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Intrinsic Hand Deformity Treatment & Management

  • Author: Dimitrios Danikas, MD, FACS; Chief Editor: Harris Gellman, MD  more...
 
Updated: Nov 06, 2015
 

Medical Therapy

Intrinsic tightness or contractures should initially be treated conservatively, with hand therapy and splinting to increase the effective range of motion and prevent fixed contractures.[15, 16, 17, 18, 19]

The potential for motor recovery guides treatment for intrinsic palsy. If recovery is anticipated, the hand should be protected with a hand-based intrinsic minus (or anti-claw) splint that prevents full MCP joint extension, thus allowing extrinsic motor units to actively extend the IP joints.[20]

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Surgical Therapy

Surgical therapy is indicated when appropriate hand therapy does not correct the disability.[21, 22, 23]

Opponensplasty

Opponensplasty aims to restore the ability to palmarly abduct the thumb from the palm and oppose against the 4 ulnar digits. Tendon transfers used for opponensplasty are the following: radial slip of the flexor pollicis longus, extensor digiti minimi, palmaris longus or flexor carpi radialis to extensor pollicis brevis, abductor digiti minimi, lexor carpi ulnaris extended with a tendon graft, fourth-finger FDS, and extensor indicis proprius.[24, 25, 26]

One of several commonly used tendon transfers employ FDS of the fourth finger as a motor. The tendon is divided close to its distal insertion and rerouted around the flexor carpi ulnaris tendon at the wrist. A pulley must be created to prevent proximal migration of the transferred tendon, which is passed in a subcutaneous path across the base of the hand to the MCP joint of the thumb, where it is inserted at the radial side of the thumb MCP joint. The transfer restores thumb rotation for a pulp-to-pulp pinch between the thumb and finger pads. The thumb should be immobilized in opposition, with the wrist in neutral position, for 3 weeks with splints. After 3 weeks, all splints are removed and range-of-motion exercises are started.

Palmaris longus opponensplasty (Camitz)

This procedure is performed for loss of thumb abduction and opposition. Camitz transfer provides palmar abduction rather than thumb opposition. A carpal tunnel incision is performed with a distal forearm extension. The distal palmaris longus is dissected free with a strip of palmar fascia attached. The strip of palmar fascia is tubed with sutures. A tunnel is created in the subcutaneous tissues from the distal forearm to the radial aspect of the MCP joint of the thumb. The fascial extension of the tendon is passed through the tunnel and secured to the abductor pollicis brevis tendon. Maximal tension is required with the wrist in neutral position. The thumb should be immobilized in opposition, with the wrist in neutral position, for 3 weeks with splints. After 3 weeks, all splints are removed and range-of-motion exercises are started.[27]

Crossed intrinsic transfer

Crossed intrinsic transfer is indicated for ulnar drift in the rheumatoid hand. When necessary, it can be combined with an arthroplasty. Interossei are released from the ulnar aspect of the second, third and fourth fingers and transferred to the radial side of the adjacent fingers to provide additional radial stability. The second web is incised, and the first volar interosseous is exposed. The first volar interosseous tendon is divided at the middle of the proximal phalanx and dissected free from central and lateral slips. Then the tendon is sutured to the distal attachment of the radial collateral ligament of the MCP joint of the third finger. In the same way, the procedure can be repeated in the third and fourth webs. Abductor digiti quinti and flexor digiti quinti tendons are divided. A dynamic extension splint keeps MCP joints in extension and radial deviation. Active flexion exercises are initiated postoperatively.

Selection of motor units for active transfers

Several classic reconstructions are described above. However, prior to any active transfer, an inventory of the active and paralyzed motor units must be made. Selection of an appropriate motor unit for transfer depends on its dispensability, length, excursion, power, and synergy with other motor units.

Bunnell lateral band tenotomy

This procedure is indicated when intrinsic muscles are not functional. The skin is incised at the level of the MCP joints, and interossei and abductor digiti minimi tendons are resected. If the MCP joint is stiff, the accessory collateral ligaments or the volar plate is released. Then the PIP joints are examined. PIP residual extension contracture requires lateral band tenotomy at the middle of the proximal phalanx. This can be done with a new skin incision or longitudinal extension of the first incision over the MCP joints. MCP joints are held with K-wires in extension for 3 weeks. PIP range-of-motion exercises should be started immediately after the procedure.

