Intrinsic contractures of the hand

Intrinsic contracture of the hands in sarcoid myopathy

Hand involvement in sarcoidosis is rare and it presents as tenosynovitis, dactylitis, nodules and osteoarticular bony destruction. We describe an unusual presentation of progressive intrinsic muscle contracture of both hands in a 42-year-old woman with sarcoid myopathy who presented with painful swelling and weakness of all four extremities. Her systemic symptoms improved with oral corticosteroids, but the hand muscle contracture remained after resolution of myositis. Serial soft tissue releases of intrinsic muscle contracture improved hand function markedly. This case highlights that surgery is a viable option to treat intrinsic muscle contracture in patients with chronic sarcoid myopathy complicated with severe muscle contracture.

Finger Metacarpophalangeal Joint Injuries in Athletes: Evaluation, Diagnosis, Treatment, and Return to Play

Metacarpophalangeal (MCP) joint injuries of the fingers are frequent among athletes and can markedly affect an athlete's ability to perform at a high level. Despite this, MCP finger injuries in athletes are not frequently discussed, particularly in comparison with MCP joint injuries of the thumb, and remain unrecognized and undertreated injuries in this cohort. Accurate diagnosis and treatment of these injuries begins with an understanding of all the potential diagnoses. The purpose of this study was to review the pertinent anatomy and differential diagnoses for MCP joint injuries in athletes, including the evaluation and management to allow for safe and early return to play.

Striatal hand deformities in Parkinson's disease ‐ hand surgical perspectives

Background

The knowledge about striatal hand deformities (SHD) in Parkinson's disease (PD), has recently increased but need more attention due to their early impact on dexterity. The focus of clinical studies has been on the staging of SHD severity and neurological features. However, a hand surgical perspective has not been considered.

Objectives

Our purpose was to examine SHD in patients with PD using hand surgical assessment methods and the recommended staging of SHD.

Methods

In this observational study, a specialist in neurological physiotherapy examined 100 consecutive PD patients and identified 35 with suspected SHD, who were then examined by two hand surgeons. Their hands were clinically evaluated for severity of SHD, according to a previous proposed staging, focusing on metacarpophalangeal (MCP) joint flexion, presence of intrinsic and extrinsic tightness, as well as other hand deformities.

Results

Three kinds of deformities were identified among 35 included patients: surgical diagnoses unrelated to PD (n = 5), SHD (n = 23), and PD related hand deformities with increased extrinsic tightness (n = 10); three of these 10 patients had also contralateral SHD, thus are included in SHD group. In addition to previously described MCP joint flexion, swan neck deformity and z‐thumb deformity, we found in most hands finger “clefting,” abduction of the little finger and/or an increased intrinsic tightness, indicating pathology of intrinsic muscles of the hand involved in SHD.

Conclusions

SHD diagnosed with a modified staging method, including features of intrinsic and extrinsic hand deformities, should be considered in PD to implement early and more accurate treatment.

Severe hand contracture treated by external fixation after proximal row carpectomy and awake tenolysis after general anesthesia: A case report

Wide-awake local anesthesia has many advantages. We describe a new method to use wide-awake local anesthesia with more flexibility. A 32-year-old man with a severe right-hand contracture after an iatrogenic tourniquet accident during an anterolateral thigh flap for a partial hand amputation underwent contracture release using external fixation after proximal row carpectomy and subsequent tenolysis. We performed most of the tenolysis procedure under general anesthesia and the final stage with an intraoperative assessment of active finger movement and dissection under local anesthesia. He regained his grip strength 2.5 years post-injury. General anesthesia is useful to treat a surgical site with extensive hard scars, whereas local anesthesia is useful for adjusting tension in an awake patient. The indication for wide-awake surgery is yet to be established; our method of combining general and local anesthesia in the tenolysis procedure illustrates the possibilities in expanding this method.

