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.
11.
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
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
15.
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
17.
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
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
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
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
Notas del editor
To be purposeful, motion must be controlled, and joints crossed by moving tendons must be stabilized by balanced antagonistic muscles.
An outstanding example of this stabilization is maintenance of wrist extension by its extensors, which prevent the wrist from being flexed by the strong finger flexors when a fist is made.
Beginning with the wrist flexed and the fingers extended and abducted, the wrist can be extended and the fingers can be flexed, and then the original position can be resumed with ease.
In treating muscle imbalance, the first choice for transfer should be tendons whose muscles are normally synergistic with the weakened or paralyzed ones.
When a major muscle in the hand is paralyzed, in addition to loss of power to perform any particular function for which the muscle is directly responsible, the balance of the hand is disrupted.
Paralysis of the intrinsic metacarpophalangeal joint flexors and intrinsic interphalangeal joint extensors (interossei and lumbricals) leads to unopposed metacarpophalangeal joint extension and interphalangeal joint flexion by the extrinsic digital extensors and flexors. The interphalangeal joints remain flexed even though a strong extensor force is exerted at the metacarpophalangeal joints; without stabilization of the metacarpophalangeal joints in a neutral or slightly flexed position by the intrinsics, the long extensors cannot extend the interphalangeal joints.