Daytime Functional Usage Versus Night-Time Wearing: Identifying the Optimal Wearing Regimen for a Custom-Made Orthosis in the Treatment of Trapeziometacarpal Osteoarthritis.

OBJECTIVE: To compare the functional (daytime) use to the nightly use of an orthosis for patients affected by trapeziometacarpal osteoarthritis (OA). DESIGN: Randomized, controlled single-blind trial. SETTING: The rheumatology outpatient clinic of the University. PARTICIPANTS: Sixty participants diagnosed with trapeziometacarpal OA. INTERVENTIONS: Participants were randomly assigned into 2 groups: a functional group that used a functional hand-based thumb immobilization orthosis during activities of daily living and a night-time group that used the same orthosis at night. MAIN OUTCOMES MEASURES: The patients were evaluated at baseline and after 45, 90, 180, and 360 days considering: pain at the base of the thumb and in the hand, range of motion of the thumb, grip, and pinch strength, manual dexterity, and hand function. RESULTS: The groups were homogeneous at the beginning of the trial. No statistically significant difference was observed between groups over time for trapeziometacarpal pain (P=.646). For general hand pain, no statistically significant difference was found between groups over time (P=.594). Although both groups improved from baseline, there were no statistically significant differences between the groups in the vast majority of the assessed parameters. Statistically significant differences between the groups were found only in the following outcomes: thumb palmar abduction of the right hand (P=.023), pick-up test with closed eyes of the right hand (P=.048), and tripod grip strength of the right hand (P=.006). CONCLUSIONS: Both groups showed improvement in pain and function from baseline to the end of the intervention. However, there were no reported differences in these outcomes after a 1-year follow-up between the functional (daytime) and night-time use of orthosis in patients with trapeziometacarpal OA. This suggests that both types of usage can be offered to patients.

Description and Clinical Assessment of the Bone Block Tendon Interposition Technique for the Management of Thumb Carpometacarpal Joint Osteoarthritis.

BACKGROUND: Pellegrini's surgical technique is the most useful for thumb carpometacarpal joint osteoarthritis. The purpose of this paper is to describe the technique of a modified version using a bone block in the tunnel through which the flexor carpi radialis tendon is passed (BBTI). METHODS: Case series of patients diagnosed with osteoarthritis of the thumb carpometacarpal joint, in stage II or higher based on Eaton's classification, that were intervened using the BBTI technique for a 2-year period. Grip and pinch strength, range of motion, and 1-2 metacarpal angle were evaluated. Pain and function were measured using the visual analogue scale and the Disabilities of the Arm, Shoulder and Hand (DASH) scale. RESULTS: The study included 16 cases in 14 patients (11 women and 3 men), with an average age of 55.7 ± 7.1 years. Encouraging results were obtained, with an average DASH score of 24.3 ± 17.9 and a minimum VAS pain score. A total of 58% showed a grip strength of over 80% and the postoperative movement was equivalent to the contralateral limb. No cases of infection were reported, and only two minor complications were observed. CONCLUSIONS: The BBTI technique is a surgical option that incorporates an interference screw, offering good functional results for managing osteoarthritis of the thumb carpometacarpal joint, with a similar complication rate to that of the original technique.

An overview of robotic/mechanical devices for post-stroke thumb rehabilitation.

