Metacarpal Joint Research Articles

Arthroscopic Thermal Shrinkage: A Novel Method for the Treatment of Chronic Volar Plate Instability at the Metacarpal Phalangeal Joint of the Thumb.

Background: Chronic volar plate instability of the thumb metacarpal phalangeal joint (MCPJ) is a disabling clinical problem. Patients usually present with pain and disability in terms of reduction in pinch and grip power. Numerous surgical techniques have been described for the treatment of this condition. Here we describe a novel method for the treatment of this condition by thermal shrinkage of the volar plate via thumb MCPJ arthroscopy. Methods: A retrospective review of 8 patients with chronic thumb MCPJ volar plate instability treated with the novel technique of thermal shrinkage of the volar plate via thumb MCPJ arthroscopy. The primary outcome is maintenance of saggital plane stability at the thumb MCPJ. Secondary outcomes include pinch and grip power, The Disabilities of the Arm, Shoulder and Hand (DASH) Score and thumb MCPJ range of movement. The duration of follow up and complications were also reviewed. Results: The mean follow up period was 41.4 months (range, 2-134 months). One case had recurrence of instability requiring open volar plate capsulodesis. All other cases had their thumb hyperextensibility resolved and maintained throughout the entire follow up period, up to 134 months for the case with the longest duration of follow up. Conclusions: Preliminary results suggest this novel, minimally invasive technique for the treatment of thumb MCPJ volar plate instability is effective and the long term follow up results are durable.

Лучевая терапия остеохондродисплазии у шотландских вислоухих кошек

Osteochondrodysplasia in the Scottish Fold cats is the genetic disease, inherited according to the autosomal-dominant type; it is manifested by the deformation of bones and cartilages of the skeleton in the form of unhealthy bone growths in the region of the wrist, metacarpal, fetlock, mesopodial and phalanx joints of breast and pelvic extremities, and also tailed vertebrae.
 
 Purpose of research. To assess the effectiveness of radiation therapy in the treatment of Scottish fold cats with osteochondrodysplasia.
 
 Materials and methods. 10 Scottish Fold cats (3 males, 7 females; age ― from 5 months to 10 years) with osteochondrodysplasia were treated from 2013 to 2017. All patients had clinical signs of disease in the form of skeletal growths in the wrist, metacarpus, finger bones, lumbar, sacral or tail spine. Most of them (9 of 10) were lame. All patients were examined clinically and radiologically before the treatment. Radiation therapy was carried out on gamma therapy unit «AGAT-R» with inclusion of the affected limbs to the middle of the shoulder or thigh. Immobilization was achieved either by general anesthesia or by means of physical restraint. Fraction doses used were 1.5 Gy up to total doses of 15.0 Gy, 2 to 3 fractions per week.
 
 Results. In 9 of 10 cases (90 %) there is a subjective improvement in mobility and regression of lameness after 6 months and furthermore after treatment. Two patients in the group died within 8 and 12 months from extraneous causes, others are alive and well for the time being with no need for pain relief. In three cases a radiological control of skeletal growths was performed, with no signs of progression 6.15 and 71 months after treatment. The maximum observation period is 2196 days, the observation median is 705 days.
 
 We used a questionnaire to improve the objectiveness of cat’s mobility and pain assessment before and after treatment. Based on animal owners’ answers the score for each symptom was assigned from 0 (severe dysfunction) to 2 (function not impaired). Scores from individual cases were summed, and the averaged total results were compared. Generally, after radiation therapy, animals’ mobility improved significantly (the averaged mobility score in the group imcreased from 3.0 to 6.5).
 
 Conclusion. The radiation therapy is an effective pathogenetic and symptomatic method of treatment of Scottish fold cats with osteochondrodysplasia: in most cases it leads to pain relief and increased mobility of the animal. According to clinical and radiological (in three cases) criteria, it can also be assumed that radiation therapy leads to suppression of the skeletal growths enlargement. The effect of treatment develops within 6 months after its completion and is persistent (lasts for many months and years). The technique involves the use of small total doses, so it does not cause complications and is practically safe for the patient.

