Good afternoon

Moderator:-Dr. A. RAMALINGAIAH. Prof and Unit chief Ortho III VH. BMCRI. Bangalore

Presenter:-Dr. BAHUBALI. ASKI. PG in Orthopaedics

claw hand

It is a characteristic deformity presenting with hyperextension at the MCP joints and flexion at the proximal and distal interphalangeal joints

The resting tone of the intrinsic is lost leading to unopposed long extensors across the MCP joints and unopposed long flexors across the interphalangeal joints resulting in characteristic deformity of the hand

Claw hand (Intrinsic minus hand)

Absence of fingers, Congenital Cleft hand, Ectrodactyly,Lobster claw hand.

SYNONYMS

Claw Hand

Partial Total

Types

true claw hand /total claw hand (both median and ulnar claw hand)

-low mixed ulnar and median nerve palsy -high mixed ulnar and median nerve palsy Claw like hand /partial claw hand (ulnar claw

hand) - low ulnar nerve palsy - high ulnar nerve palsy

TYPES

Trauma CausesBrachial plexus injuryNeoplastic DisordersPancoast tumorStorage DisordersHurler's mucopolysaccharidosisCongenital, Developmental DisordersDe Lange syndromeAcro-Facial dysostosis/Nager type

ETiOLOGY

Hereditary, Familial, Genetic DisordersLobster claw deformity/split handCurran acrorenal syndromeReference to Organ SystemBrachial plexus neuropathy,Ulnar

neuropathy, ALS, syringomyeliaInfectionsLeprosy, poliomyelitis

ETiOLOGY

MCP joint PIP joint DIP joint

Flexion Lumbricals Flexor digitorium

superficialis

Flexor digitorum profundus

Extension Extensor Digitorium

Interossei Interossei

Mechanism in Normal hand

Flexion Extension Deformity

MCP joint Lumbricals--Paralyzed

Ext. Digitorum--Active

Hyper-extension of MCP joint

PIP joint FDS--Active Interossei--paralysed

Flexion of PIP joint

DIP joint

Low ulnar palsy

FDP--Active Interossei--paralysed

Flexion of DIP joint

High ulnar palsy

FDP--Paralyzed Interossei--paralysed

Neutral position

Mechanism in PARTIAL CLAW hand

Mechanism in total CLAW hand

Flexion Extension Deformity

MCP joint Lumbricals--Paralyzed

Ext. Digitorum--

Active

Hyper-extension of

MCP joint

PIP joint FDS--Paralyzed

Ext. Digitorum--

Active

Extension of PIP joints

DIP joint FDP--Paralyzed

Ext. Digitorum--

Active

Extension of DIP joints

claw hand

Distribution of sensory nerves innervating the hand

Wasting of interossei: First dorsal interossei is the first to become noticeably affected. There is hallowing of skin on the dorsal aspect of 1st web space

Hypothenar wasting

In high ulnar nerve palsy, there will be wasting of ulnar half of the forearm

Brittle nails

Tropic ulcers of hand in ulnar distribution area

Clinical features of ulnar nerve palsy

Flexor Carpi Ulnaris: When the wrist joint is flexed against resistance, the hand tends to deviate towards radial side

Dorsal Interrossei: The patient is asked to abduct his fingers against resistance

Card test for Palmar Interossei: A card is inserted between the two fingers which are kept extended. The patient is asked to hold the card by adducting these two fingers as tightly as possible. The clinician will try to pull the card out of his fingers

Tests for Ulnar nerve

Abductor digiti minimi: Ask the patient to abduct the little finger against resistance. Inability to do so indicates ulnar nerve palsy

Flexor digitorum profundus: The middle phalanx of ring or little finger is supported and the distal IP joint is flexed against resistance. Failure to flex implies high ulnar nerve palsy

Sensation: There will be loss of sensation over the ulnar distribution (medial 1/3 of palm & dorsum of hand and ulnar one & half fingers)

