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Updated: Feb 27 2022

Intrinsic Plus Hand

Images plus.jpg plus posture.jpg
  • Summary
    • Intrinsic plus hand is a hand posture characterized by MCP flexion with PIP and DIP extension that is caused by an imbalance between spasic intrinsics and weak extrinsic muscles of the hand
    • Diagnosis is made by clinical exam which shows MCP flexion and IP joint extension
    • Treatment may be nonoperative or operative depending on the severity of the contracture and impact on quality of life.
  • Epidemiology
    • Incidence
      • rare
        • < 1 per 100,000 annually
  • Etiology
    • Pathophysiology
      • trauma
        • direct trauma
        • indirect trauma
        • vascular injury
        • compartment syndrome
      • rheumatoid arthritis
        • MCP joint dislocations and ulnar deviation lead to spastic intrinsics
      • neurologic pathology
        • traumatic brain injury
        • cerebral palsy
        • cerebrovascular accident
        • Parkinson's syndrome
    • Pathoanatomy
      • spastic intrinsics
        • leads to flexion of the MCP and extension of the IP joints
      • EDC weakness
        • fails to provide balancing extension force to MCP joint
      • FDS & FDP weakness
        • fail to provide balancing flexion force to PIP and DIP joints
  • Presentation
    • Symptoms
      • difficulty gripping large objects
    • Physical exam
      • inspection
        • MCP joint flexion and IP joint extension
      • provocative tests
        • Bunnell test (intrinsic tightness test)
          • differentiates intrinsic tightness and extrinsic tightness
          • positive test when PIP flexion is less with MCP extension than with MCP flexion
  • Imaging
    • Radiographs
      • no radiographs required in diagnosis or treatment
  • Treatment
    • Nonoperative
      • passive stretching
        • indications
          • mild cases
    • Operative
      • proximal muscle slide
        • indications
          • less severe deformities when there is some remaining function of the intrinsics (e.g., spastic intrinsics)
      • distal intrinsic release (distal to MP)
        • indications
          • more severe deformity involving both MCP and IP joints
          • dysfunctional intrinsic muscles (e.g., fibrotic)
  • Techniques
    • Proximal muscle slide
      • techinque
        • subperiosteal elevation of interossei lengthens muscle-tendon unit
    • Distal intrinsic release
      • technique
        • resection of intrinsic tendon distal to the transverse fibers responsible for MCP joint flexion
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