PURPOSE: This article aims to clarify the current state-of-the-art of robotic/mechanical devices for post-stroke thumb rehabilitation as well as the anatomical characteristics and motions of the thumb that are crucial for the development of any device that aims to support its motion. METHODS: A systematic literature search was conducted to identify robotic/mechanical devices for post-stroke thumb rehabilitation. Specific electronic databases and well-defined search terms and inclusion/exclusion criteria were used for such purpose. A reasoning model was devised to support the structured abstraction of relevant data from the literature of interest. RESULTS: Following the main search and after removing duplicated and other non-relevant studies, 68 articles (corresponding to 32 devices) were left for further examination. These articles were analyzed to extract data relative to (i) the motions assisted/permitted - either actively or passively - by the device per anatomical joint of the thumb and (ii) mechanical-related aspects (i.e., architecture, connections to thumb, other fingers supported, adjustability to different hand sizes, actuators - type, quantity, location, power transmission and motion trajectory). CONCLUSIONS: Most articles describe preliminary design and testing of prototypes, rather than the thorough evaluation of commercially ready devices. Defining appropriate kinematic models of the thumb upon which to design such devices still remains a challenging and unresolved task. Further research is needed before these devices can actually be implemented in clinical environments to serve their intended purpose of complementing the labour of therapists by facilitating intensive treatment with precise and repeatable exercises. Implications for Rehabilitation Post-stroke functional disability of the hand, and particularly of the thumb, significantly affects the capability to perform activities of daily living, threatening the independence and quality of life of the stroke survivors. The latest studies show that a high-dose intensive therapy (in terms of frequency, duration and intensity/effort) is the key to effectively modify neural organization and recover the motor skills that were lost after a stroke. Conventional therapy based on manual interaction with physical therapists makes the procedure labour intensive and increases the costs. Robotic/mechanical devices hold promise for complementing conventional post-stroke therapy. Specifically, these devices can provide reliable and accurate therapy for long periods of time without the associated fatigue. Also, they can be used as a means to assess patients? performance and progress in an objective and consistent manner. The full potential of robot-assisted therapy is still to be unveiled. Further exploration will surely lead to devices that can be well accepted equally by therapists and patients and that can be useful both in clinical and home-based rehabilitation practice such that motor recovery of the hand becomes a common outcome in stroke survivors. This overview provides the reader, possibly a designer of such a device, with a complete overview of the state-of-the-art of robotic/mechanical devices consisting of or including features for the rehabilitation of the thumb. Also, we clarify the anatomical characteristics and motions of the thumb that are crucial for the development of any device that aims to support its motion. Hopefully, this?combined with the outlined opportunities for further research?leads to the improvement of current devices and the development of new technology and knowledge in the field.

Comparación de ortesis para el tratamiento de la artrosis de la base del pulgar / Compare splint for patients with thumb osteoarthritis (OA)

