DIAGNOSIS AND MANAGEMENT

OF
CLAW HAND

Complied by:
Aditya Pratama Saanin

Advised by :
Dr. Donny H. Hamid Sp.S

Clinical Rotation in Neurology Department of RSUD Pasar Rebo

Period of Desember 24th 2018 – January 25th 2019
YARSI UNIVERSITY
 DEFINITON

• occur due to damage to the

ulnar nerve
• hyperextension on MCP joint
+ flexion on IP joint
Mecanism
Brachial Plexus
Ulnar nerve
 Mechanism in claw 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

 • Compression during general anesthesia
• Blunt trauma
• Deformities (eg, rheumatoid arthritis)
• Metabolic derangements (eg, diabetes)
• Transient occlusion of the brachial
artery during surgery Subdermal
ETIOLOGY contraceptive implant
• Venipuncture
• Hemophilia leading to hematomas
• Malnutrition leading to muscle atrophy
and loss of fatty protection across the
elbow and other joints
• Cigarette smoking
 Physical Examination

Range of
Inspection Palpation
motion
 • Wasting of interossei
• Hypothenar wasting
• Brittle nails
• Abnormal sensation on fingers 4 or 5, usually on the
sides of the palm
Clinical • Numbness, decreased sensation
Symptom •
•
Tingling, burning sensation
Hand weakness
• Pain and / or paresthesia such as tingling that
radiates downward from the elbow to the arm until
the ulnar border of the hand
• Loss of hand sensation in the distribution of the ulnar
nerve
• Claw hand deformity that is typical of chronic lesions
 FROMENT SIGN
(First Palmar Interossei
and Adductor Pollicis)

• The patient is asked to grasp a book

between the extended thumb and
the other fingers

Flexor Carpi Ulnaris: When
the wrist joint is flexed
against resistance, the hand
tends to deviate towards
radial side
TEST FOR ULNAR NERVE
Dorsal Interrossei: The
patient is asked to abduct
his fingers against Card test for Palmar Interossei: A card is
resistance 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)
 Management of deformed hands
• 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
 Non-progressive or
Irreparable nerve slowly progressive
damage neurological
Indications
disorders
for tendon
transfer
Loss of function of
a
musculotendinous
unit
 • Modified bunnell technique
• Brand technique
Operations for the • Fowler
• Srinivasan’s Extensor Diversion Graft
restoration of operation
intrinsic function • Zancolli technique
of fingers • Fowler’s Tenodesis
 • He devised a technique using
the extensor carpi radialis
brevis tendon lengthened by
a free graft from the
plantaris tendon

Brands transfer
Srinivasan’s Extensor Diversion Graft operation
• to divert part of the
excessive extensor force
acting on the MCP joint &
causing hyper-extension of
the same towards its flexor
aspect
• 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
Zancolli’s capsulodesis
Thank you