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Three Part Question

In [children with camptodactyly] is [splinting effective] in [improving PIP joint range of movement and hand function]?

Clinical Scenario

A 6 month old child is referred to Occupational Therapy (OT) from the consultant led clinic with camptodactyly. You want to try to correct the flexion deformity at the PIP joints and wonder if splinting may be a useful technique effective in improving PIP joint range of movement (ROM) and hand function.

Search Strategy

MEDLINE - searches were carried out by the librarian at Central Manchester University Hospitals. 1983-2012
CINAHL - searches were carried out by the librarian at Central Manchester University Hospitals. 2000-2012

MEDLINE
[camptodactyly.ti,ab;] AND [splint*.ti,ab; OR exp SPLINTS/;] AND [(occupational AND therapy).ti,ab: OR exp OCCUPATIONAL THERAPY/;]
CINAHL
[camptodactlyl.ti,ab] AND [splint*.ti,ab; OR exp SPLINTS/;] AND (occupational AND therapy).ti,ab; OR exp OCCUPATIONAL THERAPY] AND [(interphalang* AND flexion*).ti,ab;] AND [Limit to: Publication Year 2000-2010];

Search Outcome

A total of 35 articles were found of which 4 were deemed to be relevant. All the articles were retrospective reviews/studies. The evidence is declared as weak as there were no systematic reviews, or clinical trials comparing 'splinting' and 'non-splinting'.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Benson et al, 1994 USA	22 children representing 59 PIP joints with camptodactyly. They were categorised into 3 varieties of camptodactyly, Type1, Type 2 and Type 3.	A retrospective review.	Treatment was assessd by passive ROM measurements. Splinting and an OT programme were particularly effective for Type 1 patients. Splinting children with camptodactyly is an effective treatment.	All patients with Type 1 camptodactyly were treated with splinting. Average initial passive extension was -22.9 degrees compared to -4.3 degrees at a mean follow up of 36 months. Only 1 of the Type 2 patients followed the splinting protocol gaining full correction of -35 degrees. Type 3 patients showed an average of -23 to -1 degree after splinting. Children who are able to comply with a splinting and OT programme show improvements in PIP joint ROM and hand function.	Parents/carers play a large part in the therapy programme to achieve patient compliance, especially in the younger children
Siegart et al. 1990 USA	57 patients with camptodactyly.	A retrospective review.	Of the 38 digits treated operatively, 18% had good or excellent results. In comparison 41 digits were treated conservatively and had 66% good or excellent results. Operative treatment for children with severe and progressive camptodactyly should only be considered when conservative treatment hasn't been effective.	For the entire group of conservatively treated patients, the overall mean lack of extension at the PIP joint was 37 degrees before treatment and 16 degrees after treatment. Splinting children with camptodactyly is effective.	This paper compares splinting versus surgery for children with camptodactyly and so is not directly relevant. The conclusion however is relevant as there is evidence that splinting children with camptodactyly is effective.
Miura et al. 1992 Japan	62 patients with camptodactyly of the little finger	A retrospective review.	Out ot the 62 patients, only 5 cases failed to respond to conservative treatment. Conservative treatment by splinting is more effective than surgery and should be commenced as soon as possible. Surgery should only be carried out where conservative treatment has failed.	Conservative treatment by elastic splinting is more effective than operative treatment. Operative treatment should be used for failures of conservative treatment.	The results are not clearly presented. Results are described in very fine detail for 5 out of the 62 patients.
Munetoshi Hori et al. 1987 Japan	24 patients representing 34 joints with camptodactyly.	A retrospective study.	Improvement with dynamic splinting occurred in 29 fingers out of 34 fingers. 21 fingers showed almost full correction of the contracture after treatment by a dynamic splint.	The flexion contracture of 21 fingers were measured before and after treatment. The average flexion contracture was 40 degrees before splinting and 10 degrees after treatment. Dynamic splinting is an effective treatment for camptodactyly.	The results diagram is not clear.

Comment(s)

The effectiveness of splinting children with camptodactyly to improve finger ROM and hand function is a question posed in the consultant led clinic. All the papers clearly show that splinting children with camptodactyly does increase their ROM and hand function. In some cases there were issues of non-compliance and these patients did not have an improved finger ROM. Splinting children with camptodactyly is effective but requires careful monitoring and supervision from OTs and parents/carers.

Clinical Bottom Line

In children with camptodactyly, splinting is effective in improving PIP joint ROM and hand function.

References

1. Benson et al, Camptodactyly: Classification and Results of Nonoperative Treatment. Journal of Pediatric Orthopaedics. 1994; 14:814-819
2. Siegert et al. Management of Simple Camptodactyly. Journal of Hand Surgery (British Volume, 1990) 15B:181-189
3. Miura et al. Long-standing extensive dynamic splintage and release of an abnormal restraining structure in camptodactyly. Journal of Hand Surgery (British Volume, 1992) 17B:665-672
4. Munetoshi Hori et al. Nonoperative treatment of camptodactyly. The Journal of Hand Surgery 1987;12A:1061-5