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EXTRINSIC TIGHTNESS

Introduction

Extrinsic tightness is a lack of usual finger motion, due to loss of excursion of the extensor tendons, or due to muscle dysfunction, related to scarring and fibrosis of the extensor muscle bellies. Sometimes extrinsic tightness can be reduced by prevention, through hand therapy. After original hand injuries, physicians should advise patients to mobilize their hands as soon as possible, to lessen extensor tendon stiffness.1 In many cases, extrinsic tightness can be treated conservatively, with splinting and prescribed exercise, including passive motion.1 If the patient needs operative treatment, post-operative hand therapy should be followed, in order to recover optimal flexion.2
 

Pathophysiology

Extrinsic tightness can be caused by extensor tendon lacerations with adhesions, metacarpal fractures with adhesions, proximal phalanx fractures with adhesions, crush injuries and rheumatoid arthritis (RA). Extensor tendon injuries are often underestimated compared to flexor tendon injuries.3 In very rare cases, extrinsic tightness can also be caused by epithelioid sarcoma. If epithelioid sarcoma is suspected, it is vital to make a diagnosis as early as possible. Only 20% of patients with this diagnosis will show tenderness and/or pain.4

Related Anatomy

  • Metacarpal phalangeal (MCP) joint, proximal interphalangeal (PIP) joint
  • Extensor tendons: extensor indicis proprius (EIP), extensor pollicis brevis (EPB), extensor digitorum communis (EDC), extensor digiti minimi (EDM), extensor carpi ulnaris (ECU)
  • Extrinsic muscles: abductor pollicis longus (APL), extensor pollicis brevis (EPB) and extensor pollicis longus (EPL)
  • Intrinsic muscles: thenar and hypothenar
  • Nerves: radial, median and posterior interosseous (PIN)

Incidence and Related Conditions

  • RA
  • Parkinson’s disease
  • Epithelioid sarcoma

Differential Diagnosis

  • Crush injury
  • Extensor tendon lacerations with adhesions
  • Proximal phalanx fractures with adhesions
  • Metacarpal fractures with adhesions
  • Epithelioid sarcoma
Clinical Presentation Photos and Related Diagrams
Extrinsic Tightness
  • Laceration of the extensor tendons (insert 1) has lead to adhesions (2) and resultant extrinsic tightness with restricted ring and little finger motion.
    Laceration of the extensor tendons (insert 1) has lead to adhesions (2) and resultant extrinsic tightness with restricted ring and little finger motion.
  • Extrinsic tightness leads to restricted PIP flexion with the MP joint flexed.
    Extrinsic tightness leads to restricted PIP flexion with the MP joint flexed.
  • The PIP joint can flex when the MP joint is extended.
    The PIP joint can flex when the MP joint is extended.
Pathoanatomy Photos and Related Diagrams
Extrinsic Extensor Tendons
  • Extensor Digitorum Communis (EDC)
    Extensor Digitorum Communis (EDC)
  • Extensor Indicis Proprius (EIP)
    Extensor Indicis Proprius (EIP)
  • Extensor Digiti Minimi (EDM)
    Extensor Digiti Minimi (EDM)
Symptoms
Swelling and tenderness of the affected digit(s) with attempted motion
Decrease in range of motion5
Decrease in grip strength
Wrist stiffness and tenderness with attempted motion
Typical History