Clinical effects of dorsal perforator fascia pedicle flap of the deep palmar arch in the repair of skin and soft tissue defects of finger web area

Objective: To explore the clinical effects of dorsal perforator fascia pedicle flap of the deep palmar arch in the repair of skin and soft tissue defects of finger web area. Methods: Eleven patients (7 males and 4 females, aged from 18 to 73 years) with soft tissue defects of finger web area in distal dorsal side were admitted to Xinhua Hospital (Chongming) of Shanghai Jiao Tong University School of Medicine from October 2010 to September 2018. The sizes of skin and soft tissue defects ranged from 2.5 cm×1.5 cm to 6.0 cm×2.5 cm. According to the origin, course, branches, and distribution of the dorsal perforator of deep palmar arch, and the anatomical characteristics with vascular network of dorsal carpal and dorsal metacarpal, dorsal perforator fascia pedicle flaps of the deep palmar arch from the back of the injured hands were designed and transferred to repair the wounds of finger web area in distal dorsal side. The sizes of the flaps of patients ranged from 3.5 cm×2.0 cm to 6.5 cm×3.0 cm. The donor sites were sutured directly or covered with free forearm full-thickness skin graft. The clinical effects and swelling degree of flaps in early and late stages were evaluated during the follow-up of 3 to 36 months post surgery. Results: All the flaps survived in 11 patients, the incisions in donor and recipient sites were healed. During the follow-up of 3 to 36 months post surgery, the survival of flaps was good, and the appearance, color, and elasticity were close to normal skin, with two-point discrimination distance of 7 to 10 mm and sensory function recovery of grade S(3). The wounds in donor site had small scar without infection. The efficacy was evaluated as satisfactory in 8 patients, general in 3 patients, and dissatisfactory in no patient. Flap swelling rating in early stage was 1st degree in 7 patients, 2nd degree in 2 patients, and 3rd degree in 2 patients. Flap swelling rating in late stage was 1st degree in 8 patients, 2nd degree in 2 patients, and 3rd degree in 1 patient. The extension and flexion of the metacarpal and interphalangeal joints were basically normal and the patients were satisfied with the outcomes. Conclusions: Based on the dorsal perforator of deep palmar arch, dorsal perforator fascia pedicle flap of the deep palmar arch is reliable to transfer to repair skin and soft tissue defects of finger web area in distal dorsal side, which is worthy of promotion in clinic.

IL-1β regulates cell shape and expression of prg4 independent of actin polymerization in superficial zone chondrocytes

Purpose: The superficial zone (SZ) of articular cartilage plays a multifaceted role in joint homeostasis contributing the biomechanical integrity and metabolic homeostasis of the tissue. In the early stages of osteoarthritis (OA), one of the first observable changes is loss of the SZ. Although the pathogenesis of OA is multifactorial, elevated levels of inflammatory cytokines are one contributing factor to disease progression. Interleukin-1 is an inflammatory cytokine that contributes to joint remodeling by regulating the expression of collagenases, aggrecanases, and nitric oxide (NO). Additionally, decreased expression of the chondroprotective molecule PRG4 is observed in SZ chondrocytes (SZC) in vitro and in the SZ of cartilage explant culture with IL-1 treatment. Studies using chondrocytes isolated from full-thickness cartilage observed changes in cellular mechanics with IL-1β treatment including increased filamentous actin and cellular stiffness. Unlike full-thickness chondrocytes, where actin polymerization leads to loss of the chondrogenic phenotype, the polymerized form of actin is important for the maintenance of the SZ phenotype and expression of PRG4. Although a decrease in PRG4 expression has previously been observed with IL-1β treatment in SZC the mechanism has not yet been fully elucidated. The purpose of this study is to determine whether IL-1β regulates PRG4 expression through an actin-dependent mechanism. Methods: The SZ of articular cartilage was dissected from the metacarpal phalangeal joint of calves aged 6-9 months. SZC were isolated by sequential digestion in 0.5% protease for 45 minutes, followed by 0.1% collagenase for 14-17 hours. SZC were seeded in monolayer culture (52,000/cm2) in high glucose DMEM supplemented with ITS, 100nM dexamethasone, 40μg/mL proline, 100mM pyruvate, 100μg/mL ascorbic acid. After 24 hours in culture, SZC were treated with IL-1β (10ng/mL) and maintained for 24 hours prior to harvesting for analysis. The effect of IL-1β on cell morphology and the cytoskeleton was determined. Cellular morphology was assessed using Image J analysis software to calculate cell area and circularity. Gene and protein expression was determined by RT-PCR and Western blotting, respectively. The cytoskeleton polymerization status was determined by performing differential triton extraction containing the soluble portion (G-actin and M-tubulin) and insoluble portion (F-actin and P-tubulin). The fractions were separated by SDS-PAGE and the resultant bands were semi-quantified using Image J analysis software to determine the G-/F-actin ratio and M-/P-tubulin ratio. Confocal imaging of the actin cytoskeleton visualizing the G- and F-actin was performed by confocal microscopy. Experiments were performed with SZC from independent cell isolations. Each experiment was repeated 2-4 times; experiments were performed in triplicate, where appropriate. Student’s T-test was used to evaluate the results and significance assigned at p <0.05. Results: To confirm observations previously reported SZC treated with IL-1β were assessed by RT-PCR to determined PRG4 expression levels. PRG4 mRNA levels significantly decreased with treatment at 24 hours (p<0.05; N=4). The effect of IL-1β treatment on cellular morphology and actin organization was determined. Treatment with IL-1β resulted in no significant changes in cell area, but did result in a significant increase in cell circularity (p<0.001; N=2). Visualization of the G- and F-actin by confocal microscopy yielded no observable differences in the actin structure (N=2). To confirm this, the polymerization status of the actin cytoskeleton was determined by calculating the G-/F-actin ratio. Despite changes in cell circularity, no significant changes in the G-/F-actin ratio were observed (p=0.8; N=4). Changes in the microtubule structure can also induce changes in cellular morphology, thus we investigated whether the microtubule polymerization status was altered with IL-1β treatment, and observed no significant difference in the M-/P-tubulin ratio (p=0.3; N=3), suggesting another regulator of cell shape may be modulating PRG4 expression in SZC. Conclusions: The data suggests that the elongated morphology is an important regulator of PRG4 expression. Despite changes in cell circularity and reduced expression of PRG4, no changes in actin polymerization or tubulin polymerization were observed. Although actin polymerization has previously been shown to regulate PRG4 expression, additional regulators of cellular morphology may also be important for the maintenance of the SZ phenotype.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Electroacupuncture at "Zusanli"(ST36) and "Xuanzhong"(GB39) improves inflammatory reactions and reduces levels of serum MMP-3 and MMP-9 in adjuvant arthritis rats

