Improvement of hand function in children with cerebral palsy via an orthosis that provides wrist extension and thumb abduction

Background

The present study examines the hand movements of children with cerebral palsy during functional tests and compares the childrens' performance with and without the aid of an orthosis that provides wrist extension and thumb abduction.

Methods

The range of motion of the trapeziometacarpal joint was assessed for 32 participants via a reflexive markers image system. Observed motions included flexion–extension and abduction–adduction motions performed in the course of four tests for manual ability; the rest position, lateral and tripod pinches and cylindrical grasp. Muscle strength and manual ability were evaluated using dynamometry and the Jebsen–Taylor test.

Findings

The range of motion tests for the rest position, lateral and tripod pinches and cylindrical grasp demonstrated improvements from 17% to 42% (P < 0.001) for flexion/extension and from 36% to 54% for abduction/adduction (P < 0.001) with the use of the orthosis. Dynamometry measurements showed that the improvement in muscle strength obtained through use of the orthosis was 50% (P < 0.001). Improvements in the time required to perform the movements as determined using the Jebsen–Taylor test varied from 13% to 24% (P < 0.01) for the four considered tests of manual ability.

Interpretation

The orthosis improved the range of motion of the trapeziometacarpal joint, muscle strength and manual ability. The combination of the three techniques may provide the basis for a quantitative assessment of hand dysfunction/improvement in cerebral palsy that will ultimately guide health professionals in their clinical interventions.     

(足母)背甲皮瓣移植联合带指神经血管蒂岛状皮瓣移位再造拇指术患者的护理

总结了自1998年12月至2000年9月对6例采用背甲皮瓣移植联合带指神经血管蒂岛状皮瓣移位术再造拇指患者的临床护理,再造的拇指功能和外形好,又保留了NFDC9趾.介绍了心理支持措施、血管训练方法、皮瓣血液循环的观察特点、并发症的预防、术后感觉再训练和功能康复等护理措施.     

拇指旋转撕脱性离断再植的临床研究

目的 探讨拇指旋转撕脱性离断再植的治疗方法和临床疗效.方法 23例拇指旋转撕脱患者,采用环指浅屈肌腱转位修复拇指屈曲功能,示指固有伸肌腱转位修复拇指伸指功能,环指桡侧指动脉神经修复拇指动脉神经,示指指背静脉修复拇指静脉.结果 术后拇指全部成活,随访0.5～2.0年,再植拇指外形正常,血运好,感觉功能和肌力良好.根据中华医学会手外科学会拇、手指再造功能评定试用标准,综合评价全部为优.结论 此型转位方法治疗拇指旋转性离断再植,术后功能恢复满意,是一种安全有效的手术方法.     

拇指远节皮肤软组织缺损的修复

目的探讨拇指末节软组织缺损的修复方法及临床效果。方法2001年1月至2008年1月，对32例拇指末节软组织缺损采用游离踌甲瓣、拇指尺背侧皮瓣进行修复。结果32例完全成活。术后随访3个月-5年，平均2．5年。拇指外形基本恢复，功能均良好。其中，优25例，良7例。结论对拇指末节软组织缺损应根据缺损的部位、形状及面积和患者对功能及外观的要求，选择恰当的修复方法。     

逆行拇桡侧指背动脉筋膜蒂掌骨皮瓣修复拇指末节复合组织缺损的护理

目的：总结逆行拇桡侧指背动脉筋膜蒂掌骨皮瓣修复拇指末节复合组织缺损围术期的护理措施。方法选取12例逆行拇桡侧指背动脉筋膜蒂掌骨皮瓣修复拇指末节复合组织缺损患者做好术前心理护理﹑健康教育﹑供受区皮肤准备等。术后详细了解手术经过,特别强调该骨皮瓣血供观察与普通皮瓣观察的区别,密切观察皮瓣的颜色﹑温度﹑张力﹑毛细血管充盈时间,卧位适当,病室环境适宜,保持患者良好心情,后期加强正确的康复指导。结果本组患者中仅1例术后发生静脉危象,经护士及时观察发现,汇报医生拆除部分缝线加强换药积极处理后皮瓣成活,其余11例逆行拇桡侧指背动脉筋膜蒂掌骨皮瓣均顺利成活。所有患者均为Ⅰ期愈合,未见皮肤溃疡、磨损等情况,拇指关节功能恢复至正常水平,无一例发生并发症。结论依据拇桡侧指背动脉筋膜蒂掌骨皮瓣血运的特点开展全面的围术期护理,可有效判断血管危象的实际发生情况,进而提高骨皮瓣移植成活率,具有确切的应用价值。     

The added value of measuring thumb and finger strength when comparing strength measurements in hypoplastic thumb patients

Background

When interventions to the hand are aimed at improving function of specific fingers or the thumb, the RIHM (Rotterdam Intrinsic Hand Myometer) is a validated tool and offers more detailed information to assess strength of the involved joints besides grip and pinch measurements.