Tests for Ulnar nerve contd…

First Palmar Interossei and Adductor Pollicis:

* The patient is asked to grasp a book between the extended

thumb and the other fingers

* If the ulnar nerve is intact, the patient will grasp the book with

extended thumb taking full advantage of the adductor pollicis and

first palmar interosseous muscles

* But if the ulnar nerve is injured, these two muscles will be

paralysed and the patient will hold the book by flexing the thumb

with the help of flexor pollicis longus. This sign is known as

“Froment sign”

Froment sign

Thenar wasting

Simian or ape thumb deformity

Atrophy of pulp of index finger

Cracking of nails

Tropic changes

Wasting of lateral aspects of forearm

Clinical features of median nerve palsy

Flexor Pollicis Longus:

The patient is asked to bend the terminal phalanx of the thumb against resistance while the proximal phalanx is being steadied by the clinician

This muscle is only paralysed when the median nerve is injured at or above the elbow

Tests for median nerve

Opponens Pollicis: *This muscle swings the thumb across the palm to

touch the tips of the other fingers*The patient with paralysis of this muscle will be

unable to do this movement

Tests for median nerve contd…

FlexorDigitorumSuperficialis &

Profundus(lateral half):

If the patient is asked to clasp the hands, the index finger of the affected side fails to flex and remains as a “Pointing Index”

Oschsner’s clasping test

Abductor Pollics Brevis: The patient is asked to touch the pen which is

kept at a slightly higher level than the palm of the hand with the thumb

Pen test

Tinel sign

Sweat test

Histamine test

Skin resistance test

Electrical stimulation

Nerve conduction velocity

Electromyography

Other tests for peripheral nerve injury

It is elicited by gentle percussion by a finger or percussion hammer along the course of an injured nerve

A transient tingling sensation should be felt by the patient in the distribution of the injured nerve rather than at the area percussed, and the sensation should persist for several seconds after stimulation

It should be tested for in a distal-to-proximal direction

A positive Tinel sign is presumptive evidence that regenerating axonal sprouts that have not obtained complete myelinization are progressing along the endoneurial tube

Tinel Sign

Consists of dusting the extremity with quinizarin powder

The powder remains dry and light gray throughout the denervated area and assumes a deep purple color throughout the area of normal sweating

Sweat test (iodine starch test)

Test is carried out by injecting intradermally 0.1 ml of 1:1000 solution of histamine phosphate or chlorohydrate into hypopigmented patches or in areas of anaesthesia

In a normal patient, Lewis triple response is seen; but in a leprosy patient ‘flare’ response is lost

Histamine test

Exercises-physiotherapySplinting:- -- To immobilize all or part of a hand in a position that will

promote healing and prevent deformity

-- To correct an existing deformity and promote function in that part

-- To supply power to compensate for weakness

Surgical correction:-

-- Active or dynamic procedure: Called so because they bring extra active muscular forces in places of those lost because of muscle paralysis

-- Passive or static procedure: Called so because they attempt to restore equilibrium without introducing new active muscle forces

Management of deformed hands

Assist devices used in upper limb paralysis.

It is a procedure in which the tendon of a functioning muscle is detached or divided at or near its insertion, mobilized and reinserted into a bony part or another tendon to supplement or substitute for the lost function

The two most important points in considering a muscle for transfer are,

---Expendability

---Strength

Tendon transfer

PLAN NING

Evaluate for the cause

Tabulate muscles available for transfer and needed

function

EVALUATE THE MUSCLE

The muscle to be transferred should be healthy (appears

dark pink or red)

The strength of the muscle to be transferred should be

grade 4-5. A muscle usually loses strength by grade 1 when

transferred

Principles

It is desirable to use a synergestic muscle as it is easier to

rehabilitate the muscle after surgery

TIMING

Transfer should not be done until any scar tissue has been

satisfactorily replaced to prevent adhesion

Necessary operations to restore any loss of sensibility also

must precede tendon transfer

Wait for 18 months in polio, 6 months in radial, 3-4 months

in median and ulnar nerve.

