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Flashcards in Hand deformities Deck (39):

What is a Intrinsic minus hand?


  • Imbalance between STRONG EXTRINSICS and weak INTRINSICS


What is Intrinsic minus hand characterised by?

  • MCP Hyperextension

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Describe the Aetiology of Intrinisic minus hand?

  • Ulna Nerve Palsy
    • Cubital tunnel syndrome
    • Ulnar tunnel syndrome
  • Median Nerve Palsy
    • Volkmann's iscahemic contracture
    • Leprosy ( Hansen's disease)
    • Failure to splint hand in intrinsic plus hand after crush injury
  • Charcot Marie Tooth ( hereditaty motor-sensory neuropathy)
  • Compartment syndrome of the hand


Can you describe the pathoanatomy of intrinsic minus hand?

  • Loss of intrinsics-> loss of baseline MCP flexion/ IP extension
  • Strong extrinsics= EDC
    • unopposed action-> MCPJ extension
  • Strong FDS/FDP
    • unopposed action->PIPJ/DIPJ flexion

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What are the signs and symptoms of a intrinisc minus hand?


Decreased hand funciton


  • MCPJ hyperextension, DIPJ/PIPJ Flexion
  • in ulna nerve palsy 4/5 digits worse> than 2/3 ( lumbrical innervated by median nerve)
  • Functional weakness- reduced grip/pinch strength
  • unable to do prehensile grasp

Provocative test

If MCPJ taken out of extension-> flexion at DIPJ/PIPJ will correct


What is the tx of Intrinsic Minus hand?


  • Contracture release & Passive tenodesis
  • Active tendon transfer
  • in pts that progressive deformity effecting life
  • Goal is to prevent MCPJ hyperextension



What is an intrinisic plus hand?

Caused by muscle imblance between

  • SPASTIC Intrinsics- Interosseoi and lumbricals
  • Weak extrinsics- FDP/FDS/EDC



What are the characteristics of an intrinsic plus hand?

  • MCP flexion
  • DIPJ/PIPJ Extension

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What is the aetiology of an intrinsic plus hand?

  • Trauma- direct/indirect
  • Vascular injury
  • compartment syndrome
  • RA- mcpj dislocations & ulna deviation->spastic intrinsics
  • neurologic
    • traumatic brain injury
    • cerebral palsy
    • CVA
    • Parkinson's


What is the pathoanatomy of intrinsic plus?

  1. Spastic intrinsics->flexion MCPJ, extension IPJ
  2. EDC Weakness->fails to provide balancing forces
  3. FDP/FDS weakness->fail to provide balancing forces

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What are the signs and symptoms of intrinsic plus hand?


Difficulty gripping large objects- see pic


MCPJ flexion, IPJ extension

BUNNELL test- intrinsic tightness test-

 1) With the MCPJ in extension the intrinsics are put on a stretch. Try to flex the PIPJ with MCPJ in extension. If it doesn't flex = tight intrinsics or joint capsule contracture.

2) With MCPJ in flexion the intrinsics are relaxed. Thus if unable to flex PIPJ= tight capsule.

NB- prior to test check that passive motion of PIPJ is possible (i.e. normal PIPJ)

**so pt will not be able to flex PIPJ/DIPJ when mcp is extended cf flexed if intrinsics are tight




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What are the tx of intrinsic plus hand?

Non operative

Passive stretching- mild cases


  • Proximal muscle slide- where some func of intrinsics remains- spastic
    • Subperiosteal elevation of interossei lengthn muscle-tendon unit
  • Distal intrinsic release- distal to MP for more severe deformity involving MCP/IPJ
    • Resection of intrinsic tendon distal to transverse fibres responsible for MCPJ flexion



What is Boutonniere Deformity?

  • Zone 3 extensor tendon Injury characterised by
  • PIPJ Flexion
  • DIPJ extension


What is the aetiology of Boutonniere Deformity?

  • Rupture of the Central Slip by
    • laceration
    • traumatic avulsion
    • capsulat distension- RA


Describe the pathoanatomy of Boutonniere Deformity?

  • Rupture of central slip- loss of EDC extensor mechanism
  • Attenuation of Triangular ligament ( N prevents lat bands slip volar)-> Lumbricals ( intrinsics) act like flexors at PIPJ,  as unopposed at DIPJ lumbricals-> extend DIPJ
  • Palmar pull of collaterals and lumbricals. lumbricals pull unopposed, pull thru base of distal phalanx and volar to pipj-> PIPJ flexion/DIPJ extensio






Name associated conditions of

Boutonniere Deformity?


  • Rheumatoid arthritis
  • Pseudo- Boutonniere- PIPJ flexion without DIPJ extension


What are the signs of Boutonniere Deformity?

  • Flexion at PIPJ and extension at DIPJ
  • Elson test- weak PIPJ flexion, stiff DIPJ
    • Flex pipj to 90 over table. Ask patient to extend PIPJ.  Try and move dipj if floppy normal. If stiff rupture of central slip as lateral bands are tight and being used to keep PIPj


Describe the types of Boutonniere Deformity?

  • Passively correctible
  • Moderate
  • Stiff Contracture


What are the Tx of Boutonniere Deformity?

