Validation of the range of dry needling with the fascial winding technique in the carpal tunnel using ultrasound.

OBJECTIVES: To use ultrasound imaging to show how the needles in dry needling applied in the carpal tunnel can reach the transverse carpal ligament, acting on it in the form of traction-stretching when the fascial winding technique is performed. The potential associated risks are also assessed. DESIGN: Validation study. PARTICIPANTS: Healthy volunteers (n = 18). METHODS: Four dry needling needles were applied to the carpal tunnel, only using anatomical references, according to the original approach known as "four-pole carpal dry needling", and manipulating the needles following the so-called fascial winding technique according to the authors, in the form of unidirectional rotation. An ultrasound recording of the distance reached was then performed, and compared with the mechanical action achieved on the transverse carpal ligament. RESULTS: 93.1% of the needles placed came into contact with the transverse carpal ligament with traction-stretching of the ligament observed when the needles were manipulated with the fascial winding technique in 80.6%. The mean distance from the tip of the needle to the median nerve was 3.75 mm, with CI95% [3.10, 4.41] and it was 7.78 mm with CI95% [6.64, 8.91] to the ulnar artery. Pain immediately after the technique concluded was of mild intensity, almost nil 10 min later, and non-existent after one week. CONCLUSION: Dry needling with fascial winding technique in the carpal tunnel using the four-pole carpal dry needling approach is valid for reaching and traction of the transverse carpal ligament, and may stretch it and relax it. It is also safe with regard to the median nerve and ulnar artery, with a very mild level of pain.

Dimensional changes of the carpal tunnel and the median nerve during manual mobilization of the carpal bones.

INTRODUCTION: The carpal tunnel is a clinically important fibro-osseous conduit for the median nerve and associated tendons. It is mechanically dynamic, such that the dimensions of the tunnel and median nerve change with position, movement and application of externally applied force with mechanical devices. Therapeutic manual techniques that appear to move and change tunnel shape are part of clinical practice. The aim of this study was therefore to measure changes in dimensions of the carpal tunnel and median nerve with manual mobilization of the carpal bones. MATERIAL AND METHODS: An analytical descriptive study with 18 volunteer subjects and a total of 33 records was designed. Ultrasound measurements of the cross-sectional area (CSA), anteroposterior diameter (APD), transverse diameter (TD), perimeter, flattening ratio and circularity of the carpal tunnel and of the median nerve, were measured, both in the anatomical position of the wrist and during mobilization techniques of the carpal bones. RESULTS: During the mobilization technique, the tunnel (p = 0.003) CSA significantly increased. APD also increased significantly for the tunnel (<0.001) while TD decreased. The median nerve showed similar and significant (p < 0.001) changes than the tunnel. However, because several of the obtained differences where smaller than the SDD obtained in a previous study, these differences were considered as irrelevant. CONCLUSIONS: Manual mobilization of the carpal bones produced significant changes in the dimensions of the carpal tunnel.

Osteopoikilosis: a major diagnostic problem solved by bone scintigraphy.

Osteopoikilosis (OPK) is a rare disease with an unknown etiology. Although a benign condition, it may lead to diagnostic problems when the patient undergoes diagnostic imaging of the skeletal system due to various reasons like malignancy. Herein, we report 2 cases with OPK causing difficulties in the final diagnosis of the cases which was resolved with the contribution of bone scintigraphy and clinical follow-up.

Osteopoikilosis.

INTRODUCTION: Osteopoikilosis is a rare and asymptomatic disease of the bone that is often discovered incidentally on radiography. On a plain radiograph it is manifested by multiple, small, circular or oval shaped radio-dense lesions which are diagnostic for this condition and are often mistaken for metastatic disease. MATERIALS AND METHODS: We present the case of a 24-year-old female patient with osteopoikilosis diagnosed incidentally on radiographs. CONCLUSION: Osteopoikilosis is a benign sclerosing dysplasia of bone of unknown aetiology that requires no specific treatment.

