TECHNIQUE

Continuous Passive Elongation Through an External Fixator:

A Versatile and Beneficial Adjunct Technique to Treat Severe
and Recurrent Cases of Dupuytren Contracture
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Peter YW Chan, BA,* Alexander Marcus, MD,† and Virak Tan, MD*

Two common presentations of DC are especially difficult

Abstract: Dupuytren disease and its associated digit contracture to treat: (1) severe primary or (2) recurrent cases. Severe cases
often negatively impact the quality of life for patients. Severe cases of of DC present with large amounts of contracture in the meta-
Dupuytren contracture and symptom recurrence are both difficult for carpophalangeal (MCP) and/or proximal interphalangeal (PIP)
hand surgeons to treat. Improved treatment options are therefore joints. These contractures limit access to the palm and make
needed. One method is continuous passive elongation (CPE). In CPE, immediate surgical intervention a demanding task. Recurrent
a device is affixed to the digit, which applies a continuous extending cases prove difficult as treatment options are progressively
force to pull the affected finger out of flexion. Multiple external exhausted. Therefore, it is important for surgeons to have as
fixators used to induce CPE have been reported. However, a low- many treatment options as possible when facing DC. We report
profile, hand-specific external fixator, the DigiFix, provides benefits a versatile technique of CPE using DigiFix that demonstrates
over previously reported devices. We present the technique of CPE the potential to improve the treatment of both recurrent and
using DigiFix as a beneficial and versatile adjunct treatment for severe DC.
severe and recurrent cases of Dupuytren contracture.
Key Words: hand, dupuytren disease, dupuytren contracture, ANATOMY
continuous passive elongation, flexion contracture
Normal fascia forms a complex, interconnected network within
(Tech Hand Surg 2023;27: 125–130) the palmar surface of the hand. In DD the palmar fascia
becomes abnormal and can lead to flexion contracture in the
MCP, PIP, and rarely the distal interphalangeal joints.17,18 The
disease progresses through a series of stages, beginning with
the formation of painless nodules on existing fascia and
D upuytren disease (DD) is a benign condition affecting the
fascia of the hand where progressive tissue thickening
leads to digit contracture.1 Dupuytren contracture (DC) is often
progressing to the development of thickened, fibrotic cords,
which lead to contracture.17,18
Various fascia structures within the palm are susceptible to
debilitating for patients, impacting daily life and work DD; the specific structure, in which the fibrotic cord develops
activities.2 There are multiple available treatments for DC, will determine, which joints are predominantly affected. For
including percutaneous needle aponeurotomy (PNA), collage- example, the development of a cord in a pretendinous band,
nase Clostridium histolyticum (CCH) injections, and surgical which originates from the palmar aponeurosis at the wrist and
fasciectomy.3–6 bifurcates proximal to the metacarpal head, will often lead to
Continuous passive elongation (CPE) has also been uti- contracture at the MCP joint. Cord development in a more
lized as a minimally invasive treatment of DC, typically as an distal structure such as the fascia network along the proximal
adjunct procedure. In CPE, an external device is used to apply phalanx will likely lead to PIP contracture.18
a continuous extending force to the affected finger, which Application of the DigiFix is done with transosseous
gradually brings the digit out of flexion. Multiple studies have K-wires in the mid-lateral (coronal) plane of the finger, which
shown that combining CPE with another treatment method avoids the extensor mechanism dorsally and the neurovascular
improves outcomes.7–13 Multiple devices, which induce CPE structures and flexor tendons volarly (Fig. 1). Wires in this
have previously been described, but many of them come with plane are well-tolerated because there is minimal interference
downsides.7,10,14–16 Often, they are bulky and protruding, with tendon excursion during finger motion.
which can interfere with the patient’s daily activities and
reduce patient compliance. Some are applied dorsally and
interfere with the extensor mechanism. Other devices do not INDICATIONS/CONTRAINDICATIONS
hold the rotating joint in a reduced position fixed to the rotation The DigiFix is indicated for all presentations of DC, ranging
axis; as such, extension forces can translate or dislocate the from mild to severe. In mild cases, the device can be used as a
rotating joint. A prefabricated, low-profile, hand-specific stand-alone, minimally invasive treatment with the percuta-
external fixator (DigiFix, Virak Orthopedics LLC) demon- neous application. A limited fasciotomy or fasciectomy can also
strates the potential for improvement compared with current be performed at the surgeon’s discretion.
methods to induce CPE. In severe contracture where the surgical approach to the
cords is obstructed by the flexed digit, the device can be applied
From the *Institute for Hand and Arm Surgery, Madison, NJ; and
preoperatively as a first-stage procedure to gradually open the
†Orthopaedic Associates of Central Jersey, Edison, New Jersey. hand. Once there is sufficient access to the palm, a fasciectomy
Appropriate consent was obtained from all individuals included in this study. can be done in the second stage. The DigiFix can be removed at
Conflicts of Interest and Source of Funding: VT is a principal in Virak the time of the second procedure or kept in place to facilitate
Orthopedics, Harrison, NJ. For the remaining authors none were declared.
Address correspondence and reprint requests to Peter YW Chan, BA, 345
postoperative rehabilitation.
Main Street, Madison, NJ 07940. E-mail: [email protected]. Similarly, in cases with symptom recurrence or previously
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. failed intervention with scarring or distortion of the palmar