To observe the effect of electroacupuncture (EA) at "Zusanli" (ST36) and "Xuanzhong" (GB39) on joint inflammatory reactions and serum matrix metalloproteinase-3 (MMP-3) and MMP-9 contents in rats with adjuvant arthritis (AA), so as to explore its mechanism underlying improvement of AA. Forty male SD rats were randomly divided into control, model, acupoint and non-acupoint groups (n=10 in each group). The arthritis model was established by hypodermic injection of complete Freund's adjuvant (0.1 mL) into the bilateral footpads. EA (2 Hz, 3 V) was applied to bilateral ST36 and GB39 or two non-acupoints (5 mm left to ST36 and GB39) for 15 min, once every other day for a total of 8 times. The arthritis index score was evaluated according to the severity of local erythema and swelling of the ankle joint, plantar joint, toe joint and foot metacarpal joint (0-4 points). The inflammatory conditions of the ankle joint were observed by H.E. staining, and the contents of serum MMP-3 and MMP-9 were assayed by ELISA. The arthritis index score and serum concentrations of MMP-3 and MMP-9 were significantly increased in the model group relevant to the control group (P<0.01), and obviously decreased after EA intervention on the 18th day (P<0.01). The therapeutic effect of acupoint EA was notably superior to non-acupoint EA in down-regulating the arthritis index score and serum MMP-3 and MMP-9 concentrations (P<0.01). Under light microscope, marked proliferation of the synovial cells, inflammatory cell infiltration and increase of newly blood vessels were observed in the ankle joint of the model group, which was relatively milder in the acupoint group. acupoint EA intervention can significantly alleviate the inflammatory reaction of AA rats, which may be related to its effects in reducing the levels of serum MMP-3 and MMP-9.

Arthroscopic Hemitrapeziectomy and Suture Button Suspensionplasty in the Treatment of First Carpometacarpal Joint Eaton-Littler Stage 2-3 Arthrosis.

Background Degenerative arthritis of the first carpometacarpal (CMC) joint is a common degenerative condition in the hand. Many different surgical procedures have been applied for years. However, in the studies there is no consensus about the superiority of one technique to another. Questions/Purposes In this study, we evaluated the results of the patients with first CMC Eaton-Littler stage 2-3 arthrosis who were operated to prevent first metacarpal joint lateral subluxation and migration with arthroscopic hemitrapeziectomy and suture button suspensionplasty. Patients and Methods Between 2011 and 2014, 21 patients (16 female, five male) were evaluated retrospectively. Mean age was 52.3 years. The preoperative and postoperative assessments were performed with visual analog scale (VAS) and disabilities of the arm, shoulder, and hand score (DASH) scores. The Kapandji's thumb opposition score was used to assess thumb range of movement. The patients were assessed after arthroscopy according to Badia classification. Results Mean follow-up period was 50.1 months. According to Badia classification, seven patients were found to be type 2 and 14 patients were type 3. The mean preoperative Kapandji's score was 7.6 and the mean postoperative Kapandji's score was 9.2. The mean VAS values were 8.2 preoperatively and 1.9 postoperatively. The mean preoperative DASH value was 23.4 and the mean postoperative DASH value was 5.5. The mean preoperative grip strength was 66.2 and the mean postoperative grip strength was 75.1. The mean preoperative pinch strength was 14.8 and the mean postoperative pinch strength was 20.2. Conclusion Arthroscopic hemitrapeziectomy and suture button suspensionplasty is a minimal invasive technique and can be performed with low morbidity in the treatment of first CMC joint Eaton-Littler stage 2-3 arthrosis. By this technique, the patients' existing instability and pain problems can be solved. Complications, such as loosening of the suture button at the first metacarpal at the postoperative period due to direct trauma to the first CMC joint, could be avoided using a new suture button. Type of Study/ Level of Evidence Therapeutic IV.

