Is Posttraumatic First Web Contracture Avoidable? Prophylactic Guidelines and Treatment-Oriented...

7/31/2019 Is Posttraumatic First Web Contracture Avoidable? Prophylactic Guidelines and Treatment-Oriented Classification

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Editorial

Is Posttraumatic First Web Contracture Avoidable?Prophylactic Guidelines and Treatment-Oriented Classification

Francisco del Pial, M.D., Dr. Med., Francisco J. Garca-Bernal, M.D., Dr. Med., andJulio Delgado, M.D., Dr. Med.

Santander, Spain

The first web is a complex, multilayered an-atomic region spanning the first and secondmetacarpals. It has a triangular shape, with its

vertex located at the base of the first and sec-ond metacarpals; the skin web that joins themetacarpophalangeal joints of the index fingerand thumb corresponds to its base. It is cov-ered by glabrous skin on the palmar side andminimally hairy skin on the dorsum. It harborsthe radial extension of the superficial palmar(natatory and transverse) and deep ligamentsand the bellies of the adductor pollicis and firstdorsal interosseous muscles with their investingfascia. The radial artery deepens from dorsal topalmar at its most proximal aspect.

Suppleness and strength are the main char-acteristics of the web and can be highlightedduring grasping and pinching. In grasping, the

web has to be supple to allow maximal openingof the thumb for grabbing large objects. Oncethe object is held, power is needed to keep it inthe hand; the muscles of the web are respon-sible for 80 percent of pinch strength.1

First web contracture is common aftertrauma to the hand, particularly the radialpart, and has a tremendous negative effect onhand function. Even minor contractures will

limit the ability to grab large objects. Becauseof its triangular shape, small limitations of ap-erture at its base have a major effect on theextremes of the triangle (the thumb and indexpulps).

First web contracture is an ongoing process,and the amount of time elapsed since the in-

jury, independent of the severity, worsens theprognosis in two ways. First and more impor-

tant, the web reduction initially is elastic (orreversible) but soon becomes irreversibly fixed(except with an operation). Second, there is a

phenomenon of progressive involvement offormerly healthy layers2 4 in such a way that theproblem may start in one structure (e.g., defi-cient skin) but in time it becomes widespreadon the web (i.e., affects muscle, fascia, liga-ments). The surgeon will have to divide struc-tures that were formerly healthy and functionalto open the web.

Much of the interest has been focused onthe surgical treatment of fixed first web con-tracture. In those articles, systematic release ofskin, fascia, muscles from their origins or inser-

tions, and trapeziometacarpal ligaments andeven resection of the trapezium itself are rec-ommended for the sake of placing the thumbin an abducted position,214 and several types offlaps have been presented to cover the result-ing defect.1521 Regrettably, it has been our ex-perience that although an operation can re-store the span of the web, the function of the

web (e.g., pinch strength, allowance of thumbpronation, pinch dexterity) often will never berestored.

Most of us have been educated as if first web

contracture were an unavoidable bad compan-ion (collateral damage) of some forms oftrauma to the hand, and the surgeons role waslimited to releasing the contracture. Takinginto account the fact that once established, thedamage is irreversible, we challenged this pas-sive attitude more than 10 years ago and set thehypothesis that fixed first web contracturecould be prevented. In this editorial, we

From the Instituto de Ciruga Plastica y de la Mano, Hospital Mutua Montanesa and Clnica Mompa. Received for publication May 9, 2003;revised September 2, 2003.

DOI: 10.1097/01.PRS.0000117667.24286.54

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present a treatment-oriented classification thatwas created by answering in a stepwise fashionthe question, What causes first web contrac-ture? The purpose of this editorial is topresent guidelines to abort the progressionto a fixed first web contracture and, as an aside,

to conclude, based on the evidence (aftermore than 6,000 hand injuries, most work-related, over a 10-year period without a restrict-ing contracture when those guidelines werefollowed), that fixed first web contracture isavoidable. Five types of posttraumatic first webcontracture have been recognized: idiopathic,retracting band, major skin loss, deep scar, andischemic.

IDIOPATHIC

Even after minor trauma, the surgeon may

be surprised by a severe first web contracture inthe middle term. Aside from the obvious rea-sons, such as the splinting or dressing tightlybinding the first metacarpal to the secondmetacarpal, which was common in thepast,2,22,23 other less apparent factors surrepti-tiously drive the first metacarpal to the second.

Swelling

As the hand swells, the previously flattenedskin will expand until the hand is nearly bal-loon-shaped. In this process, the first metacar-

pal moves toward the second metacarpal toallow the skin envelope to deform as a sphere(Fig. 1).

