Metacarpophalangeal Articulation Research Articles

Translated article] Prospective study about orthopaedic treatment of fifth metacarpal neck fractures

IntroductionThe fifth metacarpal neck fracture is traditionally treated with closed reduction and intrinsic plus cast immobilisation. Another alternative and more functional treatment is the syndactylia. The aim of our study is to compare both treatments searching for any differences in their functional outcomes. MethodWe did a prospective, controlled, masked, randomised cohort study with patients over 18 years old attended from May 2019 to May 2020 in Vigo's Sanitary Area with this injure and an angle below 40°. The collected data was: sex, age, fracture angle, range of motion of the metacarpophalangeal articulation (MCFA), grip strength, pain, fracture consolidation, Quick DASH and comfort 4 and 6 weeks after the injury. Results39 men and 1 woman were included in the sample. 36.1 years old as the age average. 90% of the injuries affected the right hand, being all the patients right-handed, finding statistically significant differences in MCFA flexion within 4 weeks and in grade of discomfort, both in favour of the syndactylia (p<.05). Any of the other collected data was statistically significant. Every fracture achieved consolidation at the end of the follow-up. ConclusionFollowing the results, we consider both immobilizations good treatment options of these fractures; nevertheless, syndactylia has proven an earlier MCFA flexion recovery and a better tolerance.

Estudio prospectivo sobre el tratamiento conservador de las fracturas de cuello de quinto metacarpiano

IntroductionThe fifth metacarpal neck fracture is traditionally treated with closed reduction and intrinsic plus cast immobilization. Another alternative and more functional treatment is the syndactylia. The aim of our study is to compare both treatments searching for any differences in their functional outcomes. MethodWe did a prospective, controlled, masked, randomized cohort study with patients over 18 years old attended from May 2019 to May 2020 in Vigo's Sanitary Area with this injure and an angle below 40°. The collected data was: sex, age, fracture angle, range of motion of the metacarpophalangeal articulation (MCFA), grip strength, pain, fracture consolidation, Quick DASH and comfort 4 and 6 weeks after the injury. Results39 men and 1 woman were included in the sample. 36.1 years old as the age average. 90% of the injuries affected the right hand, being all the patients right-handed, finding statistically significant differences in MCFA flexion within 4 weeks and in grade of discomfort, both in favour of the syndactylia (p<0.05). Any of the other collected data was statistically significant. Every fracture achieved consolidation at the end of the follow-up. ConclusionFollowing the results, we consider both immobilizations good treatment options of these fractures; nevertheless, syndactylia has proven an earlier MCFA flexion recovery and a better tolerance.

Pheochromocytoma presenting as an authentic small vessel vasculitis and complicated with pulmonary embolism: An original presentation

Diagnosis of pheochromocytoma can be simple when classic manifestations are present. It can also be challenging and complicated in some cases because of its wide array of faces and presentations. We present a case of a 30-year-old female patient who came with acute respiratory distress, chest pain, hemoptysis, asthenia, anorexia, weight loss of 20kg, and paresthesia in her lower limbs. Clinical examination found high blood pressure, accelerated heart and respiratory rates, signs of acute right heart failure with jugular venous distention and ankle edema, reticularis livedo in the four limbs, ulcers in both knees and in the 3rd metacarpo-phalangeal articulations and necrotic lesions in both calcaneal tendons and in the right toes. Further investigations concluded on myocarditis associated with alveolar hemorrhage, pericardic and pleuritic effusions and a segmental pulmonary embolism of the right inferior lobe. Neuro-muscular biopsy was suggestive of myositis. Cutaneous biopsy found nonspecific chronic dermatitis. ANCA antibodies were tested twice and were negative. Cryoglobulinemia was also negative. Thoraco-abdomino-pelvic scan was performed showing a large right adrenal mass suggestive of pheochromocytoma. Diagnosis of right adrenal pheochromocytoma was confirmed by MIBG-I123 hyperfixation findings and urinary normetanephrin levels. The patient was treated surgically. Postoperative outcomes were remarkably favorable with a complete regression of the cutaneous lesions and normalization of the blood pressure. Paresthesia significantly decreased. Control echocardiography at 3 months showed an improved heart function with a persistent apical and septal akinesis.

