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Claw hand,causes,types,symptoms,management

Dr.MD.Monsur Rahman,PT
MPT-Musculoskeletal Disorders
Maharishi Markandeshwar Institute Of Physiotherapy And Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - Ambala,133-207 (Haryana)

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Claw hand,causes,types,symptoms,management

  1. 1. CLAW HAND Presented By: MD. MONSUR RAHMAN MPT (Musculoskeletal Disorders) MM UNIVERSITY, MULLANA, AMBALA 1
  2. 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. 3. TYPES OF CLAW HAND partial: • Involving only ulnar 2 digits as in isolated ulnar nerve palsy Complete • Involving all digits and resulting form combined ulnar and median nerve palsy 3
  4. 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 4
  5. 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. 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 6
  7. 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. 7
  8. 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. 8
  9. 9. Differential Diagnosis Volkmann's Contracture Intrinsic Muscle Contracture Dupuytren's Contracture Congenital Flexion Contracture (Camptodact yly) Spastic Hand Peripheral Neuropathies 9
  10. 10. Volkmann's contracture: o This deep flexor compartment compression syndrome results in ischemic necrosis of the profundus tendons in the forearm causing flexion contracture of the fingers. o 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. 10
  11. 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. 11
  12. 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 12
  13. 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. 13
  14. 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. 14
  15. 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. 15
  16. 16. MANAGEMENT 16
  17. 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. 17
  18. 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. 18
  19. 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. 19
  20. 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. 20
  21. 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.. 21
  22. 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. 22
  23. 23. THANK YOU 23