Ultrasound-guided ethyl alcohol injection to the deep branch of the ulnar nerve to relieve hand spasticity in stroke patients: A case series

Hand spasticity with a flexor pattern is a common problem affecting stroke patients and can result in pain, contractures, esthetic concerns, skin maceration, and overall loss of function. Poststroke (≥6 months) hemiparetic adult patients having a Modified Ashworth Scale (MAS) score of ≥1 for metacarpophalangeal flexion and thumb adduction spasticity were selected to receive an ultrasound-guided 20% ethyl alcohol block performed perineurally at the level of the deep branch of the ulnar nerve. Their MAS scores were evaluated pretreatment at 1 month and the change in MAS scores was assessed using Wilcoxon’s test. The threshold for statistical significance was set at p < 0.05. The mean MAS score for the flexor muscles of the 5 MCP joints and for thumb adduction was reduced from 3.3 ± 0.5 at pretreatment to 0.9 ± 0.5 at 1 month after the injection for the 10 patients. One month after the injection, the MAS scores were significantly reduced compared with those at pretreatment (p < 0.001), without complications. These are encouraging results showing that ultrasound-guided alcohol blocks of the deep branch of the ulnar nerve are safe and can help chronic stroke patients with metacarpophalangeal flexion and thumb adduction spasticity at 1 month.

Intrinsic plus hand: Painful Finger flexion and extension

Intrinsic plus hand describes a rare and painful contracture of the intrinsic hand muscles with excessive flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. Resulting from many causes to include trauma and neurologic injury, intrinsic plus hand can involve any number of fingers. Emergency department (ED) assessment should include evaluation for cerebrovascular injury, infection, compartment syndrome, and deep vein thrombosis (DVT). Conservative splinting is generally unsuccessful and ultimately requires operative intervention. We highlight the case of a 61-year-old otherwise healthy male who awoke to a painful and mildly swollen left hand with his fingers held in a contracted position. Evaluation in the ED found no active range of motion in the digits, severe pain with any passive motion, and a negative upper extremity ultrasound for DVT. Ultimately, orthopedic and neurology consults in the ED agreed upon a diagnosis of intrinsic plus hand.

Percutaneous Release of the Finger Joints and Mini-Open Intrinsic Release With Tenolysis: A Cadaveric Study

PURPOSE

To evaluate the effectiveness and safety of minimally invasive distal intrinsic release and extensor tenolysis combined with percutaneous release of proximal and distal interphalangeal joint collateral ligaments.

METHODS

The procedures were performed on 5 cadaveric upper extremity specimens, followed by a full anatomical dissection to assess completeness of the targeted releases and any damage to surrounding structures.

RESULTS

Complete distal intrinsic release, dorsal capsule release, and distal interphalangeal collateral ligament release was performed on all specimens. We achieved complete release of all proximal interphalangeal joint collateral ligaments in 38 of 40 specimens (95%). We noted damage to nontargeted structures in 2 instances (5%).

CONCLUSIONS

Minimally invasive and percutaneous techniques can effectively release several structures known to cause finger stiffness with minimal damage to surrounding structures.

CLINICAL RELEVANCE

If similar results are seen in clinical trials, this could be a quick and easy way to increase the mobility of a stiff finger with potentially minimal morbidity.

Transcutaneous high-frequency alternating current for rapid reversible muscle force reduction below pain threshold

OBJECTIVE

The development of non-invasive, quickly reversible techniques for controlling undesired muscle force production (e.g. spasticity) could expand rehabilitation approaches in those with pathology by increasing the type and intensity of exercises that can be performed. High-frequency alternating current (HFAC) has been previously established as a viable method for blocking neural conduction in peripheral nerves. However, clinical application of HFAC for nerve conduction block is limited due to the invasiveness of surgical procedures and the painful onset response. This study aimed to examine the use of transcutaneous HFAC (tHFAC) at various stimulation frequencies to address these shortfalls.

APPROACH

Ten individuals participated in the study. Surface electrodes were utilized to apply tHFAC (0.5-12 kHz) to the median and ulnar nerves. Individual pain threshold was determined by gradual increase of stimulation amplitude. Subjects then performed a force-matching task by producing grip forces up to the maximal voluntary contraction level with and without application of tHFAC below the pain threshold.