Antifunctional Postures

Most patients, after a hand or wrist injury,carry their wrist in flexion as an antalgic posi-tion. While the wrist is in flexion, the extensor

pollicis longus muscle will passively drag thethumb into extension and, most importantly,into adduction-supination.24 At this stage, it isappropriate to note that, independent of theseverity, there are two types of first web con-tracture according to thumb position: pure

and supinated. In the former, only the abilityto hold large (or small) objects is limited. Inthe latter, because the thumb is supinated, thespan is restricted and the thumb does notpinch, offering not the pulp but its ulnodorsalaspect (Fig. 2, below). The supinated contrac-ture is caused solely by the traction of theextensor pollicis longus, as this muscle is theonly thumb supinator.24A similar thumb defor-mity has been noticed after combined median-ulnar nerve palsy, but the pathomechanics aredifferent.24,25

Functional Positions

Standard functional position after trauma tothe upper limb (elbow flexed in a sling with thehand up against the trunk) also promotes firstweb contracture. In this position, if the fore-arm is in neutral rotation, the thumb is cranialand will spontaneously fall against the indexfinger by its own weight, thus closing the web.The situation is worsened if the forearm is inpronation, because then the body squeezes thethumb against the hand (Fig. 2).

This tendency of the thumb to adduct byswelling and functional and antifunctional po-sitions is aggravated because abductor forcesare much weaker than flexor adductor forces.24

Periods of Evolution

The feasibility of correcting idiopathic firstweb contracture depends mainly on the timeelapsed since the injury. The fluid seen afterany trauma is rich in proteins (from the lymphand the hematoma), and in the process of itsresorption, collagen is deposited that, as it ma-tures, becomes rigid and unyielding.26,27 Wehave recognized three periods of evolution infirst web contracture that are independent ofits severity: elastic, reversible, and fixed.

Elastic first web contracture is the term usedwhen it is possible to correct the deformitypassively after some traction on the thumb bythe examiner. This stage lasts for about 4 to 6weeks. Full correction can be expected if thepatient passively abducts the thumb and per-forms active exercises to strengthen the abduc-tor muscles. When the patient is seen laterthan 4 to 6 weeks, the surgeon will be unable to

FIG. 1. Hand-balloon deformity. Notice the limitations inaperture of the first web.

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fully open the web by traction, and this is con-sidered inelastic first web contracture. Treat-ment in this stage is based on the reversibilityof collagen cross-linking and involves applyinga light continuous force in the opposite direc-

tion of the deforming force. Several methodsand splint designs have been presented in theliterature.28,29 We prefer custom-made splintsmade with eight to 12 layers of cast (Fig. 3).The splint is worn at night and held in positionwith a bandage; care should be taken to placeit deeply in the web to maximize its effect overthe carpometacarpal joint rather than the meta-carpophalangeal joint.30 The patient is seen everyweek to assess the degree of correction, and newsplints are made as required. In our experience,serial casting will correct most cases less than 3

months old. After that time, the response varies(i.e., fixed first web contracture).

CUTANEOUS: LINEAR

It is axiomatic that any linear wound thatcrosses a flexion crease or a concavity will healby forming a retracting band; the first web is noexception. The surgeon can abort this progres-sion by performing as many Z-plasties as re-quired at the time of emergency treatment.

CUTANEOUS: MAJOR DEFECT

Any major skin loss on any part of the bodywill recruit skin from the neighboring struc-tures. On the dorsum of the hand, the onlymobile part is the first web, and the contractingforces will slowly drag the first metacarpal to-ward the second.

Lost skin should be replaced with a well-padded, noncontracting flap as an emergencyor early procedure to slow the progression to afixed contracture. The posterior interosseous

FIG. 2. Severe contracture in a neglected brachial plexusinjury (C5-T1 avulsion). (Above) The patient has been wear-ing a sling for more than 1.5 years with the forearm in pro-nation and the wrist in flexion; the thumb has been squeezedtoward the hand. (Below) The deleterious effect of traction bythe extensor pollicis longus muscle can be seen: the thumbis adducted andsupinated. In this totally paralyticupperlimb,no trauma occurred at the hand and no predominant musclegroup can be blamed for the contracture; this case corre-sponds to the paradigm of the idiopathic type of first webcontracture.

FIG. 3. Splinting of the first web. (Above) Care should betakento avoid concentrating pressure at any given point whilesteady distraction is being performed at the index finger andthumb. (Below) The splint should be made to sit in thedepths of the web, with gentle pressure at thepoint where thethumb and index finger meet.

