Average Two-point Discrimination Research Articles

TWO-POINT DISCRIMINATION ON THE PALMAR SURFACE OF HANDS IN MBBS STUDENTS: INFLUENCE OF BMI, GENDER AND AVERAGE VALUES

Aim: In our study, we attempted to measure the average two-point discrimination values on the pulp of all distal phalanges and the mid-palmar surface of the hands of Healthy MBBS Students and its inuence on BMI and Gender. Study Population & Methodology: We conducted this experiment using a two-point esthesiometer on 100 healthy 1st MBBS students (Females 52, Males 48) aged between 18-20 years from Guntur Medical College, Andhra Pradesh. Based on the BMI we classied subjects under ve categories as per WHO ASIAN-BMI SCALE. Results: Average two-point threshold value in females for right and left rst distal phalanx 3mm, 2.76mm, for second distal phalanx 1.92mm, 2.38mm, for third distal phalanx 2.69mm, 2.26mm fourth distal phalanx 2.84mm, 2.38mm, fth distal phalanx 3.30mm, 2.84mm, mid palmar surface 6mm, 6.76mm respectively. From our study, the two-point threshold is more for the mid-palmar surface. Two-point discrimination has a positive correlation between the right and left palmar surface of the hand but the relationship between variables is weak in the distal phalanges and moderate in the mid-palmar surface. As per BMI, the Two-point discrimination threshold has a positive correlation in the left rst distal phalanx, right and left fourth distal phalanges, right fth distal phalanx and right mid palmar surface. We see an association between gender and the two-point discrimination threshold in the right and left rst distal phalanx and the remaining areas don't have any association.

Reconstruction of Complex Soft Tissue Defects of the Heel With Versatile Double Skin Paddle Anterolateral Thigh Perforator Flaps: An Innovative Way to Restore Heel Shape.

BackgroundComplex heel defects constitute a significant challenge for plastic surgeons.ObjectivesIn this study, versatilities of free double skin paddle ALT flaps in the reconstruction of complex soft tissue defects of heels were explored.MethodsFrom January 2010 to December 2019, 16 patients (13 male and 3 females) aged 16–74 years underwent double skin paddle ALT flap reconstruction in our department. All the patients had large defects located at the heel, and 5 had a dead space. Underlying structures such as vessels, bones, and tendons were exposed in all cases.ResultsFlap survival rate was 100% after the reconstruction. Eleven double skin paddle ALT flaps and 5 vastus lateralis muscle-chimeric double skin paddle ALT flaps were used. The size of the skin flap ranged from 9.5 × 4.5 cm2 to 22 × 10 cm2, and the size of a muscle segment ranged from 6 × 3 × 1 cm3 to 10 × 3 × 2 cm3. The mean follow-up was 22.6 months (range: 10–81 months). The wounds healed well, providing reliable soft tissue coverage and good heel contour. All the patients ambulated independently during the follow-up period. Most of them regained protective sensation. The average two-point discrimination was 32.7 mm (range: 27–37 mm).ConclusionDouble skin paddle ALT flaps are a feasible option for the reconstruction of complex heel defects, with good functional and aesthetic results. Nonetheless, further studies comparing double skin paddle ALT flaps to other flap techniques are needed.

EP34 Ovarian cancer presenting as primary Sjögren’s syndrome: a rare but important mimic

EP34 Ovarian cancer presenting as primary Sjögren’s syndrome: a rare but important mimic

The Innervated Distally Based First Dorsal Metatarsal Artery Flap with a Wide Pedicle for Reconstruction of a Great Toe Defect.

