Updated: 11/17/2016

Intrinsic Plus Hand

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Introduction
  • Caused by muscles imbalance between spastic intrinsics (interosseoi and lumbricals)
    • weak extrinsics (FDS, FDP, EDC)
  • Characterized by
    • MCP flexion
    • PIP & DIP extension
  • Etiology
    • 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 instrinsic release (distal to MP)
      • indications
        • more severe deformity involving both MCP and IP joints
        • dysfunctional intrinsic muscles (e.g., fibrotic)
Surgical 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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