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claw hand

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Presented By: MD. MONSUR RAHMAN MPT (Musculoskeletal Disorders) MM UNIVERSITY, MULLANA, AMBALA – PowerPoint PPT presentation

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Title: claw hand


1
claw hand
  • Presented By
  • MD. MONSUR RAHMAN
  • MPT (Musculoskeletal Disorders)

  • MM UNIVERSITY, MULLANA, AMBALA

2
Claw Hand
  • Claw hand is an abnormal hand position that
    develops due to a problem with the ulnar nerve
    or, Both ulna and median nerve.
  • A hand in ulnar claw position will have the 4th
    and 5th fingers extended at the
    metacarpophalangeal joints and flexed at the
    interphalangeal joints.
  • The patients with this condition can make a full
    fist(punch) but when they extend their fingers,
    the hand posture is referred to as claw hand..

3
Types of claw hand
  • partial
  • Complete
  • Involving only ulnar 2 digits as in isolated
    ulnar nerve palsy
  • Involving all digits and resulting form combined
    ulnar and median nerve palsy

4
PATHOGENESIS
  • An ulnar claw may follow an ulnar nerve lesion
    which results in the partial or complete
    denervation of the ulnar (medial) two lumbricals
    of the hand.
  • The ulnar nerve also innervates the 3rd and 4th
    lumbricals, which flex the MCP joints, their
    denervation causes these joints to become
    extended by unopposed action of the long finger
    extensors (namely the extensor digitorum and the
    extensor digiti minimi).
  • The lumbricals and interossei also extend the IP
    (interphalangeal) joints of the fingers by
    insertion into the extensor hood their paralysis
    results in weakened extension.
  • The combination of hyperextension at the MCP and
    flexion at the IP joints gives the hand its claw
    like appearance

5
Causes
  • Claw hand can be a congenital defect, a defect
    present at birth
  • Ulnar nerve palsy is due to wrist injury
  • Paralysis of the ulna and median nerves
  • Leprosy still remains the most common cause of
    the claw hand.
  • Risk in gender and BMI, Older males are more
    likely to have ulnar mononeuropathy than females
    without regard to BMI. 95 of females with a BMI
    less than a 22.0 have a higher risk of ulnar
    nerve damage from a lack of adipose cushion.
  • Scarring after a severe burn of the hand or
    forearm.

6
Daily Activities Leading To Ulnar Claw
  • Cyclist, motorcyclist
  • Desk jobs prolong movement, elbow leaning
  • When using a pizza cutter or similar hand tools
  • Applying upper body weight to push down on the
    tool over time can cause damage to the nerve.
  • External compression at the elbow
  • High grip strength, such as string musicians, are
    more susceptible to ulnar mononeuropathy

7
Signs Symptoms
  • Hyperextension of the metacarpophalangeal joints
    and flexion of the interphalangeal joints.
  • Loss of abduction/adduction of the fingers
  • Wasting of the interosseous muscles and
    hypothenar.(Abductor digiti minimi, Flexor digiti
    minimi brevis,Opponens digiti minimi)
  • Little finger remains permanently abducted from
    the ring finger (Wartenberg's sign).
  • There will be numbness in the distribution of the
    involved nerve or nerves.
  • Median nerve thenar muscle paralysis results in
    the simian palm deformity where the thumb
    metacarpal moves dorsally into the plane of the
    finger metacarpals due to the unopposed extension
    of the pollicis longus tendon.

8
Functional Disability
  • Weakness, especially in turning doorknobs, keys
    in locks and taking tops off jars is a common
    complaint due to the lack of abduction/adduction
    of the fingers.
  • Pickup is clumsy especially in the full claw hand
    where the pulps of the fingers cannot be
    presented to the object because of inability to
    fully extend the interphalangeal joints.
  • Thumb pinch grip is also greatly weakened and
    clumsy due to adductor paralysis and the
    collapsing interphalangeal joint converting the
    pulp pinch of the thumb into nail pinch.
  • Thumb disability is further magnified in the full
    claw hand where median innervated thenar muscles
    are also paralysed.
  • Strong power grip of the fingers into the palm,
    however, is retained, except where the long
    flexors are involved in high nerve injuries.
  • Fixed flexion contractures of the proximal
    interphalangeal joints of the clawed fingers can
    develop as a secondary phenomenon due to lack of
    active extension and trophic changes may occur
    due to numbness.

9
Differential Diagnosis
10
Volkmann's contracture
  • This deep flexor compartment compression syndrome
    results in ischemic necrosis of the profundus
    tendons in the forearm causing flexion
    contracture of the fingers.
  • The superficialis tendons are usually spared, but
    the intrinsic tendons may also be contracted.
    This produces flexion of all joints of the
    fingers, rather than hyperextension of the
    metacarpophalangeal joints. The flexor tendons
    are tight.