INTRODUCCIÓN: El tratamiento de la osteoartritis (OA) tiene como primer objetivo reducir el dolor y mejorar la función de la articulación afectada. La primera indicación para el tratamiento conservador de la rizartrosis es la inmovilización. La intención de inmovilizar es proveer soporte a la articulación carpometacarpiana (CMC) del pulgar mientras se permiten movimientos funcionales de la mano. Hay una variedad de ortesis para el pulgar disponibles, tanto prefabricadas como hechas a medida, y en diferentes tipos de material. Lamentablemente no hay lineamientos específicos del tipo de ortesis adecuada para la OA de la articulación CMC. El abordaje del Terapista Ocupacional incluye la consideración de la utilización de ortesis. Además el Terapista Ocupacional confecciona ortesis termoconformadas hechas a medida. OBJETIVO: Evaluar la efectividad de las ortesis termoconformadas inmovilizadoras de las articulaciones CMC y Metacarpofalangica (MCF) del pulgar vs. las ortesis termoconformadas inmovilizadoras de la articulación CMC. PACIENTES Y MÉTODO: Ensayo clínico no farmacológico de tecnología médica de riesgo no significativo, usando un diseño cruzado de nueve semanas de duración con dos períodos de tratamiento de cuatro semanas cada uno y una semana intermedia de washout (sin ortesis). En el primer período de tratamiento al paciente se le asignó aleatoriamente una ortesis corta o la larga que utilizó durante cuatro semanas y luego de una semana de washout cambió a la otra durante otras cuatro semanas. El estudio se realizó con pacientes derivados consecutivamente asignados al azar a fin de un tratamiento diferente. El dolor se evaluó con la Escala Visual Analógica. (EVA). La capacidad funcional manual se evaluó con la Sub Escala Funcional del Australian Canadian Osteoarthritis Hand Index versión (AUSCAN; Queensland, Australia), validada al español. RESULTADOS: Se incluyeron 18 pacientes, 13 (72%) eran de sexo femenino y tenían una mediana (p25-75) edad de 59.00 (55.00-66.50) años. En cuanto al estadio radiológico 1 (5.6%) paciente tenía estadío radiológico Eaton I, 10 (55.6 %) Eaton II, y 7 (38.9%) Eaton III. Siete pacientes (38.9%) comenzaron la intervención con la ortesis corta y 11 (61.1%) con la ortesis larga. El dolor disminuyó significativamente en el primer período: al día 0 la mediana de dolor fue 7.5 (5.00-9.00), en comparación con el día 28 donde la mediana fue de 3.00 (2-6.25) (p=000.1). La función mejoró significativamente en el primer período; la mediana de función manual al día 0 fue 0.54 (00.47-00.68), en comparación con el día 28 que fue de 0.76 (0.51-0.86) (p=0.028). No se observaron cambios significativos en dolor y función en el segundo período. No hubo diferencia en el tipo de ortesis asignada de acuerdo a mano dominante, mano tratada, uso de analgésicos y estadio de Eaton, pero hubo una mayor tendencia de utilizar la ortesis corta en ocupaciones de carga media, de 12.00 pacientes (66%), 7.00 (58,3%) ortesis cortas, versus 5.00 (41,7%) ortesis larga (p=0.017). Para pacientes con ocupaciones de carga liviana de 6.00 pacientes (33,3%), 6.00 (100%) tuvieron una tendencia de utilizar ortesis largas (p=0.017). CONCLUSIONES: Independiente del modelo de ortesis que se utilice, en este estudio se observó una mejoría clínica de los pacientes tanto en intensidad de dolor como en la función al primer mes de tratamiento. Estos hallazgos indicarían que este tipo de intervención terapéutica es positiva en rizartrosis. (AU)

INTRODUCTION: The treatment of osteoarthritis (OA) has as its primary objective to reduce pain and improve function of the affected joint. The first indication for conservative treatment is immobilization. The intention is to provide support to immobilize the carpometacarpal (CMC) of the thumb while functional hand movements are allowed. There are a variety of thumb splints available, both prefabricated and custommade, and different types of material. Unfortunately there are no specific guidelines on the type of correct splint for OA of the CMC joint. The Occupational Therapist approach includes consideration of the use of orthotics. OBJECTIVE: Analyze the effect of two different splints: thermoformed orthotics immobilizing the CMC and metacarpophalangeal (MCP) joints of the thumb vs. the thermoformed orthotics immobilizing the CMC joint, on hand function and pain in individuals with CMC OA. PATIENTS AND METHODS: Non-pharmacological medical technology clinical trial no significant risk, using a two period crossover design, the two four-week treatment periods were separated by oneweek washout period (without splint). A table of random symbols was used to determine treatment order assignments. Pain was evaluated by the Visual Analogue Scale (VAS); and hand functional by the Functional Sub Scale of Canadian Osteoarthritis Hand Index Australian version (AUSCAN, Queensland, Australia), validated in Spanish. RESULTS: Eighteen patients were included, 13 (72%) were female and they were middle-aged (p 25-75) of 59.00 (55.00-66.50) years. As for the radiological stage 1 (5.6%) patient had Radiological stage Eaton I, 10 (55.6 %) Eaton II, y 7 (38.9%) Eaton III. Seven patients (38.9%) started the intervention with the short orthosis and 11 (61.1%) with the long orthosis. The pain decreased significantly in the first period: at day 0 the median pain was 7.5 (5.00-9.00), compared to day 28 where the median was 3.00 (2- 6.25) (p = 000.1). The function improved significantly in the first period; the median manual function at day 0 was 0.54 (00.47- 00.68), compared to day 28 which was 0.76 (0.51-0.86) (p = 0.028). There were no significant changes in pain and function in the second period. There was no difference in the type of splint assigned according to dominant hand, hand treated, analgesic use and Eaton stage, but there was a greater tendency to use short orthotics in medium load occupations of 12.00 patients (66%), 7.00 (58.3%) short orthoses, versus 5.00 (41.7%) long orthoses (p = 0.017). For patients with light load occupations of 6.00 patients (33.3%), 6.00 (100%) had a tendency to use long orthoses (p = 0.017). CONCLUSIONS: Regardless of the orthotic model used, in this study clinical improvement was observed in both pain intensity and function at the first month of treatment. These findings would indicate that this type of therapeutic intervention is positive in thumb osteoarthritis. (AU)