Sites of Anesthetic Block of the Lateral and Medial Palmar Metacarpal Nerves in Equines of Indeterminate Breed

Background: Local anesthesia blockage at equines claudication diagnosis besides favoring the beginning of the therapy and relieving patient’s pain, it allows the identification of the specific affected region and its origin, however, if it is done incorrectly (by improper volume of anesthetics application and/or mistakenly nerve identification due to the lack of anatomic referential) it may cause inflammation, infection or even tissue necrosis. The aim was describing anatomically lateral and medial palmar metacarpal nerves in equines to improve diagnostic anesthetic block techniques on four metacarpophalangeal articulation joints of the specie.Materials, Methods &amp; Results: A number of 20 thoracic limbs from 10 equines of indeterminate breed were used to be fixated in 10% phormaldehyde and with a marked arterial system by water solution of red dyed latex. The structures were identified by dissection, and their denomination bases on Nomina Anatomica Veterinaria (N.A.V.) by the International Committee on Veterinary Gross Anatomical Nomenclature. The study had been approved by the Board of Ethics in Animal Use of the University Center of Patos de Minas (UNIPAM), protocol n° 18/17. The lateral and medial palmar metacarpal nerves have been observed in all of the specimens originated from the deep branch of lateral palmar nerve, immediately distal to the intercarpal articulation. After its origin, the first nerve stretched ipsilaterally from the common trunk, whilst the second nerve positioned counter-lateral manner after superficially crossing the interosseus muscle. Both penetrated at the level of the mid third of the referred muscle and the metacarpal bone III and, assumed respectively a parallel medial position to the metacarpal bone IV and lateral to the metacarpal II, being intimately associated to the palmar face of the metacarpal bone III. Distally, those nerves emerged from a palmar position to a lateral and medial to the distal extremity of the metacarpal bones, corresponding and adjacent to the metacarpophalangeal articulation palmar recession, where they had finally ramified to partially innervate the associated articular capsule and the subcutaneous tissue of the region.Discussion: The lateral and medial palmar metacarpal nerves present similar origin and disposition to the above described, however, besides largely mentioned in literature, we point out here as recommended by N.A.V., no use of terms like axial and abaxial as position indicators for equine. As a part of block anesthetic diagnosis of four metacarpophalangeal articulation points, it is hereby suggested for the studied nerves desensitization, should be palpated the distal extremities of the metacarpal bones IV and II. After the identification, using thumb located from the extremity at proximal direction way, introduce the needle bilaterally for 1.5 cm downright between the above mentioned metacarpal bones and the interosseus muscle, being these latter and the flexor muscle tendons drawn in the palmar direction. Thus, it becomes valid to affirm that the technique of four-point diagnostic anesthetic block of the metacarpophalangeal articulation has been perfected for equines, and that it will limit the chances of false results on account of misplaced puncturing of nearby structures, such as, for example, the synovial recesses, mentioned as the location of the utmost gravity, hence septic synovitis may come in play.

NEW CLASSIFICATION CRITERIA FOR SCLERODERMA SYSTEMATICA (a lecture)

In 1980, the American College of Rheumatology proposed the first criteria as tentative for the diagnosis of scleroderma systematica (SDS). These criteria were aimed at revealing the comprehensive picture of mainly the diffuse form of the disease. They could not timely make a diagnosis in the low manifestive forms of the disease or virtually reveal its early stages that were most therapeutically promising. The review traces the evolution of approaches to diagnosing SDS and considers the novel classification criteria elaborated to select patients for epidemiological surveys and clinical trials. They include 8 parameters, each having scores. Skin thickening on both hands above the metacarpophalangeal articulations was highest (9 scores). The clinical variants of skin thickening on the fingers as its swelling (2 scores) or sclerodactyly (4 scores) are estimated from the maximum scores, as digital ischemia (sores, 2 scores; cicatricles, 3 scores). Teleangiectasias and characteristic capillaroscopic changes, as well as leading lung injury (pulmonary hypertension and/or interstitial lung disease) are rated as 2 scores each. Three scores are added to the total amount when Raynaud's syndrome is present and SDS-specific (anti-Scl-70, anti-centromere, and anti- RNA polymerase III) autoantibodies are detected. The patients gaining a total of 9 scores or more are classified as having definite SDS. Testing the novel criteria on a validation sample of 405 people showed that their sensitivity and specificity were 91 and 92%, respectively.