Pianism: performance communication and the playing technique

A pianist’s movements are fundamental to music-making by producing the musical sounds and the expressive movements of the trunk and arms which communicate the music’s structural and emotional information making it valuable for this review to examine upper-body movement in the performance process in combination with the factors important in skill acquisition. The underpinning playing technique must be efficient with economic muscle use by using body segments according to their design and movement potential with the arm segments mechanically linked to produce coordinated and fluent movement. Two physiologically and pianistically important actions proposed by early music scientists to deliver the keystroke involve dropping the hand from the shoulders towards the keys via a wave action with the joints activated sequentially, and forearm rotation to position the fingers for the keystroke, an action followed by the elbow/upper-arm rotating in the opposite direction. Both actions spare the forearm muscles by generating the energy needed in the larger shoulder muscles. The hand in the playing position has a curved palm through action of the metacarpal (knuckle) joints and curved fingers. Palm/finger posture controls sound quality from loud, high tempo sounds to a more mellow legato articulation, and to perform effectively the forearms should slope down towards the keyboard. The technique must be automatic through systematic practice which develops the motor skills for proficient playing, with practice duration tempered to reduce the risk of causing injury through overuse of the forearm muscles. Efficient movement patterns and strategic muscle relaxation which results in faster movement are realized only through extensive training. The constant movements of the head and trunk, and flowing arm movement with frequent hand lifts and rotational elbow movements, although generated in producing the playing technique, resonate with audience members who perceive them as expressive and thereby creating in them an empathic engagement with the music. It was proposed that music students be trained in the mechanical aspects of upper-body use in the playing technique, and practice strategies, with specialist pedagogy for children to develop motor skills for efficient playing, and training methods fostering an appreciation of the communicative aspects of music performance.

Pianism: Performance Communication and the Playing Technique.

A pianist’s movements are fundamental to music-making by producing the musical sounds and the expressive movements of the trunk and arms which communicate the music’s structural and emotional information making it valuable for this review to examine upper-body movement in the performance process in combination with the factors important in skill acquisition. The underpinning playing technique must be efficient with economic muscle use by using body segments according to their design and movement potential with the arm segments mechanically linked to produce coordinated and fluent movement. Two physiologically and pianistically important actions proposed by early music scientists to deliver the keystroke involve dropping the hand from the shoulders toward the keys via a wave action with the joints activated sequentially, and forearm rotation to position the fingers for the keystroke, an action followed by the elbow/upper-arm rotating in the opposite direction. Both actions spare the forearm muscles by generating the energy needed in the larger shoulder muscles. The hand in the playing position has a curved palm through action of the metacarpal (knuckle) joints and curved fingers. Palm/finger posture controls sound quality from loud, high tempo sounds to a more mellow legato articulation, and to perform effectively the forearms should slope down toward the keyboard. The technique must be automatic through systematic practice which develops the motor skills for proficient playing, with practice duration tempered to reduce the risk of causing injury through overuse of the forearm muscles. Efficient movement patterns and strategic muscle relaxation which results in faster movement are realized only through extensive training. The constant movements of the head and trunk, and flowing arm movement with frequent hand lifts and rotational elbow movements, although generated in producing the playing technique, resonate with audience members who perceive them as expressive and thereby creating in them an empathic engagement with the music. It was proposed that music students be trained in the mechanical aspects of upper-body use in the playing technique, and practice strategies, with specialist pedagogy for children to develop motor skills for efficient playing, and training methods fostering an appreciation of the communicative aspects of music performance.