BackgroundIt is difficult for surgeons to reconstruct soft tissue defects of the great toe. This report aims to evaluate the utility and efficacy of innervated distally based first dorsal metatarsal artery (FDMA) flap with a wide pedicle for reconstruction of soft tissue defects of the great toe.MethodsThis is a retrospective report. Between January 2015 and December 2017, six cases of skin defect of the great toe were reconstructed with an innervated distally based FDMA flap with a wide pedicle. One case was excluded in this report because of chronic pain on the metatarsophalangeal joint due to osteoarthritis before the injury. A total of five cases were evaluated for flap survival and sensory recovery. The sensory recovery was investigated by two-point discrimination and Semmes-Weinstein monofilament tests. The average age of the selected patients was 40 years (range, 36 to 56 years), and the average size of the defect in the toe was 8.3 cm2 (range, 4 to 13.8 cm2). The average follow-up period was 29.4 months (range, 18 to 38 months).ResultsAll patients survived without any complications. The average two-point discrimination test value was 8.0 ± 0.89 mm (range, 7 to 9 mm), and the average value obtained from the Semmes-Weinstein monofilament test was 4.53 ± 0.33 (range, 4.17 to 4.93). The average residual pain score evaluated with a visual analog scale was 1 (range, 0 to 2). Two patients complained of stiffness in the great toe below 30° of total range of motion during the early stages after surgery, but this stiffness gradually improved after rehabilitation. The average range of motion of three patients with a remaining metatarsophalangeal joint after surgery was 80° (range, 70° to 90°). All five cases could walk regularly without any unique footwear at the final follow-up.ConclusionsThe innervated distally based FDMA flap with a wide pedicle could be a good alternative method for repair of soft tissue defects of the great toe.

Is epineurectomy necessary in the surgical management of carpal tunnel syndrome?

In this study, it was aimed to determine whether median nerve epineurectomy is beneficial in the surgical management of carpal tunnel syndrome (CTS). The study enrolled 72 patients including 34 patients without epineurectomy (Group A) and 38 patients with epineurectomy (Group B). Surgery was performed in patients with severe electrodiagnostic CTS findings, CTS duration >1 year and flattening along with hypervascularization in median nerve. All patients were assessed by visual analog scale, two-point discrimination test as well as subjective and objective findings at baseline and on the months 1, 3, and 6 after surgery. The mean age was 58.3 years (42-75 years) in 38 patients who underwent an epineurectomy, whereas it was 61.5 years (41-82 years) in 34 patients who did not have an epineurectomy. The groups were similar with regard to age, gender, duration of symptoms, and preoperative physical findings. Mean visual analog scale (VAS) scores were 1.7 in Group A and 1.8 in Group B. Again, these differences were not significant, on physical examination, the average two-point discrimination in the distribution of the median nerve was 4.9 mm (range: 3-11 mm) in Group A and 5.3 mm (range: 3-10 mm) in Group B. In postoperative evaluations, there was a better improvement in visual analog scale scores, two-point discrimination test and subjective symptoms including dysesthesia, pain and nocturnal pain within first 3 months; however, there was no marked difference in objective and subjective findings on the 6th month. No complication or recurrence was observed. We believe that median nerve epineurectomy is unnecessary in the surgical management of primary CTS since it has no influence on the midterm outcomes.

The use of perforator radial fascial forearm flap in the management of recurrent carpal tunnel syndrome

Background Management of recurrent carpal tunnel syndrome is considered a challenge for hand surgeons. We treated this clinical entity using a novel technique involving pedicled tissue transfer using a perforator-based radial-sided fascial forearm flap. Patients and methods The procedure was performed in six patients, all of whom had undergone previous failed surgery to release the median nerve and a period of initial relief not less than 3 months. Results At an average of 24 months following the procedure, all patients reported symptomatic improvement with complete resolution of night-time symptoms. No patient reported worsening of symptoms postoperatively; however, subjective paresthesias persisted in three of the six patients. Objective assessment revealed complete resolution of Tinel's sign in half of the patients and significant improvement in the other half. The average two-point discrimination improved from 10 mm preoperatively to 6 mm postoperatively, and the average postoperative grip strength improved from 11 to 20 kg. Conclusion The radial perforator-based fascial forearm flap is a useful option in the management of selected patients with recurrent carpal tunnel syndrome.