The patient will often present with an extensor tendon injury, with or without metacarpal fracture. Ask the patient’s age, occupation, handedness, history of any recent or more likely past injuries, inflammatory arthropathy or neuromuscular disease. The patient may also have experienced intrinsic tightness, due to burns, trauma or inflammation.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the presence of extrinsic tightness
  • Define the cause of the intrinsic tightness
  • Determine the therapeutic options for the intrinsic tightness problem
Conservative
  • Use a dynamic pulley traction splint, to help the patient attain maximum simultaneous flexion of the MCP and PIP joints. This splint can be worn as much as one hour at a time, five times a day.6
  • While using the splint, the patient must carry out a prescribed exercise program to improve active and passive range of motion.6
  • In patients with neuromuscular disease, consider antispastic medicines and botulinum toxin injections for diagnosis or treatment.
Operative
  • Hand therapy should be used for at least four to six months before surgical options are considered.8,9
  • If improvement is not seen, consider tenolysis or extrinsic extensor release.8
  • In the early stages of MCP involvement in RA, synovectomy may help to relieve symptoms.10
  • Ideally, tenolysis should be done under local anaesthesia, so that the patient’s active motion can be evaluated during the surgery.
Treatment Photos and Diagrams
Treatment of Tightness Secondary to Adhesions
  • Tenolysis of extensor tendon adhesions causing extrinsic tightness.
    Tenolysis of extensor tendon adhesions causing extrinsic tightness.
Complications
  • Infection after surgery
  • Recurrent adhesions
  • More surgical complications may be seen if patients do not follow their prescribed hand therapy after surgery.  
Outcomes
  • Surgical release of PIP joint contractures gives inconsistent outcomes, so early mobilization and prevention are important.1,3
  • However, tenolysis of localized extensor tendon adhesions can be very helpful.
YouTube Video
Intrinsic and Extrinsic Tightness of the Hand
Key Educational Points
  • If the patient begins hand therapy directly after surgery so that functional mobility in the extensor tendons will be more likely.11
  • Examine the patient’s uninvolved hand to identify the patient’s normal active and passive range of motion.6 Examine the involved hand and compare results.6 Determine the patient’s level of pain. If pain is severe, as sometimes seen with spastic contractures, anesthesia can be used to carry out an accurate examination.3
  • Test each finger individually, looking for loss of grip and weak pinch strength.3
  • Passively extend the metacarpal phalangeal (MCP) joint while flexing the proximal interphalangeal (PIP) joint. Observe whether the PIP joint can be flexed as usual.7
  • Passively flex the MCP joint while flexing the PIP joint and observe whether the PIP joint can be flexed as usual. When the patient has extrinsic tightness, the PIP joints will flex as usual with the MCP joints extended, but they will have restricted flexion when the MCP joints are flexed.
  • Use radiographs to check for bone or joint injuries.
References

Cited

  1. Yang GY, McGlinn EP, Chung KC. Management of the stiff finger: evidence and outcomes. Clin Plast Surg 2020. PMID: 24996467
  2. Browne EZ, Ribik CA. Early dynamic splinting for extensor tendon injuries. J Hand Surg Am       1989;14(1):72-6. PMID: 2723371
  3. Matzon JL, Bozentka DJ. Extensor tendon injuries. J Hand Surg 2010;35A:854-61. PMID: 20439000
  4. Tomori Y, Ohashi R, Sawaizumi T, et al. Intramuscular epithelioid sarcoma presenting as extrinsic flexor tightness in the forearm. J Hand Surg Am 2018;43(10): 954. PMID: 29602652
  5. Goodrich J, Baratz M. Percutaneous release of the finger joints and mini-open intrinsic release with tenolysis: a cadaveric study. J Hand Surg Am 2019;44(11):991. PMID: 30777396
  6. Dovelle S, Heeter PK, Phillips PD. A dynamic traction splint for the management of extrinsic tendon tightness. Am J Occup Ther 1987;41(2):123-5. PMID: 3565527
  7. The Hand: Examination and Diagnosis. American Society for Surgery of the Hand, 1983.
  8. Green’s Operative Hand Surgery. Wolfe S, ed. Philadelphia: Elsevier, 2011.
  9. Ghidella SD, Segalman KA, Murphey MS. Long-term results of surgical management of proximal interphalangeal joint contracture. J Hand Surg 2002;27A:799-805. PMID: 12239667
  10. Hand Surgery Update V. Chung KC, ed. American Society for Surgery of the Hand, 2011.
  11. Lutsky KF, Matzon JL, Dwyer J, et al. Results of operative intervention for finger stiffness after fractures of the hand. Hand NY 2016;11(3):341-6. PMID: 27698638

Reviews

  1. Williamson SC, Feldon P. Extensor tendon ruptures in rheumatoid arthritis. Hand Clin 1995;11(3):449-59. PMID: 7559823

Classics

  1. Littler JW.  Surgical Clinics of North America. Vol 47. New York, 1967.
  2. Seftchick JL, Detullio LM, Fedorczyk JM, Aulicino PL. Clinical examination of the hand. 2011.
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