Hand deformities Flashcards
Intrinsic minus Intrinsic plus Boutonniere Swann neck Mallet finger Jersey finger Quadrigia effect Lumbrical plus (39 cards)
What is a Intrinsic minus hand?
- Imbalance between STRONG EXTRINSICS and weak INTRINSICS
What is Intrinsic minus hand characterised by?
- MCP Hyperextension
- PIPJ and DIPJ FLEXION
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
What are the signs and symptoms of a intrinisc minus hand?
Symptoms
Decreased hand funciton
Signs
- 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?
Operative
- 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
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?
- Spastic intrinsics->flexion MCPJ, extension IPJ
- EDC Weakness->fails to provide balancing forces
- FDP/FDS weakness->f_ail to provide balancing forces_
What are the signs and symptoms of intrinsic plus hand?
Symptoms
Difficulty gripping large objects- see pic
Signs
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
What are the tx of intrinsic plus hand?
Non operative
Passive stretching- mild cases
Operative
-
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. l_umbricals pull unopposed, pull thru base of distal phalanx and volar to pip_j-> 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
Operative
- 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?
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?
Signs
- 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