Sensory recovery following decellularized nerve allograft transplantation for digital nerve repair

This study reported preliminary clinical experience of using decelluarised nerve allograft material for repair of digital nerve defect in five hand injury patients. From October 2009 to July 2010, five patients with traumatic nerve defect were treated with nerve repair using AxoGen® nerve allograft (AxoGen Inc, Alachua, FL) in California Hospital Medical Center. All patients were followed at least for 12 months, and sensory recovery and signs of infection or rejection were documented by a hand therapist. Average two-point discrimination was 6 mm, and average Semmes-Weinstein Monofilaments test was 4.31. No wound infections or signs of rejections were observed at wound site. All patients reported sensory improvement during the follow-up period after operation. It is believed that decellularised nerve allografts may provide a readily available option for repair of segmental nerve defect.

Limb salvage surgery for calcaneal malignancy

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy increasingly possible. However, reconstructions of the calcaneal remain a major surgical challenge because of the rarity and specific anatomy of this condition. we retrospectively reviewed five patients who had primary calcaneal malignancy and underwent total calcanectomy and reconstructions with the distally pedicled osteocutaneous folded fibular flap between 2001 and 2007. The diagnoses included chondrosarcoma in 2, Ewing's sarcoma in 2 and osteosarcoma in 1. Three tumors were classified as stage-II B lesions, one as I A and one as II A. Wide resection margins were achieved in all patients. The patients were followed up for a mean of 50.4 months (range, 32-76 months). Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score. Four patients had no evidence of disease, and lung metastasis was found in one patient who was alive with disease. No local recurrence occurred in this series. At latest evaluation four patients had no evident limp or limitation of daily activities and one patient had mild limp. The average MSTS 93 score and AOFAS score were 83.2% and 86.4% at the last follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. Fibula hypertrophies were seen in three patients. The overall mean time for bone union was 6.2 months. The mean time to full weight-bearing was 8.6 months. The average two-point discrimination was 2.3 cm at the time of final follow-up. Two patients had surgery-related complications including hematoma in 1 and skin margin necrosis in 1. Following the wide resection of calcaneal malignancy, biological reconstruction using distally pedicled osteocutaneous fibular has proven to be a successful limb salvage procedure, offering satisfactory local tumor control and functional restoration of the lower extremity function.

Bilaterally pedicled V-Y advancement flap for fingertip defect reconstruction and long-term outcome

Objective To introduce bilaterally pedicled V-Y advancement flap for fingertip reconstruction and evaluate the long-term outcomes. Methods Bilaterally pedicled V-Y advancement flap was performed in 39 patients(39 digits)who had fingertip defects of no more than 1.2 cm2 in size.Postoperatively the appearance of the pulp,gripping,joint movement,sweating and sensation were evaluated.Results All the flaps survived.The finger contour,perspiring,prehension and range of motion,which were evaluated at one year postoperative follow-up,were satisfactory.Pain sensation was recovered in all 39 patients.Impaired touch sensation was noted in 7.7%of the cases,46.1%of the Cases achieyed normal two-point discrimination,and 92.3%achieyed good stcrcognosis. Conclusion The bilaterally pedicled V-Y advancement flap is a simple and practical procedure for fingertip reconstruction,which can achieve good cosmetic and functional results. Key words: Treatment outcome; Surgical flaps; Finser injuries

First dorsal metacarpal artery islanded flap: A useful flap for reconstruction of thumb pulp defects

ABSTRACTThumb pulp defects are commonly due to avulsion injuries. It is very important to reconstruct these defects using sensate flaps as the thumb pulp needs to be sensate for implementing the various functions of the thumb. A very good option for coverage of these defects is the islanded first dorsal metacarpal artery flap. Our study was done over a period of 2 years and involved 9 consecutive cases of thumb pulp defects treated at our institution. The patients included 8 males and 1 female, ranging in age from 16 to 51 years old. The flap size ranged from 2 × 1.5 cm to 5 × 3 cm. We had only one complication in the form of partial flap necrosis, which fortunately healed following debridement without the need for a secondary procedure. All our cases were done under local anesthesia with tourniquet control. All the patients had good fine touch and average two-point discrimination of 6 mm, which was satisfactory. Our good results further reinforce the islanded first dorsal metacarpal artery flap as one the best flaps for sensate reconstruction of thumb pulp defects. It replaces the soft tissue loss at the thumb pulp with minimal donor site morbidity and with good return of thumb pulp sensation.