Allometry as evidence of sexual selection in monochromatic birds: the case of the Coscoroba Swan (Anseriformes: Anatidae)

The Coscoroba Swan, Coscoroba coscoroba (Molina, 1782), is a poorly known aberrant Anserine endemic to South America. We captured adult birds (189 male, 157 female) from the largest population in Brazil at the Taim Ecological Reserve, State of Rio Grande do Sul, Brazil. Different patterns between sexes can reflect differences in selection, and positive allometry may indicate that a character is sexually selected. We used body weight and 10 morphological measurements to examine allometric differences between males and females of C. coscoroba. Males were consistently larger than females. Analysis of scaling relationships against body mass showed that nostril, tail, wing and bill height were positively allometric (i.e., heavier birds had relatively larger character lengths), but there were no sexual differences in allometric slopes. However, for a given mass, mature females had longer tails, longer wings (up to metacarpophalangeal articulation) and shorter heads than males. In the light of current debate in the literature, we discuss whether such positively allometric traits and sexual differences in scaling may be indicative of sexual selection. Although Coscoroba Swan is a monogamous species, increasing the size of some attributes may confer some advantage for mate selection or male-male competition and, contrary to other studies, we suggest that positively allometric slopes alone should not be considered as evidence for sexual selection of the considered traits.

Reproducibility and influence of hand rotation on computer-aided joint space analysis

ObjectivesComputer-aided joint space analysis (CAJSA) is a recently developed, semi-automated tool to aid in the measurement of joint space margins based on hand radiographs. The objective of this study is to verify the potential effect of hand rotation during X-ray imaging on the measurement of joint space width using CAJSA and to evaluate the reproducibility of the CAJSA technique in healthy subjects and in patients with rheumatoid arthritis. MethodsAll joint space distance (JSD) measurements were performed using CAJSA-technology at the metacarpophalangeal articulation based on conventional and digital hand radiographs. ResultsI. Hand rotation showed an effect on the reproducibility with CV ranging between 0.39% (angulation 1°) and 1.66% (angulation 19°). II. Regarding the overall reproducibility of the CAJSA method, the intra-radiograph reproducibility of JSD was calculated with CV=0.54% for conventional images and CV=0.38% for digital images. The inter-radiograph reproducibility error was observed with CV=0.66% (conventional images) and CV=0.63% (digital images). III. The study revealed a reproducibility for CAJSA measurements in RA ranging between 0.37% (JSD-MCP ring finger; van der Heijde-modification of the Sharp method Score 1) to 1.37% (JSD-MCP index finger; van der Heijde-modification of the Sharp method Score 3). ConclusionCAJSA measures JSD at the metacarpophalangeal articulation with high reproducibility in healthy subjects and in patients with differing stages of rheumatoid arthritis. Additional findings show that hand rotation during X-ray imaging has an impact on the CAJSA measurements; thus avoiding acquisition of hand radiographs with a rotation error of more than 15 degrees can be recommended.

Modelling tendon excursions and moment arms of the finger flexors: Anatomic fidelity versus function

A detailed musculoskeletal model of the human hand is needed to investigate the pathomechanics of tendon disorders and carpal tunnel syndrome. The purpose of this study was to develop a biomechanical model with realistic flexor tendon excursions and moment arms. An existing upper extremity model served as a starting point, which included programmed movement of the index finger. Movement capabilities were added for the other fingers. Metacarpophalangeal articulations were modelled as universal joints to simulate flexion/extension and abduction/adduction while interphalangeal articulations used hinges to represent flexion. Flexor tendon paths were modelled using two approaches. The first method constrained tendons with control points, representing annular pulleys. The second technique used wrap objects at the joints as tendon constraints. Both control point and joint wrap models were iteratively adjusted to coincide with tendon excursions and moment arms from a anthropometric regression model using inputs for a 50th percentile male. Tendon excursions from the joint wrap method best matched the regression model even though anatomic features of the tendon paths were not preserved (absolute differences: mean<0.33 mm, peak<0.74 mm). The joint wrap model also produced similar moment arms to the regression (absolute differences: mean<0.63 mm, peak<1.58 mm). When a scaling algorithm was used to test anthropometrics, the scaled joint wrap models better matched the regression than the scaled control point models. Detailed patient-specific anatomical data will improve model outcomes for clinical use; however, population studies may benefit from simplified geometry, especially with anthropometric scaling.

