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Meredith Brauns
Metacarpophalangeal Joint Ulnar Deviation/with MCP Subluxation

Condition Metacarpophalangeal joint ulnar deviation is a condition characterized by the fingers

drifting towards the direction of the ulnar bone and is often accompanied by subluxation
of the MCP joints. Ulnar deviation is often initiated by swollen MCP joints, a common sign
of Rheumatoid Arthritis (RA). RA causes inflammation and damage to the joint capsule and
surrounding ligaments. The progression of ulnar deviation is dependent on the individual’s
intrinsic and extrinsic factors. Intrinsic factors often affecting the progression include
factors like ulnar interossei being stronger than the radial counterparts. Extrinsic factors
include factors like thumb opposition causing a strong force in the ulnar direction against
the index finger. Early signs of the condition include: 1st dorsal interossei weakness, radial
collateral ligaments laxity, intrinsic hand muscle tightness, flexor tendons ulnar
displacement, ulnar deviation when MCP joints and fingers are in extension. Later signs
include volar subluxation, limited MCP joint extension, extensor tendons displaced ulnarly,
hypothenar muscle tightness, wrist radially deviates, extensor carpi ulnaris tendon
dislocates, thumb no longer able to oppose index finger. Assessment of the condition will
be geared towards reducing the hand’s
inflammation and increasing ROM, joint stability,
and hand function. Treatments typically include
various physical agent modalities, therapeutic
exercises, and splinting to help increase
comfortable and safe participation in activities.1
This image indicates what the condition may look
like in the clinic:2

Person Mrs. Smith, a 65 y.o. female, arrived at outpatient therapy on 5/13/2019. She has had
Scenario rheumatoid arthritis for the last 8 years and has experienced long periods of remission and
flair-ups during that time. Her latest flair up has been going on for 4 months and she is now
starting to experience ulnar deviation as a result of her painfully, swollen MCP joints.

The pain and swelling from the RA, and the immobility from the ulnar deviation is severely
interfering with Mrs. Smith’s ability to accomplish her ADL’s and participate in activities
around the home. Mrs. Smith is retired and lives at home with her husband who is also
retired. They share most of the household chores, but Mrs. Smith wants to be able to dress
and groom herself independently and in as little pain as possible. During the spring and
summer, Mrs. Smith enjoys tending to her vegetable garden and going on walks; during the
winter, she enjoys knitting and playing games with her grandchildren. She has sought
occupational therapy services in the past to help manage her RA symptoms but has now
returned when she noticed her fingers beginning to deviate and feared the possibility of
subluxation.

Standard Normal alignment at rest while
Posture standing:
In a standing posture, the resting and
standard alignment of the hand’s
position begins with the forearm and
wrist in a neutral position hanging at
the individual’s side. The hand hangs
anterior to a laterally placed plumb line
along the body. The MCPs, PIPs, and
DIPs all hang in a slightly flexed
position, creating a loose fist. The
thumb hangs slightly abducted with a
small amount of opposition. In this
neutral, resting position, there should
be no pronation and supination at the
forearm and little to no extension,
flexion, or deviation at the wrist.
Abduction at the MCP joints is also not
present.
Skeletal Skeletal Anatomy (primary/secondary):
Imbalance MCP joint ulnar deviation with
subluxation occurs from the
imbalanced pulling of phalangeal
extensors. As the inflammation in the
MCP joints increases, the extensor
tendons begin to deviate towards the
ulnar side, pulling the phalanges in that
direction.
As the extensor tendons deviate off
their fulcrum at the MCP joint and lose
their power, the phalanges will begin to
hang in a more flexed position. If such a
condition goes untreated, the flexor
muscles and tendons will start to
experience contractures, and volar
subluxation may precede or follow
soon after.
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Dynamic Movement:
The MCP joint is formed by the articulation of
the rounded heads on the distal end of the
metacarpal bones and the cavities on the
proximal end of the proximal phalanges. The
movements possible at the MCP joint include
flexion, extension, abduction, adduction, and
circumduction. When the MCP joint is in a flexed
position, abduction is not possible.
Additionally, joints proximal and distal to the
MCP joints in the kinematic chain can affect MCP
motions. When the wrist is in full extension,
distal joints’ (like the MCP, PIP, and DIP)
extension becomes strained as finger flexors are
drawn more tightly and finger extensors are
given more slack. Similarly, wrist flexion can
make MCP flexion difficult as the finger
extensors receive more tension and the finger
flexors receive more slack.
X-ray
From a dorsal view, phalanges begin ulnarly
deviating at the MCP joint at the base of the
proximal phalanx.
The phalangeal motions of adduction and
abduction are oriented around the middle finger
(phalanx #3). So, when ulnar deviation begins to
occur in all the phalanges, phalanx #2 begins to
adduct while phalanges #3-5 abduct. This
deviation would be clearly visible on x-ray
imaging. Additionally, the inflammation from
Rheumatoid Arthritis present at the MCP joints
would most likely be visible as well.
A lateral view of the hand may reveal some volar
subluxation, appearing as if the phalanges are
disconnected at the MCP joint.