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 Chan et al Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 2, June 2023

Proximal Interphalangeal Application

Application of the DigiFix device is typically done under local
anesthesia or regional block. A true lateral of the PIP joint is
obtained using fluoroscopy. A 0.054” K-wire is inserted
through the axis of rotation of the PIP joint such that it exits
the other side of the proximal phalanx; this K-wire serves as the
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“axis pin.” After placement, the location of the axis pin is

checked by fluoroscopy on lateral and posteroanterior views.
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Once this axis pin is in place, a DigiFix bracket is slid over the
pin on 1 side of the finger through the Axis Pin Hole.
Using the DigiFix bracket as a guide, a 0.045” K-wire is
percutaneously inserted perpendicular to the long axis of
the finger and through the most proximal of the Distal K-Wire
Holes and driven across the middle phalanx to exit on the
opposite side of the finger. Another K-wire of identical dia-
meter is inserted through 1 of the remaining Distal K-wire
FIGURE 1. Simplified figure depicting the axial view of a finger.
Holes in a similar manner, ensuring the K-wire is perpendicular
The DigiFix is affixed using transosseous K-wires, which enter in to the long axis and in the mid-axial plane of the middle pha-
the mid-lateral (coronal) plane of the finger (red arrow). The lanx, and not in the distal interphalangeal joint. A second
DigiFix is well-tolerated because it avoids the extensor mechanism DigiFix bracket is placed over the 3 K-wires on the opposite
dorsally (above) and neurovascular structures and flexor side of the finger, keeping the brackets about 3 mm from the
mechanism volarly (below). In general, dorsally (dotted arrows) is skin to allow for postoperative swelling. The axis pin ends
the safe zone for percutaneous pin placement in the finger. are bent 90 degrees to prevent the pin from disengaging from
the brackets. The excess pin length is cut short. The remaining
anatomy, postoperative use of DigiFix can decrease the surgical K-wires are cut flush to the outer portion of the DigiFix
burden for the physician. The CPE in the postoperative period brackets and the distal set screws are tightened. Distraction of
is expected to provide additional extension beyond what is the joint is recommended by crimping the Diamond using pliers
achieved on the operating table. Therefore, the surgeon does not to increase the length of the brackets; this will induce longi-
have to completely excise all diseased cords, minimizing the tudinal stretching of the digit, including the contracted diseased
risks of iatrogenic neurovascular injury. fascia (Fig. 3).
The DigiFix can be applied to any PIP joint and the MCP A fourth K-wire (anchor pin) is inserted perpendicular to
joint of the small and index fingers. This device is not suited for the long axis through the proximal phalanx, proximal to the end
contracture of the middle and ring finger MCP joints. The device of the DigiFix bracket. The ends of this K-wire are bent to
requires a pin to be inserted through the axis of rotation of the create “hooked” ends and cut. An elastomer band is looped
joint in the coronal plane, and in the case of middle and ring around this anchor pin, placed dorsal to the axis pin, and affixed
finger MCP contracture, the axis pin placement is obstructed by to the hook on the DigiFix bracket (Fig. 4A); this orientation
the border digits. General contraindications include poor patient induces a continuous, low load, resultant extension moment
compliance, active infection, and severe osteoporosis or other proportional to the force of the elastomer band (3/8”, 6.5 oz)
conditions, which lead to poor bone quality and prohibit the and perpendicular to the axis of rotation to overcome the flexion
insertion of K-wires into the metacarpals or phalanges. contracture (Figs. 4B and C). Another elastomer band is placed
in a similar manner for the DigiFix on the opposite side of the
finger. Increasing the number of bands will proportionally
increase the extension moment about the joint.
SURGICAL TECHNIQUE
Povidone-iodine sponge dressing is placed between the
Application of the DigiFix device (Fig. 2) for MCP and PIP
skin and brackets, around the K-wires, and the finger is
contracture varies slightly and is detailed below.

