What is the recommended management for camptodactyly?

Management of Camptodactyly

For mild to moderate camptodactyly (contracture <60°), initiate conservative management with splinting and hand therapy; for severe progressive camptodactyly (≥60° contracture or progression of 30° within one year) in young children, early surgical intervention with flexor digitorum superficialis (FDS) release and gentle passive manipulation should be performed to prevent the need for more aggressive procedures later. 1

Initial Assessment and Classification

When evaluating camptodactyly, determine the severity of the proximal interphalangeal (PIP) joint flexion contracture and rate of progression 2, 3:

• Mild contracture: <30° flexion deformity
• Moderate contracture: 30-60° flexion deformity
• Severe contracture: ≥60° flexion deformity 3, 1
• Aggressive/progressive: Contracture increase of ≥30° within one year 1

Document active range of motion, functional impairment, and whether single or multiple digits are involved 3, 4. The fifth finger is most commonly affected, followed by ring and middle fingers 3, 4.

Conservative Management

Non-Surgical Approach for Mild-Moderate Cases

Begin with conservative treatment for contractures <60° 1, 5:

• Static or dynamic extension splinting is the first-line treatment 5
• Manipulations and passive stretching exercises should be performed regularly 5
• Continue conservative management as long as improvement is observed 5

Important caveat: Conservative treatment outcomes are variable—in one series, only 46% of splinted fingers improved, while 21% deteriorated despite treatment 5. Close monitoring every 3-6 months is essential to detect progression requiring surgical intervention.

Surgical Management

Indications for Surgery

Surgery should be considered when 3, 1:

• Moderate to severe contracture (≥60°) with functional impairment persists despite conservative treatment 3
• Progressive/aggressive camptodactyly with rapid deterioration (30° increase within one year) 1
• Young age with severe deformity—earlier intervention (before adolescence) yields better outcomes 1, 5

Surgical Approach: Stepwise Algorithm

The surgical strategy should follow a logical, stepwise approach based on intraoperative findings 3:

Step 1: Volar soft tissue release 3, 5

• Release tight volar skin with rotation flap for lengthening 3, 5
• Fascial release of contracted structures 3

Step 2: Flexor digitorum superficialis (FDS) tenotomy 3, 1

• This is the cornerstone procedure—all operated digits in successful series underwent FDS tenotomy 3, 1
• For young children with aggressive camptodactyly, early FDS release alone with gentle passive manipulation may suffice 1

Step 3: Volar plate release 3

• Sliding volar plate release if contracture persists after FDS tenotomy 3
• Required in 89% of cases in one surgical series 3

Step 4: Additional procedures as needed 3, 1

• Intrinsic transfers for extension lag correction (rarely needed) 3
• Fowler extensor tenotomy if hyperextension deformity develops 3
• Critical pitfall: Avoid disturbing the extensor mechanism unnecessarily, as this correlates with poorer outcomes 4

Special Considerations

For multiple digit involvement or syndromic cases: Additional procedures to restore dynamic dorsal apparatus and active extension are often required 1

For adolescents/adults with fixed joint blocking: Surgical outcomes are limited; corrective osteotomy may be the only option 5

For failed previous surgery or older children: More aggressive reconstruction including dynamic extensor restoration is necessary 1

Expected Outcomes

Surgical Results

When surgery is performed using the stepwise approach 3, 1:

• Mean postoperative flexion contracture improves from 57-90° to 0-3° 3, 1
• 83-88% achieve excellent or good outcomes (Siegert grading) 3, 1
• Mean PIP joint flexion preserved at 88-90° 3, 1

However, outcomes remain unpredictable: One series reported only 7% good results, 40% fair, and 53% poor outcomes, emphasizing the challenging nature of this condition 4.

Postoperative Management

Dynamic extension splinting is mandatory both before and after surgery 5:

• Apply dynamic splint immediately postoperatively 5
• Continue splinting for several months to maintain correction 6
• Early active range-of-motion exercises to restore flexion 6
• Position in maximum extension for 30 minutes daily 6

Critical Pitfalls to Avoid

• Operating too late: Adolescent cases with established joint changes respond poorly to surgery 1, 5
• Inadequate FDS release: This is the most important surgical step and should not be omitted 3, 1
• Disrupting extensor mechanism: Avoid unnecessary manipulation of extensor structures, as this worsens outcomes 4
• Insufficient postoperative splinting: Recurrence is common without rigorous splinting protocols 6, 5
• Unrealistic expectations: Even with optimal surgery, some cases will have suboptimal results requiring realistic goal-setting with families 4