Littler distal intrinsic release

The Littler procedure is indicated for intrinsic tightness without significant stiffness of the MCP joint. In this operation, the lateral band tenotomy is performed and the oblique fibers of the extensor hood are excised. A dorsal skin incision from the MCP joint to the PIP joint provides access to the extensor mechanism. Only the oblique fibers of the extensor hood are divided. Lateral bands are divided proximal to the conjoint tendons. MCP joints are maintained at full extension with volar splints for 2 weeks. PIP joints are not splinted, and range-of-motion exercises are started immediately. MCP exercises are started 2 weeks later.

Intrinsic tenodesis

This procedure is indicated for PIP hyperextension caused by contractures. Lateral bands are divided at the proximal one third of the proximal phalanx. Then they are dissected free from the central slip and triangular ligaments until the distal end of the middle phalanx. The lateral bands are placed volar to Cleland's ligament; thus they are rerouted volar to the axis of motion of the PIP joint. The free end of the lateral band is attached to the flexor tendon sheath at the base of the PIP joint or through a drill hole to the neck of the proximal phalanx. In this way the PIP joint is held at 30º of flexion. A PIP dorsal extension splint is placed for 6 weeks and flexion exercises are started immediately after the procedure.

Spiral oblique retinacular ligament (SORL) construction

This technique is indicated for severe swan-neck deformity. A distal intrinsic release is performed. A free tendon graft is secured on the base of the distal phalanx or the terminal extensor tendon. The graft is placed deep to the neurovascular bundle and obliquely across the volar aspect of the flexor tendon sheath proximal to the PIP joint. It is secured into the neck of the proximal phalanx with a tunnel or a pull-out suture technique holding the PIP joint in 30-40º of flexion. An extension block splint is placed for 6 weeks, and the pull-out sutures are removed at 4 weeks. PIP joint active flexion exercises should start immediately.

Interosseous slide

The interosseous slide is indicated for interossei if muscle activity is still present. The dorsal interosseous fascia is incised, and all interossei are subperiosteally dissected free from their origins. The abductor digiti quinti and flexor digitorum brevis tendons are divided. The MCP joints are kept extended and the PIP joints flexed with a splint for 3 weeks. Range-of-motion exercises are then performed.

Lumbrical release

Lumbrical release is indicated for lumbrical muscle contracture. Contracture of the lumbrical muscles places the fingers in an intrinsic-plus position. The diagnostic test is the intrinsic tightness test. The radial lateral band with or without its oblique fibers is resected. Passive and active range-of-motion exercises should be started immediately.

PIP joint arthrodesis with intrinsic muscle release

PIP joint arthrodesis with intrinsic muscle release may be indicated for advanced or complex contractures with joint fibrosis.

Thumb intrinsic slide or excision

Excision may be indicated for fibrotic and nonfunctional adductor pollicis and first dorsal interosseous muscles. The slide procedure is indicated for functional muscles. Both muscles are released from metacarpals. Opponensplasty may be necessary as a result of the underlying condition. The first web space is maintained with Kirschner wires placed between the first and the second metacarpals. This may create an open wound with skin deficit. The defect on the first web space is covered with a skin graft.

Zancolli lasso procedure

This procedure is designed to provide integration of MCP and PIP joint motion. The distal palmar crease in incised with a transverse incision. The FDS is divided and split into 2 slips. Both slips are passed volar through the A1 or A2 pulley and sutured to themselves. MCP joints are held in 20-30º of flexion and PIP joints extended with a cast for 5 weeks. Active range-of-motion exercises are then begun.[28]

Fowler technique

Fowler used the extensor digiti quinti and the extensor indicis proprius for direct transfers to the lateral bands of the extensor mechanism. Intrinsic-plus deformity was common because of excessive tension. In patients in whom the extensor digiti quinti was the only effective little-finger extensor, little finger extension was lost.

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Preoperative Details

Patient education is an integral and important part of the preoperative preparation.

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Postoperative Details

Casts, splints, and dressings should not be tight. The thumb should never be splinted in adduction. Dependent edema can be avoided by raising the hand. Prompt treatment of compartment syndrome with surgical release of all interspaces is done when indicated. Immediate initiation of range-of-motion exercises, when indicated, is a requirement for the best functional outcome.

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Follow-up

For optimal postoperative results patients should follow hand-therapy protocols.

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Future and Controversies

In terms of medicolegal pitfalls, prolonged immobilization in a tight cast or splint can cause intrinsic muscle tightness. Hand compartment syndrome should be treated promptly. The ability to flex PIP joints does not exclude intrinsic contracture. PIP flexion should be evaluated while the MCP joint is extended.

