The Use of External Skeletal Fixation to Facilitate the Surgical Release of Wrist Flexion and Thumb Web Space Contractures

Purpose: To evaluate the use of external fixation as a splint to keep the hand in the desired position after simultaneous joint and soft-tissue release in a single stage for treatment of first web space and wrist contractures. Methods: Six first web space adduction and 7 wrist flexion contractures were released surgically. All patients had prior unsuccessful surgery. After surgical release of the contracture and capsulotomy, external fixator pins were inserted into the first and second metacarpals to maintain thumb abduction and into the radius and second metacarpal to maintain wrist extension, followed by skin grafting. External fixation was followed by splinting. Results were based on persistence of contracture release, rate of complications, and functional outcome. Results: Before surgery, the thumbs were contracted at an average of 0° of adduction with no range of motion, and wrists were contracted between 85° to 100° of flexion. The duration of contracture and number of prior surgeries did not influence the amount of release obtained during the surgery. After 7 months to 7 years of follow-up of first web space contractures, the thumb was in an average of 55° of palmar abduction. Patients were able to oppose and fully adduct. At long-term follow-up examinations of the wrist contractures, patients had the wrist in the neutral position (0°) in the resting state, with active extension ranging between 5° and 15° and flexion ranging between 35° and 45°. In 1 patient the wrist was at 45° of flexion in the resting state with an arc of motion of 20°. In 1 patient the wrist contracted back to the preoperative position, requiring another surgery. All patients experienced increased activity and improvement in grasping objects at 6-month follow-up evaluations. Complications included 3 pin site infections, 1 severe discomfort after 6 weeks, and 1 median nerve compression. All were treated successfully. Conclusions: External fixation can be used to maintain position in cases of first web space and wrist flexion contractures after surgical release, especially in patients for whom standard methods have failed. It is safe, efficacious, and well tolerated. Type of study/level of evidence: Therapeutic IV.