Principles contd…

TECHNICAL CONSIDERATION

The origin and the newly transferred insertion should be in

a straight line. Whenever acute angle is used, a pulley

should be used

Any bony deformity should be corrected by osteotomy

Tendon should be attached under moderate tension

When tendon is split to provide insertion to various points,

tension should be equal to all points

Principles contd…

The transferred tendon should pass through the gliding bed

(either through subcutaneous fat or through a tendon

sheath)

Transfer should not pass through the raw bone

Amplitude of motion should be sufficient

There must be free range of movements in the joint to be

activated by transplanted muscle

Principles contd…

Joint proximal to parts to be moved should be stabilized, either by tendon action or by arthrodesis

---To restore thumb pinch, stabilize the carpometacarpal joint in extension and MCP joint in flexion

---To restore finger extension, the MCP joint is maintained in slight flexion

Principles contd…

Irreparable

nerve

damage

Non-progressive or

slowly progressive

neurological

disorders

Loss of function

of a

musculotendinou

s unit

Indications for tendon transfer

Opposition of the thumb is necessary for pinch and may be defined as the refined, unique movement that places the thumb within the flexion arc of the fingers so that the tips of the thumb and fingers can oppose

Opposition depends primarily on function of the intrinsic muscles of the thumb, especially the Abductor pollicis brevis

Frequently, opposition is either partially or totally lost in poliomyelitis or median nerve palsy

RESTORATION OF PINCH

Thumb-index pinch

Transfer of Extensor indices proprius — Burkhalter technique

Transfer of Sublimis tendon —

a) Riordan technique b) Brand technique

Transfer of Palmaris longus – Camitz technique

Transfer of Flexor carpi Ulnaris combined with sublimis tendon — Groves & Goldner technique

Transfer of abductor digiti quinti to restore opposition – Littler & Cooley technique

Tendons selected for transfer to restore opposition

Expose and divide the sublimis tendon of the ring finger, and make the incision over the thumb

Withdraw the sublimis tendon through a small transverse incision about 5 cm proximal to the flexor crease of the wrist

Make a small longitudinal incision just to the radial side of and about 6 mm distal to the pisiform.

Deepen this incision until the quality of fat changes from the fibrous superficial type to a soft, loose, free type that bulges into the wound. This change in the fat marks the entry into a tunnel that runs proximally and contains a branch of the ulnar nerve

Brand technique

In this loose fat, make a tunnel in the proximal direction to the forearm incision, grasp the end of the sublimis tendon, and pull it through into the palmar incision

Pass the tendon to the MCP joint of the thumb, and attach it proximal and distal to the joint after splitting its end; attach the proximal slip of the tendon to the ulnar side of the joint and the distal slip to the tendons of the abductor pollicis brevis and the extensor pollicis longus

This dual insertion of the tendon may prevent the tendon from shifting in position as it crosses the MCP joint

Brand technique contd…

Adduction of the thumb is as necessary for strong pinch and

may be defined as the force that stabilizes the thumb in the

desired position

If the adductor pollicis is paralyzed, as in ulnar nerve palsy,

firm pinch between the pulps of the thumb and the flexed

index and long fingers is impossible

RESTORATION OF ADDUCTION OF THUMB

Transfer of Brachioradialis or radial wrist extensor

– Boyes technique

Transfer of Extensor carpi radialis brevis – Smith

technique

Transfer of Flexor Digitorum Superficialis for

restoration of both adduction & opposition of

thumb -- Royle-Thompson Transfer (Modified)

technique

Tendon transfers for restoration of Adduction of thumb

Transfer of the brachioradialis is preferred. Detach the insertion of the muscle, and carefully free the tendon proximally of all fascial attachments, increasing its excursion

