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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
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