First dorsal metacarpal artery islanded flap: A useful flap for reconstruction of thumb pulp defects

Thumb pulp defects are commonly due to avulsion injuries. It is very important to reconstruct these defects using sensate flaps as the thumb pulp needs to be sensate for implementing the various functions of the thumb. A very good option for coverage of these defects is the islanded first dorsal metacarpal artery flap. Our study was done over a period of 2 years and involved 9 consecutive cases of thumb pulp defects treated at our institution. The patients included 8 males and 1 female, ranging in age from 16 to 51 years old. The flap size ranged from 2 × 1.5 cm to 5 × 3 cm. We had only one complication in the form of partial flap necrosis, which fortunately healed following debridement without the need for a secondary procedure. All our cases were done under local anesthesia with tourniquet control. All the patients had good fine touch and average two-point discrimination of 6 mm, which was satisfactory. Our good results further reinforce the islanded first dorsal metacarpal artery flap as one the best flaps for sensate reconstruction of thumb pulp defects. It replaces the soft tissue loss at the thumb pulp with minimal donor site morbidity and with good return of thumb pulp sensation.

Anatomic study and clinical application of neuromyocutaneous flap based on nutritional vessel of median nerve palmar cutaneous branch

Objective To investigate the anatomical features of neuromyocutaneous flap based on nutritional vessel of median nerve palmar cutaneous branch and evaluate the clinical application of this flap for repairing soft tissue defect of the thumb. Methods Thirty adult cadaver hand specimens were dissected after red Latex perfusion. The configuration, branches, and distributions of the nutritional vessel of median nerve palmar cutaneous branch and its anastomoses with thenar musole vessels were observed. Since February 2007, neuromyocutaneous flap distally based on the nutritional vessel of median nerve palmar cutaneous branch was transferred to repair soft tissue defect of 17 thumbs. Results Superficial palmar branch of the radial artery gives out 3-5 myocutaneous perforators to abductor pollicis brevis and flexor pollicis brevis. Those perforators form the nutrient vessel chain of palmar cutaneous branch of the median nerve. The external diameter of the perforators was (0.3±0.1 )mm on average. It is accompanied by one. vein. All of the 17 cases of neuromyocutaneous flap survived. The function and appearance of the thumbs were good. One week after the surgery, the average two-point discrimination at thumb pulp resurfaced by the flaps was (6.1-8.2) ram in 11 cases. Conclusion There exists anastomosis between the nutritional vessel chain of median nerve palmar cutaneous branch and the perforators of abductor pollicis brevis and flexor pollicis brevis. The neuromyocutaneous flap is a good option to repair soft tissue defect of the thumb. Key words: Surgical flaps; Median nerve; Thumb; Anatomy,regional

