CLAW HAND

Dr Hakeem N K
 definition
 Hand deformity with hyperextension of MCP jt
and flexion(semiflexion or extn lag) of IP jt due
to weakness of intrinsic muscles of hand.
 Anatomy of ulnar nerve
 Medial cord of brachial plexus
 Supplies FCU, ulnar half of FDP,hypothenar
Mm,medial two lumbricals,interrossei and
adductor pollicis.
 sensory
 MEDIAN NERVE
 In the hand – motor supply
 -- sensory supply
 ETIOLOGY
 1.Acute– nerve injury- ulnar nerve
 (a)distal forearm: MC site
 gun shot wounds,lacerations,#s
and dislocations.
 (b)tardy ulnar nerve palsy
 cubital tunnel syndrome
 (c)neoplasms,Rh
synovitis,aneurysms,thrombosis,anomalous mms
and copression at guyons canal at wrist
 (d)post operative– direct pr
 indirect – prolonged flexion
of elbow esp in pronation
 MEDIAN NERVE:-COMPRESSION
SYNDROMES- m c cause of palsy
 pronator syn,CTS
 lacerations in forearm and wrist
 Traction injury to brachial plexus.
 2.CHRONIC
CAUSE:leprosy,diabetes,poliomyelitis
 Clinical features
 (a) typical posture– claw hand– due to intrinsic
mm paralysis(biarticular bitendinous system)
 -intrinsic zero
 -intrinsic minus
 -intrinsic plus deformities
 (b)when no contractures
 Severity– depends on extend of motor paralysis
 only lumbricals --- no deformity
 Bouvier – Beever phenomenon– long extensors
can extend the IP jt if MCPJ is stabilised in any
position except hyperextn.
 No worsening in the deformity after first year in
the absence of stiffness.
 Guttering– on making a tight fist ext tendon
slides of the summit of MCPJ knuckle.
 Other deformities
 -wasting of thenar and
hypothenar mm ,hollowing of inter MC spaces
on the dorsum due to wasting of
interrosi,deviation of fingers towards ulnar side
when hand fully opened.
 Beaking of nails in long standing cases,flattening
of distal MC arch
 Associated wrist flexion deformity
 Hooding of PIP jt
 Ulnar paradox
 Froment’s sign
 DISABILITIES
 Abd & add of fingers lost
 Loss of power grip
 Weak digito palmar power grip
 Cupping of palm impossible
 Non functional thumb in combined ulnar &
median nr palsy
 -- Martin Gruber anastomosis
 EVALUATION
 1.Degree of deformity
 2.intrinsic minus disability
 3.Integrity of ext apparatus
 4.presence of flexion contractures
 5.Postural capabilities of articular system of
fingers
 6.Presence of other complications
 TREATMENT
 Temporary– splinting
 Permanent– surgery
 SPLINTING:-As a permanent mode if unfit for
surgery or refuses it
 -leprosy – not adviced
 SURGERY:-Aim :- correction of deformity &
improving disability
 deformity-derangement of pattern of extn
of fingers.
 disability-derangement of pattern of flexion
of fingers.
 Hence derangement of opening & closing
paterns should be corrected.
 TYPES OF SURGERY:-
 (A) active-Muscle substitution
procedures by transfer of mus tendon units.
 (B) passive-existing forces rearranged or
new non muscular structures introduced to
redistribute or alter the relationship b/n existing
opposing forces(like changing their moment
arm)
 PROCEDURES
 1. To restrict MCPJ hyper extn:Volar
capsuloplasty & flexor pulley advancement.
 :Dermadesis & flexor pulley
advancement
 :Extensor diversion graft
 : Posterior bone block
 2. INTRINSIC SUBSTITUTION:-
 Volar root procedures: tendon trasfer using
ECRL,FDS,PL
 :tendodeses
 Dorsal root procedures:Brand’s EF4T transfer
of ECRB
 :Fowler-Riordan’s
transfer
 :Riodan’s tenodesis
 3.To provide proper flexor for proximal phalanx
 :Bone insertion procedures(Burkhalter’s)
 :Pulley insertion procedures
 :Direct lasso FDS
 :Indirect lasso procedures
(FDS,ECRL,PL)
 Sequence of operations in combined palsy
 If thumb & fingers affected same sitting in
intrinsic zero or minus or else finger clawing
first & then thumb for effective use of thumb.
 Is radial Nn palsy present wrist should be
stabilised first.
 Two finger correction Vs four finger correction
 Pre operative physiotherapy.
 Post operative care & post operative
physiotherapy
 THANK YOU