11
Intrinsic Muscle Contracture
  • This can be of ischaemic origin, due to crush
    injuries and produces the opposite deformity to
    the claw hand, namely tight intrinsic, or
    intrinsic plus hand, rather than the loose
    intrinsic minus claw hand.
  • This condition spontaneously occurs in rheumatoid
    arthritis and may lead to Swan neck deformity.
  • The Bunnell test for intrinsic tightness involves
    passive extension of the metacarpophalangeal
    joint followed by assessment of the passive
    flexibility of the interphalangeal joints.
  • In the normal hand when the metacarpophalangeal
    joint is maximally extended the interphalangeal
    joints can be fully flexed passively.

12
Dupuytren's Contracture
  • Dupuytren's contracture is a condition in which
    one or more fingers become permanently bent in a
    flexed position.
  • It usually begins as small hard nodules just
    under the skin of the palm then worsens over time
    until the fingers can no longer be straightened.
    While typically not painful some aching or
    itching may be present.
  • The ring finger followed by the little and
    middle fingers are most commonly affected. It can
    interfere with preparing food, writing, and other
    activities

13
Congenital Flexion Contracture (CAMPTODACTYLY)
  • This condition usually involves only the little
    finger, it is often bilateral and is hereditary.
    It is present at birth.
  • The finger is flexed at the proximal
    interphalangeal joint and often cannot be
    passively fully straightened.

14
Spastic Hand
  • This results from an upper motor neuron palsy and
    usually involves a clasping deformity of the
    thumb in the palm and tightening of the flexor
    tendons that cannot be easily passively extended.
  • The wrist is also characteristically flexed.

15
Peripheral Neuropathy
  • When a person has damage to the peripheral
    nervous system, this is called peripheral
    neuropathy. Peripheral neuropathy is complex, and
    many diseases, injuries, body chemical
    imbalances, tumors, repetitive motion disorders,
    exposure to toxins, or genetic inheritance can
    cause it.
  • It can also vary in symptoms, severity, and rate
    of cure, depending upon the cause. This damage
    can have a number of symptoms and can include
    numbness, tingling, weakness of the muscles the
    damaged nerves serve, and in some cases severe
    pain.
  • If a nerve is permanently damaged, the muscles it
    serves can gradually die, resulting in movement
    impairment. In some cases, neuropathy can result
    in complete paralysis of the affected areas. On
    the other hand, some conditions cause damage to
    the nerves temporarily. While people with
    affected nerves may experience the above
    conditions on a temporary basis, the nerves are
    able to recover, so the condition is not
    permanent.

16
Management
17
  • Surgical Treatment
  • Nerve repair or decompression where possible is
    the treatment of choice. If the nerves are
    unrepairable or repairs have failed, tendon
    transfers can be considered. Tendon transfers at
    best correct the claw deformity and thumb
    collapse, but do little to restore the functional
    disability of loss of abduction/adduction of the
    fingers or thumb collapse.

18
  • Postoperative management includes-
  • Immobilization of the operated fingers by a
    dorsoulnar forearm plaster cast including the
    metacarpophalangeal joints which are flexed to
    70.
  • After 2 weeks replacement of the cast by a
    thermoplastic splint for another 4 weeks.
  • During the whole period exercises for the finger
    and thumb should be carried out.

19
Hand and Finger Exercises
  • Fist
  • Make a gentle fist with thumb wrapped across the
    fingers and hold it for 30-60 seconds. Then
    release and spread the hands wide. Try to do this
    at least four times with each hand.
  • Stretches
  • Sit ups and press ups may be great for the abs
    but there are also versions that are good for the
    hands. Finger stretches increase the motion of
    your hand and can also help with pain relief.
    Place your hand palm down on a flat surface and
    gently straightened your fingers until they are
    as flat as possible without forcing it. Hold the
    position for 30-60 seconds then release and try
    to do this at least four times per hand.

20
  • Claw
  • Another exercise to help with motion range is the
    claw stretch. Hold out the hand in front of you
    with the palm facing up. Bend over your
    fingertips to touch the base of each finger joint
    hence the claw and hold this for 30-60
    seconds. Release the hand and then repeat at
    least four times.
  • Lift
  • Another fitness exercise mimicked is the finger
    lift. Put your hand palm down on a flat surface
    and lift one finger off the top then lower it.
    Try lifting all of your fingers at once if you
    can. Do this 8-12 times per hand.

21
  • Squeeze The Ball
  • squeeze the ball into palm of the hand as hard
    as you can and hold it there for a few seconds.
    The idea is to do this around 10-15 times per
    session and have around 2-3 sessions a week,
    leaving at least 48 hours between sessions..

22
Prevention
  • Preventive therapy is recommended to preserve the
    function of the fingers. This may include
    physical exercise, stretching, proper bodily
    function and myofascial release (massage, foam
    roller).
  • Exercises are focused on the forearm muscles,
    such as the extensor carpi ulnaris extensor
    digitorum to antagonize the flexion of the
    fingers.
  • Massaging the forearm muscles also alleviates the
    tightness that occurs with muscles exertion.
  • Stretching allows the muscles more flexibility,
    decreasing interference with the innervations of
    the ulnar nerve to the fingers.

23
Thank You
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