Once aflexion contracturehas occurred, the first modality should always be nonsurgical. Avariety of techniques have been described: serial casting, dynamic, and/or static splinting. The decision to abandonconservative treatmenthas no definitive time line. The literaturedoes not give any specifics as to when to proceedwithsurgicalrelease.Mosthand surgeons would consider surgical options after afailure to progress with three months of therapy and arange of motion of less than 458 .

Avariety of external fixators have been developed and applied to PIP flexion contractures. External fixators have the advantageoftransmitting theextensionforce through the bone, as opposed to through the skin in splinting or casting. The few small case series in the literature have shown initial favorable results. However,they tend to have ahigh long-term recurrence of contracture and high rate of pin site infections (1,3,10).

There have been many reports on the open release of PIP joint contractureswith varying results (2,8,10,11,13–18). Curtis reported that the greater the number of anatomic structures involved in the limitation of motion, the worse the postopera­tive range of motion (8). Ghidella et al. perf ormed a retrospective review of 68 PIP joints released as previously describedbyCurtis (8), whichidentified preoperative and intraoperative factorsthat were associatedwith worse outcomes. Accordingtotheir study,the ideal surgical candidate for correction of acontracted PIP joint has an exostosis (which can be removed), asimple diagnosis, is younger than 28 years, and has apreoperative maximum flexion measurement of ! 438 (2). In arecentliterature review of thetreatmentofpost­traumatic PIP flexion contractures, Hogan and Nunley found that after openrelease fin gerextension most commonly improves approximately 258 to 308 but is often accompanied by aloss of finger flexion (10). Overall, there has been anet improvement in motion, but some patients even lost motion after open release (2,10).

Five fresh frozen hands were thawed and the index, long, ring,and little wereexaminedusing imag ingtoensure congruent gliding and to rule-outbonydeformity. The dorsal joint capsule of the MCP and PIP joints was located using fluoroscopy.A19-gauge needle was placed laterally into the dorsal joints under the capsule and perpendicular to the digit. A15-blade scalpel was used to incise the skin long­itudinally and asmall curved hemostat was used to bluntly dissect the soft tissue and punch into the dorsal joint through the capsule. Imaging was used to confirm the position of the hemostat in the dorsal joint. The hemostat was then pivoted at the joint entrance sweeping the tips proximally over the dorsal head,rupturing theproximal dorsal capsuleattachment. Sweeping more proximal the extensor tendon was elevated offthe proximal phalanx. Having completed the percutaneous release, tractionwas placed on theext ensor,flexor,and intrinsictendons,which werepreviouslyidentified and tagged. Each of the digits demonstrated normal congruent jointglidingthroughacomple te flexion and extension arc, withtip to palmand full extension without extensor lag.Lastly,eachofthe digits wasdissected by making a longitudinal incision andthe dorsal jointportal site was identified.The dorsal proximalcapsulewas completely divided. No extensor or joint injury was identified.

Once aflexioncontracture hasoccurred, thepatientsare enrolledinahand rehabilitationprogram before surgery until progress in therapy has reached aplateau, usually not before three months.Patientsselectedfor surgicalrelease complainedofjoint stiffnessimpairing hand function, possessed anormal congruent articular jointsurface,and had normal motor function. Extensive previous surgery with altered anatomic landmarks maybeacontraindication to surgery.