MAIN RESULTS

Pain threshold current amplitude increased linearly with stimulation frequency. Statistical analysis showed that both stimulation frequency and charge injected per phase had significant effects (p   <  0.05) on grip force reduction. At the group level, application of tHFAC below pain threshold reduced grip force by a maximum of 40.7%  ±  8.1%. Baseline grip force trials interspersed between tHFAC trials showed consistent grip force, indicating that fatigue was not a factor in force reduction.

SIGNIFICANCE

Our results demonstrate the effectiveness of tHFAC at reducing muscle force when applied below the pain threshold, suggesting its potential clinical viability. Future studies are necessary to further elucidate the mechanism of force reduction before clinical application.

Impaired Extension of the Digits due to Bilateral Idiopathic Intrinsic Contracture: A Case Report

Idiopathic intrinsic contracture (IIC) with no history of trauma, ischemia, or spasticity is extremely rare. We report herein a case of impaired extension of the digits due to bilateral IICs occurred in a 30-year-old woman with a past medical history of eating disorder and amenorrhea. Although no previous case has been reported in the literature, eight similar cases of IIC have been presented at Japanese domestic conferences. In these eight cases and the present case, resection of the thenar muscle cords and unilateral resection of the lateral band were effective. Since IIC in patients with an eating disorder is a rare condition, it would be treated conservatively at first as tendon sheath inflammation or locking. However, this condition may be resistant to conservative treatment, and surgical treatment should be considered in such cases.

Etiology, Evaluation, and Management Options for the Stiff Digit

The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient's level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors including joint, intrinsic, extensor, and flexor tendon pathology, and the patient's individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patient's compliance with formal hand therapy and a home exercise program.

Surgical Treatment Guidelines for Digital Deformity Associated With Intrinsic Muscle Spasticity (Intrinsic Plus Foot) in Adults With Cerebral Palsy

Intrinsic plus foot deformity has primarily been associated with cerebral palsy and involves spastic contracture of the intrinsic musculature with resultant toe deformities. Digital deformity is caused by a dynamic imbalance between the intrinsic muscles in the foot and extrinsic muscles in the lower leg. Spastic contracture of the toes frequently involves curling under of the lesser digits or contracture of the hallux into valgus or plantarflexion deformity. Patients often present with associated pressure ulcers, deformed toenails, shoe or brace fitting challenges, and pain with ambulation or transfers. Four different patterns of intrinsic plus foot deformity have been observed by the authors that likely relate to the different patterns of muscle involvement. Case examples are provided of the 4 patterns of intrinsic plus foot deformity observed, including global intrinsic plus lesser toe deformity, isolated intrinsic plus lesser toe deformity, intrinsic plus hallux valgus deformity, and intrinsic plus hallux flexus deformity. These case examples are presented to demonstrate each type of deformity and our approach for surgical management according to the contracture pattern. The surgical approach has typically involved tenotomy, capsulotomy, or isolated joint fusion. The main goals of surgical treatment are to relieve pain and reduce pressure points through digital realignment in an effort to decrease the risk of pressure sores and allow more effective bracing to ultimately improve the patient's mobility.

Intrinsic contracture of the hand: diagnosis and management

Intrinsic contracture of the hand may result from trauma, spasticity, ischemia, rheumatologic disorders, or iatrogenic causes. In severe cases, the hand assumes a posture with hyperflexed metacarpophalangeal joints and hyperextended proximal interphalangeal joints as the contracted interossei and lumbrical muscles deform the natural cascade of the fingers. Considerable disability may result because weakness in grip strength, difficulty with grasping larger objects, and troubles with maintenance of hygiene commonly encumber patients. Generally, the diagnosis is made via history and physical examination, but adjunctive imaging, rheumatologic testing, and electromyography may aid in determining the underlying cause or assessing the severity. Nonsurgical management may be appropriate in mild cases and consists of occupational therapy, orthoses, and botulinum toxin injections. The options for surgical management are diverse and dictated by the cause and severity of contracture.