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Adakah melencongkan jari dianggap sebagai lenturan digit?

Adakah melencongkan jari dianggap sebagai lenturan digit?


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Adakah melencongkan jari dianggap fleksi jari dan meluruskan jari dianggap sebagai sambungan jari? Saya rasa ini betul dalam bahasa seharian, tetapi saya tidak pasti sama ada ia betul dari segi anatomi.


Dalam satah menegak, lenturan jari memang dirujuk sebagai lenturan, manakala meluruskan dipanggil sambungan. Dalam satah mendatar, menyebarkan jari dipanggil penculikan, dan penghampiran dipanggil penambahan (Rajah 1).


Rajah 1. Pergerakan dan istilah jari. sumber: Jabatan Hal Ehwal Veteran AS


Bab 33. Tangan

Fascia tangan adalah berterusan dengan fascia lengan bawah (antebrachium). Di tangan, fascia berbeza dalam ketebalan dan membahagikan tangan kepada lima petak berasingan yang sepadan dengan lima digit dan mempunyai bekalan darah, pemuliharaan, dan tindakan yang serupa.

Lapisan Fassial Sisi Palmar Tangan (Rajah 33-1A)


  • aponeurosis palmar. Terletak di atas tapak tangan dan meliputi tendon fleksor dan struktur tangan yang lebih dalam. Aponeurosis palmar memanjang secara distal dan menjadi berterusan dengan sarung digital berserabut.
  • Sarung digital berserabut. Bentuk terowong yang menutupi tendon fleksor digit 2 hingga 5 dan tendon otot flexor pollicis longus dan sarung sinovial yang berkaitan.
  • Retinakulum fleksor (ligamen karpal melintang). Membentuk bumbung di atas lekuk yang dicipta oleh tulang karpal, membentuk terowong (iaitu, terowong karpal). Saraf median dan tendon flexor digitorum superficialis, flexor digitorum profundus, dan otot flexor pollicis longus, dan sarung sinovial yang berkaitan, melalui terowong ini. Retinakulum fleksor berlabuh secara medial pada pisiform dan cangkuk hamate. Secara lateral, retinakulum fleksor berlabuh pada scaphoid dan trapezium.
  • Ligamen palmar melintang. Berterusan dengan retinakulum ekstensor dari bahagian dorsal pergelangan tangan dan melilit, ke anterior, untuk membentuk jalur fascial di sekeliling tendon fleksor. Ligamen ini tidak boleh dikelirukan dengan retinakulum fleksor, yang terletak lebih dalam ke ligamen palmar melintang.
Rajah 33-1

A . Fascia tapak tangan dan terowong karpal. B . Fascia tangan posterior dan petak ekstensor. C . Tindakan digit 2–4. D . Tindakan digit 1 (ibu jari).

Petak Fassial Sisi Palmar Tangan

Lapisan fascial membahagikan bahagian tapak tangan kepada lima petak berikut (Rajah 33-1A):


  • Petak Thenar. Mengandungi tiga otot yang bertindak pada digit 1 (ibu jari).
  • Petak hipotenar. Mengandungi tiga otot yang bertindak pada digit 5.
  • Petak tengah. Terletak di antara petak tenar dan hipotenar dan mengandungi tendon fleksor dan otot lubrikal.
  • Ruang tambah. Mengandungi otot adductor pollicis.
  • Petak interosseous. Terletak di antara metakarpal dan mengandungi otot interossei dorsal dan palmar.

Lapisan Fassial Bahagian Dorsal Tangan


  • Retinakulum ekstensor. Berterusan dengan fascia lengan bawah dan dilekatkan secara lateral pada jejari dan medial pada triquetrum dan tulang pisiform. Retinakulum ekstensor berfungsi untuk mengekalkan tendon yang berada berhampiran tulang sambil membenarkan gelongsor proksimal dan distal tendon (Rajah 33-1B).
  • Pengembangan digital dorsal. Aponeurosis yang menutupi dorsum digit dan melekat distal pada phalanx distal. Secara proksimal dan tengah, otot extensor digitorum, extensor digiti minimi, extensor indicis, dan extensor pollicis brevis otot melekat pada pengembangan digital dorsal. Secara lateral, otot lubrikal dan otot dorsal dan palmar interossei melekat. Otot intrinsik kecil yang melekat di sisi bertanggungjawab untuk pergerakan jari yang halus yang tidak mungkin dilakukan dengan extensor digitorum, flexor digitorum superficialis, dan otot profundus sahaja. Kerana perlekatan otot dan lokasi hud, otot intrinsik kecil akan menghasilkan fleksi pada sendi metacarpophalangeal sambil memanjangkan sendi interphalangeal.

Petak Fassial Bahagian Dorsal Pergelangan Tangan

Retinakulum ekstensor tangan membahagikan dorsum pergelangan tangan kepada enam petak berikut:


  • Petak 1. Mengandungi otot abductor pollicis longus dan extensor pollicis brevis.
  • Petak 2. Mengandungi otot extensor carpi radialis longus dan brevis.
  • Petak 3. Mengandungi otot extensor pollicis longus.
  • Petak 4. Mengandungi otot extensor digitorum dan extensor indicis.
  • Petak 5. Mengandungi otot extensor digiti minimi.
  • Petak 6. Mengandungi otot extensor carpi ulnaris.

Tindakan Jari dan Ibu Jari

Gambar besar

Tangan terdiri daripada lima digit (empat jari dan ibu jari). Ibu jari dianggap digit 1 jari telunjuk adalah digit 2 jari tengah adalah digit 3, jari manis adalah digit 4, dan jari kelingking adalah digit 5. Terdapat 19 tulang dan 19 sendi di tangan distal tulang karpal. Setiap digit mempunyai carpometacarpal, metacarpophalangeal, dan sendi interphalangeal.