A tribute to Wartenberg's refined neurological examination.

Robert Wartenberg was a renowned 20th century neurologist who contributed greatly to our understanding of the neurological examination. This article aims to illustrate his legacy by highlighting five seminal neurological signs.

A tribute to Wartenberg's refined neurological examination / Um tributo ao refinado exame neurológico de Wartenberg

ABSTRACT Robert Wartenberg was a renowned 20th century neurologist who contributed greatly to our understanding of the neurological examination. This article aims to illustrate his legacy by highlighting five seminal neurological signs.

RESUMO Robert Wartenberg foi um renomado neurologista do século XX que contribuíu enormemente para o entendimento do exame neurológico. Este artigo tem como objetivo principal ilustrar seu legado, ressaltando cinco sinais neurológicos seminais.

Reorientation osteotomy for the atypical clasp thumb in children with arthrogryposis.

Congenital thumb contractures are a well described but complex deformity to manage. Thumb contractures are common in patients with arthrogryposis. Many patients with arthrogryposis develop a supination, adduction, and flexion contracture at the thumb carpometacarpal join. Despite some thumb function, their thumb position and contracted first webspace precludes effective pinch or grasp, with the thumb opposing only to the palmar space. An extension, reorientation metacarpal osteotomy that places thumb in an efficient position has the potential to improve function in of these patients. This report provides a new classification system for congenital thumb deformities that can dictate management based upon thumb joint positions. We describe a previously unreported, arthrogrypotic thumb contracture that can be managed with an extension/pronation metacarpal osteotomy with simultaneous widening of the first webspace.

Prognostic value of thumb pain sensation in birth brachial plexopathy.

OBJECTIVE: To evaluate the prognostic value of absent thumb pain sensation in newborns and young infants with birth brachial plexopathy. METHODS: We evaluated 131 patients with birth brachial plexopathy with less than two months of age. Pain sensation was evoked by thumb nail bed compression to evaluate sensory fibers of the upper trunk (C6). The patients were followed-up monthly. Patients with less than antigravity elbow flexion at six months of age were considered to have a poor outcome. RESULTS: Thirty patients had absent thumb pain sensation, from which 26 showed a poor outcome. Sensitivity of the test was 65% and specificity was 96%. CONCLUSION: Evaluation of thumb pain sensation should be included in the clinical assessment of infants with birth brachial plexopathy.

Prognostic value of thumb pain sensation in birth brachial plexopathy / Valor prognóstico da sensibilidade dolorosa do polegar na plexopatia braquial relacionada ao parto

OBJECTIVE: To evaluate the prognostic value of absent thumb pain sensation in newborns and young infants with birth brachial plexopathy. METHODS: We evaluated 131 patients with birth brachial plexopathy with less than two months of age. Pain sensation was evoked by thumb nail bed compression to evaluate sensory fibers of the upper trunk (C6). The patients were followed-up monthly. Patients with less than antigravity elbow flexion at six months of age were considered to have a poor outcome. RESULTS: Thirty patients had absent thumb pain sensation, from which 26 showed a poor outcome. Sensitivity of the test was 65% and specificity was 96%. CONCLUSION: Evaluation of thumb pain sensation should be included in the clinical assessment of infants with birth brachial plexopathy.