FIGURE 2. Diagram of the DigiFix bracket. For treatment of Dupuytren contracture (DC) in the proximal interphalangeal (PIP) joint, a
K-wire (the axis pin) is inserted through the proximal phalanx to align the Axis Pin Hole with the center of rotation of the PIP joint. Two
additional K-wires are inserted through separate Distal K-Wire Holes through the middle phalanx. The distal set screw is tightened. A
fourth K-wire is inserted through the proximal phalanx, proximal to the end of the DigiFix bracket. One or more elastomer band(s) is
wrapped around the most proximal K-wire, placed dorsal to the axis pin, and looped on the Hook to induce continuous passive
elongation (CPE) of the digit. The Diamond can be crimped using pliers to lengthen the device and thus the digit, unloading the joint(s)
and stretching the collateral ligaments during treatment.

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 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 2, June 2023 CPE Through an External Fixator
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FIGURE 3. Distraction of the digit during the extension process can also be obtained. Lengthening of the DigiFix bracket through
crimping the Diamond with pliers (A). Compressive forces applied to the Diamond (yellow arrows, B) distracts the digit, unloading the
joint, disrupting the Dupuytren’s cords, and allowing the collateral ligaments to heal in a lengthened position.

wrapped with Coban. The dressing may be replaced every 10 to Metacarpophalangeal Application
14 days. The device is left in place at the discretion of the Application of the DigiFix for MCP joint contracture follows
physician to obtain the desired extension of the digit, typically the same procedure as PIP joint fixation with small changes in
for 6 to 8 weeks. Elastomer bands should be replaced every the positioning of the device. The axis pin is inserted
week and the number of bands may be adjusted over the course transversely through the axis of rotation in the metacarpal head
of treatment to titrate force as tolerated by the patient. rather than the proximal phalanx. The second and third K-wires
are inserted through the proximal phalanx using the DigiFix
bracket as a guide. The anchor pin is inserted proximal to the
DigiFix bracket through the metacarpal shaft rather than the
proximal phalanx. Finally, only 1 DigiFix bracket is used for
MCP contracture, either on the radial side of the index finger or
the ulnar side of the small finger.

Case 1
A 63-year-old right-hand dominant man presented with DC in
the left middle, ring, and small fingers. Six years prior, the
patient underwent PNA for DC in the same fingers with good
immediate results. However, the patient’s contracture recurred.
The patient had MCP contracture of 20 degrees, 40 degrees,
and 35 degrees of the middle, ring, and small finger,
respectively. The ring and small finger PIP joint contracture
were 45 degrees and 95 degrees, respectively (Figs. 5A and B).
The tip of the small finger was within 1 cm of the palm.
Treatment options were discussed including amputation
given the recurrence of the contracture after PNA. The patient
wanted to avoid amputation and requested surgical treatment.
However, given the severe contractures and lack of volar skin
in the small finger, immediate surgical fasciectomy posed high
risks. Instead, the patient underwent percutaneous application
of the DigiFix of the small finger with CPE. After 7 weeks of
CPE, the tip of the small finger opened to 5 cm from the palm.
He went back to the operating room for the removal of the
external fixator and limited fasciectomy of the 3 affected digits.
Hand therapy was started in the early postoperative period and
lasted about 2 months. At 5 months after the application of the
DigiFix, he was able to work on regular duty.
Final follow-up was at 13 months and the patient had a
full grip. Active finger extension was near full in the middle and
ring fingers. In the small finger, the PIP joint had a residual
contracture of 40 degrees to 45 degrees (Figs. 5C–E).

Case 2
A 68-year-old right-hand dominant woman presented with
recurrent right carpal tunnel syndrome after an open release 2
FIGURE 4. Appropriate application of elastomer bands on the decades earlier. She also had DC of the ipsilateral small finger
DigiFix for treatment of flexion contractures. Once the K-wires MCP to 60 degrees (Fig. 6A). There was no contracture of the
and DigiFix bracket(s) are in place, an elastomer band is wrapped
around the anchor pin, placed dorsal to the axis pin, and around interphalangeal (IP) joints. She underwent revision carpal tun-
the hook on the bracket (A). This orientation induces an nel release with a hypothenar fat pad transfer and a limited
extending force on the digit about the axis pin, which acts as the fasciectomy and application of the DigiFix across the MCP
pivot point (B and C) for the distal portions of the finger to be joint for CPE. At 2.5 weeks postoperatively, the MCP joint had
pulled out of flexion. attained near full extension (Figs. 6B and C). After 4 weeks of

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FIGURE 5. A 63-year-old right hand dominant male with DC in the left middle, ring, and small fingers. There was contracture of 20
degrees at the middle finger metacarpophalangeal (MCP) joint; 45 degrees and 30 degrees at the ring finger MCP and PIP joints; and
45degrees and 95degrees at the small finger MCP and PIP joints, respectively (A and B). The DigiFix device was attached for 7 weeks to
extend the small finger and allow for sufficient access to the palm. Thereafter, a limited fasciectomy was undertaken on the ring, middle,
and small fingers. Clinical photographs at 13 months postoperatively (C–E).