Tindakan Jari

Sendi jari dan pergerakan yang berkaitan adalah seperti berikut (Rajah 33-1C):


  • Sendi carpometacarpal. Sendi gelongsor yang membolehkan meluncur dan berputar.
  • Sendi metacarpophalangeal. Sendi kondilar yang membolehkan fleksi dan lanjutan serta penculikan dan penambahan. Pergerakan penculikan dan penambahan diterangkan berkaitan dengan digit 3 (jari tengah). Semua pergerakan menjauhi digit 3 dianggap penculikan, dan pergerakan ke arah digit 3 dianggap penambahan. Putaran adalah terhad kerana ligamen cagaran.
  • Sendi interphalangeal. Sendi engsel yang membolehkan fleksi dan lanjutan. Terdapat sendi interphalangeal proksimal dan sendi interphalangeal distal untuk digit 2 hingga 5. Mereka sering dirujuk sebagai PIP dan DIP, masing-masing.

Tindakan Ibu Jari

Sendi ibu jari dan pergerakan yang berkaitan adalah seperti berikut (Rajah 33-1D):


  • Sendi Carpometacarpal. Sendi pelana yang membolehkan penentangan dan kedudukan semula.
  • Sendi metacarpophalangeal. Sendi engsel yang membolehkan fleksi dan lanjutan.
  • Sendi interphalangeal. Sendi engsel yang membolehkan fleksi dan lanjutan. Hanya terdapat satu sendi interphalangeal untuk digit 1 (ibu jari).

Ibu jari diputar 90 darjah ke digit 2 hingga 5. Oleh itu, penculikan dan penambahan berlaku pada satah sagital, dan lenturan dan lanjutan berlaku pada satah koronal.


Kandungan

Biasanya, kontraktur Dupuytren mula-mula muncul sebagai penebalan atau nodul di tapak tangan, yang pada mulanya boleh dengan atau tanpa rasa sakit. [8] Kemudian dalam proses penyakit, yang boleh bertahun-tahun kemudian, [9] terdapat kehilangan julat pergerakan jari yang terjejas tanpa rasa sakit yang semakin meningkat. Tanda awal kontraktur ialah "kerutan" segi tiga pada kulit tapak tangan apabila ia melepasi tendon fleksor sejurus sebelum lipatan fleksor jari, pada sendi metacarpophalangeal (MCP).

Secara amnya, kord atau kontraktur tidak menyakitkan, tetapi, jarang sekali, tenosynovitis boleh berlaku dan menghasilkan kesakitan. Jari yang paling biasa terjejas ialah jari manis ibu jari dan jari telunjuk lebih jarang terjejas. [10] Penyakit ini bermula di tapak tangan dan bergerak ke arah jari, dengan sendi metacarpophalangeal (MCP) terjejas sebelum sendi interphalangeal proksimal (PIP). [11]

Dalam kontraktur Dupuytren, fascia tapak tangan dalam tangan menjadi tebal secara tidak normal, yang boleh menyebabkan jari-jari melengkung dan boleh menjejaskan fungsi jari. Fungsi utama fascia palmar adalah untuk meningkatkan kekuatan cengkaman oleh itu, dari masa ke masa, kontraktur Dupuytren mengurangkan keupayaan seseorang untuk memegang objek. Orang ramai mungkin melaporkan kesakitan, sakit, dan gatal-gatal dengan kontraksi. Biasanya, fascia palmar terdiri daripada kolagen jenis I, tetapi bagi penghidap Dupuytren, kolagen berubah kepada kolagen jenis III, yang ketara lebih tebal daripada kolagen jenis I. [ rujukan diperlukan ]

Syarat berkaitan Edit

Orang yang mengalami penglibatan teruk selalunya menunjukkan ketulan pada bahagian belakang sendi jari mereka (dipanggil "Pad Garrod", "pad buku jari", atau "nodul Dupuytren dorsal"), dan ketulan di lengkungan kaki (plantar fibromatosis atau penyakit Ledderhose). [12] Dalam kes yang teruk, kawasan di mana tapak tangan bertemu dengan pergelangan tangan mungkin mengalami ketulan.

Kontraktur Dupuytren adalah penyakit yang tidak spesifik, tetapi terutamanya memberi kesan:

Suntingan yang tidak boleh diubah suai

  • Orang keturunan Scandinavia atau Eropah Utara [13] ia telah dipanggil "penyakit Viking", [6] walaupun ia juga tersebar luas di beberapa negara Mediterranean, contohnya, Sepanyol [14] dan Bosnia. [15][16] Dupuytren adalah luar biasa di kalangan kumpulan etnik seperti Cina dan Afrika. [17]
  • Lelaki berbanding wanita lelaki lebih cenderung untuk mengembangkan keadaan (80%) [10][13][18]
  • Orang yang berumur lebih dari 50 tahun (5% hingga 15% lelaki dalam kumpulan itu di AS) kemungkinan mendapat penyakit Dupuytren meningkat dengan usia [10][17][18]
  • Orang yang mempunyai sejarah keluarga (60% hingga 70% daripada mereka yang menderita mempunyai kecenderungan genetik untuk kontraktur Dupuytren) [10][19]

Suntingan yang boleh diubah suai

  • Perokok, terutamanya mereka yang menghisap 25 batang rokok atau lebih sehari [17][20]
  • Orang yang lebih kurus, iaitu mereka yang mempunyai indeks jisim badan yang lebih rendah daripada purata. [17]
  • Pekerja manual [17][6][20]

