Left Thumb Research Articles

Spontaneous rupture of extensor pollicis longus tendon with tophaceous gout infiltration

Spontaneous rupture of the extensor pollicis longus (EPL) tendon has been reported in the literature. Various mechanisms have been proposed to account for this problem, but gouty infiltration is a rare mechanism. Here we report a patient with a long-standing history of gout who presented with sudden loss of interphalangeal extension of the left thumb. Spontaneous rupture of the EPL tendon caused by gout was discovered. The successful treatment done involved surgical exploration and extensor indicis proprius tendon transfer. Postoperative thumb spica immobilization for 6 weeks was applied. Pathology disclosed urate crystals deposited within the ruptured EPL tendon. The functional recovery is satisfactory at the 1-year follow-up. Spontaneous rupture of the EPL tendon caused by gout is rare. Successful treatment was done with surgical management. Life-long medical follow-up to prevent a repeated acute attack can lower the risk of a large amount of tophaceous gout infiltration in tendons and may possibly prevent acute spontaneous tendon rupture.

Phonetic perceptual identification by native- and second-language speakers differentially activates brain regions involved with acoustic phonetic processing and those involved with articulatory–auditory/orosensory internal models

This experiment investigates neural processes underlying perceptual identification of the same phonemes for native- and second-language speakers. A model is proposed implicating the use of articulatory–auditory and articulatory–orosensory mappings to facilitate perceptual identification under conditions in which the phonetic contrast is ambiguous, as in the case of second-language speakers. In contrast, native-language speakers are predicted to use auditory-based phonetic representations to a greater extent for perceptual identification than second-language speakers. The English /r–l/ phonetic contrast, although easy for native English speakers, is extremely difficult for native Japanese speakers who learned English as a second language after childhood. Twenty-two native English and twenty-two native Japanese speakers participated in this study. While undergoing event-related fMRI, subjects were aurally presented with syllables starting with a /r/, /l/, or a vowel and were required to rapidly identify the phoneme perceived by pushing one of three buttons with the left thumb. Consistent with the proposed model, the results show greater activity for second- over native-language speakers during perceptual identification of /r/ and /l/ relative to vowels in brain regions implicated with instantiating forward and inverse articulatory–auditory articulatory–orosensory models [Broca's area, anterior insula, anterior superior temporal sulcus/gyrus (STS/G), planum temporale (PT), superior temporal parietal area (Stp), SMG, and cerebellum]. The results further show that activity in brain regions implicated with instantiating these internal models is correlated with better /r/ and /l/ identification performance for second-language speakers. Greater activity found for native-language speakers especially in the anterior STG/S for /r/ and /l/ perceptual identification is consistent with the hypothesis that native-language speakers use auditory phonetic representations more extensively than second-language speakers.

Myofascial pain and fibromyalgia: Influence of tenderness on cerebral response to equal physical pressures and equally painful pressures applied to patients with fibromyalgia (FM)

Functional MRI (fMRI) studies of fibromyalgia patients (FM) demonstrate augmented pain processing, and fMRI studies of healthy controls show that individual pain sensitivity is associated with pain-evoked cerebral activity. This study examined the influence of tenderness to blunt pressure on the cerebral responses of 25 [41SD10yr] patients with FM. During 10 min fMRI scans, a set of 4 stimulus pressures were delivered to the left thumb via a 1 cm2 diameter probe 3 times each in a random sequence in an alternating pattern of 25 s stimulation, no stimulation. One of the stimulus pressures was always 2 kg (2 kg condition), and another was always adjusted to evoke slightly intense pain (subjectively equal pain condition). After standard preprocessing (motion correction, intensity normalizations, spatial smoothing and detrending), difference maps between these stimuli and the no-stimulation conditions were registered into standardized space and correlated with the amount of pressure (PRESS) needed to evoke a subjective report of slightly intense pain determined by a multiple random staircase procedure. PRESS correlated negatively with activity evoked by 2 kg pressure in contralateral insula, and positively with activity in contralateral primary somatosensory cortex (S1) and inferior parietal lobule (IPL). PRESS correlated negatively with activity evoked by subjectively equal stimuli in contralateral secondary somatsosensory cortex and frontal medial gyrus, and with activity in ipsilateral globus pallidus (all associations: r>0.5, p < .05, corrected). The differential results observed for insula and S1-IPL in the 2 kg stimulus condition suggests that tenderness may be mediated in part by altered affective processing in the insula. The influence of tenderness on the effects of subjectively equal painful stimulation suggests that variation in symptomatic tenderness is associated with altered cerebral activity during otherwise similar levels of subjective pain magnitude. Supported by Department of Army grant DAMD17-00-2-0018.

