BLUK017-Tjandra September 12, 2005 8:33
Textbook of Surgery
Edited by Joe J. Tjandra, Gordon J.A. Clunie, Andrew H. Kaye & Julian A. Smith
73 Claw hand
Wayne Morrison
Introduction
A common clinical deformity is ‘claw hand’, also
known as the ‘intrinsic minus’ hand. This is charac-
terised by hyperextension of the metacarpophalangeal
joints and flexion of the proximal and distal interpha-
langeal joints. Any functional deformity of this type
results from an imbalance of the actions of the ten-
dons acting in this region. The intrinsic tendons of
the fingers, namely lumbricals and interossei, span the
metacarpophalangeal joints palmar to their axis of ro-
tation and function to flex these joints. The lumbri-
cals act more powerfully than the interossei because
they attach more distally and have a greater moment
of force. Beyond the metacarpophalangeal joints these
tendons continue on as the lateral bands of the ex-
tensor tendons linking with the extensor mechanism
and pass dorsal to the axis of the proximal and dis-
tal interphalangeal joints thus extending these joints.
The interosseous muscles also insert into the bases of
the proximal phalanges, such that the dorsal interossei
abduct the fingers from each other while the palmar in-
terossei adduct. Loss of function of intrinsics leads to
an imbalance of the tensions between the long extrinsic
(extensor and flexors) and the short intrinsic muscles.
The resting tone of the intrinsics is lost leading to unop-
posed long extensors across the metacarpophalangeal
joints and unopposed long flexors across the interpha-
langeal joints, resulting in this characteristic deformity
of the hand.
Causes
Ulnar nerve palsy
In this condition all interossei are paralysed as well
as the ulnar-sided lumbricals, but the median nerve
© 2006 by Blackwell Publishing Ltd
innervated lumbricals to the index and middle fingers
are preserved. As a consequence the clawing is con-
fined to the ring and little fingers and the thumb. The
most common cause of ulnar nerve palsy is wrist lac-
eration. At this level the proximally innervated long
flexors to the ring and little fingers are intact, com-
pared to high ulnar nerve injuries where the long flex-
ors are also paralysed, making finger flexion and the
claw deformity less obvious. Ulnar nerve compression
at the elbow will cause ulnar claw and ulnar sensory
loss. Spontaneous ulnar clawing with no sensory loss
is most likely due to compression of the motor branch
by a ganglion in the region of the piso-hamate joint.
Paralysis of the ulna and median nerves
This produces a full claw hand. This deformity will also
result from C8 and T1 nerve root lesions.
Nerve palsy due to leprosy
On a worldwide basis, leprosy still remains the most
common cause of the claw hand.
Differential diagnosis
Certain conditions mimic the claw hand.
Volkmann’s contracture
This deep flexor compartment compression syndrome
results in ischaemic necrosis of the profundus tendons
in the forearm causing flexion contracture of the fin-
gers. The superficialis tendons are usually spared, but
the intrinsic tendons may also be contracted. This pro-
duces flexion of all joints of the fingers, rather than hy-
perextension of the metacarpophalangeal joints. The
flexor tendons are tight.
641
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642 Problem Solving
Intrinsic muscle contracture
This can be of ischaemic origin, due to crush injuries
and produces the opposite deformity to the claw hand,
namely tight intrinsics, or intrinsic plus hand, rather
than the loose intrinsic minus claw hand. The metacar-
pophalangeal joints are flexed and the interphalangeal
joints extended. This condition spontaneously occurs
in rheumatoid arthritis and may lead to Swan neck
deformity. The Bunnell test for intrinsic tightness in-
volves passive extension of the metacarpophalangeal
joint followed by assessment of the passive flexi-
bility of the interphalangeal joints. In the normal
hand when the metacarpophalangeal joint is maxi-
mally extended the interphalangeal joints can be fully
flexed passively. When the intrinsics are tight and the
metacarpophalangeal joints are stretched into exten-
sion, thereby further tightening the intrinsics, there
will be secondary tightening of the extensor mecha-
nism distally in the fingers, which will limit passive
flexion of the interphalangeal joints. By individually
manipulating the fingers into either ulnar or radial an-
gulation and applying the Bunnell test, tightness of
the radial or ulnar intrinsics can be selectively exam-
ined.