Reliability of ultrasonography to detect inflammatory lesions and structural damage in juvenile idiopathic arthritis

BackgroundMusculoskeletal Ultrasonography (MSUS) is an important tool for the clinical assessment in Juvenile Idiopathic Arthritis (JIA). The objective of this study was to evaluate the reliability of MSUS to detect elementary lesions: synovitis, tenosynovitis, cartilage damage and bone erosions in the wrist and metacarpal (MCP) joints of patients with JIA.MethodsThirty children in various subgroups of JIA according to ILAR criteria, were included in this cross-sectional study. Clinical data including painful, swollen and limited joints were recorded. Five rheumatologist ultrasonographers, blinded to the clinical evaluation, evaluated the presence of elementary lesions in the wrist and MCP 2 and 3 joints bilaterally. The synovitis was graded in B-Mode and Power Doppler (PD). In addition to descriptive statistics intra- and inter-observer reliability was calculated using Cohen’s kappa according to Landis and Koch.ResultsUS detected more synovitis than the clinical examination (62% vs 28%, 30% vs 23% and 22% vs 17% in the wrist, second and third MCP joints respectively). The intra-observer concordance for synovitis in all joints was excellent in B-Mode (k 0.84 .63–1.0 p = 0.001), except for MCP 2, where it was good (0.61, IC 95% .34–89, p = 0.001). For both modalities (PD, B-Mode) tenosynovitis, cartilage damage and bone erosions it was also excellent. Regarding synovitis grading the concordance was excellent for all grades (0.83–1.0, IC 95% 0.51.1.0, p = 0.001), except for grade 1 where it was good (0.61, IC 95% 0.43–.83, p = 0.001). Reliability inter-observer for grayscale synovitis (0.67–0.95, IC 95% 0.67–1.0, p = 0.001), tenosynovitis grayscale (0.89, IC 95% 0.78–0.99, p.001), damage cartilage (0.89, IC 95% 0.78–0.99, p = 0.001), PD (0.66, IC 95% 0.39–1.0, p = 0.001). The concordance for grading synovitis was excellent, but for grayscale grade 1 and 2 (.66, IC 95% .53–.74, p = 0.007) and PD grade 1 and 2 (0.63, IC 95% .58–.91, p = 004) was good.ConclusionsThe intra- and inter-observer reliability of MSUS for inflammatory and structural lesions is good to excellent for the wrist and MCP in patients with JIA.

Microwave Radiometry-Derived Thermal Changes of Small Joints as Additional Potential Biomarker in Rheumatoid Arthritis: A Prospective Pilot Study.

A prospective pilot study was performed using microwave radiometry (MR), a noninvasive method detecting in-depth tissue temperature, to evaluate whether temperature-of-small-joint-derived scores correlate to parameters commonly used to assess disease activity in rheumatoid arthritis (RA). Ten patients with active, untreated RA underwent clinical and laboratory assessments and joint ultrasound and MR of hand and foot small joints at baseline and at 15, 30, and 90 days after treatment onset. Mixed-model analysis for repeated measures was used to compare patient characteristics in sequential visits. Twenty age- and sex-matched healthy individuals served as control subjects. Using 1248 MR-derived separate recordings from patients' joints, several thermoscores involving different joint combinations were created. When compared with clinical and ultrasound data, the best performing thermoscore involved temperatures of 16 joints (second to fifth metacarpal and proximal interphalangeal joints, bilaterally). This thermoscore correlated to the 28-joint Disease Activity Score-C-reactive protein, tender and swollen joint counts, patient's visual analog scale (all P ≤ 0.02), and the standard 7-joint ultrasound score (P < 0.03) and could also discriminate patients in high (mean, 9.2 [SD, 5.6]) or moderate (7.1 [SD, 3.5]) versus low disease activity/remission (4.2 [SD, 1.8]) (P ≤ 0.01) or healthy subjects (5.0 [SD, 1.7]) (P = 0.002). Microwave radiometry-derived increased in-depth temperature indicative of local inflammation of small joints may serve as an additional biomarker in RA. Optimization of MR-based methods may result in objective assessments of RA disease activity in clinical practice.

Sports Injury-Related Fingers and Thumb Deformity Due to Tendon or Ligament Rupture.