Methods

In this study, strength was measured in 65 thumbs in 40 patients diagnosed with thumb hypoplasia. These 65 thumbs were classified according to Blauth. Longitudinal radial deficiencies were also classified. The strength measurements comprised of grip, tip, tripod and key pinch. Furthermore palmar abduction and opposition of the thumb as well as abduction of the index and little finger were measured with the RIHM.

Findings

For all longitudinal radial deficiency patients, grip and pinch strength as well as palmar abduction and thumb opposition were significantly lower than reference values (P < 0.001). However, strength in the index finger abduction and the little finger abduction was maintained or decreased to a lesser extent according to the degree of longitudinal radial deficiency. All strength values decreased with increasing Blauth-type. Blauth-type II hands (n = 15) with flexor digitorum superficialis 4 opposition transfer including stabilization of the metacarpophalangeal joint showed a trend toward a higher opposition strength without reaching statistical significance (P = 0.094),however compared to non-operated Blauth-type II hands (n = 6) they showed a lower grip strength (P = 0.019).

Interpretation

The RIHM is comparable in accuracy to other strength dynamometers. Using the RIHM, we were able to illustrate strength patterns on finger-specific level, showing added value when evaluating outcome in patients with hand related problems.     

Effect of prior experience and task stability on the intrinsic muscle activity of the thumb

Manual techniques involving the use of the thumb are commonly employed by physical therapists for treating patients with vertebral disorders. The demands on the intrinsic muscles of the thumb in these manual tasks are very different from those of the pinch tasks. The aim of this study was to investigate the influence of clinical experience and different mobilization techniques on the electromyographic activity (EMG) of thumb intrinsic muscles. Fifteen participants without exposure to manual techniques (the Novice Group) and fifteen physical therapists with at least 3 years of orthopaedic experience (the Experienced Group) participated. Each participant exerted thumb tip forces with 3 different posterioanterior (PA) glide techniques including unsupported, with digital support and with thumb interphalangeal joint supported by the index finger. The exerted force was increased from 25% to 100% maximum force at 25% increments on a 6 component load cell. The thumb tip force and EMG activity of four intrinsic muscles (flexor pollicis brevis, adductor pollicis, abductor pollicis brevis, first dorsal interosseus) were recorded with surface electrodes. Both experience and technique influenced intrinsic muscle activity of the thumb. While participants of both groups generated the same magnitude of force, experienced participants generated less intrinsic muscle activity while performing PA glide through practice. However, novice participants increased activity of the intrinsic muscles in accordance with the stability status of the technique. PA glide with thumb interphalangeal joint supported by the index finger was a more stable technique as evidenced by smallest relative errors of thumb tip force.     

拇指再造患者的心理状况与护理对策

目的 探讨拇指再造患者术前、术后存在的心理问题及相应的护理对策.方法 应用自行设计的问卷对56例拇指再造患者术前、术后存在的心理问题进行调查分析,采取相应的护理对策.结果 外伤及手术应激使拇指再造患者术前、术后均存在不同程度、不同类别的心理问题.在施行对应心理护理后,术前、术后存在的心理问题明显改善,能积极配合手术和治疗.结论 对拇指再造患者进行心理分析并施行相应的心理护理,可明显减其心理应激,提高再造指的成功率.     

正常人拇指及拇趾末节指骨基底的超声测值及其临床意义

目的 应用高频超声测量健康志愿者的拇指末节指骨及拇趾末节趾骨基底横径及前后径.方法 对120例健康志愿者,采用高频超声对拇指末节指骨基底及同侧拇趾末节趾骨基底横径及前后径进行测量,对测量数据进行统计学分析.结果 拇指末节指骨基底及拇趾末节趾骨基底高频超声特征:两组拇指及拇趾末节指骨基底横切面上高频超声表现为强回声带,边界清楚,与之邻近的筋膜、肌腱组织表现为低回声区.男性组拇指末节指骨基底的前后径为(8.07±0.67)mm,拇趾末节趾骨基底的前后径为(8.34±1.02)ram(t=1.73,P=0.86);拇指末节指骨基底的横径为(11.61±0.89)mm,拇趾末节趾骨基底的横径为(14.25±0.84)mm(t=16.77,P=0.01).女性组拇指末节指骨基底的前后径为(7.52±0.62)mm,拇趾末节趾骨基底的前后径为(7.72±0.67)ram(t=1.72,P=0.14);拇指末节指骨基底的横径为(10.94±0.97)mm,拇趾末节趾骨基底的横径为(13.51±0.75)mm(t=16.21,P:0.00).结论 通过健康志愿者拇指及拇趾末节指骨基底的前后径和横径高频超声测量正常值,对带末节趾骨拇甲瓣修复拇指Ⅱ度缺损手术时切除趾末节趾骨的方法具有重要指导价值.

