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Intrinsic Plus Hand Treatment & Management

  • Author: Bradon J Wilhelmi, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Jan 21, 2015
 

Medical Therapy

Any injury to the hand can lead to intrinsic contracture.[11] Early recognition is essential. Efforts must be directed at decreasing edema in the injured hand. Limb elevation is crucial, and care must be taken to avoid applying compressive dressings such as Ace wraps or restrictive circular casts. If these conservative measures fail or if the surgeon notices persistent swelling and pitting edema, increasing median nerve hypesthesia, or poor capillary refill, a quantitative measurement of intracompartmental pressure may be obtained.

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Surgical Therapy

Early and acute trauma: interosseus and adductor compartment release

When increased intracompartmental pressures do not respond quickly to conservative measures, the interosseous compartments should be released promptly. Most patients also require release of the adductor pollicis and carpal tunnel. When flexion of the metacarpophalangeal (MCP) joints is limited, Kirschner (K)-wires should be used to fix the MCP joints in 60° of flexion to stretch the collateral ligaments.

Late and mild posttraumatic intrinsic contracture: distal intrinsic release

Patients with mild intrinsic muscle contracture may be able to open and close their fingers normally, but they may have persistent limited flexion at the proximal interphalangeal (PIP) joint several months after an injury to the hand or wrist. These patients often have little to no MCP flexion contracture but limited PIP flexion.

In these instances, the edema of the hand causes the collateral ligaments to swell and tighten. Although the intrinsic contracture is mild, the swollen and tight collateral ligaments resist stretching, and the MCP joints are not pulled into flexion. The results of the intrinsic tightness test are positive. For these patients, distal intrinsic release is recommended. In this procedure, the lateral bands and oblique fibers of the distal third of the proximal phalanges are resected.[12]

Postoperatively, the MCP joints are splinted in extension (neutral) position for 3 weeks. The interphalangeal (IP) joints are ranged in active and passive flexion/extension exercises to avoid relapse of the deformity. Dynamic splinting in the MCP extension splint, otherwise known as the reverse knuckle-bender splint, is useful in this period.

Late posttraumatic intrinsic contracture with MP and PIP joint contractures: muscle slide/release

With more severe ischemic contracture of the interossei and lumbricals, flexion contracture occurs at the MCP joints and extension contracture at the IP joints. With extensive edema of the hand, the contracted interossei overcome the resistance of the tightened collateral ligaments and pull the proximal phalanx into flexion. Secondary changes may include contraction of the volar plate and collateral ligaments of the PIP joints. The results of the intrinsic tightness test are positive, and the deformity of the hand is severe.

Extensive release of the dorsal aponeurosis is necessary to correct severe intrinsic muscle contractures that involve both the MCP and the PIP joints.[13] Muscle slide may be used if the interossei are fibrotic and tight but have retained some contractility. With more severe ischemic damage, the interossei are often necrotic and nonfunctional. Proximal intrinsic release is indicated, and the lateral tendons of all interossei, including the abductor digiti quinti tendon, are resected at the level of the MCP joints.

The volar plate is also freed of any attachments at the base of the proximal phalanx, and the accessory collateral ligaments may be resected at their insertion into the volar plate. K-wires may be inserted obliquely through the MCP joints to maintain them in maximal extension. If passive PIP joint flexion is still incomplete with the MCP joints in extension, the lateral bands are resected at the distal half of the proximal phalanx.

Postoperatively, the MCP joints are kept in extension for about 3 weeks. After this time, the K-wires usually are removed. Passive and active flexion/extension of the PIP joints should begin on the first postoperative day.

Spastic contracture of interossei: muscle slide

Patients with cerebral palsy, central nervous system (CNS) disease, or stroke may have spastic contracture of the interossei causing disability.[14, 15, 16] Often, intrinsic muscle spasticity is masked by extrinsic muscle spasticity and is seen several weeks after release of the extrinsic spasticity. After extrinsic release, the hand assumes the intrinsic plus position owing to its intrinsic contractures. The goal of treatment is not to remove the tightened muscles but to weaken them. This can be accomplished by means of muscle slide.

Muscle slide is accomplished via a dorsal approach to protect the palmar blood supply to the intrinsic muscles. The metacarpal origins of all interossei are released subperiosteally. The tendons of the abductor digiti quinti and the flexor digiti quinti brevis are also usually transected.[17] The MCP joints are then extended and the PIP joints flexed, allowing the muscles to advance distally. The hand is then splinted in this claw position for a period of 3 weeks.

In a single-center retrospective review of 50 patients (54 hands) with CNS lesions and contractures of the wrist and extrinsic finger flexor and forearm pronator muscles, Thevenin-Lemoine et al found that the Page-Scaglietti technique (proximal release of extrinsic flexor and pronator muscles) yielded significant improvements in range of motion and function as evaluated according to the Zancolli and House classifications.[18]

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Outcome and Prognosis

The prognosis for each patient is variable and depends on the severity of the contracture and the underlying cause of the contracture. The surgeon's objective is to restore structure and function to the contracted hand. The ultimate goal is to provide the patient maximal comfort and functional independence.