Background:Hand injuries are very common in sports, such as skiing and ball sports. One of the major reasons causing hand and finger deformity is due to ligament and tendon injury. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) can demonstrate the complex anatomy of the fingers and thumb, especially the tendons and ligaments, and provide the accurate diagnosis of clinically important fingers and thumbs deformity due to ligamentous and tendinous injuries during sport activities.Methods:Sixteen fresh un-embalmed cadaveric hands were harvested from eight cadavers. A total of 20 healthy volunteers' hands and 44 patients with fingers or thumb deformity due to sports-related injuries were included in this study. All subjects had MR examination with T1-weighted images and proton density-weighted imaging with fat suppression (PD FS) in axial, coronal, and sagittal plane, respectively. Subsequently, all 16 cadaveric hands were sliced into 2-mm thick slab with a band saw (six in coronal plane, six in sagittal plane, and four in axial plane). The correlation of anatomic sections and the MRI characteristics of tendons of fingers and the ulnar collateral ligament (UCL) at the metacarpal phalangeal joint (MCPJ) of thumb between 20 healthy volunteers and 44 patients (confirmed by surgery) were analyzed.Results:The normal ligaments and tendons in 16 cadaveric hands and 20 volunteers' hands showed uniform low-signal intensity on all the sequences of the MRI. Among 44 patients with tendinous and ligamentous injuries in the fingers or thumb, 12 cases with UCL injury at MCPJ of the thumb (Stener lesion = 8 and non-Stener lesion = 4), 6 cases with the central slip injury, 12 cases with terminal tendon injury, and 14 cases with flexor digitorum profundus injury. The ligaments and tendons disruption manifested as increased signal intensity and poor definition, discontinuity, and heterogeneous signal intensity of the involved ligaments and tendons.Conclusions:Sports injury-related fingers and thumb deformity are relatively common. MRI is an accurate method for evaluation of the anatomy and pathologic conditions of the fingers and thumb. It is a useful tool for accurate diagnosis of the sports-related ligaments and tendons injuries in hand.

Reliability of Metacarpal Subsidence Measurements after Thumb Carpometacarpal Joint Arthroplasty.

Thumb metacarpal subsidence after trapeziectomy can affect clinical function over time. Methods for measuring subsidence after trapeziectomy have been described, and they rely on an intact thumb metacarpal or proximal phalanx for measurement. The authors evaluated the reliability and reproducibility of measuring the trapezial space ratio, using previously described methods. In addition, the authors evaluated a new method that measures trapezial space on a posteroanterior (PA) hand/wrist radiograph that does not rely on an intact thumb metacarpal or proximal phalanx for measurement, which can often be altered by degenerative changes or in cases in which metacarpophalangeal arthrodesis is performed during carpometacarpal (CMC) joint arthroplasty to correct excessive hyperextension. The authors hypothesized that a new method of calculating trapezial space would have comparable reliability and reproducibility to previously proposed methods. Thirty-seven PA hand/wrist radiographs from patients who had trapeziectomy with ligament reconstruction and tendon interposition were evaluated. Trapezial space was measured using PACS (Picture Archiving and Communication System) digital tools as the distance perpendicular to the tangents of the scaphoid and first metacarpal joint surfaces. All X-rays were evaluated individually by five fellowship-trained hand surgeons, twice, 4 weeks apart. The reviewers calculated trapezial space ratios, using three different methods, two previously described and a novel one: (1) trapezial space relative to first metacarpal length (classic 1); (2) trapezial space relative to proximal phalanx length (classic 2); and (3) trapezial space relative to capitate height (novel). Inter- and intraobserver reliabilities were measured using intraclass correlation coefficients (ICC) and limits of agreement for each method. The authors identified excellent agreement between the classic 1, classic 2, and novel methods with an ICC greater than 0.8, indicating excellent agreement. The average trapezial space ratios for the thumb proximal phalanx, thumb metacarpal, and capitate methods were measured as 0.19, 0.12, and 0.24, respectively. The upper and lower limits of the 95% confidence intervals for both the inter- and intraobserver agreements of the aforementioned trapezial space ratios were (0.17-0.26), (0.11-0.17), and (0.21-0.34) for the interobserver rates and (0.11-0.25), (0.06-0.16), and (0.12-0.33) for the intraobserver rates, respectively. Measuring trapezial space is an important diagnostic tool to assess postoperative changes in thumb length. The trapezial space indexed to the capitate height method (novel) provides a simple and similarly reliable method for calculating the trapezial space ratio on a PA radiograph of the hand/wrist when other measurement techniques are unavailable and when the thumb metacarpal or proximal phalanx is not intact. The authors found a high degree of reproducibility and inter- and intraobserver reliability as measured by the ICC and the 95% limits of agreement that compare with previous agreements in the literature.

