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Saddle Syndrome a Non-Operative Approach
Horatiu C. Dancea, MD; Hagop Manushakian, MD; Sunil T. Thirkannad, MD
Christine M Kleinert Institute for Hand and Microsurgery, Louisville, KY

Introduction: Saddle deformity is defined as post traumatic interosseous-lumbrical adhesions, producing impingement on the deep transverse metacarpal ligament during intrinsics contracture. Previous studies advocated surgical intervention in all cases of saddle deformity, and more recent studies suggest a role of the non-operative treatment.
Materials and Methods: Our cohort represents all patients diagnosed with saddle deformity by the senior surgeon from 2009 to 2012. We excluded patients with other causes for the intermetacarpal pain. We collected information regarding demographics, work status, comorbidities, mechanism of injury, presentation and treatment.
Results: Our series comprises 15 patients of about 4000 new patients seen by the senior author (0.4%). Nine were men and 6 women. All patients presented with pain at the metacarpo-phalangeal joint region, mostly on the dorsum of the hand. Pain was elicited or increased by stressing the intrinsics when making a tight fist. Twelve patients had moderate or severe tenderness over the affected saddle. All had stable and painless MP joint on lateral stress, and positive intrinsic stress test (forced active flexion of PIP and DIP with MP held in hyperextension). The first treatment was always conservative, including splinting and physical therapy (intrinsic stretching) in 6 patients, or steroid injection in the web space in 9 patients. This injection was also used as a diagnostic tool, when the discomfort was immediately relieved by the local anesthetic. Out of the 6 patients treated initially with splinting and physical therapy, the symptoms resolved in 3 patients, while the others required a steroid injection for 2 patients or surgical intervention for one patient. Of the 9 patients treated with steroid injection in the web space as the first treatment, seven experienced relief of the pain. In one patient a second injection achieved resolution of the pain, and one patient underwent surgical exploration. As a second treatment, 3 patients resolved with steroid injection to the web space and 2 resolved after surgical intervention. All patients who submitted workmen's compensation claims failed the initial treatment, but resolved after secondary treatment.
Conclusions: Saddle deformity is a rare condition, around 0.4% in our experience. Steroid injection is highly effective in providing relief in our patients. Surgical intervention is rarely necessary, as 87% of our patients resolved with non-surgical treatment. We propose an approach including web injection in conjunction with intrinsic stretching exercises as initial treatment, followed by surgical exploration in case of persistent symptoms.


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