Muscle Structures w/ description:
Imbalance Extensor muscles of the
forearm and hand that
lose much of their
contracting power include:
- Extensor digitorum
- Extensor digiti minimi
- Extensor pollicis brevis
- Extensor indicis
- Extensor carpi ulnaris
Interossei muscles that
experience weakening:
- Dorsal interossei (1-4) –
abduct
- Palmar interossei (1-3) –
adduct
3
Progression:
Early Signs:
- 1st dorsal interossei weakness
- Radial collateral ligaments laxity
- Intrinsic hand muscle tightness
- Flexor tendons ulnar displacement
- Ulnar deviation when MCP joints and fingers are in extension
Later Signs:
- Volar subluxation (proximal phalanx partially dislocates and
move towards palmar direction)
- Limited MCP joint extension, leading to flexion contractures
- Extensor tendons displaced ulnarly, making them ineffective
MCP extensors
- Hypothenar muscle tightness
- Wrist radially deviates
- Extensor carpi ulnaris tendon dislocates
- Thumb no longer able to oppose index finger

- The skin overtop the

MCP joints may show
signs of inflammation
which may present as
pain, warmth, redness,
swelling, and tight skin.
Adaptive Shortenings:
As the tendons deviate ulnarly, not only do the bone structures
follow, but the overall strength at the MCP joints decline. The
metacarpal heads which previously supplied convex surfaces and
fulcrum sites for the extensor tendons are no longer able to
stabilize the extensor tendons running through them. As a result
of the ineffective extensors, the wrist and finger flexors will flex
unopposed and lead to potential contractures if unaddressed.

Compensations In the ulnar drift condition, the phalanges’ extensor tendons slip from their regular placement
on the dorsum of the MCP joints. As a result, the normal grip made possible by controlled
flexion and extension motions become limited as the hand begins to experience muscle
imbalances. As the condition worsens, the individual will begin compensating for these lack of
motions. Most of the compensations will occur proximally to the MCP joint at the wrist joint.
Here, individuals may begin overusing their palms and wrists to complete tasks that they
previously used their fingers for. Some examples include using palms instead of a flexed finger
grip to open jars and turn knobs, or using thumb adducted against palm to hold eating
utensils instead of using usual grip. Joints further up the kinematic chain like the elbow may
start experiencing some compensation as well. Tasks such as holding purses and grocery bags
may be delegated to the elbow and forearm as the fingers cannot produce a strong enough
grip. While that method may be a normal way for individuals without the condition to
perform the task, the increased frequency and need to compensate could lead to further
injury for the individual.
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Potentially ADL’s Bathing/Showering
Impaired - Turning the water handle to dispense water
Occupations - Squeezing shampoo and soap out
- Lathering shampoo in hair
Dressing
- Pulling up pants
- Buttoning/snapping/tying pants or shirts
Feeding
- Grasping eating utensil and bringing food to mouth

IADL’s Meal preparation and clean up

- Opening refrigerator door
- Opening jars
- Transferring a pot of water
- Squeezing out washcloth
- Picking up grandchildren

Rest and Sleep Sleep preparation

- Putting on pajamas – gripping hems, zippers, or buttons
- Locking doors
- Turning off lamp light
Sleep participation
- Falling and staying asleep despite pain

Leisure Leisure participation

- Using gardening tools
- Holding knitting needles and yarn
- Picking up puzzle pieces
- Holding smartphone with one hand and using thumb for texting

Social Community and family

Participation - May have difficulty participating in tasks that the family enjoys doing
together; ex) puzzles and crafts

Assessments Impairment- Range of Motion3 – Assess with a goniometer the patient’s UE range of
based motion compared to normal values. Focus especially on ROM at the wrist,
assessments MCP, and IP joints.
Manual Muscle Test3 – Perform MMT on patient’s UE. Again, focus
especially on wrist, MCP, and IP joints. Be aware of patient’s pain and
potentially subluxated fingers.
Fearnley Classification System4 – classifies the extent of ulnar drift
deformity into three stages: (1) voluntarily correctible; (2) passively
correctible; (3) fixed.
(1) At rest, fingers fall into an ulnar drift position but can be corrected
with active repositioning.
(2) Correction in the lateral plane is no longer feasible and subluxation
may start occurring at this stage. Passive correction is still possible.
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(3) The MCP joints are fixed at this point and little to no passive
movement is possible.

Performance- Nine-Hole Peg Test5 – Used to assess finger dexterity of individual through
based timed activity. Would provide insight into the functional impact of
assessments condition.
Box and Blocks Test6 – Assessment would help compare patient’s
performance to norm values. Patient’s difficulty grasping and releasing
blocks will be indicated through slower completion pace.