Abstract：

Objective To measure the normal sagittal and coronal diameters of thumb and great toe distal phalanx bottom by ultrasonography. Methods One hundred and twenty volunteers' sagittal and coronal diameters of thumb and great toe distal phalanx bottom were measured by ultrasonography. The measurements was analysed by the statistical method. Results The thumb and great toe distal phalanx bottom showed hyperechoic zone,clear boundary with the adjacent fascia and tendon tissue showed low echo area at cross section by high frequency ultrasound. The sagittal diameters of thumb distal phalanx bottom was (8. 07 ± 0. 67)mm in men, while that of great toe distal phalanx bottom was (8. 34 ± 1. 02) mm( t = 1.73, P =0.86).The coronal diameters of thumb distal phalanx bottom was (11.61 ±0.89)mm in men, while that of great toe distal phalanx bottom was (14. 25 ± 0. 84)mm( t = 16. 77, P = 0. 00). The sagittal diameters of thumb distal phalanx bottom was (7. 52 ± 0. 62) mm in women, while that of great toe distal phalanx bottom was (7. 72 ± 0. 67) mm( t = 1. 72, P =0. 14). The coronal diameters of thumb distal phalanx bottom was (10.94 ± 0.97) mm in women, while that of great toe distal phalanx bottom was (13. 51 ±0. 75) mm( t =16.21, P = 0.00). Conclusions The normal sagittal and coronal diameters of thumb and great toe distal phalanx bottom measured by the ultrasonography can guide the operation of wrap-around flap of a great toe with phalanx ungual for thumb II degree defect reconstruction.     

断指再植和拇指再造术后的计划性康复

目的 :探索断指再植和拇指再造术后康复方法和效果。方法 :设计断指再植和拇指再造术后计划性康复程序 ,应用BTEPrimus康复评估仪进行断指再植和拇指再造术后计划性、系统性康复 2 1例 ,并与 2 0例未系统康复的患者进行比较。结果 :计划康复组手指活动度恢复至健侧的 77%± 9% ,两指捏力恢复至健侧的 81%± 12 % ,三指捏力恢复至健侧的 83 %± 7% ,3个月后全部返回原工作岗位。计划康复组手功能的恢复明显优于对照组。结论 :断指再植和拇指再造术后计划性康复能有效地提高再植术后的手功能。     

难治性类风湿关节炎的治疗

简述了难治性类风湿关节炎 (RRA)的定义 ,分析了难治的可能原因 ,详述了RRA的用药策略。如加大病情改善药(DMARD)用量 ,联合用DMARD如甲氨蝶呤、柳氮磺吡啶与羟氯喹联用 ,加用皮质激素 ,用新型免疫抑制剂来氟米特 ,生物制剂如肿瘤坏死因子阻滞剂等。     

瘦素与类风湿关节炎

瘦素是脂肪细胞分泌的肽类激素,在能量营养代谢方面起着重要调节作用。越来越多的证据表明,瘦素既作为激素又作为免疫因子在神经内分泌免疫网络中起着重要调节作用,是营养状况、能量代谢、神经内分泌免疫相互影响、相互作用的重要中介物。其含量消长与多种自身免疫病的发生、发展有密切联系,可能在免疫系统中具有双向调节作用。因此瘦素作为新型免疫介质在炎症及免疫应答中发挥作用受到关注。现就瘦素在自身免疫病及类风湿性关节炎中的作用作一概述。     

Conservative management of thumb carpometacarpal osteoarthritis: An Italian survey of current clinical practice

Objective

The purpose of this study was to elucidate expert opinion on the conservative treatment of thumb carpometacarpal (CMC) joint osteoarthritis (OA).

