Moderator:-

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

Presenter:-
Dr. BAHUBALI. ASKI.
PG in Orthopaedics
 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
 Absence of fingers,
 Congenital Cleft hand,
 Ectrodactyly,
 Lobster claw hand.
 Claw
Hand

Partial Total
 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
 Trauma Causes
 Brachial plexus injury
 Neoplastic Disorders
 Pancoast tumor
 Storage Disorders
 Hurler's mucopolysaccharidosis
 Congenital, Developmental Disorders
 De Lange syndrome
 Acro-Facial dysostosis/Nager type
 Hereditary, Familial, Genetic Disorders
 Lobster claw deformity/split hand
 Curran acrorenal syndrome
 Reference to Organ System
 Brachial plexus neuropathy,Ulnar
neuropathy, ALS, syringomyelia
 Infections
 Leprosy, poliomyelitis
 MCP joint PIP joint DIP joint

Flexion Lumbricals Flexor Flexor

digitorium digitorum
superficialis profundus

Extension Extensor Interossei Interossei

Digitorium
 Flexion Extension Deformity
MCP joint Lumbricals-- Ext. Digitorum-- Hyper-
Paralyzed Active extension of
MCP joint
PIP joint FDS--Active Interossei-- Flexion of PIP
paralysed joint
Low ulnar palsy
FDP--Active Interossei-- Flexion of DIP
DIP joint paralysed joint
High ulnar palsy
FDP--Paralyzed Interossei-- Neutral
paralysed position
 Flexion Extension Deformity

MCP joint Lumbricals- Ext. Hyper-

-Paralyzed Digitorum-- extension
Active of MCP
joint
PIP joint FDS-- Ext. Extension
Paralyzed Digitorum-- of PIP
Active joints
DIP joint FDP-- Ext. Extension
Paralyzed Digitorum-- of DIP
Active joints
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

 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
 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)
 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”
 Thenar wasting

 Simian or ape thumb deformity

 Atrophy of pulp of index finger

 Cracking of nails

 Tropic changes

 Wasting of lateral aspects of forearm

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
 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
 FlexorDigitorum
Superficialis &
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”
 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
 Tinel sign

 Sweat test

 Histamine test

 Skin resistance test

 Electrical stimulation

 Nerve conduction velocity

 Electromyography
 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
 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
 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
 Exercises-physiotherapy
 Splinting:-
-- 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
 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
 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
 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.
 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

 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

 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
 Irreparable
nerve
damage

Non-progressive
Loss of function of
or slowly
a
progressive
musculotendinous
neurological
unit
disorders
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 Campbell’s operative orthopedics 11th
edition
 Rockwood Green 6th edition
 Greys Anatomy 39th edition
 Human Anatomy by Chourasia 4th ed.
 Essentials of hand surgery 3rd ed.
 Netters atlas.