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Contributor Information and Disclosures
Author

Dimitrios Danikas, MD, FACS Attending Plastic Surgeon, Pikeville Medical Center

Dimitrios Danikas, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Academy of Anti-Aging Medicine, Northeastern Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Neumeister, MD, FRCSC, FACS Chairman, Professor, Division of Plastic Surgery, Director of Hand/Microsurgery Fellowship Program, Chief of Microsurgery and Research, Institute of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine

Michael Neumeister, MD, FRCSC, FACS is a member of the following medical societies: American Association for Hand Surgery, American Burn Association, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Canadian Society of Plastic Surgeons, Illinois State Medical Society, Illinois State Medical Society, Ontario Medical Association, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, Society of University Surgeons, American Council of Academic Plastic Surgeons

Disclosure: Nothing to disclose.

Sotirios Papafragkou, MD Chair, Department of Surgery, Hand and Microvascular Surgery, Northern Maine Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

William B Nolan, MD Assistant Professor, Department of Surgery, Division of Plastic Surgery, Cornell University Medical College

William B Nolan, MD is a member of the following medical societies: American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

References
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The intrinsic muscles innervated by the median nerve (abductor pollicis brevis and opponens pollicis) are checked by resisting palmar abduction of the thumb.
Image in a patient with ulnar neuropathy demonstrates the Froment sign during pinching. Loss of the ulnar-innervated adductor pollicis results in reliance on the flexor pollicis longus and exaggerated interphalangeal (IP) joint flexion. Loss of the metacarpophalangeal (MCP) joint flexor leads to MCP hyperextension over time.
The ulnar-innervated intrinsic muscles can be checked by resisting abduction of the index (first dorsal interosseous muscle) and small fingers (abductor digiti quinti muscle).
The gloved examiner checks for intrinsic tightness. With the metacarpophalangeal (MCP) joint hyperextended, the proximal interphalangeal (PIP) joint is passively flexed. The intrinsic muscles are volar to the axis of rotation of the MCP joint and dorsal to the axis of the PIP joint. MCP joint hyperextension tightens the intrinsics. Results of this test are compared with those in the contralateral, normal hand. Note intrinsic atrophy in the first dorsal web space.
Image in a patient with a partial ulnar nerve paralysis is asked to extend the digits. Hyperextension of the metacarpophalangeal (MCP) joints of the ring and small fingers occurs with the loss of intrinsic ulnar-innervated MCP flexors. The index and middle fingers have median innervated intrinsics (lumbricals) that allow the extrinsics to extend the interphalangeal (IP) joints.
When the examiner prevents metacarpophalangeal hyperextension of the ring and fifth fingers, the patient can completely extend the interphalangeal joints with the extrinsic tendons.
Table. Muscles of the Forearm
Muscles of anterior fascial compartment
Name of Muscle Nerve Supply
Pronator teres Median nerve
Flexor carpi radialis Median nerve
Palmaris longus Median nerve
Flexor carpi ulnaris Ulnar nerve
Flexor digitorum superficialis Median nerve
Flexor pollicis longus Anterior interosseous



branch of median nerve



Flexor digitorum profundus Ulnar and median nerves
Median nerve supplies index and middle fingers in 75% of patients. Ulnar nerve supplies middle, ring, and little fingers in 75% of patients (therefore, the middle finger has dual innervation in 75% of patients)
Pronator quadratus Anterior interosseous branch of median nerve
Muscles of lateral fascial compartment
Brachioradialis Radial nerve
Extensor carpi radialis longus Radial nerve
Muscles of posterior fascial compartment
Extensor carpi radialis brevis Deep branch of radial nerve
Extensor digitorum Deep branch of radial Nerve
Extensor digiti minimi Deep branch of radial Nerve
Extensor carpi ulnaris Deep branch of radial Nerve
Anconeus Radial nerve
Supinator Deep branch of radial Nerve
Abductor pollicis longus Deep branch of radial Nerve
Extensor pollicis brevis Deep branch of radial Nerve
Extensor pollicis longus Deep branch of radial Nerve
Extensor indicis Deep branch of radial Nerve
Muscles of the hand lumbricals
Two radial lumbricals Median nerve
Two ulnar lumbricals Ulnar nerve
Interossei Ulnar nerve
Abductor pollicis brevis Median nerve
Flexor pollicis brevis Median nerve
Opponens pollicis Median nerve
Adductor pollicis Ulnar nerve
Abductor digiti minimi Ulnar nerve
Flexor digiti minimi Ulnar nerve
Opponens digiti minimi Ulnar nerve
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