint is approached dorsally by splitting
Additional surgical interventions are designed to
the extensor tendon or by incising the sagittal
release contracted capsuloligamentous structures
band.3,45 An extensor tenolysis may be performed
and reconstruct dysfunctional muscle-tendon units.
first for exposure, followed by a dorsal capsulot-
omy or capsulectomy. The most dorsal fibers of
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