Claw hand

correction of claw hand by Dr Vivek Singh

1. Correction of Claw Hand Dr Vivek Singh Department of Orthopaedics 27/10/2017

2. Anatomy Ulnar Nerve FCU FDP to little & ring fingers Lumbricals-3/4 Interossei -All Hypothenar muscles Adductor Pollicis

3. Hand Functions Pinch , Grasp,and Hook Combination

4. Hand Functions-Grasp & Hook Grasp Hook

5. Normal Hand Functions To be purposeful, motion must be controlled, and joints stabilized by antagonists

6. Normal Hand Function In a normal hand, the transition from one stable position to another is rhythmic G roups of muscles act in proper phase and cooperate with one another- synergistic motion

7. Normal Hand Function When a major muscle in the hand is paralyzed the balance of the hand is disrupted.

8. Claw Hand-Intrinsic Minus Hand Loss of Intrinsic function – Lumbricals and interossei Hyperextension of MCP joints Flexion o f PIP and DIP joints Loss of hand dexterity and strength Complete vs incomplete claw

9. Claw Hand- Pathoanatomy Movements of MCP joints & IP joints independent Movements of two IP joints coordinated

10. Biomechanics of finger movements Prime extensor of MCP is long finger extensor Prime extensor of IP joint is Lumbricals and Interossi Interossei much stronger than lumbricals Prime flexor of MCP is Lumbricals and Interossi Prime flexor of IPJ is long finger flexors Hook making

11. Clawhand-Pathoanatomy Without stabilization of MCPJ in slight flexion , long extensor function “blocked” by diversion of this tension to sagittal band, producing hyperextension and blocking extensor's ability to extend PIP J

12. LOSS OF GRASP Paralysis of adductor pollicis muscle Impairment of precision grip Loss of normal cascade of finger extension and flexion

13. Aetiology Leprosy in endemic areas Trauma to Ulnar nerve Compression in cubital tunnel Compression in Guyons canal Neuropathologies Syringomyelia CMT Poliomyelitis MND

14. Clinical Signs Bouvier's maneuver -to test the integrity of the central slip and the lateral bands of the extensor expansion

15. Froment's sign

16. Wartenberg's sign

17. Management A ctive and passive finger ROM Patient compliance Grip strength Then demonstrate Bouvier's maneuver C onsider operations that address MPJ hyperextension Capsulodesis or tenodesis of the MP joint

18. Management If Bouviers not demonstrable A static procedure not useful A tendon transfer is needed to provide flexion at MPJ and extension at the PIPJ

19. Static Techniques They prevent hyperextension of the MPJ by either shortening their palmar capsules or tenodeses Static procedures avoid the need for tendon transfers Do not restore the normal pattern of finger flexion and strength Correction may stretch o ut over time

20. Palmar Capsulodesis of MCPJ ( Zancolli's Technique) Zancolli EA: J Bone Joint Surg Am 1957

21. Zancolli MCPJ Capsulodesis

22. Zancolli MCPJ Capsulodesis

23. Volar Plate Capsulodesis

24. Riordan Static Tenodesis Riordan DC:JBJS Am;1953

25. Fowler's Wrist Tenodesis

26. Dynamic Tendon Transfers Transferring functional muscle-tendon units to restore another by transferring the working unit to a new location. Sacrificing an expendable muscle-tendon unit ( eg wrist extensor donor, ) so that hand function remains balanced. If grip strength is to be improved If the MCP joints need to be flexed beyond 40, then significant stretching of the PIP extensor mechanism has ensued and dynamic tendon transfers to the lateral bands is indicated to improve the clawing. Condition of soft tissue gliding planes

27. Advantages of Dynamic Transfers Correction of the claw deformity Improving grip strength, Restoration of power pinch Restoring the synchronistic flexion of the fingers.

28. Routes of transfer 1.The volar route Brand (1961) using a wrist extensor and Bunnell (1942) using a FDS

29. Routes of transfer 2.The dorsal route Brand (1958) T ransfer though the intermetacarpal spaces V olar to the deep transverse metacarpal ligaments T hrough the lumbrical canals

30. Volar route transfer(Modified Stiles- Bunnell procedure) Littler JW.J Bone Joint Surg Am 1949;31:225–34.

31. Dorsal Route Transfer of Extensor Carpi Radialis Longus or Brevis (Brand I)

32. Interweave suture

33. Dorsal Route Transfer of ECRL/ECRB(Brand I)

34. Dorsal Route Transfer of ECRL/ECRB(Brand I)

35. Volar Route Transfer of ECRL/ECRB(Brand II)

36. A tribute to Paul Brand Legendary Orthopaedic surgeon Helped humankind to better understand and treat leprosy F irst physician to appreciate that leprosy did not cause the rotting away of tissues, but it was the loss of the sensation of pain which made sufferers susceptible to injury Innovated numerous tendon transfers

37. Born 1914 to British parents in Vellore Education & medical training 1923-46 in Britain First professor of Orthopaedics & Hand research at CMC Vellore in 1946-1965 Performed thousands of corrective surgeries on leprotic deformities He was awarded the Hunterian professorship of the  Royal College of Surgeons in 1952 Queen Elizabeth  honoured him with a title of the  Commander of the Order of the British Empire  in 1961

38. A tribute to Paul Brand R received the U.S. Surgeon General's Medal for his rehabilitation work in Carville, Louisiana . His thesis, "Clinical Mechanics of the Hand," is still regarded as an authoritative reference for hand & reconstructive surgeons  A uthor of 100 scientific papers and six books A uthored three inspirational books Fearfully and Wonderfully Made ,   In His Image Pain - The Gift Nobody Wants . Died 2003

39. God designed the human body so that it is able to survive because of pain-Paul Brand