Syarat lain Edit

  • Orang yang mempunyai paras glukosa darah puasa yang lebih tinggi daripada purata[17]
  • Orang yang mengalami kecederaan tangan sebelum ini [10]
  • Orang yang mempunyai penyakit Ledderhose (plantar fibromatosis)[10]
  • Orang yang menghidap epilepsi (mungkin disebabkan oleh ubat anti-kejang) [21]
  • Orang yang menghidap diabetes mellitus[6][21]
  • Penghidap HIV[6]
  • Infarksi miokardium sebelumnya[17][18]

Dalam satu kajian, mereka yang mempunyai tahap 2 penyakit itu didapati mempunyai sedikit peningkatan risiko kematian, terutamanya daripada kanser. [22]

Jenis Edit

Menurut pakar Dupuytren Amerika Dr. Charles Eaton, mungkin terdapat tiga jenis penyakit Dupuytren: [23]

  • Jenis 1: Bentuk penyakit yang sangat agresif ditemui hanya pada 3% orang yang menghidap Dupuytren, yang boleh menjejaskan lelaki di bawah umur 50 tahun dengan sejarah keluarga Dupuytren. Ia sering dikaitkan dengan gejala lain seperti pad buku jari dan penyakit Ledderhose. Jenis ini kadangkala dikenali sebagai diatesis Dupuytren. [24]
  • Jenis 2: Jenis penyakit Dupuytren yang lebih normal, biasanya terdapat di tapak tangan sahaja, dan yang biasanya bermula di atas umur 50 tahun. Menurut Eaton, jenis ini mungkin menjadi lebih teruk oleh faktor lain seperti diabetes atau buruh kasar yang berat. [23]
  • Jenis 3: Bentuk ringan Dupuytren yang biasa di kalangan pesakit kencing manis atau yang mungkin juga disebabkan oleh ubat-ubatan tertentu, seperti anti-konvulsan yang diambil oleh penghidap epilepsi. Jenis ini tidak membawa kepada pengecutan penuh jari, dan mungkin tidak diwarisi. [23]

Rawatan ditunjukkan apabila apa yang dipanggil ujian atas meja adalah positif. Dengan ujian ini, orang itu meletakkan tangannya di atas meja. Jika tangan terletak betul-betul rata di atas meja, ujian itu dianggap negatif. Jika tangan tidak boleh diletakkan rata sepenuhnya di atas meja, meninggalkan ruang antara meja dan bahagian tangan sebesar diameter pen mata bola, ujian itu dianggap positif dan pembedahan atau rawatan lain mungkin ditunjukkan. Selain itu, sendi jari mungkin menjadi tetap dan tegar. Terdapat beberapa jenis rawatan, dengan sesetengah tangan memerlukan rawatan berulang.

Kategori utama yang disenaraikan oleh Persatuan Dupuytren Antarabangsa mengikut urutan peringkat penyakit ialah terapi sinaran, aponeurotomi jarum (NA), suntikan kolagenase, dan pembedahan tangan. Sehingga 2016 [kemas kini] bukti tentang keberkesanan terapi sinaran dianggap tidak mencukupi dari segi kuantiti dan kualiti, dan sukar untuk ditafsirkan kerana ketidakpastian tentang sejarah semula jadi penyakit Dupuytren. [25]

Aponeurotomi jarum paling berkesan untuk Peringkat I dan II, meliputi 6–90 darjah ubah bentuk jari. Walau bagaimanapun, ia juga digunakan pada peringkat lain.

Suntikan kolagenase juga paling berkesan untuk Peringkat I dan II. Walau bagaimanapun, ia juga digunakan pada peringkat lain.

Pembedahan tangan berkesan pada peringkat I hingga peringkat IV. [26]

Suntingan Pembedahan

Pada 12 Jun 1831, Dupuytren melakukan prosedur pembedahan ke atas seseorang yang mengalami kontraktur digit ke-4 dan ke-5 yang sebelum ini telah diberitahu oleh pakar bedah lain bahawa satu-satunya ubat adalah memotong tendon fleksor. Beliau menerangkan keadaan dan operasi di Lancet pada tahun 1834 [27] selepas membentangkannya pada tahun 1833, dan selepas kematiannya pada tahun 1836 dalam penerbitan Perancis oleh Hôtel-Dieu de Paris. [28] Prosedur yang diterangkannya ialah prosedur jarum invasif minima.

Kerana kadar berulang yang tinggi, [ rujukan diperlukan ] teknik pembedahan baru telah diperkenalkan, seperti fasciectomy dan kemudian dermofasciectomy. Kebanyakan tisu berpenyakit dikeluarkan dengan prosedur ini. Kadar berulang adalah rendah. [ jelaskan ] Bagi sesetengah individu, pemasukan separa "wayar-K" ke dalam sama ada sambungan DIP atau PIP bagi digit yang terjejas untuk tempoh sekurang-kurangnya 21 hari untuk menggabungkan sendi adalah satu-satunya cara untuk menghentikan perkembangan penyakit. Selepas penyingkiran wayar, sambungan diikat menjadi lentur, yang dianggap lebih baik daripada gabungan pada sambungan.