Implementation of Z-Scores as an Age- and Sex-independent Parameter for Estimating Joint Space Widths in Rheumatoid Arthritis

To compare normative data of joint space distances (JSD) with the JSD of patients with rheumatoid arthritis (RA) as measured by computer-aided joint space analysis (CAJSA) at the metacarpophalangeal (MCP) articulations, and to differentiate age- and sex-related alterations from the disease-related joint space narrowing. In total, 256 healthy subjects and 248 patients with verified RA (following revised ACR criteria) underwent computerized semiautomated measurements of JSD (CAJSA, version 1.3.6) at the MCP articulation (JSD-MCP) based on digital radiographs. The Z-score, a comparative parameter that differentiates joint space alterations caused by RA-related cartilage destruction from age- and sex-related changes, was calculated. Our data showed a relationship between measured joint space widths (MCP total and MCP thumb to little finger) and age for healthy subjects and also the RA group. The RA group revealed an age-related joint space narrowing that was surpassed by the RA-related narrowing of joint space widths classified by Sharp joint space narrowing score and resulting in smaller Z-scores for RA patients. The CAJSA technique seems to distinguish age-related JSD changes in healthy volunteers from RA-induced alterations. In addition the Z-score was also able to differentiate RA-dependent narrowing of JSD. Calculation of the Z-scores based on sex- and age-specific reference data may facilitate earlier identification of patients with RA, allowing initiation of a more optimal, individually adapted therapeutic strategy.

Effects of leflunomide and methotrexate in rheumatoid arthritis detected by digital X-ray radiogrammetry and computer-aided joint space analysis

The aim of the present study was to evaluate the effect of long-term leflunomide and methotrexate (MTX) therapy during the course of rheumatoid arthritis (RA) estimated by digital X-ray radiogrammetry (DXR) and computer-aided joint space analysis (CAJSA) as diagnostic tools for the quantification of disease-related periarticular osteoporosis and joint space narrowing. Fourty matchable patients with verified RA were treated with leflunomide or MTX during an observation period of 2.5 years. All patients underwent complete computerized calculations of bone mineral density (BMD) and metacarpal index (MCI) by DXR as well as semi-automated measurements of joint space widths (JSW) at the metacarpophalangeal articulations (MCP, thumb to small finger) and proximal interphalangeal joints (PIP, index finger to small finger) using digitized hand radiographs. DXR-BMD revealed an increase of 0.4% (leflunomide-group) versus a reduction of -9.1% (MTX-group). Regarding DXR-MCI, a reduction of -1.1% (leflunomide-group) and -5.3% (MTX-group) was observed. The CAJSA parameters showed a decline of -2.7% (JSW-MCP) versus -2.1% (JSW-PIP) in patients treated with leflunomide. An accentuated joint space narrowing was revealed (JSW-MCP: -5.7%; JSW-PIP: -6.2%) in the MTX group. Digital X-ray radiogrammetry and CAJSA could discriminate the influence of different therapeutic regimes on periarticular osteoporosis and joint space narrowing showing a less accentuated radiographic progression in patients treated with leflunomide.

Le premier rayon de la main et du pied chez les primates (II). Anatomie fonctionnelle