Clinical, cytogenetic, and molecular findings of prenatally diagnosed mosaic trisomy 4

To present the clinical, cytogenetic, and molecular findings of prenatally diagnosed mosaic trisomy 4. An amniocentesis was performed at 21 weeks' gestation because of maternal anxiety. Cytogenetic analysis revealed mosaicism for trisomy 4, 47,XX,+4[4]/46,XX[16]. Level II ultrasound demonstrated tetralogy of Fallot. Repeated amniocentesis at 23 weeks' gestation revealed 47,XX,+4[4]/46,XX[19]. The pregnancy was terminated. Phenotypic findings included tetralogy of Fallot, hypertelorism, micrognathia, abnormal ears, duplicated phalanges of the left thumb, clinodactyly, and overlapping of the toes. The karyotype of the cord blood was 46,XX. Cytogenetic analyses of the multiple tissue samplings showed a karyotype of 47,XX,+4 in 40/40 cells of the amniotic membrane (amnion), and 47,XX,+4/46,XX with various levels of trisomy 4 in the cells of the liver, lungs, placenta, skin, and umbilical cord. The levels of trisomy 4 were 11/40 in the liver, 8/40 in the lungs, 31/40 in the placenta, 9/40 in the skin, and 8/40 in the umbilical cord. The parental origin and meiotic origin of trisomy 4 were determined by examining the amniotic membrane using quantitative fluorescent polymerase chain reaction assays with polymorphic markers specific for chromosome 4. The result was consistent with a paternal meiosis I nondisjunction error. The cord blood showed a biparental inheritance. An extra paternal heterozygous allele with partial dosage increase was noted in other fetal and extraembryonic tissues studied. A diagnosis of trisomy 4 mosaicism in amniocytes indicates an increased risk for fetal abnormalities. Associated abnormal findings include congenital heart defects and anomalies of the digits and thumb. A confirmatory placental sampling may be helpful, whereas a fetal blood sampling is of a very limited value. A postnatal amnion sampling may provide additional clues to the fetal involvement of trisomy 4.

