Published Online:1 Nov 1958https://doi.org/10.1302/0301-620X.40B4.618
1. Village life: love and babies mod apk. The intrinsic paralysis that occurs in leprosy has been treated by the sublimis transfer of Stiles and Bunnell for the past nine years. Since 1951 300 hands have been operated upon, and 150 patients selected geographically have been followed up in this study.
The only other thing I have heard or read claw hand called (besides claw hand, and its etiologies) is intrinsic minus hand. But since the 1st and 2nd lumbricals are innervated by the median nerve, only the ring and small finger are involved in a pure ulnar lesion. Clawing is an accepted medical term describing the resulting deformity. Ectrodactyly (also known as a split hand-split foot malformation, cleft hand or lobster claw hand) is a skeletal anomaly predominantly affecting the hands (although the feet can also be affected). The condition has a highly variable severity.
2. The patients have been assessed by a standard method involving: 1) Measurement of range of movement of the interphalangeal joint (unassisted movement, assisted active movement and passive movement); 2) grasp index; and 3) photographs of each hand in six standard positions.
3. Assessment of the open handâThe Stiles-Bunnell procedure is effective in achieving a fully open hand: 73 per cent of the fingers scored good or excellent results. A defect in the operation is that it sometimes hyperextends the interphalangeal joint, producing an 'intrinsic plus' hand.
4. Assessment of sequence of joint flexionâThe Stiles-Bunnell operation restores satisfactory mechanism of closure of the hand in 93 per cent of casesâthat is, the metacarpo-phalangeal joints flex before the interphalangeal joints.
5. The closedfist assessmentâAbout 30 per cent of patients had some defect in the complete closure of the fist after operation. In 5 per cent of cases the fingers did not reach the palm after operation.
6. ComplicationsâThe 'intrinsic plus' defect is commonest in the best and most mobile hands. This is a late complication which gets worse in succeeding years. It can be corrected by Littler's operation together with a profundus tenodesis in the middle segment of the finger. Lateral deviation of fingers due to radial-side attachment of the transferred tendon can be avoided by ulnar-side attachment of the tendon used for the index finger. Bowstringing of the sublimis stump in the flexor sheath may be avoided by division of the sublimis at it insertion. Weakness of grasp and pinch from loss of sublimis may be avoided by using only one or two sublimis tendons split into several strands. The index finger sublimis should be left in position.
7. It is concluded that the sublimis transfer of Stiles and Bunnell is a very powerful corrective of intrinsic paralysis of the fingers. Its chief defect is that it is too powerful and produces the opposite deformity. For this reason the use of this operation should be restricted to fingers in which there is some limitation of passive extension. For fully mobile fingers an operation should be selected which does not remove the sublimis from its normal position.
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IntroductionUlnar nerve palsy can result in loss of sensory and motor function. This can occur after injury to any portion of the ulnar nerve. The ulnar nerve is the terminal branch of the medial cord (C8, T1). The ulnar nerve innervates the flexor carpi ulnaris after it passes through the cubital tunnel.The nerve provides sensation over the medial half of the 4th finger and the entire 5th finger and the ulnar portion of the dorsal aspect of the hand.Other muscles innervated by the ulnar nerve are the flexor digitorum profundus of the ring and small fingers and the following hand muscles:.
The first dorsal interosseousWhen the ulnar nerve is injured, the muscles innervated by the nerve begin to weaken. This leads to an imbalance between the strong extrinsic muscles (i.e., extensor digitorum communis) and the weakened intrinsic muscles (i.e., interossei and lumbricals). This imbalance is characterized clinically by metacarpophalangeal (MCP) hyperextension and proximal interphalangeal (PIP) and distal interphalangeal (DIP) flexion. After carpal tunnel syndrome, entrapment of the ulnar nerve is the second most common neuropathy of the upper extremity.The ulnar nerve can be entrapped at several sites that include the following:. EtiologyCauses of claw hand can also be due to anything that may lead to ulnar nerve palsy. Ulnar nerve palsy can arise from a laceration anywhere along its course. Proximal injuries to the medial cord of the brachial plexus may also present with sensory loss distally.
Ulnar nerve palsies can also be due to cubital tunnel syndrome and ulnar tunnel syndrome. These are compression neuropathies at the elbow and wrist. Another cause of ulnar nerve palsy may be due to a failure to splint the hand in an intrinsic-plus posture following a crush injury. There are a few systemic diseases which may also lead to ulnar nerve palsy. These include leprosy, syringomyelia, and Charcot-Marie-Tooth disease. However, these systemic diseases usually involve more than one nerve.When a claw hand results, it is usually due to paralysis of the lumbricals.
History and PhysicalThe initial presentation will include a decrease in normal hand function.The MCP joints will be hyperextended, and the IP joints flexed.The second and third digits will not be as involved as the fourth and fifth digits with a true ulnar nerve palsy. This is because the median nerve innervates the lumbricals involving the second and third digits, and the ulnar nerve innervates the lumbricals involving the fourth and fifth digits.The patient may also exhibit functional weakness while attempting a grasp, grip or pinch.A provocative test for claw hand is bringing the MCP joints into flexion. This will correct the DIP and PIP joint deformities.Several other specific tests for ulnar nerve palsy include:.
Treatment / ManagementNonoperative management is applied if a fixed flexion contracture of more than 45 degrees occurs at the PIP joint. A strenuous hand therapy program is utilized involving serial casting.Exercises that strengthen the interosseous muscles and lumbricals are recommended. The individual should be taught to exercise each finger and thumb in abduction and adduction motion while the hand is pronated. In addition, the MCP and ICP joints should be exercised and over time the interosseous and lumbricals will gain strength.The majority of cases will need operative management in the form of contracture release and passive tenodesis versus active tendon transfer. This treatment is reserved for those patients with a progressive deformity that is affecting their quality of life. The goal is to prevent lasting MCP joint hyperextension. Postoperative and Rehabilitation CareA very experienced hand therapist plays a vital role in the postoperative care of tendon transfers for ulnar nerve palsy.
Protecting the transfers with custom splints while mobilizing uninvolved joints requires strict adherence to postoperative protocols. Following most procedures, the hand is immobilized for 3 to 4 weeks, followed by a blocking splint to allow movement within the restraints of the splint for the next 3 to 4 weeks. Passive exercises are started at 6 weeks and strengthening at 8 weeks for the adductorplasty and 10 to 12 weeks for the intrinsic tendon transfers.
Enhancing Healthcare Team OutcomesWhen patients present with a claw hand, an interprofessional team that includes a hand surgeon, neurologist, neurosurgeon, physical therapist, emergency department physician, and nurse practitioner should be involved in the diagnosis and management. Because there are several causes of a claw hand the initial referral should be to the neurologist. The treatment depends on the cause and extent of nerve injury.The treatment depends on the acuteness of the condition and severity of the injury. Physical and occupational therapy is necessary for all individuals.Extensive rehabilitation is required and patients should be urged to be compliant with treatment. Other comorbidities like diabetes should be treated and the pharmacist should urge the patient to discontinue smoking and abstain from alcohol. Since many patients do develop anxiety and depression, a consult with a mental health nurse is recommended. The occupational and physical therapists should continue with exercises that strengthen the hand muscles.
Close communication with the team is highly recommended to ensure good outcomes.The prognosis for most patients is guarded.