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flap3133 is ideally suited for this purpose. Whenthe defect is too large or a better-vascularizedflap is required, a free flap is favored, andamong them we prefer the ipsilateral lateralarm flap.34,35 In our opinion, skin grafts haveno role in this scenario; besides the require-

ment that they must fully take to avoid second-ary retraction, their inherent tendency to con-tract is difficult to control. A postoperativesplinting program is required to achieve a suc-cessful result.

Although much has been written on the ne-cessity of Kirschner cross-wiring and on the useof external or internal devices to maintain thefirst web during the immediate posttrauma pe-riod after major web injury,2,3,10,3638 we havefound these approaches unnecessary. In fact, itmay be harmful, as Kirschner wire insertion

will produce additional damage to the musclesand hence promote contracture. Use of Kirsch-ner wires may, however, be considered whenthere is damage to the ulnar collateral liga-ment of the metacarpophalangeal joint of thethumb or radial collateral ligament of themetacarpophalangeal joint of the index thatwill prohibit the use of web splints during theimmediate posttrauma period. Similarly, whenthe thumb can hyperextend because of volarplate laxity, splints will fail to control a palmarcontracture as in a volar burn. Finally, when

the thumb has been amputated near its meta-carpophalangeal joint, the lack of a lever armto apply a cast and the lack of use of the thumbcause rapid first web contracture development.We have found the best option in the latterscenario to be an early toe-to-hand transfer.

DEEP SCAR

Major penetrating trauma to the first web isgenerally accompanied by partial muscle de-struction (first dorsal interosseous or adductorpollicis muscle) and/or fractures, sometimeswith concomitant bone loss. The skin envelopemay or may not be deficient, but this is unim-portant in this type of contracture. What isimportant in this scenario are the hemorrhagicfluid, edema, and contused-necrotic musclethat fill up the web space, which will resolve byforming a cicatricial-retracting magma in thedepths of the web. After this type of trauma,neighboring structures not directly damagedby the injuring agent will be filled with edem-atous fluid (e.g., the carpometacarpal liga-ments, muscle fascia), and as stated, this will

resolve with fibrosis and stiffness in a short-ened position.

The critical step in halting the progressionof this form of first web contracture is imme-diate radical dbridement of all devitalized tis-sues to diminish the potential cicatricial mass

and to minimize the risk of infection, andhence inflammatory edema. This should befollowed by rigid bony fixation and primarycoverage with a nonretracting flap. Kirschnercross-wiring or an external fixator is discour-aged; however, a program of night splintingshould be scrupulously followed in the post-trauma period.

ISCHEMIC

Failure to release swelling muscles confined

in closed osteofascial compartments invariablycauses muscle death and, subsequently, con-tracture.39 At the radial part of the hand, thiswill cause an adduction contracture (with an-tepulsion or retropulsion).22,23,40 In contradic-tion to the small number of cases of acutecompartment syndrome of the hand reportedin the literature, even in large trauma cen-ters,41 we noticed a high number of patientswho, after sustaining a closed crush injury tothe hand, developed acute compartment (orcompartments) of the hand with minimal

symptoms.42

We are firmly convinced that si-lent (untreated) compartment syndrome ofthe radial part of the hand is behind the scenesin many fixed first web contractures. By thesame token, early recognition and treatmentallow complete recovery. For these reasons, theclinician must have a low-threshold policy toindicate measuring the intracompartmentalpressure, because elevated subfascial pressuremay be present despite the fact that classicsigns and symptoms are absent.42

Treatment requires opening the offendedcompartments (and subcompartments)43 byone incision in the thenar area and one in linewith the second metacarpal if only the radialcompartments are affected. Detailed informa-tion on the surgical technique can be found inclassic textbooks.44,45 The surgeon has to havethe sagacity when releasing the compartmentsto place the incisions in such a way that afterinternally fixing the fractures, he or she is ableto fully protect the hardware. Skin grafting anddelayed closure should be used as necessary.Again, use of Kirschner cross-wiring or an ex-ternal fixator has minimal, if any, effect on



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postoperative contention of the web; splinting,however, is once more a critical part of care.

We believe that fixed first web contracture isoften preventable if the appropriate surgicaland orthotic steps are taken in due time. Be-cause time is a negative factor in this entity and

release of a fixed first web contracture will notrestore things to normal, the surgeon isobliged to act diligently to halt the progressionto a fixed widespread retraction.

Francisco del Pial, M.D., Dr. Med.Caldern de la Barca 16-entloE-39002 Santander, [email protected].

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