Dupuytren’s contracture
This typically involves the little and ring fingers and can
mimic a claw hand, but the metacarpophalangeal joint
is flexed and the contracted fingers cannot passively
be extended. Palpation of the Dupuytren’s tissue in the
palm confirms the diagnosis.
Congenital flexion contracture (camptodactyly)
This condition usually involves only the little finger, it
is often bilateral and is hereditary. It is present at birth.
The finger is flexed at the proximal interphalangeal
joint and often cannot be passively fully straightened.
Spastic hand
This results from an upper motor neuron palsy and usu-
ally involves a clasping deformity of the thumb in the
palm and tightening of the flexor tendons that cannot
be easily passively extended. The wrist is also charac-
teristically flexed.
Neuropathies
Various muscular dystrophies present as bizarre hand
deformities of an atypical type.
Signs
The classic claw hand involves hyperextension of the
metacarpophalangeal joints and flexion of the inter-
phalangeal joints. The ulnar nerve paralysis results in
ulnar claw, where the clawing is confined to the little
and ring fingers. The high ulnar palsy has less obvious
clawing than the low ulnar palsy.
There is loss of abduction/adduction of the fingers
and wasting of the interosseous muscles, most obvious
in the first web space and the hypothenar eminence.
There will be numbness in the distribution of the
involved nerve or nerves.
Frequently in ulnar paralysis, the little finger remains
permanently abducted from the ring finger (Warten-
berg’s sign). The basis of this deformity is unclear, but
in some way relates to an imbalance between the in-
trinsic muscles either side of the little finger metacar-
pophalangeal joint and the long extensor mechanism.
Median nerve thenar muscle paralysis results in the
‘simian palm’ deformity where the thumb metacarpal
moves dorsally into the plane of the finger metacarpals
due to the unopposed extension of the pollicis longus
tendon. Abduction and opposition of the thumb are
now impossible. Although the claw hand is most ob-
viously a deformity of the fingers, the thumb is inex-
tricably involved and disturbance of thumb function is
frequently the major disability.
Functional disability
Weakness, especially in turning doorknobs, keys in
locks and taking tops off jars is a common complaint
due to the lack of abduction/adduction of the fingers.
Pickup is clumsy especially in the full claw hand where
the pulps of the fingers cannot be presented to the object
because of inability to fully extend the interphalangeal
joints. This results in the nails pushing the object away
during attempts at pick-up. Thumb pinch grip is also
greatly weakened and clumsy due to adductor paraly-
sis and the collapsing interphalangeal joint converting
the pulp pinch of the thumb into nail pinch. Thumb
BLUK017-Tjandra September 12, 2005 8:33
disability is further magnified in the full claw hand
where median innervated thenar muscles are also paral-
ysed. Strong power grip of the fingers into the palm,
however, is retained, except where the long flexors
are involved in high nerve injuries. Fixed flexion con-
tractures of the proximal interphalangeal joints of the
clawed fingers can develop as a secondary phenomenon
due to lack of active extension and trophic changes may
occur due to numbness. Wartenberg’s abducted little
finger is a frequent source of nuisance.
Treatment
Nerve repair or decompression where possible is the
treatment of choice. If the nerves are unrepairable or
repairs have failed, tendon transfers can be considered.
Tendon transfers at best correct the claw deformity and
thumb collapse, but do little to restore the functional
disability of loss of abduction/adduction of the fingers
73: Claw hand 643
or thumb collapse. Various techniques have been de-
scribed. Most have been designed for the management
of the sequelae of leprosy.
If surgical treatment cannot be offered, rehabilitation
with physiotherapy and splintage may help the patient.
MCQs
Select the single correct answer to the following question.
1 The claw hand:
a is sometimes called an intrinsic plus hand
b occurs following a median nerve injury
c results in loss of power grip of the fingers into the
palm
d is more obvious in a proximal, ulnar palsy than a distal
palsy
e includes metacarpophalangeal joint extension of the
involved fingers