To study the articular amplitude of the first ray of both hands and feet using passive mobilisation, either on fresh human cadavers or on living primates after anesthesia (namely eight pongidae, 15 cercopithecidae, two platirrhinii, eight lemuroidae, three daubentonidae, two loridae and two galagonidae). Plans slightly parasagittal and parafrontal have been chosen to obtain the maximum dorsal and palmar or plantar inclinations and the maximum lateral and medial inclinations. The pronosupination of the first ray has been evaluated in relation of these plans and alike for the hand of the simian primates on the plan of the concavity and the convexity of trapezial surface. The results have been compared with these obtained in the man. The pronosupination of the first ray, so denominated by analogy with the pronosupination of the fore-arm is the movement which allows the pulp of the thumb or of the hallux to look now forward or now backward in order to be opposed at the other fingers during the pollici- or the hallucidigital pinch. It can be considered like "effective" unless if there is rotation around the longitudinal axis of its metacarpus (or metatarsus). The prosimian primates had great and sensibly similar circular amplitude of their first metacarpus and first metatarsus, which reached more than 90 degrees in all the directions. It allowed a pronosupination of 90 degrees, but this was only "apparent" because it has been obtained by the alone combined action of the two orthogonal axes at the basis of the ray by simple effect of cardan joint. The anthropoids had only limited circular amplitude, not exceeding 45 degrees. It was associated with an "effective" pronosupination according to a longitudinal axis. The rotation reached 90 degrees. It was produced around the point of anchorage made up by the medial ligaments for the trapezometacarpal articulation and the lateral ligaments for the cuneometatarsal. This movement was possible because of the peculiar relief of the articular surfaces: modified cardan for the trapezometacarpal and spiraled trochoid for the cuneometacarpal joint. The man was the sole primate, which had practically no mobility at the level of the first ray of his foot. However, the morphology of his cuneometatarsal articulation was similar to that of the other anthropomorphous primates. The muscles which was inserted on the first metacarpus (or metatarsus) played an active role in the circular amplitude and in the apparent circular amplitude, but very discreet in the effective circumduction. The transversal fascicle of the short abductor of the thumb and of the hallux had a little pronator effect. At the level of the foot, the tendon of the fibular longus had an action of pronation and the abductor longus muscle an action of supination. The metacarpophalangeal and the metatarsophalangeal articulations of all the primates were condylar with laterality movements, which were able to reach 40 degrees and which were then unsteady. The metacarpophalangeal articulation of the man was the single exception. He was the sole one with a really steady thumb.

Investigation of Ossification Pattern of Structures of Equine Metacarpophalangeal Articulation with the Aid of Digital Imaging Segmentation and Processing Techniques: A Preliminary Report

Radiographs, taken at lateromedial (LM) view, were obtained from metacarpophalangeal articulations of 25 horses of variable ages, ranging from 2 to 20 years, as well as a few of undetermined ages. Images of radiographs were acquired as digitized images with the aid of high-resolution (megapixel) digital cameras directly from lighted platforms, and the acquired 24-bits bitmap formatted images were converted to 8-bit grayscale tagged-image format (TIF) images. The TIF images were processed by a technique involving an on-screen quantitative evaluation of spot pixel intensity values in the digitized images, followed by monadic arithmetic pixel subtraction and addition. A color mapping of the pixels into their respective red and blue sub-spectra of the RGB spectrum also was performed. The entire processing operation was accomplished through the use of a standard digital imaging software. The results demonstrate typical bands of possible ossification pattern within the diaphyses , metaphyses , and the epiphyses of the articulating metacarpal and proximal phalanx in the processed radiographic images compared with their nonprocessed counterparts. The relevance of this novel observation, although preliminary, lies in the prospects of assessing pre-race skeletal health status of horses through a cost-effective, simple, and reliable method.

Quintus varus supraductus congénital : technique chirurgicale

Quintus varus supraductus is a congenital malformation that associates a hyperextension, a varus and an external rotation of the fifth toe coming over the fourth. The goal of this study is to explain an easy, reproductible and efficient surgical procedure to correct that malformation. Our procedure is only about soft tissues. It comprises a fifth toe extensor tenolysis, a circular capsulotomy and lateral ligament section of the fifth metacarpophalangeal articulation. The glenoid plaque is desinserted only if the peroperative reduction did not seem sufficient. The stabilization is achieved through a cutaneous plasty of modified BUTLER, with a cutaneous lengthening VY plasty. Exceptionally, an axial broaching of the articulation has been done. On about 20 children, aged 4–17 years, operated with this procedure, we have noticed a complete and definitive correction in 19 patients. Only one patient showed an incomplete resurgence, but without any functional disturbance. We did not notice any failure. This procedure seems efficient, and all the more interesting that it is technically easy to perform.