Clinical and Ultrasonic Evaluation of the Thumb: Comparison of Young Adults With and Without Thumb Pain With Text Messaging

ObjectiveThe aim of this study was to compare clinical and ultrasound findings of thumb joints in young adults with and without thumb pain associated with text messaging. MethodsIn this case-control study, 117 students with thumb pain associated with text messaging were evaluated clinically and with ultrasound analysis of the thumb. Age- and sex-matched controls received ultrasound evaluation to note any subclinical changes. ResultsClinical examination in the cases identified tenderness most commonly in the metacarpophalangeal joints, followed by the carpometacarpal joints, and then the interphalangeal joints. Tenderness was noted in the web space and the anatomic snuff box. Hypermobility on the Beighton scale was recorded as 2. Grind tests were positive in 21% of participants. Grip strength did not differ, but lateral and tip pinch strength were significantly reduced in the cases compared with controls. Fluid was detected in the metacarpal joints by ultrasound but not in the carpometacarpal or interphalangeal joints. No changes were detected in the controls. ConclusionClinical examination indicated involvement of all joints of the thumb, but ultrasound evaluation could identify changes only in metacarpal joints, indicating signs of possible subclinical changes taking place in the thumb in these participants as a result of repetitive use.

The peritrapezial view: New radiograph for evaluating joints around trapezium.

The purpose of this study was to present a new radiograph of peritrapezial view and examine whether this view could supply clear and reliable radiographs of the joints around trapezium. The radiographs of peritrapezial and Robert views were taken on both hands of the 30 healthy volunteers (15 men and 15 women). The four peritrapezial joints were evaluated by two trained hand surgeons to find out whether these views could clearly show the joint spaces around the trapezium. Intra- and interobserver agreement for evaluation of each joint space and the ratio of joints which both of the two observers rated as clear joint space were compared between peritrapezial and Robert views. The κ values of inter- and intra-observer reliability were, respectively, 0.559 and 0.715 in peritrapezial view and 0.462 and 0.355 in Robert view. The ratios of joints, which both of the two observers rated as clear joint space in each of the two time evaluations, were slightly higher in peritrapezial view than Robert view for the thumb carpometacarpal (100% vs. 96.7%) and scaphoid-trapezium joints (100% vs. 93.3%). In addition, these ratios were significantly higher in peritrapezial view than Robert view for the trapezium-index metacarpal (90.0% vs. 46.7%, p < 0.001) and trapezium-trapezoid joints (93.3% vs. 50.0%, p < 0.001). The peritrapezial view clearly shows the joint spaces around the trapezium. This view showed better inter- and intra-observer reliability for peritrapezial joints than Robert view especially in trapezium-index metacarpal and trapezium-trapezoid joint. This radiograph could provide a preliminary step for evaluating and managing pathologies of the peritrapezial joints.

Ultrasonographic characterization of the ulnar collateral ligament of normal thumbs in different age groups

OBJECTIVES:The aim of this study was to perform ultrasonographic characterization of the normal ulnar collateral ligament in different age groups and compare it in men and women and in dominant and nondominant hands.METHODS:Forty right-handed volunteers in the age groups 20–30, 31–40, 41–50, and 51–60 years without a history of trauma or surgical procedure in the studied joint were evaluated. The studied parameters were ligament length, greatest ligament thickness, ligament longitudinal section area in the longitudinal plane, distance from the aponeurosis of the adductor muscle to the metacarpal head surface and joint opening at rest and under abduction stress.RESULTS:The results indicated that the mean values of all parameters had minor variations with age, hand dominance, and gender and were slightly higher in men than in women and in the dominant hand than the nondominant hand. However, a statistically significant difference was observed between the joint opening at rest and under stress. In terms of age, there was a small but nonsignificant decrease in the values, likely because of the natural aging process.CONCLUSION:The low variability in the evaluated parameters indicates that large differences between sides or genders are not to be expected. A greater change is likely to indicate a pathological situation.

Three cases of dermatomyositis presenting with inverse Gottron′s papules

Three cases of dermatomyositis presenting with inverse Gottron′s papules were reported. Of the 3 patients, there were 2 males and 1 female aged 43, 41 and 46 years respectively, whose disease durations were 1, 6, 7 months respectively. Inverse Gottron′s papules manifested as papules overlying the palmar aspect of the metacarpal and interphalangeal joints, which were arranged in a linear pattern in 2 cases. Of the 3 cases, 1 presented with interstitial pneumonia, 3 with myositis, and 2 showed negative anti-nuclear antibody test. Histopathological examination of inverse Gottron′s papules in 1 case revealed focal liquefaction degeneration of basal cells and perivascular infiltration with inflammatory cells, especially lymphocytes, in the superficial dermis. The 3 patients received oral glucocorticoids and immunosuppressive agents in the early period of treatment. After 3-month treatment, clinical symptoms including muscle weakness and muscle pain were improved evidently, but no obvious improvement in inverse Gottron′s papules was observed. After 1-year treatment, these papules on the palmar aspect were markedly relieved in 1 case. Key words: Dermatomyositis; Lung diseases, interstitial; Inverse Gottron′s papules

Quantitative evaluation of hand functions using a wearable hand exoskeleton system.

