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Updated: May 18 2021

Intrinsic Minus Hand (Claw Hand)

Images image intrinsic minus 460_moved.jpg
  • Summary
    • Intrinsic Minus Hand is a hand deformity characterized by MCP joint hyperextension with PIP joint and DIP joint flexion caused by an imbalance between strong extrinsics and deficient intrinsics.
    • Diagnosis is made by clinical exam which shows MCP hyperextension and IP joint flexion which corrects when the MCP joint is brought out from hyperextension. 
    • Treatment may be nonoperative or operative depending on the severity of the contracture and impact on quality of life.
  • Etiology
    • Pathophysiology
      • ulnar nerve palsy
        • cubital tunnel syndrome
        • ulnar tunnel syndrome
      • median nerve palsy
        • Volkmann's ischemic contracture
        • leprosy (Hansen's disease)
        • failure to splint the hand in an intrinsic-plus posture following a crush injury
      • Charcot-Marie-Tooth disease (hereditary motor-sensory neuropathy)
      • compartment syndrome of the hand
  • Pathoanatomy
    • Pathoanatomic components
      • loss of intrinsics
        • leads to loss of baseline MCP flexion and loss of IP extension
      • strong extrinsic EDC
        • leads to unopposed extension of the MCP joint
        • remember the EDC is not a significant extensor of the PIP joint
          • most of the MCP extension forces on the terminal insertion of the central slip come from the interosseous muscles
      • strong FDP and FDS
        • leads to unopposed flexion of the PIP and DIP
  • Presentation
    • Symptoms
      • decreased hand function
    • Physical exam
      • MCP hyperextension and IP joint flexion
        • with an ulnar nerve palsy, the deformity will be worse in the 4th and 5th digits (lumbricals innervated by the ulnar nerve)
          • not as severe in the 2nd and 3rd digits (lumbricals innervated by the median nerve)
      • functional weakness
        • unable to perform prehensile grasp
        • diminished grip and pinch strength
      • provocative tests
        • if MCP joints are brought out of hyperextension, the flexion deformity of the DIP & PIP will correct
  • Treatment
    • Operative
      • contracture release and passive tenodesis vs. active tendon transfer
        • indications
          • progressive deformity that is affecting quality of life
        • technique
          • goal is to prevent MCP joint hyperextension
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