Dalam kes yang melampau, amputasi jari mungkin diperlukan untuk kes yang teruk atau berulang atau selepas komplikasi pembedahan. [29]

Fasciectomy terhad Edit

Fasciectomy terhad/selektif membuang tisu patologi, dan merupakan pendekatan biasa. [30] [31] Bukti berkualiti rendah menunjukkan bahawa fasciektomi mungkin lebih berkesan untuk orang yang mengalami kontraktur Dupuytren lanjutan. [32]

Semasa prosedur, orang itu berada di bawah anestesia serantau atau am. Tourniquet pembedahan menghalang aliran darah ke anggota badan. [33] Kulit sering dibuka dengan hirisan zig-zag tetapi hirisan lurus dengan atau tanpa Z-plasti juga diterangkan dan boleh mengurangkan kerosakan pada berkas neurovaskular. [34] Semua kord dan fasia yang berpenyakit dipotong. [30] [31] [33] Pengasingan mestilah sangat tepat untuk menyelamatkan berkas neurovaskular. [33] Oleh kerana tidak semua tisu berpenyakit dapat dilihat secara makroskopik, pengasingan lengkap tidak pasti. [31]

Kajian 20 tahun mengenai komplikasi pembedahan yang berkaitan dengan fasciectomy menunjukkan bahawa komplikasi utama berlaku dalam 15.7% kes, termasuk kecederaan saraf digital (3.4%), kecederaan arteri digital (2%), jangkitan (2.4%), hematoma (2.1%). , dan sindrom kesakitan serantau yang kompleks (5.5%), sebagai tambahan kepada komplikasi kecil termasuk tindak balas suar yang menyakitkan dalam 9.9% kes dan komplikasi penyembuhan luka dalam 22.9% kes. [35] Selepas tisu dikeluarkan, hirisan ditutup. Dalam kes kekurangan kulit, bahagian melintang hirisan zig-zag dibiarkan terbuka. Jahitan dikeluarkan 10 hari selepas pembedahan. [33]

Selepas pembedahan, tangan dibalut dengan pembalut mampatan ringan selama satu minggu. Fleksi dan lanjutan jari boleh bermula sebaik sahaja anestesia telah diselesaikan. Ia adalah perkara biasa untuk mengalami kesemutan dalam minggu pertama selepas pembedahan. [32] Terapi tangan sering disyorkan. [33] Kira-kira 6 minggu selepas pembedahan pesakit boleh menggunakan tangan sepenuhnya. [36]

Kadar pengulangan purata ialah 39% selepas fasciectomy selepas selang median kira-kira 4 tahun. [37]

Fasciektomi terjaga luas Edit

Fasciectomy terhad/selektif di bawah bius tempatan (LA) dengan epinefrin tetapi tiada tourniquet boleh dilakukan. Pada tahun 2005, Denkler menerangkan teknik tersebut. [38] [39]

Dermofasciectomy Edit

Dermofasciectomy adalah prosedur pembedahan yang boleh digunakan apabila:

  • Kulit terlibat secara klinikal (lubang, tethering, kekurangan, dll)
  • Risiko berulang adalah tinggi dan kulit kelihatan tidak terlibat (penglibatan kulit subklinikal berlaku dalam

Lazimnya, kulit yang dipotong digantikan dengan cantuman kulit, biasanya ketebalan penuh, [31] yang terdiri daripada epidermis dan keseluruhan dermis. Dalam kebanyakan kes cantuman diambil dari fossa antecubital (kedutan kulit pada sendi siku) atau bahagian dalam lengan atas. [41] [42] Tempat ini dipilih kerana warna kulit paling sesuai dengan warna kulit tapak tangan. Kulit di bahagian dalam lengan atas adalah nipis dan mempunyai kulit yang cukup untuk membekalkan cantuman tebal penuh. Tapak penderma boleh ditutup dengan jahitan terus. [41]

Cantuman itu dijahit pada kulit di sekeliling luka. Selama satu minggu tangan dilindungi dengan pembalut. Tangan dan lengan dinaikkan dengan anduh. Pembalut kemudian dikeluarkan dan mobilisasi berhati-hati boleh dimulakan, secara beransur-ansur meningkatkan intensiti. [41] Selepas prosedur ini risiko berulang dikurangkan, [31] [41] [42] tetapi Dupuytren boleh berulang dalam cantuman kulit [43] dan komplikasi daripada pembedahan mungkin berlaku. [ samar-samar ] [44]

Fasciectomy segmen dengan/tanpa selulosa Edit

Fasciektomi segmen melibatkan pemotongan bahagian (-bahagian) kord yang dikontrak supaya ia hilang atau tidak lagi mengecutkan jari. Ia kurang invasif daripada fasciectomy terhad, kerana tidak semua tisu berpenyakit dipotong dan hirisan kulit lebih kecil. [45]

Orang itu diletakkan di bawah bius serantau dan tourniquet pembedahan digunakan. Kulit dibuka dengan hirisan kecil melengkung di atas tisu berpenyakit. Sekiranya perlu, hirisan dibuat di jari. [45] Kepingan kord dan fascia lebih kurang satu sentimeter dipotong. Kord diletakkan di bawah ketegangan maksimum semasa ia dipotong. Pisau bedah digunakan untuk memisahkan tisu. [45] Pakar bedah terus mengeluarkan bahagian kecil sehingga jari boleh memanjang sepenuhnya. [45] [46] Orang itu digalakkan untuk mula menggerakkan tangannya sehari selepas pembedahan. Mereka memakai bidai lanjutan selama dua hingga tiga minggu, kecuali semasa terapi fizikal. [45]

Prosedur yang sama digunakan dalam fasciectomy segmental dengan implan selulosa. Selepas pemotongan dan hemostasis yang berhati-hati, implan selulosa diletakkan dalam satu lapisan di antara bahagian kord yang tinggal. [46]