OBJETIVO: Avaliar o valor prognóstico da hipoestesia dolorosa no polegar em recém-nascidos e lactentes jovens com plexopatia braquial obstétrica. MÉTODOS: Avaliamos 131 pacientes com plexopatia braquial obstétrica com menos de dois meses de idade. A sensação dolorosa foi provocada pela compressão do leito ungueal do polegar para avaliar fibras sensitivas do tronco superior (C6). Os pacientes foram seguidos mensalmente. Prognóstico desfavorável foi atribuído aos pacientes sem força antigravitacional para flexão do cotovelo aos seis meses de idade. RESULTADOS: Trinta pacientes apresentaram hipoestesia dolorosa do polegar, dos quais 26 tiveram prognóstico desfavorável. A sensibilidade do teste foi de 65% e a especificidade 96%. CONCLUSÃO: A avaliação da sensibilidade dolorosa do polegar deve ser incluída na avaliação clínica de pacientes com plexopatia braquial obstétrica.

The trapeziometacarpal joint. Tenotomy of the accessory tendons in early osteoarthritis.

The TMC joint is an articulation with special articular surfaces adapted to produce simple (nonrotatory) and complex (rotatory) metacarpal movements. Its articular anatomy and biomechanics are closely related to the pathogenesis of osteoarthritis. The joint works under high transarticular compressive-shearing forces. In osteoarthritic thumbs, the articular forces are increased because of the constant presence of accessory APL tendons, almost exclusively of the digastric type. Other factors should be considered in the pathogenesis of TMC joint osteoarthritis, such as repetitive use of the thumb under unfavorable patterns of function) strong side-to-side pinch grips, thumb with the tendency to maintain in reposition), cartilage aging, hormonal disturbances in women, and general osteoarthritic disease. Osteoarthritic thumbs in stages I and II that have failed to respond to conservative treatment are candidates to unload the joint by tenotomy of the transarticular accessory tendons. Long-term results have been very satisfactory (97%), eliminating or substantially reducing pain and returning patients to their activity. The procedure is contraindicated in severe (stage III) TMC joint osteoarthritis and in primary articular instability.

Silent period in carpal tunnel syndrome.

The silent period is a misunderstood electrophysiological phenomenon leading to several different hypotheses explaining its electrogenesis. It has been studied by different authors and different methodologies giving a wide variability of results, therefore an exact pattern of its normal values does not exist. This work was undertaken to define the normal morphology and duration of the silent period obtained by supramaximal stimulus of the median nerve, during maximum isometric effort of the abductor pollicis brevis muscle against resistance, using 20 adult volunteers without neurological alterations. The normal median duration was 104.6 milliseconds. The same methodology was applied to 20 hands from 20 patients with carpal tunnel syndrome. The silent period showed many types of morphological alterations, but the major alteration observed was a tendency to temporal elongation. No correlation between the severity of the carpal tunnel syndrome and the silent period alterations were observed.

Artificial grasping system for the paralyzed hand.

Neuromuscular electrical stimulation has been used in upper limb rehabilitation towards restoring motor hand function. In this work, an 8 channel microcomputer controlled stimulator with monophasic square voltage output was used. Muscle activation sequences were defined to perform palmar and lateral prehension and power grip (index finger extension type). The sequences used allowed subjects to demonstrate their ability to hold and release objects that are encountered in daily living, permitting activities such as drinking, eating, writing, and typing.

Tratamiento de la osteoartritis de la base del pulgar con la técnica de Eaton modificada / Treatment for ostearthritis of the base of the thumb finger by the modified Eaton's technique

Esta es una serie de 7 enfermos con 10 casos de osteoartritis de la articulación trapecio-metacarpiana del pulgar, 6 del sexo femenino, con edad promedio de 56 años. Se trataron mediante resección parcial o total del hueso trapecio y plastía por interposición del tendón transpuesto del palmar menor. Después de la cirugía el dolor despareció en el 70 por ciento de las manos; los arcos de movimiento se incrementaron en el 80 por ciento y el 20 por ciento restante permanecieron sin cambios. La fuerza de la prensión permaneció igualmente sin cambios. El resultado se consideró excelente en 7 manos y buenos en 3

