Updated: 5/18/2021

Intrinsic Plus Hand

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  • Summary
    • Intrinsic Plus Hand is a hand posture characterized by MCP flexion with PIP and DIP extension. caused by imbalance between spastic intrinsics and weak extrinsics 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 instrinsic 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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(OBQ08.238) A 45-year-old carpenter complains of difficult gripping a hammer, which worsens with repeated use. On physical exam, he is able to passively flex the proximal interphalangeal (PIP) joint when the metacarpophalangeal (MCP) joint is flexed but not when the MCP joint is extended. What is the most likely explanation?

QID: 624
1

Quadrigia effect

5%

(212/4107)

2

Extrinsic tightness

13%

(530/4107)

3

Intrinsic tightness

66%

(2709/4107)

4

Central slip rupture

8%

(329/4107)

5

Lumbrical plus

7%

(308/4107)

L 3 B

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Evidence (5)
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EXPERT COMMENTS (16)
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