Complex Regional Pain Syndrome

많은 의학자들이 끊임없이 복합부위통증증후군(CRPS)의 원 인규명, 진단법의 모색과 검증, 치료법 연구 등에 매진하면서 점차 CRPS에 대한 우리들의 이해가 증대되고 있다. 그러나 아직도 우리는 CRPS의 확실한 원인이 무엇인지 여전히 모르 고 있으며, CRPS가 의심되는 환자들에서 여전히 확진을 망설 이고 있고, 또한 완벽하게 치료되는 증례가 거의 없음을 인정 하지 않을 수 없다. 참으로 안타까운 상황이다. 국내에서도 이러한 환자들이 많이 있음에도 불구하고 진 단적 기준 및 명확한 치료기준의 결여로 치료시기를 놓치고 결국 영구장애라는 판정을 내리게 되는 경우가 많다. 본인 의 경험에 의하면 CRPS 증세를 가진 환자를 조기에 진단하 여 치료한 경우 완치된 경우들이 있는데 이 때의 보람이란 말로 표현할 수 없으며 조기에 이를 의심하여 통증치료실로 환자를 소개한 의사 선생님들의 혜안에 감사함을 느낀 적이 여러 번이었다. 결국 임상 현실에서 가장 문제가 되는 점은 “CRPS에 대한 명확한 진단기준을 적용하여 빠르고 명확하 게 진단을 하느냐”와 일단 진단되면 “어떻게 적절한 치료를 할 것인가”에 있는 것이다. 이 과정에서 다학과적인 접근이 절실하다. 그러나 현재 국내의 의료 상황으로는 이러한 다 학과적인 접근이 어려우므로 통증치료 의사가 최선을 다해 지식을 수련하고 연마하는 길 밖에 없다고 하겠다. 이번 논문에서는 치료적인 측면이나 복잡한 발생기전에 대한 설명은 생략하고 주로 진단기준, 특히 세계통증연구학 회(IASP)에서 제시된 기준에 대해 설명하고 최근에 제시된 변형된 진단기준 등을 소개하고자 한다.

Gangrene of digits associated with radial artery cannulation

Gangrene of digits associated with radial artery cannulation

Locking of the thumb in a patient with de Quervain’s disease: a case report

AbstractWe report a patient with a locked left thumb in association with de Quervain’s disease. While bathing her baby 1 month after giving birth a 32-year-old woman suddenly noticed that she could not radially abduct her left thumb. Magnetic resonance imaging showed thickening of the abductor pollicis longus tendon with a heterogeneous signal intensity on T2-weighted images. Bandage fixation for 4 weeks did not improve her thumb movement, and she was subsequently treated by surgery. Operative findings revealed inhibition of the tendon gliding proximally as a result of nodule formation in the abductor pollicis longus tendon distal to the first dorsal compartment. This condition, locking of the thumb, was improved by excising the extensor retinaculum of the first dorsal compartment and tenosynovium around the abductor pollicis longus and extensor pollicis brevis tendon. At the 1-year follow-up examination the patient had no limitations or pain during active radial abduction of the left thumb.

Ontogenetic trends in gnostic hand function in 3- to 12-yr-old children.

The intimate relation between the sensory and motor functions of the hands during object manipulation and exploratory touch, the well-known improvement in object handling and constructive performance in ontogenesis and the emergent laterality thereof, assume changes in morphognostic capabilities in children. In this study we tried to corroborate the hypothesis of Mesker that mature and lateralized finger-thumb opposition is preceded by a stage of two-sided manual form agnosia in preschool children, followed by acquisition of morphognosis of the fingers and, finally, the thumbs. This study examined the development of gnostic hand function in 290 children from 3 to 11 years of age who drew the outlines of a meaningless wooden object passively felt with each hand without visual control. Analysis showed a clear ontogenetic change across the two age groups of increasing morphognostic function: 48% of the 6-yr.-olds drew correctly what the fingers of both left and right hands had perceived (thumbs, 14%). Of the 11-yr.-olds 91% and 61% performed perfectly with the right and left hands, respectively. The fingers preceded the thumbs in reproduction by most children, and the correct reproduction by the left thumb precedes that of the right thumb. The ontogenesis of bimanual sensorimotor functioning is discussed in the light of cortical and callosal development.

Anaesthesia for total hip replacement in a patient with Holt-Oram syndrome

Anaesthesia for total hip replacement in a patient with Holt-Oram syndrome

An 18-year-old man with swelling in his left thumb.

The patient is afebrile. He has a mild to mod-erate swelling of the left thumb and an ill-defined palpable enlargement (4 ×1 cm) inthe wrist that is not visible grossly. The thumband wrist are tender to palpation and painfulon movement against resistance.Absent are signs suggestive of mediannerve compression at the wrist, ie, the Tinelsign (a tingling sensation in the fingers in thedistribution of the median nerve with percus-sion over the median nerve) or the Phalensign (reproduction of pain with hyperflexionor hyperextension of the wrist). The rest ofthe physical examination is unremarkable.