Anchor a tendon graft (plantaris or palmaris longus) to the adductor tubercle of the thumb by a pull-out wire, or suture the graft to the tendon of insertion of the adductor pollicis

Boyes technique

Pass the graft along the adductor muscle belly and through the third interosseous space to the dorsum of the hand

Pass it subcutaneously in a proximal and radial direction, and suture it to the end of the brachioradialis tendon. If a radial wrist extensor is used, pass the tendon graft deep to the extensor digitorum communis tendons, and attach it to the wrist extensor

Boyes technique contd…

The Index is the finger against which the thumb is brought most frequently in pinch. If pinch is to be strong, this finger must be stable enough to provide the necessary resistance to the thumb; flexion, extension, abduction, and a stable metacarpophalangeal joint are required

Tendon transfers restoration of the abduction of index finger:

Transfer of extensor indicis proprius

Transfer of slip of abductor pollicis longus – Neviaser, Wilson & Gardner technique

RESTORATION OF ABDUCTION OF INDEX FINGER

RESTORATION OF INTRINSIC FUNCTION OF FINGERS

Loss of intrinsic muscle function of the fingers may result from paralytic disease or low median and ulnar nerve lesions

With intrinsic paralysis, grasp is diminished 50% or more because of the lack of power of flexion at the MCP joints. In addition, there is asynchronous movement in flexion of the fingers themselves

The roll-up maneuver of the fingers in the intrinsically paralyzed hand shows this characteristic. The interphalangeal joints must flex first, followed next by the metacarpophalangeal joints and ultimately by full flexion of the fingers

Transfer of Flexor digitoum sublimis of ring finger –

Modified bunnell technique

Transfer of ECRL or ECRB – Brand technique

Transfer of Extensor indicis proprius & Extensor digiti

quinti proprius – Fowler

Srinivasan’s Extensor Diversion Graft operation

Capsulodesis – Zancolli technique

Fowler’s Tenodesis

Operations for the restoration of intrinsic function of fingers

When the finger & wrist flexors and extensors are strong, and when there is no habitual flexion of the wrist, the operation of choice to restore the function of the finger intrinsic is the modified Bunnell procedure

When flexing the wrist is habitual or there is a flexion contracture, the Riordan transfer of Flexor carpi radialis to the dorsum of the wrist prolonged by tendon grafts is a good choice

Selection of surgery

When wrist extensors are strong and flexors are weak, the Brand’s transfer prolonged by tendon graft through the carpal tunnel may be indicated

When the FDS or a wrist flexor or extensor is not available, the Fowler technique may be indicated

When no muscle is available for transfer, the Zancolli’s capsulodesis of MCP joints or Fowlers tenodesis or Riordan may be indicated

Selection of surgery contd…

He devised a technique using the extensor carpi radialis brevis tendon lengthened by a free graft from the plantaris tendon

Brand advised transferring the extensor carpi radialis longus or brevis to the volar side of the forearm and extending it by a four-tailed graft through the carpal tunnel and the lumbrical canals and finally to the extensor aponeuroses

Brands transfer

The principle of this procedure is to divert part of the excessive extensor force acting on the MCP joint & causing hyper-extension of the same towards its flexor aspect with the view to stabilize this joint in an acceptable position

This is achieved by the insertion of a free tendon graft, which besides stabilizing the MCP joint, also couples it with proximal IP joint, in such a way that the intrinsic minus disability is also improved

The advantage of this operation is that, it is technically less demanding than brand’s operation and fingers can be individually corrected

Srinivasan’s Extensor Diversion Graft operation

Elliptical segment of volar fibrocartilaginous plate is resected

Suture the volar plate with heavy silk; If desired insert transarticular ‘K’ wires to maintain position of the joints

Zancolli’s capsulodesis

Campbell’s operative orthopedics 11th editionRockwood Green 6th editionGreys Anatomy 39th editionHuman Anatomy by Chourasia 4th ed.Essentials of hand surgery 3rd ed.Netters atlas.

References

Thank you