Selepas pembedahan, orang memakai pembalut tekanan ringan selama empat hari, diikuti dengan bidai lanjutan. Belat itu dipakai secara berterusan pada waktu malam selama lapan minggu. Semasa minggu pertama selepas pembedahan, splint boleh dipakai pada waktu siang. [46]

Rawatan kurang invasif Edit

Kajian telah dijalankan untuk pelepasan perkutaneus, aponeurotomi perkutaneus yang meluas dengan lipografting dan kolagenase. Rawatan ini menunjukkan janji. [47] [48] [49] [50]

Fasciotomy jarum perkutaneus Edit

Aponeurotomi jarum ialah teknik invasif minima di mana kord dilemahkan melalui pemasukan dan manipulasi jarum kecil. Kord dibelah pada tahap sebanyak mungkin di tapak tangan dan jari, bergantung pada lokasi dan tahap penyakit, menggunakan jarum 25-tolok yang dipasang pada picagari 10 ml. [47] Setelah lemah, kord yang menyinggung boleh diputuskan dengan meletakkan ketegangan pada jari dan menarik jari lurus. Selepas rawatan, pembalut kecil digunakan selama 24 jam, selepas itu orang ramai boleh menggunakan tangan mereka secara normal. Tiada splint atau fisioterapi diberikan. [47]

Kelebihan aponeurotomi jarum adalah campur tangan yang minimum tanpa hirisan (dilakukan di pejabat di bawah bius tempatan) dan kembali ke aktiviti normal yang sangat cepat tanpa memerlukan pemulihan, tetapi nodul boleh tumbuh semula. [51] Satu kajian melaporkan keuntungan selepas pembedahan adalah lebih besar pada tahap MCP-sendi berbanding pada tahap IP-sendi dan mendapati kadar operasi semula sebanyak 24% komplikasi adalah terhad. [52] Aponeurotomi jarum boleh dilakukan pada jari yang bengkok teruk (peringkat IV), dan bukan hanya pada peringkat awal. Kajian 2003 menunjukkan kadar berulang 85% selepas 5 tahun. [53]

Kajian menyeluruh mengenai keputusan aponeurotomi jarum dalam 1,013 jari telah dilakukan oleh Gary M. Pess, MD, Rebecca Pess, DPT, dan Rachel Pess, PsyD, dan diterbitkan dalam Jurnal Pembedahan Tangan April 2012. Susulan minimum ialah 3 tahun. Kontraktur sendi metacarpophalangeal (MP) telah diperbetulkan pada purata 99% dan kontraktur sendi interphalangeal proksimal (PIP) pada purata 89% serta-merta selepas prosedur. Pada susulan akhir, 72% pembetulan dikekalkan untuk sambungan MP dan 31% untuk sambungan PIP. Perbezaan antara pembetulan akhir untuk sambungan MP berbanding PIP adalah signifikan secara statistik. Apabila perbandingan dilakukan antara orang yang berumur 55 tahun dan lebih tua berbanding di bawah 55 tahun, terdapat perbezaan yang signifikan secara statistik pada kedua-dua sendi MP dan PIP, dengan pembetulan yang lebih besar dikekalkan dalam kumpulan yang lebih tua.

Perbezaan jantina tidak signifikan secara statistik. Aponeurotomi jarum memberikan pembetulan yang berjaya kepada 5° atau kurang kontraktur serta-merta selepas prosedur dalam 98% (791) sendi MP dan 67% (350) sendi PIP. Terdapat pengulangan 20° atau kurang berbanding tahap pembetulan pasca prosedur asal dalam 80% (646) sambungan MP dan 35% (183) sambungan PIP. Komplikasi jarang berlaku kecuali koyakan kulit, yang berlaku dalam 3.4% (34) digit. Kajian ini menunjukkan bahawa NA adalah prosedur selamat yang boleh dilakukan dalam keadaan pesakit luar. Kadar komplikasi adalah rendah, tetapi berulang adalah kerap pada orang yang lebih muda dan untuk kontraktur PIP. [54]

Aponeurotomi perkutaneus yang meluas dan lipografting Sunting

Teknik yang diperkenalkan pada tahun 2011 ialah aponeurotomi perkutaneus yang meluas dengan lipografting. [48] ​​Prosedur ini juga menggunakan jarum untuk memotong kord. Perbezaan dengan fasciotomy jarum perkutaneus ialah kordnya dipotong di banyak tempat. Kord juga dipisahkan dari kulit untuk memberi tempat bagi lipograf yang diambil dari perut atau rusuk ipsilateral. [48] ​​Teknik ini memendekkan masa pemulihan. Hasil cantuman lemak menghasilkan kulit yang anjal. [48]

Sebelum aponeurotomi, liposuction dilakukan pada perut dan rusuk ipsilateral untuk mengumpul lipograf. [48] ​​Rawatan boleh dilakukan di bawah bius serantau atau am. Digit diletakkan di bawah tegangan lanjutan maksimum menggunakan retraktor tangan plumbum yang kukuh. Pakar bedah membuat beberapa luka tusukan tapak tangan dengan luka kecil. Ketegangan pada kord adalah penting, kerana jalur penyempitan yang ketat paling mudah dipotong dan terkoyak oleh torehan kecil, manakala struktur neurovaskular yang agak longgar terhindar. Selepas kord dipotong sepenuhnya dan dipisahkan dari kulit lipograft disuntik di bawah kulit. Sejumlah kira-kira 5 hingga 10 ml disuntik setiap sinar. [48]

