WALANT for Linburg-Comstock Syndrome: Clinical Case

Abstract

The Linburg-Comstock syndrome is characterized by the inability to actively flex the interphalangeal joint of the thumb without an involuntary flexion of the distal and proximal interphalangeal joints of the index finger. The syndrome results from tendinous interconnections between the flexor pollicis longus tendon or muscle belly and the flexor digitorum profundus tendon. We report the case of a policewoman with this anomaly who had to temporarily leave her job and relocate because she could not get her gun without the risk of shooting it. To date, no previous case report has been published showing the wide-awake local anesthesia with no tourniquet (WALANT) technique as an option for surgical treatment of the Linburg-Comstock syndrome.

Keywords

linburg-comstock - syndrome - hand - WALANT

Introduction

In 1979, Richard M. Linburg and Brian E. Comstock described tendinous connections between the flexor pollicis longus (FPL) tendon or muscle belly and the flexor digitorum profundus (FDP) tendons,[1] usually with the flexor indicis profundus (FPI) tendon. The populational incidence of these connections is 31% (unilateral) and 14% (bilateral).

The tendinous connections between FPL and FDP prevent the independent course of these tendons. Thus, active flexion of the interphalangeal (IP) joint of the thumb results in involuntary flexion of the distal interphalangeal (DIP) joint of the index and, in some cases, of the middle and ring fingers.[1] [2] In other cases, patients present persistent wrist pain[3] due to synovitis at the tendinous connection.

Even though the populational prevalence is high, the condition is only occasionally symptomatic.

This strange syndrome is often not diagnosed[4] probably due to the lack of awareness about it.

The treatment recommended for symptomatic patients is connection resection; however, the syndrome can reappear[3] [5] due to an incomplete fibrous tissue excision or recurrence.

To date, we found no publication regarding the wide-awake local anesthesia with no tourniquet (WALANT) technique[6] as a surgical technique for this syndrome. This technique allows the intraoperative assessment of the active movement to verify the complete release of the connections.

We present a case of symptomatic Linburg-Comstock syndrome successfully treated by resection using the WALANT technique.

Clinical Case

A 43-year-old woman, a police officer, presented volar wrist pain for 1 year and inability to actively flex the IP joint of the thumb of her right hand without an involuntary flexion of the DIP and FPI joints of the index finger as well ([Fig. 1]).

Fig. 1 Preoperative image showing the involuntary flexion of the distal interphalangeal joint of the index during active flexion of the interphalangeal joint of the thumb.

The clinical picture began after the performance of an electromyogram on the right arm due to an episode of cervicobrachialgia.

Curiously, the same symptoms appeared on her left hand but subsided in 1 month.

This clinical picture led the patient to be on leave from work; later, she was relocated because of her inability to handle the service weapon without involuntarily shooting it.

As Linburg and Comstock described as pathognomonic, passive flexion restriction of the index finger while actively flexing the thumb produced severe pain in the wrist and distal forearm.[1]

A magnetic resonance imaging (MRI) scan did not show any tendon condition. An ultrasound did not reveal a tendinous connection but showed a synchronous movement between the FPL and the FPI when the patient was asked to reproduce pathological motion.

We decided on a surgical intervention due to the suspicion of Linburg-Comstock syndrome and the lack of improvement with the conservative treatment.

With the patient in the supine position and using the WALANT technique[6] with 10 mL of lidocaine 1% and adrenaline 1:100,000 with no bicarbonate, we made two longitudinal injections, from proximal to distal, in the distal third of the anterior face of the forearm over the access route. Surgery occurred after 25 minutes when we observed the required area of ischemia. We made a longitudinal volar incision in the distal forearm over the flexor carpi radialis and found a tendinous connection and a thickened synovial tissue between the FPL and FPI tendons ([Fig. 2]). We asked the patient to actively flex her thumb to show how the connection produced a synchronous movement of both tendons. We performed the excision of the intertendinous tissue and actively evaluated it, assuring the correct independent mobility ([Fig. 3]).

Fig. 2 Intraoperative image of the tendon connection between the flexor pollicis longus and flexor indicis profundus tendons.

Fig. 3 Intraoperative image after excision of the abnormal tissue, showing the independent movement of both tendons using the WALANT technique.

Results

During the immediate postoperative period, symptoms subsided, and the wound healed without complications. The patient fully recovered and could return to her job 6 weeks after surgery ([Fig. 4]).

Fig. 4 Postoperative image 6 weeks after the intervention.

One year after the intervention, the patient presents no pain, and her thumb and index finger move independently.

Discussion

The Linburg-Comstock anomaly is a rare syndrome. It is usually undiagnosed, probably due to a lack of awareness.

The few differential diagnoses include writer's dystonia and psychiatric conditions.

The diagnostic is fundamentally clinical, although an MRI may reveal the tendon connections.[7] Unfortunately, supplementary imaging tests could not demonstrate these connections in our case.

Conservative treatment is often unsuccessful for wrist pain and combined motion.[3] In a series of 17 patients, local infiltration of betamethasone and lidocaine into the tendon sheath produced temporary relief, but symptoms recurred in all cases.[5]

Therefore, the treatment of choice is surgical excision of the tendinous connection and synovial tissue.[1] [3] [8] [9] However, surgical outcomes are inconsistent. Lombardi et al. published outcomes from 17 patients undergoing surgery and followed up for 6 months,[5] in which four were average or bad. The authors did not identify any factors related to the mechanism of injury, surgical findings, history, age, gender, or postoperative elements correlating with the clinical outcome.

In our case, we decided to perform the surgery using the WALANT technique because it allows an intraoperative assessment of the complete excision of the abnormal tissue and the independent, active flexion of the fingers. As such, we encourage surgeons to perform this procedure using the WALANT technique.

Conflict of Interest

None.

• Referencías

• 1 Linburg RM, Comstock BE. Anomalous tendon slips from the flexor pollicis longus to the flexor digitorum profundus. J Hand Surg Am 1979; 4 (01) 79-83
• 2 Yoon HK, Kim CH. Linburg-Comstock syndrome involving four fingers: a case report and review of the literature. J Plast Reconstr Aesthet Surg 2013; 66 (09) 1291-1294
• 3 Badhe S, Lynch J, Thorpe SK, Bainbridge LC. Operative treatment of Linburg-Comstock syndrome. J Bone Joint Surg Br 2010; 92 (09) 1278-1281
• 4 Yammine K, Erić M. Linburg-Comstock variation and syndrome. A meta-analysis. Surg Radiol Anat 2018; 40 (03) 289-296
• 5 Lombardi RM, Wood MB, Linscheid RL. Symptomatic restrictive thumb-index flexor tenosynovitis: incidence of musculotendinous anomalies and results of treatment. J Hand Surg Am 1988; 13 (03) 325-328
• 6 Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am 2013; 38 (10) 2025-2028
• 7 Karalezli N, Haykir R, Karakose S, Yildirim S. Magnetic resonance imaging in Linburg-Comstock anomaly. Acta Radiol 2006; 47 (04) 366-368
• 8 Gancarczyk SM, Strauch RJ. Linburg-Comstock anomaly. J Hand Surg Am 2014; 39 (08) 1620-1622
• 9 Takami H, Takahashi S, Ando M. The Linburg Comstock anomaly: a case report. J Hand Surg Am 1996; 21 (02) 251-252

Publication History

Received: 07 April 2020

Accepted: 01 February 2023

Article published online:
07 June 2023