Therapeutic angiogenesis by autologous bone-marrow transplantation in a general hospital setting

Eur J Vasc Endovasc Surg 25, 276–278 (2003)

悪性黒色腫 Ｓｔａｇｅ ＩＶ悪性黒色腫の長期生存例

We report two cases of stage IV malignant melanoma with long survival. The first case was a 43-year-old man with a black tumor on his back. In September, 1992 he received wide resection and 10 courses of DAV-feron chemotherapy after the operation. In October, 1997 metastases of the right axillary and right supraclavicular lymph nodes and skin metastasis on the nape were found. He received resection of these lesions followed by 2 courses of DAC-Tam chemotherapy. He has been tumor-free for more than 57 months thereafter.The second case was a 42-year-old man with a black tumor on his left thumb. In October, 1994 amputation of the left thumb and right axillary lymph node dissection were performed. He received 14 courses of DAV-feron chemotherapy after the operation. In April, 2000 left subclavicular lymph node metastasis was found. He received resection of metastasis and 2 courses of DAC-Tam chemotherapy. He has been tumor-free for more than 23 months thereafter. These two cases of stage IV malignant melanoma were successfully threated by DAC-Tam chemotherapy combined with surgical resection of metastasic lesions. [Skin Cancer (Japan) 2003; 18: 203-207]

Gonococia extragenital cutánea primaria

Abstract—An isolated primary cutaneous presentation, with no genital involvement or evidence of prior or coexisting bacteremia, is an exceptional event in gonococcal infections. The patient was a white male aged 25 years, who presented pain and inflammation in the periungual region of the left thumb, with no apparent precipitating factor and no evidence of associated genital or systemic infection. Drainage was indicated, along with treatment with oral cloxacillin, and the patient improved in a few days.The cultures of the purulent exudate shows isolation of Neisseria gonorrhoeae strains.

Burns in patients with impaired sensibility of the hands—a case of osteomyelitis in a neglected thumb burn

Inadvertent thermal injury is a constant potential hazard for individuals with impaired sensibility. As a result of the absence of normal physiological protective reflexes contact with a noxious stimulus may be prolonged, resulting in an injury of greater depth than might otherwise be expected. Subsequent complications, such as infection, may develop in the absence of classical signs and symptoms. Clinically significant osteomyelitis is a rare complication of burns [1]. In this article the case of a woman with syringomyelia is presented. As a result of marked thermo-anaesthesia of both hands she sustained a burn to the left thumb and subsequently developed septic arthritis of the interphalangeal joint that progressed to osteomyelitis of the proximal phalanx. The pathophysiology of osteomyelitis after burns is discussed and the hazard of inadvertent thermal injury in patients with impaired sensation is highlighted to raise awareness of potential complications in this group of patients.

