Updated: 5/18/2021

Intrinsic Minus Hand (Claw Hand)

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  • 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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Flashcards (1)
Cards
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Questions (2)

(SBQ11UE.1) A 40-year-old male sheet metal worker sustained a crush injury to his hand. His hand was treated in a short arm splint after closed reduction and percutaneous pinning of multiple metacarpal fractures. The patient’s fractures healed uneventfully however, he presented six months later with the deformity shown in Figure A. What pathoanatomic process is responsible for his deformity?

QID: 4236
FIGURES:
1

Volar plate laxity and tethering of the lateral bands at the proximal interphalangeal joints

3%

(135/4979)

2

FDP laceration distal to the origin of the lumbricals

1%

(55/4979)

3

Adhered FDP tendon of the middle finger

1%

(42/4979)

4

Imbalance between spastic intrinsics and weak extrinsics

18%

(908/4979)

5

Imbalance between strong extrinsics and deficient intrinsics

77%

(3814/4979)

L 2 B

Select Answer to see Preferred Response

(OBQ04.33) Extrinsic imbalance from splinting a crushed hand with metacarpophalangeal joint extension causes what characteristic hand deformity?

QID: 94
1

Distal interphalangeal joint extension

3%

(100/3170)

2

Ulnar subluxation of the metacarpophalangeal joints

2%

(76/3170)

3

Proximal interphalangeal joint extension

12%

(394/3170)

4

Proximal interphalangeal joint flexion

72%

(2297/3170)

5

Swan-neck deformity

9%

(288/3170)

L 2 D

Select Answer to see Preferred Response

Evidence (5)
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EXPERT COMMENTS (19)
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