Claw hand, or intrinsic minus hand, is caused by paralysis of the intrinsic hand muscles due to ulnar nerve injury. This results in hyperextension of the MP joints and flexion of the PIP and DIP joints, impairing hand function. Management involves restoring flexion at the MP joints and extension at the PIP joints through static procedures like capsulotomy or dynamic tendon transfers. Dynamic transfers use expendable donor tendons like the ECRL/ECRB to restore finger flexion and grip strength. Legendary orthopedic surgeon Dr. Paul Brand pioneered many tendon transfer techniques for treating leprosy-related hand deformities and rehabilitating patients.

1. Correction of Claw Hand
DR VIVEK SINGH
DEPARTMENT OF ORTHOPAEDICS
27/10/2017

2. Anatomy
Ulnar Nerve
FCU
FDP to little & ring
fingers
Lumbricals-3/4
Interossei-All
Hypothenar muscles
Adductor Pollicis

6. Hand Functions
 Pinch,
 Grasp,and
 Hook
 Combination

7. Hand Functions-Grasp & Hook
Grasp
Hook

8. Normal Hand Functions
 To be purposeful, motion
must be controlled, and
joints stabilized by
antagonists

9. Normal Hand Function
 In a normal hand, the transition from one stable
position to another is rhythmic
 Groups of muscles act in proper phase and
cooperate with one another- synergistic motion

10. Normal Hand Function
 When a major muscle in the hand is paralyzed the
balance of the hand is disrupted.

12. Claw Hand-Intrinsic Minus Hand
 Loss of Intrinsic function –Lumbricals and interossei
 Hyperextension o f M C P joints
 Flexion o f PIP and D I P joints
 Loss of hand dexterity and strength
 Complete vs incomplete claw

13. Claw Hand-Pathoanatomy
Movements o f M C P joints & IP
joints independent
Movements o f two IP joints
coordinated

14. Biomechanics of finger movements
 Prime extensor of MCP is long
finger extensor
 Prime extensor of IP joint is
Lumbricals and Interossi
 Interossei much stronger than
lumbricals
 Prime flexor of MCP is
Lumbricals and Interossi
 Prime flexor of IPJ is long
finger flexors
Hook making

16. Clawhand-Pathoanatomy
 Without stabilization o f M C P J in slight flexion,
long extensor function “blocked” b y diversion
of this tension to s a g i t t a l band, producing
hyperextension and blocking extensor's ability t o
extend PIPJ

18. LOSS O F GRASP
Paralysis of a d d u c t o r pollicis muscle
Impairment of p r e c i s i o n grip
Loss of normal cascade of finger extension and
flexion

19. Aetiology
 Leprosy in endemic areas
 Trauma to Ulnar nerve
 Compression in cubital tunnel
 Compression in Guyons canal
 Neuropathologies
 Syringomyelia
 CMT
 Poliomyelitis
 MND

20. Clinical Signs
 Bouvier's maneuver -to test
the integrity of the central slip
and the lateral bands of the
extensor expansion

21.  Froment's sign

22.  Wartenberg's sign

23. Management
 Active and passive finger ROM
 Patient compliance
 Grip strength
 Then demonstrate Bouvier's maneuver
 Consider operations that address MPJ hyperextension
 Capsulodesis or tenodesis of the MP joint

24. Management
 If Bouviers not demonstrable
 A static procedure not useful
 A tendon transfer is needed to provide flexion at MPJ
and extension at the PIPJ

25. Static Techniques
 They prevent hyperextension of the MPJ by either shortening
their palmar capsules or tenodeses
 Static procedures avoid the need for tendon transfers
 Do not restore the normal pattern of finger flexion and strength
 Correction may stretch
out over time

26. Palmar Capsulodesis of MCPJ
(Zancolli's Technique)
Zancolli EA:JBone Joint Surg Am 1957

27. Zancolli MCPJ Capsulodesis

28. Zancolli MCPJ Capsulodesis

29. Volar Plate Capsulodesis

30. Riordan Static Tenodesis
Riordan DC:JBJS Am;1953

31. Fowler's Wrist Tenodesis

32. Dynamic Tendon Transfers
Transferring functional muscle-tendon units to restore another by
transferring the working unit to a new location.
Sacrificing an expendable muscle-tendon unit (eg wrist extensor
donor,) so that hand
function remains balanced.
 If grip strength is to be improved
 If the MCP joints need to be
 flexed beyond 40, then significant stretching of
 the PIP extensor mechanism has ensued and
 dynamic tendon transfers to the lateral bands is
 indicated to improve the clawing.
 Condition of soft tissue gliding planes

33. Advantages of Dynamic Transfers
 Correction of the claw deformity
 Improving grip strength,
 Restoration of power pinch
 Restoring the synchronistic flexion of the fingers.

34. Routes of transfer
1.The volar route
Brand (1961) using a wrist extensor and
Bunnell (1942) using a FDS

35. Routes of transfer
2.The dorsal route
Brand (1958)
Transfer though the intermetacarpal spaces
Volar to the deep transverse metacarpal ligaments
Through the lumbrical canals

36. Volar route transfer(Modified Stiles-
Bunnell procedure)
Littler JW.J Bone Joint Surg Am 1949;31:225–34.

37. Dorsal Route Transfer of Extensor
Carpi Radialis Longus or
Brevis(Brand I)

38. Interweave suture

39. Dorsal Route Transfer of
ECRL/ECRB(Brand I)

40. Dorsal Route Transfer of
ECRL/ECRB(Brand I)

44. Volar Route Transfer of
ECRL/ECRB(Brand II)

46. A tribute to Paul Brand
 Legendary Orthopaedic surgeon
 Helped humankind to better understand and treat leprosy
 First physician to appreciate that leprosy did not cause the
rotting away of tissues, but it was the loss of the sensation
of pain which made sufferers susceptible to injury
 Innovated numerous tendon transfers

47.  Born 1914 to British parents in Vellore
 Education & medical training 1923-46 in Britain
 First professor of Orthopaedics & Hand research at CMC Vellore in
1946-1965
 Performed thousands of corrective surgeries on leprotic deformities
 He was awarded the Hunterian professorship of the Royal College of
Surgeons in 1952
 Queen Elizabeth honoured him with a title of the Commander of the
Order of the British Empire in 1961

48. A tribute to Paul Brand
 Rreceived the U.S. Surgeon General's Medal for his
rehabilitation work in Carville, Louisiana.
 His thesis, "Clinical Mechanics of the Hand," is still
regarded as an authoritative reference for hand &
reconstructive surgeons
 Author of 100 scientific papers and six books
 Authored three inspirational books
 Fearfully and Wonderfully Made,
 In His Image
 Pain - The Gift Nobody Wants.
 Died 2003

49.  God designed the human body so that it is able to
survive because of pain-Paul Brand