Selepas rawatan orang itu memakai belat sambungan selama 5 hingga 7 hari. Selepas itu orang itu kembali ke aktiviti biasa dan dinasihatkan untuk menggunakan splint malam sehingga 20 minggu. [48]

Kolagenase Edit

Suntikan clostridial collagenase didapati lebih berkesan daripada plasebo. [5] Kord dilemahkan melalui suntikan sejumlah kecil enzim kolagenase, yang memecahkan ikatan peptida dalam kolagen. [49] [55] [56] [57] [50] [ petikan yang berlebihan ]

Rawatan dengan kolagenase adalah berbeza untuk sendi MCP dan sendi PIP. Dalam kontraktur sendi MCP, jarum mesti diletakkan pada titik tali busur maksimum yang boleh diraba. [49]

Jarum diletakkan secara menegak pada tali busur. Kolagenase diedarkan merentasi tiga titik suntikan. [49] Untuk sambungan PIP jarum mesti diletakkan tidak lebih daripada 4 mm distal ke lipatan digital tapak tangan pada kedalaman 2–3 mm. [49] Suntikan untuk PIP terdiri daripada satu suntikan yang diisi dengan 0.58 mg CCH 0.20 ml. [50] Jarum mesti diletakkan mendatar ke kord dan juga menggunakan pengagihan 3 mata. [49] Selepas suntikan, tangan orang itu dibalut dengan pembalut kasa besar dan mesti dinaikkan sepanjang hari. Selepas 24 jam orang itu kembali untuk sambungan digital pasif untuk memutuskan kord. Tekanan sederhana selama 10–20 saat memutuskan kord. [49]

Selepas rawatan dengan kolagenase seseorang itu harus menggunakan bidai malam dan melakukan senaman lenturan/pelanjutan digital beberapa kali sehari selama 4 bulan. [49]

Pada Februari 2010, Pentadbiran Makanan dan Dadah AS (FDA) meluluskan kolagenase suntikan yang diekstrak daripada Clostridium histolyticum untuk rawatan kontraktur Dupuytren pada orang dewasa dengan kord Dupuytren yang boleh dirasai. (Tiga tahun kemudian, ia telah diluluskan juga untuk rawatan penyakit Peyronie yang kadangkala berkaitan.) [58] [9] Pada tahun 2011 penggunaannya untuk rawatan kontraktur Dupuytren telah diluluskan juga oleh Agensi Ubat Eropah, dan ia menerima kelulusan serupa di Australia pada tahun 2013. [9]

Terapi sinaran Sunting

Terapi sinaran telah digunakan kebanyakannya untuk penyakit peringkat awal, tetapi tidak terbukti. [7] Bukti untuk menyokong penggunaannya pada 2017 [kemas kini] , bagaimanapun, adalah lemah—usaha untuk mengumpul bukti adalah rumit kerana pemahaman yang lemah tentang cara keadaan itu berkembang dari semasa ke semasa. [7] [25] Ia hanya dilihat pada penyakit awal. [7]

Perubatan alternatif Edit

Beberapa terapi alternatif seperti rawatan vitamin E telah dikaji, walaupun tanpa kumpulan kawalan. Kebanyakan doktor tidak menghargai rawatan tersebut. [59] Tiada satu pun daripada rawatan ini menghentikan atau menyembuhkan keadaan secara kekal. Kajian pada tahun 1949 mengenai terapi vitamin E mendapati bahawa "Dalam dua belas daripada tiga belas pesakit tidak ada bukti apa-apa pun perubahan. . Rawatan telah ditinggalkan." [60] [61]

Rawatan laser (menggunakan merah dan inframerah pada kuasa rendah) telah dibincangkan secara tidak rasmi pada tahun 2013 di forum Persatuan Dupuytren Antarabangsa, [62] yang mana sedikit atau tiada penilaian formal teknik telah diselesaikan.

Penjagaan selepas pembedahan Edit

Penjagaan selepas pembedahan melibatkan terapi tangan dan splinting. Terapi tangan ditetapkan untuk mengoptimumkan fungsi selepas pembedahan dan untuk mengelakkan kekakuan sendi. [ rujukan diperlukan ]

Selain terapi tangan, ramai pakar bedah menasihatkan penggunaan splin statik atau dinamik selepas pembedahan untuk mengekalkan mobiliti jari. Bidai digunakan untuk memberikan regangan yang berpanjangan pada tisu penyembuhan dan mencegah kontraktur fleksi. Walaupun splinting adalah intervensi pasca operasi yang digunakan secara meluas, bukti keberkesanannya adalah terhad, [63] yang membawa kepada variasi dalam pendekatan splinting. Kebanyakan pakar bedah menggunakan pengalaman klinikal untuk memutuskan sama ada untuk belat. [64] Kelebihan yang disebut termasuk penyelenggaraan sambungan jari dan pencegahan kontraktur fleksi baru. Kelemahan yang disebut termasuk kekakuan sendi, sakit yang berpanjangan, ketidakselesaan, [64] seterusnya mengurangkan fungsi dan edema.