Carcinoma espinocelular en lecho ungueal / Squamous cell carcinoma in the nail bed

Paciente masculino de 36 años con un carcinoma espinocelular en el lecho ungueal del pulgar izquierdo de 8 meses de evolución, tratado quirúrgicamente con amputación parcial y cierre primario del muñón

Artoplastia fascial del trapecio del carpo, para tratamiento de la artrosis metacarpofalángica del pulgar: indicaciones y revisión de 14 pacientes / Carpo-metacarpal arthroplasty of the thumb, by sustitution of the trapezium with fascia, for treatment of degenerative arthritis. A serie of 14 patients

Los procesos degenerativos de la articulación basal del pulgar ocasionan problemas funcionales en un gran número de personas. Se presenta una revisión de 14 pacientes con 15 pulgares operados en que se realizó artroplastia de interposición con fascia para tratar la panartrisis del trapecio. Los resultados fueron calificados con base en la fuerza, estabilidad, movilidad y dolor en el pulgar. De los 15 pulgares, 12 tuvieron un resultado excelente y tres, bueno. La artroplastia fascial es una alternativa de tratamiento para estos pacientes, ya que se logra un pulgar estable, fuerte e indoloro, sin los inconvenientes de las artroplastias sintéticas.

Index finger pollicization for congenital aplasia or hypoplasia of the thumb.

Sensation, strength, dexterity, length, and range of motion were evaluated after index finger pollicization in 10 patients (14 hands). Diagnoses included congenital absence of the thumb (10 hands) and hypoplasia (4 hands). Average age at operation was 7 years, and follow-up averaged 9 years. Patients with unilateral pollicization averaged 67% grip strength, 60% lateral pinch, 56% palmar pinch, and 39% three-point pinch as compared with the normal contralateral hand. Manual dexterity averaged 70% efficiency as compared with normal standards defined according to age and sex. However, 55% of the patients, when stressed, used side-to-side pinch. It was noted that in those patients who used side-to-side pinch performance averaged 54% of normal standards, compared with 93% in patients who used tip-to-tip pinch for prehension.

Early restoration of pinch grip after ulnar nerve repair and tendon transfer.

Restoration of pinch in ulnar nerve lesions may be achieved within three or four weeks by a one-stage operation combining nerve repair and tendon transfer. We have been using this approach for nerve injuries of the upper limb since 1961, to meet the socio-economic needs of patients who would otherwise need splints and long-term physiotherapy. In our experience, the procedure of choice is transfer of E.I.P. to adductor pollicis and E.P.B. to the first dorsal interosseous. The operative technique and its results in 18 patients followed up for 37-515 days are discussed.

Pulgar adducto atrosico: biomecanica, fisiopatogenia, criterios terapeuticos / Adducted thumb

A partir de un planteo biomecanico como es el de postular la existencia de cuplas musculares estabilizadores de la articulacion trapecio-metacarpiana, proponemos un proceso fisiopatologico de desequilibrio para la subluxacion y artrosis adducta del pulgar. La revision de la bibliografia sobre el tema que se comenta en la introduccion de este trabajo nos enseña acerca de la complejidad que la profundizacion depara a aquellos que se han preocupado por aumentar su conocimiento. Revisamos 42 casos operados con diversas tecnicas, haciendo hincapie en la necesidad de retrotraer los elementos estabilizadores activos a la situacion de equilibrio para la obtencion de resultados cercanos a la situacion normal. Realizamos el comentario del uso de una u otra tecnica y analizamos pros y contras de cada una de ellas. Los factores de exitos y fracasos en su utilizacion y las posibles mejoras tecnicas que sugerimos. Insistimos en la necesidad de tratar la patologia de todas las articulaciones involucradas en el proceso: trapecio-trapezoideo-bimetacarpiana y metacarpo-falangica. Aportamos finalmente los elementos que nos parecen importantes para la correcta formulacion de planteos terapeuticos y tacticas operatorias