Non operative

Splinting in extension for 6 weeks- actute closed injuries <4 weeks- keep dipj moving in splint.further 4-6 part time


  • Primary central band repair- acute displaced avulsion fracture
  • Lateral band relocation/ terminal tendon tenetomy( modified Fowler)/ Tendon Reconstruction- chronic injuries when FROM obtained. Never central slip tenotomy
  • PIPJ Arthrodesis- painful stiff pipj






What is this?

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Jersey Finger

Avulsion injury of Flexor Digitorium Profundus


Can you describe the epidemiology of Jersey finger?


  • Forcefully extension when dipj in max flexion- FDP at max contractility
  • Ring finger involved in 75% cases- ring is 5mm longest in grip cf other digits in 90% patients


What flexor tendon zoneof injury is this?

  • Zone 1
  • distal to insertion of FDS 


What is the Classification of Jersey finger? 

Leddy and Packer

NB green bay Packers

  • Type 1- FDP rupture retraction to palm- asvascular- Prompt surgical tx 7-10 days
  • Type 2- FDP retrracts to PIPJ- attempt repair within several wks for optimium outcome
  • Type 3- Large avulsion fracture- limits retraction to DIPJ -tx attempt repair within several wks for optimium outcome
  • Type 4-Ossoeus fragment and FDP avusion from fragment- Double avusion with retractionof FDP to palm tx fix fracture then attach fdp like type 1


What are the signs  of a Jersey Finger?


  • Tenderness over volar distal finger
  • Finger lies in slight extension cf other fingers in rest position
  • No active flexion of DIPJ
  • Maybe able to palpate flexor tendon in sheath

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What investigations are helpful in Jersey Finger?

Xray - may seen avulsion fracture

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Describe the Tx of Jersey FInger?


  • Direct tendon repair or tendon resinsertion using endobutton (suture grasp tendon dorsally , tie over nail)- in acute injury <3 weeks
    • advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia 

      postoperative rehab should include either

      early patient assisted passive ROM (Duran) or 

      dynamic splint-assisted passive ROM (Kleinert)

  • ​​​ORIF fracture fragment- type 3/4

    • ​use minifrag screw, K wire, exam for symmetrical cascade

  • 2 stage flexor tendon graft- chronic injury >3/12 with from of dipj/pipj

    • silicone free gliding Dacron rod first implanted then a tendon graft with palmaris or plantaris thru the pseudosheath formed by the rod - desrcibed by Hunter and Salisbury 1971

  • DIPJ arthrodesis - salvage procedure




What are the complications of Jersey Finger?

>1cm advancement of FDP risk of DIPJ flexion contracture and  quadrigia


What is the Quadrigia Effect?

  • Is evidence of active flexion lag in fingers adjacent to a digit previously injured or repair of FDP

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What is the aetiology of quadrigia effect?

  • Functional shortening of FDP due to 
    • advancement >1cm of FDP during tendon repair
    • Adhesions
    • Over the top FDP repair post amputation


Describe the Pathoanatomy of the quadrigia effect?

  • The index, middle and rind finger FDP share a common musscle belly
  • So tendon Excursions are defined by the shortest tendon
  • so improper shorteninf of a tendon during repair->inabilty to fully flex adjacent fingers

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Describe the signs and symptoms of quadrigia effect?


  • Inability to fully flex fingers adjacent to injured hand
  • May complain of weak grip


  • Upon making a fist adjacent fingers unable to fully flex
  • Weak grip

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What is the tx of Quadragia effect?

Non operative

Observational - mild symptoms


  • Release FDP of injured digit - severe symptoms limiting function


Define the Lumbricl plus finger?

  • Paradoxial extension at the dipj when trying to flex IPJ


What is the aetiology of lumbrical plus finger?

  • FDP disruption distal to origin of lumbricals ( most common) due to 
    • FDP transection
    • FDP avulsion
  • DIP amputation
  • Amputation thru middle prox shaft
  • Too long tendon graft

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What finger is most commonly affected in intrinsic plus finger?

  • Middle finger- 2nd lumbrical
  • FDP 3,4,5 share common muscle belly can't flex 2 digits without pulling third
  • index finger has independent FDP


What is the pathoanatomy of lumbrical plus finger?

  • Lumbrical originate ftoom FDP

  • with FDP laceration, FDP contraction->  pull on lumbricals 

  • lumbricals pull on lateral bands->PIP and DIP extension of involved digit 

  • with the middle finger, when the FDP is cut distally, the FDP shifts ulnarly (because of the pull of the 3rd lumbrical origin) (bipennate)-> 
     tightening of the middle finger lumbrical (2nd lumbrical, unipennate), and amplifies the "lumbrical plus" effect





Describe the anatomy of the lumbricals?

  • 1st/2nd lumbricals
    • unipennate
    • median nerve supply
    • index/middle finger
    • origin radial side of FDP 2/FDP 3
  • 3/4 Lumbricals
    • bipennate
    • ulnar nerve supply
    • Middle, ring and little finger
    • origin radial side of FDP3/4 (3), FDP4/5 (4)
  • all insert RADIAL side of Extensor expansion

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Describe the symptoms and signs of lumbrical plus effect?


  • Notices that when attempting to grip an object or form a fist, 1 digit sticks out or gets caught on clothes


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What is the TX of lumbrical plus effect?


  • Tenodesis of  FDP to terminal tendon or reinsertion to distal phalanx= FDP lacerations
  • Lumbricals release- fdp retracted/segemental loss difficult to fix- transect at base of flexor sheath in palm-don't do this to lumbricals 1/2 if concurrent ulnar nerve palsy