claw hand

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claw hand

• Presented By
• MD. MONSUR RAHMAN
• MPT (Musculoskeletal Disorders)
  
  
• MM UNIVERSITY, MULLANA, AMBALA
  

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Claw Hand

• Claw hand is an abnormal hand position that
  develops due to a problem with the ulnar nerve
  or, Both ulna and median nerve.
• A hand in ulnar claw position will have the 4th
  and 5th fingers extended at the
  metacarpophalangeal joints and flexed at the
  interphalangeal joints.
• The patients with this condition can make a full
  fist(punch) but when they extend their fingers,
  the hand posture is referred to as claw hand..

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Types of claw hand

• partial

• Complete

• Involving only ulnar 2 digits as in isolated
  ulnar nerve palsy

• Involving all digits and resulting form combined
  ulnar and median nerve palsy

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PATHOGENESIS

• An ulnar claw may follow an ulnar nerve lesion
  which results in the partial or complete
  denervation of the ulnar (medial) two lumbricals
  of the hand.
• The ulnar nerve also innervates the 3rd and 4th
  lumbricals, which flex the MCP joints, their
  denervation causes these joints to become
  extended by unopposed action of the long finger
  extensors (namely the extensor digitorum and the
  extensor digiti minimi).
• The lumbricals and interossei also extend the IP
  (interphalangeal) joints of the fingers by
  insertion into the extensor hood their paralysis
  results in weakened extension.
• The combination of hyperextension at the MCP and
  flexion at the IP joints gives the hand its claw
  like appearance

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Causes

• Claw hand can be a congenital defect, a defect
  present at birth
• Ulnar nerve palsy is due to wrist injury
• Paralysis of the ulna and median nerves
• Leprosy still remains the most common cause of
  the claw hand.
• Risk in gender and BMI, Older males are more
  likely to have ulnar mononeuropathy than females
  without regard to BMI. 95 of females with a BMI
  less than a 22.0 have a higher risk of ulnar
  nerve damage from a lack of adipose cushion.
• Scarring after a severe burn of the hand or
  forearm.

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Daily Activities Leading To Ulnar Claw

• Cyclist, motorcyclist
• Desk jobs prolong movement, elbow leaning
• When using a pizza cutter or similar hand tools
• Applying upper body weight to push down on the
  tool over time can cause damage to the nerve.
• External compression at the elbow
• High grip strength, such as string musicians, are
  more susceptible to ulnar mononeuropathy

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Signs Symptoms

• Hyperextension of the metacarpophalangeal joints
  and flexion of the interphalangeal joints.
• Loss of abduction/adduction of the fingers
• Wasting of the interosseous muscles and
  hypothenar.(Abductor digiti minimi, Flexor digiti
  minimi brevis,Opponens digiti minimi)
• Little finger remains permanently abducted from
  the ring finger (Wartenberg's sign).
• There will be numbness in the distribution of the
  involved nerve or nerves.
• Median nerve thenar muscle paralysis results in
  the simian palm deformity where the thumb
  metacarpal moves dorsally into the plane of the
  finger metacarpals due to the unopposed extension
  of the pollicis longus tendon.

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Functional Disability

• Weakness, especially in turning doorknobs, keys
  in locks and taking tops off jars is a common
  complaint due to the 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.
• Thumb disability is further magnified in the full
  claw hand where median innervated thenar muscles
  are also paralysed.
• Strong power grip of the fingers into the 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
  develop as a secondary phenomenon due to lack of
  active extension and trophic changes may occur
  due to numbness.

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Differential Diagnosis
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Volkmann's contracture

• This deep flexor compartment compression syndrome
  results in ischemic necrosis of the profundus
  tendons in the forearm causing flexion
  contracture of the fingers.
• The superficialis tendons are usually spared, but
  the intrinsic tendons may also be contracted.
  This produces flexion of all joints of the
  fingers, rather than hyperextension of the
  metacarpophalangeal joints. The flexor tendons
  are tight.

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Intrinsic Muscle Contracture

• This can be of ischaemic origin, due to crush
  injuries and produces the opposite deformity to
  the claw hand, namely tight intrinsic, or
  intrinsic plus hand, rather than the loose
  intrinsic minus claw hand.
• This condition spontaneously occurs in rheumatoid
  arthritis and may lead to Swan neck deformity.
• The Bunnell test for intrinsic tightness involves
  passive extension of the metacarpophalangeal
  joint followed by assessment of the passive
  flexibility of the interphalangeal joints.
• In the normal hand when the metacarpophalangeal
  joint is maximally extended the interphalangeal
  joints can be fully flexed passively.