Self-report Michigan Hands Outcome Questionnaire (MHQ)7 – Questionnaire

outcome assessment that allows patients to evaluate their performance in different
measures scenarios. Can be self-administered and can be useful to track
improvements or declines.
Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)8 –
Provides therapist with information about patient’s functional
performance in everyday activities. Includes 30 items and is simple to
administer.
Arthritis Impact Measurement Scales (AIMS)9 – Assessment composed of
nine scales designed to measure outcomes in arthritis (both rheumatoid
arthritis and osteoarthritis). Would help in guiding treatment goals specific
to arthritic patients.

Therapy Therapeutic Short Term Goal: Interventions:

Interventions Exercises Pt will demonstrate 1. Pt will increase FMC by demonstrating correct
increased tip pinch donning and doffing techniques of custom-made
Type: strength (1.5 lbs) MCP protection orthosis to increase I’nce with
Preparatory and through managing 8 tightening belt around waist.1 (MCP protection
concurrent out of 10 buttons on orthosis is a mobilizing, static orthosis that should be
tasks shirt to increase I’nce worn at least 12 hours a day during functional
with dressing routine. activities.)
(Upgrade: Pt will put on orthosis and tighten belt
demonstrating correct grip.)
(Downgrade: Pt will follow visual aide to correctly
put on orthosis.)

2. To improve FMC for tying shoes, pt will stretch

the lumbricals by actively holding MCP joint in
extension and PIP and DIP joints in flexion. Hold
stretch for 1 minute, 3 reps, daily.1
(Upgrade: Pt will use Theraband to stretch lumbricals
while elbow and wrist are in extension.)
(Downgrade: Pt will stretch lumbricals while wearing
orthosis.)

3. To improve FMC for threading zipper, pt will

stretch interossei by holding the MCP in
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hyperextension and applying a passive stretch to the
PIP joint for 2 minutes, 3 reps, daily.1
(Upgrade: Pt will gently stretch fingers in radial
direction.)
(Downgrade: Pt will hold MCP joint in normal
extension.)

Occupation- Short Term Goal: Interventions:

based Pt will demonstrate 1. Pt will use Dycem to open jar with radially
Interventions protective directed movement, rather than ulnarly directed.1
adaptations by (Upgrade: Pt will use a larger, more resistant jar.)
Type: preparing a simple (Downgrade: Pt will follow visual cue on lid to use
Augmented – meal with modified different hands for opening and closing.)
Pt’s independence for the
participation in use of adaptive 2. Pt will hold cook book with palms, rather than
occupational equipment. fingers.1
activities will be (Upgrade: Pt will hold large cook book.)
adapted to (Downgrade: Pt will load cookbook into book stand.)
prevent
excessive force 3. Pt will use both hands to carry a heavy pot to the
from being stove, holding wrist in active radial deviation.1
applied to MCP (Upgrade: Pt will walk further carrying the pot.)
joints. Pt may (Downgrade: Pt will use lighter pot.)
use adaptive
equipment to
reduce strain on
affected joints
and tendons.
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References

1. Best Practice Recommendations for Management of Ulnar Drift Deformity in Rheumatoid Arthritis. Mary

Pack Arthritis Program. http://mpap.vch.ca/wp-content/uploads/sites/16/2014/08/Best-Practise-

Recommendations-for-Management-of-Ulnar-Drift-Deformity-in-Rheumatoid-Arthritis.pdf. Published

2011.

2. What is Ulnar Deviation? Wrist Supports. https://www.wristsupports.co.uk/blog/what-is-ulnar-

deviation.html. Published August 8, 2017. Accessed July 23, 2019.

3. Dadio G, Nolan J. Clinical Pathways: An Occupational Therapy Assessment for Range of Motion & Manual

Muscle Strength. 1st ed. LWW; 2018.

4. FEARNLEY GR. Ulnar deviation of the fingers. Ann Rheum Dis. 1951;10(2):126–136.

doi:10.1136/ard.10.2.126

5. Nine-Hole Peg Test. Physiopedia. https://www.physio-pedia.com/Nine-Hole_Peg_Test. Accessed June 8,

2019

6. Box and Block Test. Physiopedia. https://www.physio-pedia.com/Box_and_Block_Test. Accessed June 8,

2019.

7. MHQ Michigan Hand Outcomes Questionnaire. MHQ Michigan Hand Outcomes Questionnaire.

http://mhq.lab.medicine.umich.edu/home. Accessed June 8, 2019.

8. Disabilities of the Arm, Shoulder, and Hand Questionnaire. Shirley Ryan Ability Lab - Formerly RIC.

https://www.sralab.org/rehabilitation-measures/disabilities-arm-shoulder-and-hand-questionnaire.

Accessed June 8, 2019.

9. Arthritis Impact Measurement Scales (AIMS/AIMS2). American College of Rheumatology.

https://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Arthritis-

Impact-Measurement-Scales-AIMS. Accessed June 8, 2019.

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