Antley-Bixler syndrome: description of two patients

The Antley-Bixler syndrome comprises malformations of cartilage and bone. The essential signs are a dysmorphic facies with flattening of the central region of the face, humeroradial synostosis with flexed attitude of the upper limbs and swelling of the distal interphalangeal and metacarpophalangeal articulations. Congenital atresia of the nasal choanae, which is often present, makes the prognosis of this syndrome extremely severe. Two patients affected by the syndrome are described. Atresia of the nasal choanae was absent in both. The first patient had genital ambiguity, a condition which has been described in the literature in only two other cases; the second one had all the fundamental characteristics of the syndrome except for humeroradial synostosis, although hypoplasia of the lateral condyle of the humerus and dislocation of the radius are present in association with synostosis between the 2nd metatarsal and the intermediate cuneiform.

The mechanical role of the digital fibrous sheath: application to reconstructive surgery of the flexor tendons.

The movements of flexion of the digital articular chain are dependent upon a vast functional complex comprising the long flexor tendons, their antagonist long extensor tendons, and the coupled action of the interosseous and lumbricales muscles. Based on theoretical biomechanical data backed up by experimental investigation, the authors emphasize the important role of the digital fibrous sheath in the mechanism of action of the long flexor tendon. Any proximal resection (even of minor degree) of the proximal pulley of the digit induces severe mechanical disturbances by enhancing flexion of the metacarpophalangeal joint to the detriment of the proximal interphalangeal joint. Conversely, distal resection of the pulley enhances flexion of the interphalangeal joint to the detriment of the metacarpophalangeal articulation, although the resulting abnormalities are less pronounced than those due to proximal resection. The fibrous pulley plays a role in tendinous orientation in the frontal plane and in digital orientation of the index finger where the angulation between the pulley and flexor tendon is most pronounced. In this latter case ulnar deviation of the second finger occurs on flexion. Reconstructive surgery of the long flexor tendons requires that the digital fibrous sheath, especially its proximal segment, be preserved. The metacarpophalangeal joint seems to be the most vulnerable to morphological modifications of the pulley, as stressed from the anatomical standpoint by the absence of insertion of the long flexor tendons on the proximal phalanx.

La mobilisation précoce des fractures des métacarpiens et des phalanges

Early mobilization of fractures of the metacarpals and phalanges is advocated. It should begin as soon as the stability of the fracture and the condition of the soft tissues permits. It has to be adapted to each case, and often consists of mobilization of the distal phalanges with the wrist and metacarpophalangeal articulations immobilized in a protective position. It is effective in preventing stiffness. Because it is a specific technique, it must be entrusted to specially trained physiotherapists, and requires regular and repeated clinical and radiologic follow up by the surgeon.

SYNOVIAL LESIONS OF THE SKIN

Attention was first called to synovial lesions of the skin by Hyde1in 1883. More recently the subject has been discussed by Lingenfelter,2Ormsby,3and Sutton.4 Synovial lesions of the skin occur over the dorsal aspects of the interphalangeal, metacarpo-phalangeal and metatarso-phalangeal articulations. The most frequent situation is over the dorsum of the articulation between the distal and adjacent phalanges of the index finger and thumb. There is usually a history, extending at least over several months, of the appearance in one of these situations of a small, globular projection from the skin, which is insensitive unless roughly handled, and which slowly develops to the size of a large pea. When punctured a syrupy, whitish, yellowish or brownish, fluid exudes, occasionally mingled with masses like sago grains. As the lesion develops, it ordinarily assumes the appearance of a vesicle or bulla; some lesions have only an

The Migratory Needle Story.

Mescalero, N. M., Nov. 24, 1906. To the Editor: —In response to the editorial inThe Journal, Nov. 17, 1906, urging that cases presenting the phenomena of migration be reported, the following report is made: E. S., German, blacksmith, presented himself at my office, April 18, 1906, and showed me a pea-sized tumor on the upper outer aspect of the metacarpophalangeal articulation of the index finger of the right hand. The tumor was slightly tender on pressure, easily movable, and had a hard, gristly feel. He gave as a history that 14 years ago, while working over his anvil a small piece of his hammer flew off and embedded itself in the right side of his neck just under the angle of the jaw. From his description of the bleeding, evidently an artery was severed. It required the services of two physicians and several hours' time to arrest the hemorrhage

Lacerated Wound of the Fetlock, with Complete Dislocation of the Metacarpo-Phalangeal Articulation

Lacerated Wound of the Fetlock, with Complete Dislocation of the Metacarpo-Phalangeal Articulation