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Dupuytren's Contracture

• Dupuytren's contracture is a condition in which
  one or more fingers become permanently bent in a
  flexed position.
• It usually begins as small hard nodules just
  under the skin of the palm then worsens over time
  until the fingers can no longer be straightened.
  While typically not painful some aching or
  itching may be present.
• The ring finger followed by the little and
  middle fingers are most commonly affected. It can
  interfere with preparing food, writing, and other
  activities

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Congenital Flexion Contracture (CAMPTODACTYLY)

• This condition usually involves only the little
  finger, it is often bilateral and is hereditary.
  It is present at birth.
• The finger is flexed at the proximal
  interphalangeal joint and often cannot be
  passively fully straightened.

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Spastic Hand

• This results from an upper motor neuron palsy and
  usually involves a clasping deformity of the
  thumb in the palm and tightening of the flexor
  tendons that cannot be easily passively extended.
  
• The wrist is also characteristically flexed.

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Peripheral Neuropathy

• When a person has damage to the peripheral
  nervous system, this is called peripheral
  neuropathy. Peripheral neuropathy is complex, and
  many diseases, injuries, body chemical
  imbalances, tumors, repetitive motion disorders,
  exposure to toxins, or genetic inheritance can
  cause it.
• It can also vary in symptoms, severity, and rate
  of cure, depending upon the cause. This damage
  can have a number of symptoms and can include
  numbness, tingling, weakness of the muscles the
  damaged nerves serve, and in some cases severe
  pain.
• If a nerve is permanently damaged, the muscles it
  serves can gradually die, resulting in movement
  impairment. In some cases, neuropathy can result
  in complete paralysis of the affected areas. On
  the other hand, some conditions cause damage to
  the nerves temporarily. While people with
  affected nerves may experience the above
  conditions on a temporary basis, the nerves are
  able to recover, so the condition is not
  permanent.

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Management
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• Surgical Treatment
• Nerve repair or decompression where possible is
  the treatment of choice. If the nerves are
  unrepairable or repairs have failed, tendon
  transfers can be considered. Tendon transfers at
  best correct the claw deformity and thumb
  collapse, but do little to restore the functional
  disability of loss of abduction/adduction of the
  fingers or thumb collapse.

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• Postoperative management includes-
• Immobilization of the operated fingers by a
  dorsoulnar forearm plaster cast including the
  metacarpophalangeal joints which are flexed to
  70.
• After 2 weeks replacement of the cast by a
  thermoplastic splint for another 4 weeks.
• During the whole period exercises for the finger
  and thumb should be carried out.

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Hand and Finger Exercises

• Fist
• Make a gentle fist with thumb wrapped across the
  fingers and hold it for 30-60 seconds. Then
  release and spread the hands wide. Try to do this
  at least four times with each hand.
• Stretches
• Sit ups and press ups may be great for the abs
  but there are also versions that are good for the
  hands. Finger stretches increase the motion of
  your hand and can also help with pain relief.
  Place your hand palm down on a flat surface and
  gently straightened your fingers until they are
  as flat as possible without forcing it. Hold the
  position for 30-60 seconds then release and try
  to do this at least four times per hand.

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• Claw
• Another exercise to help with motion range is the
  claw stretch. Hold out the hand in front of you
  with the palm facing up. Bend over your
  fingertips to touch the base of each finger joint
  hence the claw and hold this for 30-60
  seconds. Release the hand and then repeat at
  least four times.
• Lift
• Another fitness exercise mimicked is the finger
  lift. Put your hand palm down on a flat surface
  and lift one finger off the top then lower it.
  Try lifting all of your fingers at once if you
  can. Do this 8-12 times per hand.

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• Squeeze The Ball
• squeeze the ball into palm of the hand as hard
  as you can and hold it there for a few seconds.
  The idea is to do this around 10-15 times per
  session and have around 2-3 sessions a week,
  leaving at least 48 hours between sessions..

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Prevention

• Preventive therapy is recommended to preserve the
  function of the fingers. This may include
  physical exercise, stretching, proper bodily
  function and myofascial release (massage, foam
  roller).
• Exercises are focused on the forearm muscles,
  such as the extensor carpi ulnaris extensor
  digitorum to antagonize the flexion of the
  fingers.
• Massaging the forearm muscles also alleviates the
  tightness that occurs with muscles exertion.
• Stretching allows the muscles more flexibility,
  decreasing interference with the innervations of
  the ulnar nerve to the fingers.

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Thank You