Guides Case Exercise: Carpal Tunnel Syndrome

Abstract Case exercises are an effective way to increase one's understanding of the appropriate application of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Following is one of more than seventy cases that are included in the new edition of The Guides Casebook. This case illustrates the process of assessing impairment for carpal tunnel syndrome using the fourth, fifth, and sixth editions. In this case, a 45-year-old woman who packed boxes on an assembly line developed insidious onset numbness and tingling in her right, dominant hand. A nerve conduction study was consistent with a sensory conduction delay, and she underwent a carpal tunnel release. Physical examination revealed normal monofilament testing and normal two-point discrimination (5 mm) in all digits, and focal muscle testing results were normal, without atrophy. According to an assessment using the fourth edition, 0% whole person impairment was given because no objective evidence showed ongoing sensory or motor deficits. According to the AMA Guides, Fifth Edition, the patient would receive a 1% whole person impairment because in the past the diagnosis of carpal tunnel syndrome was confirmed by electrophysiological studies. Use of the sixth edition yields 1% whole person impairment on the basis of the patient's QuickDASH score of 0 and, providing her with the benefit of the doubt, one would assign the lowest impairment for grade modifier 1, ie, 1% whole person impairment.

Klinische Ergebnisse von End-zu-Seit-Nervennähten

In end-to-side-neurorrhaphy the collateral sprouting of axons has been proven in many animal studies. It has not yet been determined if a satisfactory sensory recovery occurs. Unfortunately, there is still a lack of well documented clinical studies. We have used end-to-side nerve sutures in five patients. Four of them showed gaps in digital nerves, the fifth patient had a partial transsection of the superficial branch of the radial nerve. At the time of follow-up examination, surgery had been performed an average of 21 months previously (11 - 39 months). We examined sensibility, temperature perception, patient satisfaction and the presence of pain and neuroma. Two of the patients with injured digital nerves reached an almost normal two-point discrimination of 6 mm, the other two patients only achieved a value > 10 mm. With monofilaments one patient was able to recognise the 3.61 filament, which constitutes a standard value. The other three recognised the 4.31 filament, which is only one degree less. All measurements concerning the superficial branch of the radial nerve turned out to be less satisfactory, however, one must consider that the sensation qualitiy in this area is less to begin with. No neuromas occurred, except in the case of the radial nerve. None of the patients showed full recovery of temperature perception. Two were able to recognise a warm and three a cold probe head. Our results confirm the findings made in other studies which also found a clinical correlate to collateral axonal sprouting. Unfortunately results are still inconsistent.

The Hatchet Flap for Reconstruction of Fingertip Amputations

Emmett has described a single triangular flap that contains a partial skin bridge on one of its sides and called it the hatchet flap. It was successfully used for defects located on various body parts. The aim of this study was to present the authors' experience and results obtained with this flap in fingertip amputations. Nine patients who have completed their 1-year follow-up period were included in the study. Two-point discrimination and stiffness were tested, and the patients were queried about the existence of cold intolerance, hypersensitivity, numbness, and pain in the early (3 months) and late (1 year) postoperative periods. The amputations were located on the thumb in three patients, index finger in one patient, middle finger in three patients, and ring finger in two patients. The average defect size was 2.1 x 1.5 cm. Partial wound dehiscence was observed in one patient. The flap has provided good protective padding and aesthetic contour for the fingers. All incisions healed with inconspicuous scars. Average two-point discrimination was 6.3 mm (range, 4 to 8 mm). Cold intolerance was observed in two (22.2 percent) and paresthesia in one patient (11.1 percent). Joint stiffness was not noted. Most patients could return to their normal routine in approximately 4 to 5 weeks. The hatchet flap is a good alternative for transverse and lateral oblique fingertip amputations and valuable for volar oblique amputations (defects <2 cm) with more extensive flap designs. The technique is simple and safe and provides good protective padding and acceptable tactile gnosis.

Two-point vibrotactile discrimination related to parameters of pulse burst stimulus.

Tactile spatial resolution is an important factor in the design of vibrotactile arrays. The two-point discrimination distance is used as a measure of tactile spatial resolution. An experimental study is presented showing the effect of pulse burst stimulus parameters, pulse repetition period and duty cycle on two-point vibrotactile spatial discrimination. An array of piezoceramic vibrators is used to measure two-point spatial discrimination on the index finger. In a group of 14 subjects, the average two-point discrimination distance for a pulse repetition period of 1/25s is 2.1 mm (SD = 1.0), whereas for 1/500 s it is 5.1 mm (SD = 0.9). Differences in discrimination distances are statistically significant according to the ANOVA analysis (p < 0.001). Results show that the two-point discrimination distance is better for longer pulse repetition periods. Therefore the pulse repetition period in an excitatory waveform composed of bursts of pulses is important for tactile resolution. No statistically significant differences in discrimination distances are found between bursts of pulses of 50% duty cycle and those of lower duty cycle. The latter result indicates that, by choosing low-duty cycle waveforms for vibrotactile stimulation, the power can be reduced with no loss in two-point discrimination capacity.