Osteoid osteoma of the carpal bones. Two case reports.

Osteoid osteoma rarely develops in the wrist. The symptoms resemble atypical tenosynovitis, with variations according to the location of the tumor. As a result, diagnostic wanderings are common. In addition, the pain may seem related to an injury, as illustrated by two cases reported herein. Conventional investigations often fail to contribute to the diagnosis. The most specific investigation is thin-slice computed tomography (CT), which can be coupled to magnetic resonance imaging. CT typically visualizes a round lucency surrounded by a rim of sclerosis; in addition, CT shows the exact location of the tumor, particularly relative to neighboring joints. Complete excision of the nidus must be achieved to ensure a permanent cure. Same-stage carpal bone fusion may be required in patients with extensive joint involvement.

Carpal bone maturation assessment by image analysis from computed tomography scans.

Bone maturation is the only reliable indicator of growth and its radiologic assessment with or without automated systems is a qualitative method. Image processing allows the study of bone maturation with quantitative data. Carpal bone maturation was studied in 20 children (13 boys and 7 girls, ages ranging from 4 to 15 years) without any clinical evidence of endocrine disease by image analysis from computed tomography (CT) scans. Each wrist CT scan was processed in order to extract the carpal bones and to measure quantitative data regarding volume, axes of inertia and density for each bone. The volumes and the length of the inertia axes were significantly correlated with age. Whatever the age, there were strong correlations between the volume or the length of the main inertia axis of one carpal bone and that of all others. The decrease in the carpal bone volume measured from the processing procedure compared with the theoretical volume of bone defined from the length of the three inertia axes indicated a change in bone shape during growth. Although the mean density was constant, there was an increase in the standard deviation of density with age. Skeletal maturity assessment with image analysis from CT scans seems to be a good complementary investigation to determine bone age in children.

The anatomy of Nikyo (Aikido's second teaching).

Nikyo is the second teaching of Aikido (ni-two, kyo-teaching, in Japanese). It is a joint-lock technique that results in extreme pain. It allows one to control an opponent by destroying his will to continue fighting. Nikyo is accomplished by flexing and adducting an opponent's wrist producing an instantaneous sharp pain that causes him to fall to his knees involuntarily to alleviate the pressure. The exact etiology of the pain elicited by this technique has been obscure to many practitioners. The usual explanations have been nerve compression, joint capsular stretch, tendon/muscle strain, or partial ligamentous disruption. Studies of a cadaver's wrist have shown that Nikyo forcibly compresses the pisiform bone against the ulna, two bones that do not normally articulate. The intense pain thereby produced results from stimulation of the periosteal nerves in these bony surfaces.

Scaphoid malunion.

Forty-five patients with 46 scaphoid fractures were studied more than 6 months after union by clinical examination and trispiral tomography. Twenty had normal scaphoid alignment with lateral intrascaphoid angles less than 35 degrees; the rest had varying degrees of increased flexion angulation of the scaphoid, ranging from 36 degrees to 60 degrees. Increasing lateral scaphoid angulation, eventually resulting in a "humpback" deformity, was associated with progressively poor clinical and radiographic results. There were satisfactory clinical outcomes in 83% and posttraumatic arthritis in only 22% of those with normal scaphoid anatomy. Those with greater than 45 degrees of lateral intrascaphoid angulation present at the time of union had a satisfactory clinical outcome in 27% and posttraumatic arthritis in 54%. Union alone is an insufficient criterion for success in treating scaphoid fractures.

Some observations on lameness associated with pain in the proximal metacarpal region.