Pendekatan ketiga menekankan latihan diri awal dan regangan. [39]

Penyakit Dupuytren mempunyai kadar berulang yang tinggi, terutamanya apabila seseorang mempunyai apa yang dipanggil diatesis Dupuytren. Istilah diatesis berkaitan dengan ciri-ciri tertentu penyakit Dupuytren, dan menunjukkan perjalanan penyakit yang agresif. [24]

Kehadiran semua faktor diatesis Dupuytren baharu meningkatkan risiko penyakit Dupuytren berulang sebanyak 71%, berbanding dengan risiko asas sebanyak 23% pada orang yang tidak mempunyai faktor tersebut. [24] Dalam kajian lain nilai prognostik diatesis telah dinilai. Disimpulkan bahawa kehadiran diatesis boleh meramalkan berulang dan lanjutan. [65] Sistem pemarkahan telah dibuat untuk menilai risiko berulang dan lanjutan, berdasarkan nilai berikut: penglibatan tangan dua hala, pembedahan jari kelingking, permulaan penyakit awal, fibrosis plantar, pad buku jari, dan penglibatan sisi jejari. [65]

Terapi invasif minimum mungkin mendahului kadar berulang yang lebih tinggi. Berulang tidak mempunyai definisi konsensus. Tambahan pula, piawaian dan ukuran yang berbeza mengikut daripada pelbagai definisi. [ rujukan diperlukan ]


KEJADIAN DD MENGIKUT KELUARGA

Dalam bukunya pada 1963, pakar bedah tangan Australia John Hueston menulis, 𠇍upuytren’s contracture hampir terhad kepada orang berketurunan Eropah” (2). Insiden tertinggi dicatatkan di Iceland. Seperti yang dijangkakan, kejadian juga tinggi di Scandinavia: Dalam kajian Norway terhadap 15,950 warganegara, DD hadir dalam 10.5% lelaki dan dalam 3.2% wanita (3). Dalam tinjauan besar tahun 1962 mengenai angka yang diterbitkan, P. F. Awal menyusun negara-negara saham Eropah mengikut urutan kejadian DD: Denmark, Australia, New Zealand, Kanada, United Kingdom, Jerman, dan Amerika Syarikat. Beliau juga mengulas bahawa kejadian di Australia, Kanada, England, dan Wales adalah serupa kerana populasi mereka pada asasnya adalah stok Inggeris, yang mungkin sendiri mewakili ketegangan stok Denmark (Viking) yang dicairkan (4). Insiden di Sweden dipadankan di Edinburg. Dua kajian berbeza oleh James dan Ling di Scotland menunjukkan insiden keluarga yang tinggi sehingga DD digambarkan sebagai diwarisi melalui gen autosomal dominan tunggal penembusan berubah-ubah (5, 6).

Dalam kajian di pelabuhan Perancis Toulon, 60% daripada populasi umum mempunyai mata coklat dan 40% mempunyai mata biru, tetapi 80% penduduk dengan DD mempunyai mata biru. Individu yang terakhir dikesan kepada keluarga pelayar Breton dan Norman dalam sejarah bandar itu (7).

DD agak jarang berlaku di Sepanyol, Greece dan Itali, kecuali Greece dan Pantai Adriatik utara Itali, yang ditembusi oleh pencerobohan genetik utara semasa Empayar Austria-Hungary.

Pada tahun 1985, Robert McFarlane dari Kanada menerbitkan laporan awal mengenai aktiviti jawatankuasa DD Persekutuan Persatuan Antarabangsa untuk Pembedahan Tangan. Dalam 812 pesakit, asal keluarga adalah Eropah Utara dalam 68%, Eropah Selatan dalam 3%, Afrika hitam dan India Amerika dalam 0.2%, Cina dalam 2%, dan Jepun dalam 16%. Keturunan Eropah Utara hampir tidak boleh digunakan untuk Jepun, di mana DD nampaknya merupakan keadaan yang berbeza, iaitu 95% kes berlaku pada lelaki dan hanya 6% kes berlaku dalam keluarga yang mempunyai sejarah DD�rbanding dengan 26% di negara lain. Saya faham bahawa kemas kini kajian besar-besaran ini akan diterbitkan tidak lama lagi (8).

Baru-baru ini, Hueston telah mengubah suai pandangan awalnya. Beliau kini menyatakan bahawa sifat dominan autosomal “menerangkan sedikit tentang etiologi DD,” tetapi masih banyak usaha untuk menjelaskan “keutamaan yang jelas untuk kaum yang berasal dari Eropah Utara” (9). Memetik pengalamannya sendiri ȁmerakam melihat 40 kes DD setiap minggu dalam perundingan di Melbourne,” dia mengulas: � kini boleh didakwa oleh peminat telah menembusi semua lima perlumbaan utama dunia. Tetapi apakah kepentingan laporan insiden yang sangat kecil ini dalam kaum yang begitu ramai penduduknya? Ada yang menafsirkan kejadian meluas ini sebagai menafikan asal genetik Eropah. Walau bagaimanapun, laporan mengenai satu atau dua kes eksotik dalam populasi ratusan juta ini hampir tidak boleh dipandang serius” (9).


Pelbagai pergerakan yang dibenarkan oleh sendi sinovial menghasilkan pelbagai jenis pergerakan. Pergerakan sendi sinovial boleh dikelaskan sebagai salah satu daripada empat jenis yang berbeza: meluncur, sudut, putaran, atau pergerakan khas.

Pergerakan Meluncur

Pergerakan meluncur berlaku apabila permukaan tulang yang agak rata bergerak melepasi satu sama lain. Pergerakan meluncur menghasilkan sedikit putaran atau pergerakan sudut tulang. Sendi tulang karpal dan tarsal adalah contoh sendi yang menghasilkan pergerakan meluncur.