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Contributor Information and Disclosures
Author

Bradon J Wilhelmi, MD Leonard J Weiner Professor and Chief of Plastic Surgery, Plastic Surgery Residency Program Director, Hiram C Polk Jr Department of Surgery, University of Louisville School of Medicine

Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Society for Reconstructive Microsurgery, Association for Surgical Education, Plastic Surgery Research Council, American Association of Clinical Anatomists, Wound Healing Society, American Society for Aesthetic Plastic Surgery, American Burn Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons

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.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

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

Jessica Nguyen Gillespie, MD Plastic and Reconstructive Surgeon, Franciscan Physician Network

Jessica Nguyen Gillespie, MD is a member of the following medical societies: American Society for Reconstructive Microsurgery, American Society of Plastic and Reconstructive Surgery, Indiana State Medical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References
  1. Jupiter JB, Goldfarb CA, Nagy L, Boyer MI. Posttraumatic reconstruction in the hand. Instr Course Lect. 2007. 56:91-9. [Medline].

  2. Brody GS. Management of stiff metacarpophalangeal and interphalangeal joints. In: McCarthy JG, May JW Jr, Littler JW, eds. Plastic Surgery. Vol 7. The Hand, Part 1. Philadelphia, Pa:. WB Saunders, Co. 1990:4655-4670.

  3. Watson HK, Weinzweig J. Stiff Joints. In: Green DP, ed: Green's Operative Hand Surgery. 4th ed. Philadelphia, Pa:. Churchill Livingstone. 1999:552-562.

  4. Wong JM. Management of stiff hand: an occupational therapy perspective. Hand Surg. 2002 Dec. 7(2):261-9. [Medline].

  5. Revol M, Servant JM. [Paralysis of the intrinsic muscles of the hand]. Chir Main. 2008 Feb. 27(1):1-11. [Medline].

  6. Formsma SA, van der Sluis CK, Dijkstra PU. Effectiveness of a MP-blocking splint and therapy in rheumatoid arthritis: a descriptive pilot study. J Hand Ther. 2008 Oct-Dec. 21(4):347-53. [Medline].

  7. Pitts DG, O'Brien SP. Splinting the hand to enhance motor control and brain plasticity. Top Stroke Rehabil. 2008 Sep-Oct. 15(5):456-67. [Medline].

  8. Bowers WH, Wolf JW, Nehil JL, Bittinger S. The proximal interphalangeal joint volar plate. I. An anatomical and biomechanical study. J Hand Surg [Am]. 1980 Jan. 5(1):79-88. [Medline].

  9. Ling MZ, Kumar VP. Myofascial compartments of the hand in relation to compartment syndrome: a cadaveric study. Plast Reconstr Surg. 2009 Feb. 123(2):613-6. [Medline].

  10. Guyton GP, Shearman CM, Saltzman CL. Compartmental divisions of the hand revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br. 2001 Mar. 83(2):241-4. [Medline].

  11. Paksima N, Besh BR. Intrinsic contractures of the hand. Hand Clin. 2012 Feb. 28(1):81-6. [Medline].

  12. Espiritu MT, Kuxhaus L, Kaufmann RA, Li ZM, Goitz RJ. Quantifying the effect of the distal intrinsic release procedure on proximal interphalangeal joint flexion: a cadaveric study. J Hand Surg [Am]. 2005 Sep. 30(5):1032-8. [Medline].

  13. Lansmeer JMF. The anatomy of the dorsal aponeurosis of the human finger and its functional significance. Anat Rec. 1949. 104:31.

  14. Smith RJ. Surgery of the hand in cerebral palsy. In: Pulvertaft RG, ed. Operative Surgery. The Hand. 3rd ed. London, England:. Butterworth. 1977:215.

  15. Pitts DG, O'Brien SP. Splinting the hand to enhance motor control and brain plasticity. Top Stroke Rehabil. 2008 Sep-Oct. 15(5):456-67. [Medline].

  16. Lannin NA, Cusick A, McCluskey A, Herbert RD. Effects of splinting on wrist contracture after stroke: a randomized controlled trial. Stroke. 2007 Jan. 38(1):111-6. [Medline].

  17. Smith RJ. Intrinsic muscles of the fingers: Function, dysfunction and surgical reconstruction. In: AAOS Instructional Course Lectures. Vol. 24. St. Louis, Mo:. Mosby. 1975:200-220.

  18. Thevenin-Lemoine C, Denormandie P, Schnitzler A, Lautridou C, Allieu Y, Genêt F. Flexor origin slide for contracture of spastic finger flexor muscles: a retrospective study. J Bone Joint Surg Am. 2013 Mar 6. 95(5):446-53. [Medline].

 
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The metacarpal head is uniquely shaped in that it is ovoid in the sagittal plane, and it widens from the dorsal to the volar dimension. The collateral ligaments are eccentrically mounted dorsal to the axis of rotation of the metacarpophalangeal joint. This anatomy causes variable degrees of tightness on the collateral ligaments based on the position of the joint by a camlike effect. When the joint is in extension, the collateral ligaments are lax. In flexion, the collateral ligaments span a greater distance and are tight.
Proximal interphalangeal (PIP) joint collateral ligaments originate close to the axis of rotation, providing a smaller change in length with joint position and providing lateral stability. The PIP joint ranges in only 1 plane, and its trochlear shape also adds to its lateral stability.
Edema is the initial response to any insult to the hand and leads to adverse sequelae. Joint stiffness develops as intra-articular hematoma and fluid accumulate within the synovial space, distending the capsule. Increased fluid content within the articular capsule and collateral ligaments effectively shortens these structures, favoring extension.
With injury, checkreins form at the IP joints. Checkreins are collagenous bands connecting the lateral sides of the proximal volar plate to the assembly lines on the volar lateral surfaces of the phalanx. Assembly lines are the 2 ridges along the volar lateral surfaces of the phalanx to which are attached volar ligamentous structures, such as the flexor sheath, Cleland and Grayson ligaments, and the oblique retinacular ligaments of Landsmeer.
 
 
 
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