The carpus and metacarpus of 40 horses which were free from lameness and 40 horses with lameness associated with the metacarpophalangeal joint or more distal limb were examined radiographically (Group A). The opacity of the proximal third of the third metacarpal bone was regular, with a uniform trabecular pattern. Osseous cyst-like lesions (OCLLs) were identified in the radial carpal bone (1), the ulnar carpal bone (2), the second carpal bone (15) and the fourth carpal bone (1). Thirty-one of 638 horses (4.8 percent) with forelimb lameness had pain localised to the proximal metacarpal region using local anaesthesia (Group B). All these horses were examined radiographically and an ultrasonographic examination was performed in seven. No definitive diagnosis was reached in 16 horses, seven of which had an OCLL in one of the carpal bones or the second metacarpal bone. One horse had, in addition to a poorly defined lucent area in the second carpal bone, radiographic evidence of degenerative joint disease of the carpometacarpal joint and an hypoechoic lesion in the accessory ligament of the deep digital flexor tendon. One horse had an hypoechoic lesion in the proximal part of the suspensory ligament. Abnormalities of the trabecular structure of the third metacarpal bone were identified in 13 horses. In 11 of these there was a vertically orientated lucent line, usually surrounded by sclerotic bone. These lucent lines may represent fatigue fractures seen end on. In one horse an horizontal lucent line was seen. One of these 13 horses also had a lesion in the proximal part of the suspensory ligament. Ten of the 13 (77 per cent) horses with presumed fractures of the third metacarpal bone recovered completely, whereas only eight of the 16 (50 per cent) horses in which no definitive diagnosis was reached returned to their former function.

Avascular necrosis of the carpal lunate: a case report.

A case is presented of avascular necrosis of the carpal lunate (Kienböck's disease). Orthopedic findings included marked decrease in ranges of motion in all directions and marked decrease in grip strength. Radiographic findings revealed increased density of the lunate, along with evidence of rotation. Conservative therapy of immobilization, ultrasonic and galvanic currents was later followed by orthopedic surgery. This case clearly demonstrates the importance of a team approach to the management of a problem of this sort and the importance of proper and timely diagnosis and treatment in order to prevent chronic disability of the wrist. Initial management of this case consisted of conservative treatment to alleviate pain and swelling. Surgery further alleviated pain and provided increased ranges of motion of flexion, extension and ulnar deviation and grip strength. Movement of radial deviation did not improve at this time. The goal of postsurgical conservative (rehabilitative) therapy, designed to provide satisfactory ranges of movement in all directions and grip strength, was expected to be reached.

[Pseudarthrosis of the scaphoid]. / Die Pseudarthrose des Scaphoids.

For the treatment of scaphoid non-unions, innumerable curative and palliative operations have been recommended. Of the curative operations, the various methods of bone grafting give the best results, whereas screw fixation is not satisfactory. Bone pegs with a cortical graft are no longer used because of technical difficulties. Corticocancellous grafts (Matti-Russe) yield bony union in almost 90% of cases. The combination of corticocancellous grafts with plate stabilization gives the highest rate of bony union (99%). A cure should therefore always be attempted in all non-union cases, with the exception of cases already involving severe, generalized osteoarthritis or extensive necrosis of the scaphoid. Of the different palliative methods, the early results of prosthetic partial or total replacement of the scaphoid are satisfactory. Late results are less satisfactory, with a high rate of complications and carpal collapse. With severe osteoarthrosis, proximal carpectomy, especially the transscaphoideo-lunate resection, gives good results. Intercarpal arthrodeses have been disappointing. Radiocarpal arthrodesis results in a pain-free, strong wrist; however, there is complete loss of motion, whereas denervation gives satisfactory results in 57% and preserved mobility of the wrist.

Scaphoid (navicular) fracture of the wrist.

This common fracture most frequently affects young males. In most cases, the fracture is found on initial examination. Occasionally, it is missed on the initial radiographic evaluation but becomes apparent on follow-up films. Although most scaphoid fractures respond to conservative therapy, some fail to heal. Nonunion of the scaphoid may respond to various nonoperative and operative techniques. In such cases, consultation with a hand surgeon is useful.

Treatment of nonunion of the scaphoid by direct current.