To investigate, improve, and observe the effect of rehabilitation therapy, many studies have been conducted on evaluating the motor function quantitatively by developing various types of robotic systems. Even though the robotic systems have been developed, functional evaluation of the hand has been rarely investigated, because it is difficult to install a number of actuators or sensors to the hand due to limited space around the fingers. Therefore, in this study, a hand exoskeleton was developed to satisfy the required specifications for evaluating the hand functions including spasticity of finger flexors, finger independence, and multi-digit synergy and algorithms to evaluate such functions were proposed. The hand exoskeleton was composed with the four 4-bar linkages, two motors, and three loadcells for each finger, and it was able to flex/extend the metacarpal (MCP) and proximal interphalangeal(PIP) joints independently while measuring the pulling force at each phalanx. Using the hand exoskeleton, the hand functions of the three healthy subject were evaluated and the experimental results were analyzed.

Novel isometric exercises for the dynamic stability programs for thumb carpal metacarpal joint instability

Novel isometric exercises for the dynamic stability programs for thumb carpal metacarpal joint instability

Training the “clinical eye”. Rubens’ Three Graces: how many pathologies?

Art can serve as a powerful resource for medical students to both train the so called “clinical eye” and to better understand disease [1]. Herein a paleopathological analysis is performed on one of Ruben’s final artworks, “The Three Graces” (1630-1635; oil on oak panel; 220.5 x 182 cm; Museo del Prado, Madrid). Rubens depicts the three Graces beside a fountain, under a garland of flowers in a landscape. The circular rhythm and elegant undulation are based on classical sculpture. Painted shortly after his marriage, it bears witness to the happiness of the artist’s life. The figure on the left is directly inspired by his second wife, Helene Fourment (23 years old); the central and right Graces probably illustrate Rubens’ sisters-in-law. Besides overweight, scoliosis, and hyperlordosis observed in all three Graces, the left Grace evidences flat feet; hyperextension of the right metacarpal joints; signs of rheumatoid arthritis (even fibromyalgia has been proposed); lateral deviation of the nipple (Mondor’s disease?); varicose thighs, and right hallux vagus. The central Grace (Clara Fourment?), in turn, shows cellulite and, interestingly, positive Trendelenburg sign. Finally, the Grace on the right -Susanna Fourment- has been subject of a long debate on signs of a locally advanced breast cancer in the left external upper quadrant. In fact, several specialists agree in the observation of signs of an open ulcer; redness of the surrounding skin (an inflammatory sign); nipple retraction; reduction of the left breast volume, and enlarged axillary lymph nodes [2-3]. Rubens was one of main Baroque and realist painters, i.e. he painted whatever his eyes captured. If the Graces were sisters, then they are likely to share genetic traits. The latter, together with all the other signs described, favour the working diagnosis of familial benign hypermobility syndrome. Observation has a key role in clinical medicine; the paleopathological observation in art show us how artists could record abnormalities long before doctors did [2]. Therefore, artworks still represent useful teaching tools for refining visual skills in traditional and innovative medical education.

Hallazgos gammagráficos en manos de población adulta, sin patología osteoarticular, bajo un análisis semicuantitativo

IntroductionBone and joint disease has a high incidence and impact on the population. The bone scan is a diagnostic tool that provides important metabolic and clinical information, therefore the interpretation of the images by the nuclear medicine physician must be very precise. The isotopic distribution pattern in hands has not yet been described. For this reason a description is presented of common scintigraphic findings in adults without osteoarticular disease. Materials and methodsA prospective analysis was conducted on 156 hands of patients whose bone scans met inclusion criteria. There were delineated regions of interest in the carpal, metacarpal, proximal, and distal interphalangeal joints of the second and third fingers of both hands. An analysis was made, including the total counts, means, and standard deviations. The cut-offs were selected using the normal distribution, which was defined as the cut at the 99th percentile of each variable. A semi-quantitative analysis was made of the images. ResultsThe study included 36 men (23%) and 119 women (77%), and the mean age was 44.9± 13.9. The mean total counts gradually decreased from proximal to distal in all age groups and in both genders in the following proportions: the activity in carpus was 4.4 fold more than the metacarpus; the metacarpus was 1.7 fold more than proximal interphalangeal joint; proximal interphalangeal joint was 1.4 fold more than distal one. ConclusionsA scintigraphic pattern consisting of a gradual decrease from proximal to distal joints (degradation) was found in the hands of adults without bone and joint disease, regardless of gender and age.