Fingertip replantations: clinical evaluation of 135 digits.

From July 1985 to February 1993, 135 digits in 119 patients with complete amputations at or distal to the distal interphalangeal joint (zone I for amputations distal to the nail base of zone II for amputations between the distal interphalangeal joint and the nail base) were replanted using a microsurgical technique at Korea University Guro Hospital. Because of the high social value placed on body form and function, the indication for replantation was extended to cases with severe soft-tissue injuries and attempted replantation as a routine procedure in nearly all distal amputation cases. The overall survival rate was 78 percent, with the survival rate for zone I being 70 percent and that for zone II reaching 86 percent. Even in cases with severe soft-tissue injury, the survival rate was high, with viability in avulsion injuries and crush injuries reaching 75 percent each. The most common type of vascular repair in zone I cases was revascularization of one artery only and no vein repair (87 percent). Of these cases, interpositional vein grafts were used in 65 percent. In zone II cases, the most common combination repair was one artery and one vein anastomosis (70 percent), with interpositional vein grafts for arterial anastomosis in 49 percent; most of the venous repair was feasible by the direct method (78 percent). The follow-up period ranged from 1 month to 5 years with a mean of 14.8 months; 52 patients were followed-up for more than 6 months. In 52 long-term follow-up patients, the average two-point discrimination was 8 mm. Patient satisfaction, aesthetically and functionally, was high (91 percent).

Clinical assessment of primary digital nerve repair.

We have carried out a retrospective study of 64 primary digital nerve repairs in 50 patients who presented to our department between 1988 and 1993. 45 of the patients were operated on within 6 hours of the injury using microscope (x 14). Normal two-point discrimination was regained in only 9 cases, while 6-10 mm two-point discrimination was achieved in 22, 11-15 mm in 15 and protective sensation in 18. A close correlation between age and recovery of sensation after repair was observed. Microsurgical repair of digital nerve gives satisfactory results, since a normal or good two-point discrimination can be obtained in about half of cases, while sensation improves in the rest. A high rate of complete recovery of sensation, however, is to be expected only in children.

The long term result of digital nerve repair in no-man's land

30 isolated lesions of digital nerves which had been repaired by microsurgical techniques were examined in 27 patients. The average length of follow-up was 25 months (range: 12–48 months). Patients were assessed subjectively using a visual analogue scale and examined for light touch, pain, two-point discrimination, electrical conductance and sensory threshold. Although 37% of fingers regained normal two-point discrimination, only 27% of patients graded their overall result as excellent and 40% complained of persistent hyperaesthesia for up to two years. None felt that their finger had regained normal sensation. All patients undergoing digital nerve repair should be warned that hyperaesthesia may persist for several years and that an adult will never regain normal sensation.

A versatile method for reconstruction of finger defects: reverse digital artery flap

Four types of the reverse digital artery flap—standard, extended, and innervated standard and extended—were developed for 52 finger defects. The arising pattern of the dorsal branch which was included in the innervated flap was studied and classified in cadaver dissections. Topographically, the described “Lai's line” is a useful guide to locate the underlying digital artery. Refinements in flap design and surgical technique resulted in favourable functional and cosmetic results. The average two-point discrimination of the reconstructed fingertip was 6.8 mm and 3.9 mm in the noninnervated and innervated flaps, respectively. This versatile flap is an ideal and reliable option for one-stage reconstruction of various finger defects.