Seventy-one per cent (12 of 17) of scaphoid nonunions previously treated by other methods united when the semi-invasive technique of electrical stimulation was used. Patient acceptance of this electrode technique is high, and morbidity is lower than in patients treated by iliac bone grafting. The treatment of nonunion of the scaphoid by the semi-invasive electrical stimulation technique is a reasonable alternative to bone grafting and provides a salvage procedure when bone grafting or other therapeutic modalities have failed.

Skeletal tuberculosis of the wrist and hand: a study of 27 cases.

The 27 cases of skeletal tuberculosis in the hand and wrist reported represented 6.9% of the skeletal tuberculosis seen at our hospital and 32% of the skeletal tuberculosis found in the upper extremity. In a majority of these patients a single bone or joint was involved and 18.5% of the patients had bone and/or joint involvement outside the hand. Pulmonary tuberculosis was present in 10.7% of these cases. The clinical picture of tuberculosis is similar to that of other infections and tumorous conditions, but a history of absent bacille Calmette Guérin protection and positive tine test should arouse one's suspicion to the condition. Eight-six percent of our patients had x-ray findings that included bone atrophy, bone or joint destruction with discrete periostitis, or the presence of the typical spina ventosa. We found no case of resistance to various combinations of the usual drugs in any patients. Supportive orthopaedic splints were used over short periods (3 months) and surgery was used for diagnostic purposes (biopsies) and in treatment by fusion of two wrists in this patient series. Finger joint involvement responded satisfactorily to drug and conservative orthopaedic treatment and in no case were these joints fused or replaced by a prosthesis.

Repair of nonunions by electrically pulsed current stimulation.

Five congenital and 52 acquired nonunions of bone were stimulated using an invasive device. The unit delivered a constant but pulsed right-angled current of positive polarity measuring 20 to 25 muAmps (voltage of 750 mV) and a frequency of 20 Hz. The power pack encapsulated in epoxy resin was implanted at the time of operative fragment stabilization. THe cathode was inserted at the site of the nonunion gap. After two to 12 months, all but two of the acquired nonunions and one of the congenital pseudarthroses healed. In the unsuccessful cases, the bone ends were often totally necrotic. Four cases required reimplantation because of broken wires or expiration of the battery, and two cases failed owing to purulent infection. Electrostimulation is an adjuvant treatment to fragment stabilization in hyporeactive and hypovascular or congenital pseudarthroses. Electrical stimuli may be assumed to simulate conditions which are essential for bone healing.

The electrical treatment of scaphoid nonunion.

Seventy-one percent (12 out of 17) of the previously treated nonunions united within 12 weeks by a semi-invasive technique of electrical stimulation. The electrodes are stainless steel and Teflon-coated except for the 1 cm bare tip. The power source is a 7.5 volt battery in circuit with resistors and transistors such that a constant continuous current of 20 muamp is applied to each electrode. Three or four cathodes are implanted percutaneously, using local or regional anesthesia with radiographic control, usually an image intensifier. A long-arm cast is used for three weeks and then reduced to a short-arm cast which is used for nine additional weeks. The indication for this technique is failure of previous bone grafting. The contraindications are wrist arthritis and an avascular proximal pole. Patient acceptance of this electrode technique was high and morbidity was less than in those patients treated by iliac bone grafting. The treatment of nonunion of the scaphoid by this semi-invasive electrical stimulation technique is a reasonable alternative to bone grafting and provides a salvage procedure when bone grafting or other therapeutic modalities have failed.

Albright's hereditary osteodystrophy.

The authors observed different clinical forms of Albright's hereditary osteodystrophy in 4 members of a family (two sisters, their mother and the maternal grandfather). The sisters were affected by pseudohypoparathyroidism type I, the older manifested the hypocalcemic variety, the younger the normocalcemic variety; the mother and the grandfather presented only with short stature and subcutaneous calcifications. The variety of clinical and biochemical alterations observed in these 3 generations supports evidence that Albright's hereditary osteodystrophy has a broad spectrum and that distinctions between the various forms of pseudohypoparathyroidsim should not be rigidly considered.