CPE, the patient was given the choice to remove the device in After device removal, she was placed into a removable hand-
the office or in the operating room. She elected to have the based splint to keep the small finger MCP and IP joints in full
device removed with intravenous sedation and local anesthetic. extension. She used the orthosis at night for 3 months. At

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 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 2, June 2023 CPE Through an External Fixator
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FIGURE 6. A 68-year-old with DC of the small finger MCP joint of 60 degrees (A). She had a limited fasciectomy and application of CPE
through the DigiFix for a total of 4 weeks. At 2.5 weeks, the small finger was nearly completely straight (B and C). Clinical photographs at
7 years after the surgery (D).

7 years, she presented for an unrelated condition, and the right gradually over at least 6 weeks. If the patient experiences pain
small finger MCP had a recurrence of contracture to 20 degrees or swelling, the force-inducing extension can be reduced, by
to 25 degrees with no IP contracture (Fig. 6D). She had full removing excess elastomer bands, and then maintained until
grip, and the hand remained fully functional without additional symptoms subside. Treatment can then continue until an
treatment for DD. appropriate extension is obtained.

COMPLICATIONS EXPECTED OUTCOMES AND CONCLUSIONS

The primary concern after treatment of DC is recurrence. All CPE is an attractive treatment option for DC for multiple
treatments for DC, including CPE, do not address the reasons. First, it is associated with fewer complications than
underlying disease and cause of the contracture; recurrence is other surgical treatments likely due to its minimally invasive
thus common even after appropriate treatment and therapy.6,19 nature.6 In addition, studies have shown that CPE with low-load
The incidence, severity, and time to onset of recurrence vary prolonged stretch can beneficially alter the biochemical and
between patients. Any of the conventional treatments for DC biomechanical properties of the diseased tissue; CPE has been
may be used to treat recurrence, although there is no current shown to increase degradative enzyme levels, which can soften
consensus on the best treatment. As such, treatment selection is and degrade the contractive fibers, and cause fibroblasts and
at the discretion of the patient and surgeon.20 Of note, some collagen fibrils within the hand to realign parallel to the
options may make treatment of recurrence more difficult; for stretching force.23,24 Further, multiple studies have shown that
example, fasciectomy may be more technically difficult as a the use of CPE as an adjunct treatment improves the outcome of
secondary procedure if CCH had been previously used.21 fasciectomy, fasciotomy, or CCH injection.7–13
Some patients may not wish to proceed with the length of Our cases build on existing literature that CPE demonstrates
treatment necessary for CPE. Fortunately, the morbidity asso- the potential to improve outcomes when used pre or post-
ciated with these cases is low given that CPE is often used as an operatively. However, we also demonstrate the versatility and
adjunct to other treatments. Pin tract infection and cellulitis may utility of CPE in the treatment of DC, especially in the notoriously
occur with CPE through an external fixator, which was difficult cases of symptom recurrence and severe contracture.
encountered in our patient in Case 2.6,11 Risk of infection can Over the past 30 years, multiple devices, which induce
be minimized by utilizing the appropriate sterile technique CPE, have been reported.7,10,14–16 Compared with other devices,
during DigiFix attachment and leaving appropriate space the DigiFix used in this series possesses multiple benefits. First,
between the brackets and skin (~3 mm). We find that the use of the DigiFix is low-profile, especially compared with other
the betadine sponge between the skin and bracket has resulted devices, and well-tolerated. Unlike most external fixators, the
in very few incidences of pin tract infection. In the case of DigiFix is affixed to the sides of the fingers, rather than dorsally,
postoperative infection, oral antibiotic therapy is preferred. which further reduces its potential to interfere with daily activ-
Finally, pain or swelling in the digit may occur during the ities. In addition, because the DigiFix is not applied dorsally, it
extension process.6,22 To avoid this issue, CPE should progress does not interfere with the extensor mechanism.

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 Chan et al Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 2, June 2023

Unlike many other external fixators, the DigiFix stabilizes 10. White JW, Kang SN, Nancoo T, et al. Management of severe
and reduces the primary joint of rotation using the axis pin, Dupuytren’s contracture of the proximal interphalangeal joint with use
which provides a 2-fold benefit. First, an extension can be of a central slip facilitation device. J Hand Surg Eur Vol. 2012;37:
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In addition, the axis pin fixation prevents potential joint sub-
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distraction versus checkrein ligament release after fasciectomy in the

luxation or dislocation due to the forces imposed on the digit treatment of dupuytren proximal interphalangeal joint contractures.
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tudinal stretch of the joint capsule, collateral ligaments, and Dupuytren disease in 2 steps: progressive distraction with external
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