Referat
Claw and Club Hand
Ribka Theodora – Hand 3
Mentor : dr. Betha Egih Riestiano, SpBP-RE
INTRODUCTION
Intrinsic Minus Hand or Claw Hand is a hand
deformity characterized by MCP joint
hyperextension with PIP joint and DIP joint flexion
Imbalance between strong extrinsics and deficient
intrinsics
Congenital, Trauma, Infection
TYPES
PARTIAL COMPLETE
CLINICAL EXAMINATION : LOOK
AND FEEL
Hyperextension MCP + Flexion IP
Wasting of the interosseus muscle and hypothenar
(Abductor digiti minimi, Flexor digiti minimi brevis, Opponens digiti minimi)
Little finger remains permanently abducted from the ring finger (Wartenberg’s sign)
Simian palm deformity (Flattened palm with extended thumb)
CLINICAL EXAMINATION
LOOK
Anatomy
MOVE
Weakness, especially in turning doorknobs, keys in locks and taking tops off jars is a common complaint due to lack of
abduction/adduction of the fingers
Pickup is clumsy especially in the full claw hand where the pulps of the fingers cannot be presented to the object
because of inability to fully extend the interphalangeal joints
Thumb pinch grip is also greatly weakened and clumsy due to adductor paralysis and the collapsing interphalangeal
joint converting the pulp pinch of the thumb into nail pinch
MOVE
Strong power grip of the fingers into palm, however, is retained, except where the long flexors are involved in high
nerve injuries
Fixed flexion contractures of the proximal interphalangeal joints of the clawed fingers can developed as a secondary
phenomenon due to lack of the active extension and thropic changes may occur due to numbness
Surgery : Static Procedure
• Prevent MCP joint hyperextension or flex the MCP joint so that
the IP joints can be extended and are therefore indicated only if
the Bouvier test is positive.
• These procedures include MCP joint arthrodesis, bone block,
tenodeses, and volar plate capsulodesis.
Capsulodesis
● Flexor tendons
reflected
laterally,
exposing the
volar plate.
● Volar plate
incised and
advanced
proximally.
Tenodesis
● Fig. 12. Schematic Riordan tenodesis. One-
half of ECRL and one-half of ECU are used (A)
and split into a total of 4 tails. Each tail is
then routed volar to the deep transverse
metacarpal ligament and attached to the
lateral band (B). (Reprinted from Riordan DC.
Tendon transplantations in median and
ulnar-nerve paralysis. J Bone Joint Surg Am
1953;35:317; with permission.)
Tenodesis
● Fig. 14. Smith described a sling tenodesis in
which a graft was passed around the deep
transverse metacarpal ligament and sutured
to the lateral bands of adjacent fingers. The
lateral bands are approached through
midaxial incisions on the opposing sides of
the ring and small or middle and index
fingers. A tendon graft is passed proximally
through one of the midaxial incisions and
dorsal to the deep transverse metacarpal
ligament.
Surgery : Dynamic Procedures
Tendon Transfer
• The ring finger flexor digitorum superficialis (FDS) tendon may be
used to correct MCP hyperextension (claw deformity) in patients
with a low ulnar nerve palsy
• Timing of tendon transfers may be classified as early,
conventional or late. A conventional tendon transfer is usually
performe after reinnervation of the paralyzed muscle fails to occur
by three months after the expected time of reinnervation based
on the rate of nerve regeneration of one millimeter per day.
Surgery : Tendon Transfer
• Brand, Omer and Burkhalter have advocated “early” tendon
transfers in certain circumstances, in which a tendon transfer is
performed simultaneously with the nerve repair or before the
expected time of reinnervation of the muscle.
• This “early” tendon transfer therefore serves as a temporary
substitute for the paralyzed muscle until reinnervation occurs, by
acting as an internal splint.
• If reinnervation is sub-optimal the “early” tendon transfer acts as
a helper to augment the power of the muscle and if reinnervation
fails to occur it then acts as a permanent substitute.
Surgery : Tendon Grafts
• Parkes : Tendon graft sutured to the transverse carpal ligament
and passed volar to the deep transverse intermetacarpal
(intervolar plate) ligaments to insert into the radial lateral band of
each finger.
• Fowler : Attached tendon grafts to the radial lateral bands,
passed them volar to the deep transverse intermetacarpal
ligaments, routed them dorsally through the intermetacarpal
spaces, and then attached the grafts to the dorsal carpal
ligament.
Clawing should be treated
proactively with a
lumbrical block splint,
some patients may
benefit from early static
transfers to prevent MCP
hyperextension and
clawing
Postoperative Care and Expected Outcomes
Follow up X-ray
Night splint after 3 months
Postoperative Care and Expected Outcomes
• Recurrence or persistence of the deformity is common
Wrist stiffness and forearm growth impairment
• Cosmetic and functional problem for the adolescent
References
● Kevin C. Chung. Hand Operative Techniques 3rd Ed., 2018
● Green Operative Hand Surgery, 6th ed. 2011
● Nelligan Plastic Surgery, 4th ed. Vol 6. 2018
HATUR NUHUN