A 58-Year-Old Man With a Diagnosis of Chronic Lyme Disease

DR BURNS: Mr C is a 58-year-old man diagnosed as having chronic Lyme disease. He lives in a suburb of Boston and works as a consultant. He has managed care insurance. Mr C had an episode of Bell’s palsy on the left side of his face in August 1992 and reported that he spent a lot of time on Martha’s Vineyard, an endemic area for Lyme disease. Subsequently, he noticed that he became less competent mentally. He could not do simple math and he became depressed. In 1994, he was diagnosed as having Lyme disease. At that time, he complained of neck pain radiating to his left shoulder and hand, with numbness and tingling in his hand; back pain that radiated down his left leg; bilateral joint aches in both elbows and, to a lesser extent, his shoulders; bilateral tinnitus; periodic blurred vision (worse in the right eye than the left); difficulty concentrating and word finding; and periodic sweats. Results of his physical examination were normal with the exception of having difficulty spelling “world” backward and subtracting 7 serially. In October 1994, his Lyme (IgM/IgG) antibody titer was positive at 1:4. He was treated with tetracycline, 500 mg 3 times daily for 1 year. Following the initial course of tetracycline, his symptoms improved. However, in July 1996, Mr C restarted tetracycline 500 mg 3 times daily, for complaints of generalized aches and pains, hot flashes, nausea, sweats, dizziness, and a general uneasy feeling. Since then, persistent symptoms have included fatigue, sweats, slight memory loss, generalized aches and pains, headache, facial flushing, numbness of his left thumb, altered sensation on the left side of his face, and weight gain. Mr C was treated with repeated courses of tetracycline as well as several courses of clarithromycin, 500 mg twice daily, combined with hydroxychloroquine, 200 mg twice daily. His last course of tetracycline was in early 1999, at which time a Lyme Western blot assay showed an IgM reaction to the 83-kd protein and IgG reactions to the 41and 62-kd proteins. In the fall of 1999, due to a change in his insurance, Mr C transferred to a new primary care physician, Dr N. His new physician was not convinced of the benefit of recurrent courses of antibiotics. In the fall of 2001, Mr C returned with multiple concerns including difficulty sleeping, forgetfulness, cognitive difficulties especially with calculations, decreased libido, anxious feelings, facial stiffness, puffy eyes, and cracking in his neck and shoulder. Mr C was concerned that some of his symptoms may be related to Lyme disease. At that time, physical examination findings were normal. Dr N thought that Mr C might have a mild depression and prescribed paroxetine, 10 mg/d, which was later increased to 20 mg/d. With this regimen, Mr C reported that he noticed less anxiety, less joint pain, and improved cognition. He also was sleeping better. His current medications include paroxetine, 20 mg/d, quinapril, 10 mg/d, and atorvastatin, 10 mg/d. Mr C has no known drug allergies. He exercises regularly and rarely drinks. He previously smoked about 1 pack per day but quit smoking about 7 years ago. Mr C has a past medical history of hypertension, hyperlipidemia, seborrheic dermatitis, and chronic Lyme disease. His father died of “natural causes” and his mother of ovarian cancer. He has one brother who recently underwent coronary artery bypass graft surgery.

滑膜肉腫の１例

We report a case of a 75-year-old man with synovial sarcoma.There was a painful mass, 3.5×3×2cm in size, on the dorsum of the DIP joint of his left thumb. The mass was smooth on the surface, relatively well-demarcated, elastic soft, weak and hemorrhagic. There was osteolytic change in the phalanx of the thumb on X-ray.Histological examination revealed the tumor mainly consisted of hypercellular sheets of small round cells with dark-stained nuclei. Another portion of the specimen showed presence of a typical biphasic pattern, which was composed of epitheloid cells and spindle cells. Immunohistochemically, the small round cells and spindle cells were positive for vimentin, and the epitheloid cells were positive for CAM 5.2. These cells were negative for CEA, S-100 protein, HMB-45 and CD34. The tumor was diagnosed as poorly differentiated synovial sarcoma. Chest X-ray and CT showed a giant mass in the upper lobe of the right lung. We couldn't obtain a biopsy specimen of the mass because of severe hemoptysis during the bronchoscopic examination. We assumed that the tumor was lung metastasis of synovial sarcoma.The patient's left thumb was amputated. Radiotherapy for the lung mass was not effective. He died of respiratory failure 6 months after the tumor of the left thumb appeared. [Skin Cancer (Japan) 2002; 17: 70-74]

Periosteal chondroma presenting as a subcutaneous mass in the thumb

We describe an unusual case of periosteal chondroma of the distal phalanx in the left thumb presenting as a subcutaneous mass in an 81-year-old woman. Magnetic resonance (MR) imaging demonstrated a subcutaneous lesion with hypointensity on T1-weighted images and marked hyperintensity on T2-weighted images, eroding the underlying cortical bone. Computed tomographic (CT) scans showed an erosive change in the dorsal cortex of the distal phalanx. Bone tumors arising from bone surface should be considered in the differential diagnosis of subcutaneous finger masses.