类风湿关节炎实验室诊断进展

类风湿关节炎 (RA)早期诊断是减少致残率 ,提高治愈率的关键。诊断不符合美国风湿病院诊断标准的早期RA有赖于血清学。本文着重阐述了抗角蛋白抗体、抗核周因子、抗Sa抗体、抗RA3 3 及抗RA3 6抗体、抗丝集蛋白自身抗体、抗Ⅱ型胶原抗体、基质金属蛋白酶及血管内皮生长因子的临床应用。     

“三合一”预制皮瓣移植修复拇指脱套伤的临床应用

目的总结“三合一”预制皮瓣移植修复拇指脱套伤的临床应用效果。 方法2007年1月至2018年1月兰州手足外科医院应用“三合一”预制皮瓣移植修复拇指脱套伤8例。其中，男7例，女1例；年龄22~39岁，平均（32.0±9.6）岁。预制皮瓣的旋股外侧降支血管动脉和静脉分别与桡动脉背侧支动脉和静脉相吻合，供区创面行直接缝合。 结果1例供区发生小的切口裂开，经再次缝合后愈合，预制皮瓣全部成活，取得了较满意的效果。术后随访2~5.5年，平均（3.5±1.6）年，供区无明显的功能障碍，受区外形较好。 结论“三合一”预制皮瓣移植技术修复拇指脱套伤效果优良，尤其适合不宜行 甲瓣移植手术的拇指脱套伤。     

Treatment Options for Patellofemoral Arthritis

Purpose of ReviewTo present a synthesis of recent literature regarding the treatment of patellofemoral arthritisRecent FindingsRisk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature.SummaryPatellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.     

Wheelchair-related thumb injury of multifactorial etiology: a case report

A 56-year-old man presented with bilateral transtibial amputations secondary to peripheral vascular disease and diabetes. While using a hospital-owned wheelchair to descend a 27-m-long, 5.6 degrees slope in an underground tunnel connecting the rehabilitation center to a neighboring acute care facility, the patient had difficulty slowing the wheelchair to negotiate a turn. After sustaining burns on the palmar aspects of the thumbs due to friction against the metal handrims, he shifted his thumbs onto the treaded tires. This pulled his right thumb between the wheel lock and the tire of the wheelchair. The resulting laceration and small chip fracture of the dorsal aspect of the thumb metacarpal required immobilization. This injury might have been prevented if the ramp had not violated accessibility guidelines, if the handrims and wheel locks had been different, if brakes had been available, if the patient had been wearing gloves, and/or if the patient had used appropriate procedures for descending long, steep inclines. This case has several implications for the wheelchair-delivery system.     

风湿病中关节炎与支原体感染的关系研究

目的　应用套式聚合酶链反应 (nPCR)检测技术探讨风湿病中关节炎与支原体感染的关系。方法　对 2 6例类风湿关节炎 (RA) ,2 4例反应性关节炎 (ReA)、3例系统性红斑狼疮 (SLE)、1例干燥综合症 (SS)、1例骨关节炎 (OA)、1例未分化结缔组织病 (UCTD)、3例强直性脊柱炎 (AS)病人关节液用nPCR方法联合检测支原体 :解脲脲原体 (Uu)、人型支原体 (Mh)、发酵支原体 (Mf)、关节炎支原体 (Mar)。结果　 2 6例RA患者中 ,2例Uu阳性、1例Mh阳性、1例Mar阳性。 2 4例ReA患者中 ,2例Uu阳性、2例Mh阳性。 3例SLE患者中 ,1例Uu阳性。2例Mh阳性 ,1例SS患者Mh阳性。结论　风湿病中关节炎与支原体感染有密切关系 ,支原体感染可能是风湿病发病的一个重要因素之一。     

Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial

Objective

This study evaluated the effects of Kaltenborn manual therapy on sensory and motor function in elderly patients with secondary carpometacarpal osteoarthritis (CMC OA).

Method

Twenty-nine female patients with secondary CMC OA (70-90 years old) were randomized into Kaltenborn manual therapy and sham groups. This study was designed as a double-blind, randomized controlled trial (RCT). Therapy consisted of Kaltenborn mobilization of posterior-anterior gliding with distraction in grade 3 of the carpometacarpal (CMC) joint of the dominant hand during 6 sessions over 2 weeks. Pain was measured by algometry, as the pressure pain threshold (PPT) at the CMC joint and tubercle of the scaphoid bone. The tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. Measurements were taken before treatment and after 1 week (first follow-up [FU]) and 2 weeks (second FU).

Results

All values in the sham group remained unchanged during the treatment period. In the treated group, the PPT in the CMC joint was 2.98 ± 0.30 kg/cm², which increased after treatment to 4.07 ± 0.53, and was maintained at the same level during the first FU (3.46 ± 0.31) and second FU (3.84 ± 0.36). Similarly, the PPT in the scaphoid bone was 3.61 ± 0.29 kg/cm², which increased after treatment to 4.87 ± 0.37, and was maintained at the same level during the first FU (4.44 ± 0.43) and second FU (4.22 ± 0.32). In contrast, we found no differences in the tip, tripod pinch, and grip strength measurements between the treatment and sham groups.

Conclusions

This study showed that Kaltenborn manual therapy decreased pain in the CMC joint and scaphoid bone areas of elderly female patients; however, it did not confer an increase in motor function in patients with CMC OA.