Thumb Avulsion Injury during Pregnancy: Caution When Using Oxytocin

A pregnant patient sustained a near complete degloving injury to her left thumb during the end of her third trimester. Surgical revascularization was successfully performed. Ten days after revascularization, the patient was induced into labour with oxytocin. Four hours after delivery, she experienced ischemic pain in the revascularized thumb, with subsequent failure and necrosis of the digit. The vasoactive properties of oxytocin are discussed, in particular, its role as a vasoconstrictor. The importance of sustaining adequate blood flow to newly revascularized tissue is stressed, as well as the need to be cautious when using vasoconstrictive agents during microvascular surgery.

The acute effects of smokeless tobacco (snuff) on gingival blood flow in man.

Snuff-induced blood flow responses in the gingiva were evaluated in 22 healthy casual consumers of tobacco. Laser Doppler flowmetry (LDF) was used to measure blood flow simultaneously and continuously on two gingival sites (buccal aspect of the papillae between the upper lateral incisors and canines). In addition, measurements of skin blood flow in the forehead and palmar side of the left thumb were performed. Arterial blood pressure (BP) and heart rate (HR) were also recorded. Unilateral application of commercial snuff (500 mg, 1%) caused a marked and rapid increase in gingival blood flow (GBF) on the exposed side (p < 0.001). Blood flow increased also in the contralateral gingiva and forehead skin (p < 0.05). Skin blood flow in the thumb showed an insignificant decrease. BP and HR increased. Vascular conductance increased significantly in the snuff-exposed gingiva but not in the contralateral gingiva or the forehead. Vascular conductance was largely unaffected in the thumb. It is concluded that acute application of snuff, besides giving rise to typical changes in BP and HR, increases GBF in and around the exposed area, probably through activation of sensory nerves and the subsequent release of vasodilatory peptides from their peripheral endings. Blood flow in unexposed gingival and forehead skin may increase probably due to humoral or nervously mediated mechanisms. However, a passive pressure-induced hyperaemia in the unexposed gingiva and forehead skin can not be excluded.

Event-related desynchronization in reaction time paradigms: a comparison with event-related potentials and corticospinal excitability

Objectives: To study cortical activity in different motor tasks, we compared event-related desynchronization (ERD) and event-related potentials (ERPs) in different reaction time (RT) paradigms with the time course of corticospinal excitability. Methods: Nine right-handed, normal subjects performed right or left thumb extensions in simple, choice and go/no go auditory RT paradigms. Eight subjects had participated in a previous study evaluating changes in corticospinal excitability during the same paradigms. Twenty-nine EEG channels with electrooculogram and bilateral EMG monitoring were collected. ERPs and ERD of 10 and 18–22 Hz bands were obtained with respect to tone administration and EMG onset. Results: Trials with movement showed lateralized ERP components, corresponding to the motor potential (MP), both in the averages on the tone and on EMG. The MP corresponded well in time and location to the rise in corticospinal excitability on the moving side observed in the previous study. Sensorimotor ERD, followed by event-related synchronization (ERS), was present for trials with movements and for the no go. ERD was present contralaterally during movement preparation and in no go trials, while it was bilateral during motor execution. No go ERD was followed more rapidly by ERS than in trials with movement. This finding suggests that in no go trials, there is a brief active process in the sensorimotor areas. ERD and ERS do not correspond, respectively, in time and location to increases and decreases in corticospinal excitability. In fact, ERD is bilateral during movement execution, when corticospinal inhibition of the side at rest is observed. Contralateral no go ERS occurs later than corticospinal inhibition, which is bilateral. Conclusions: These findings may suggest that ERD is compatible with both corticospinal activation and inhibition, ERS indicating the removal of either, resulting in cortical idling.