Pergerakan Sudut

Pergerakan sudut terhasil apabila sudut antara tulang sendi berubah. Terdapat beberapa jenis pergerakan sudut yang berbeza, termasuk fleksi, lanjutan, hiperekstensi, penculikan, penambahan, dan circumduction. Fleksi, atau lenturan, berlaku apabila sudut antara tulang berkurangan. Menggerakkan lengan bawah ke atas pada siku atau menggerakkan pergelangan tangan untuk menggerakkan tangan ke arah lengan bawah adalah contoh fleksi. Sambungan adalah bertentangan dengan fleksi kerana sudut antara tulang sendi bertambah. Meluruskan anggota badan selepas fleksi adalah contoh lanjutan. Extension past the regular anatomical position is referred to as hyperextension. This includes moving the neck back to look upward, or bending the wrist so that the hand moves away from the forearm.

Abduction occurs when a bone moves away from the midline of the body. Examples of abduction are moving the arms or legs laterally to lift them straight out to the side. Adduction is the movement of a bone toward the midline of the body. Movement of the limbs inward after abduction is an example of adduction. Circumduction is the movement of a limb in a circular motion, as in moving the arm in a circular motion.

Rotational Movement

Rotational movement is the movement of a bone as it rotates around its longitudinal axis. Rotation can be toward the midline of the body, which is referred to as medial rotation, or away from the midline of the body, which is referred to as lateral rotation. Movement of the head from side to side is an example of rotation.

Special Movements

Some movements that cannot be classified as gliding, angular, or rotational are called special movements. Inversion involves the soles of the feet moving inward, toward the midline of the body. Eversion is the opposite of inversion, movement of the sole of the foot outward, away from the midline of the body. Protraction is the anterior movement of a bone in the horizontal plane. Retraction occurs as a joint moves back into position after protraction. Protraction and retraction can be seen in the movement of the mandible as the jaw is thrust outwards and then back inwards. Elevation is the movement of a bone upward, such as when the shoulders are shrugged, lifting the scapulae. Depression is the opposite of elevation—movement downward of a bone, such as after the shoulders are shrugged and the scapulae return to their normal position from an elevated position. Dorsiflexion is a bending at the ankle such that the toes are lifted toward the knee. Plantar flexion is a bending at the ankle when the heel is lifted, such as when standing on the toes. Supination is the movement of the radius and ulna bones of the forearm so that the palm faces forward. Pronation is the opposite movement, in which the palm faces backward. Opposition is the movement of the thumb toward the fingers of the same hand, making it possible to grasp and hold objects.

Types of Synovial Joints

Synovial joints are further classified into six different categories on the basis of the shape and structure of the joint. The shape of the joint affects the type of movement permitted by the joint (Figure 3). These joints can be described as planar, hinge, pivot, condyloid, saddle, or ball-and-socket joints.

Figure 3. Different types of joints allow different types of movement. Planar, hinge, pivot, condyloid, saddle, and ball-and-socket are all types of synovial joints.

Planar Joints

Planar joints have bones with articulating surfaces that are flat or slightly curved faces. These joints allow for gliding movements, and so the joints are sometimes referred to as gliding joints. The range of motion is limited in these joints and does not involve rotation. Planar joints are found in the carpal bones in the hand and the tarsal bones of the foot, as well as between vertebrae (Figure 4).

Figure 4. The joints of the carpal bones in the wrist are examples of planar joints. (credit: modification of work by Brian C. Goss)

Hinge Joints

Dalam hinge joints, the slightly rounded end of one bone fits into the slightly hollow end of the other bone. In this way, one bone moves while the other remains stationary, like the hinge of a door. The elbow is an example of a hinge joint. The knee is sometimes classified as a modified hinge joint (Figure 5).

Figure 5. The elbow joint, where the radius articulates with the humerus, is an example of a hinge joint. (credit: modification of work by Brian C. Goss)

Pivot Joints

Figure 6. The joint in the neck that allows the head to move back and forth is an example of a pivot joint.

Pivot joints consist of the rounded end of one bone fitting into a ring formed by the other bone. This structure allows rotational movement, as the rounded bone moves around its own axis. An example of a pivot joint is the joint of the first and second vertebrae of the neck that allows the head to move back and forth (Figure 6). The joint of the wrist that allows the palm of the hand to be turned up and down is also a pivot joint.

Condyloid Joints

Condyloid joints consist of an oval-shaped end of one bone fitting into a similarly oval-shaped hollow of another bone (Figure 7). This is also sometimes called an ellipsoidal joint. This type of joint allows angular movement along two axes, as seen in the joints of the wrist and fingers, which can move both side to side and up and down.

Figure 7. The metacarpophalangeal joints in the finger are examples of condyloid joints. (credit: modification of work by Gray’s Anatomy)

Saddle Joints

Saddle joints are so named because the ends of each bone resemble a saddle, with concave and convex portions that fit together. Saddle joints allow angular movements similar to condyloid joints but with a greater range of motion. An example of a saddle joint is the thumb joint, which can move back and forth and up and down, but more freely than the wrist or fingers (Figure 8).

Figure 8. The carpometacarpal joints in the thumb are examples of saddle joints. (credit: modification of work by Brian C. Goss)

Ball-and-Socket Joints

Ball-and-socket joints possess a rounded, ball-like end of one bone fitting into a cuplike socket of another bone. This organization allows the greatest range of motion, as all movement types are possible in all directions. Examples of ball-and-socket joints are the shoulder and hip joints (Figure 9).

Figure 9. The shoulder joint is an example of a ball-and-socket joint.

Rheumatologist

Rheumatologists are medical doctors who specialize in the diagnosis and treatment of disorders of the joints, muscles, and bones. They diagnose and treat diseases such as arthritis, musculoskeletal disorders, osteoporosis, and autoimmune diseases such as ankylosing spondylitis and rheumatoid arthritis.

Rheumatoid arthritis (RA) is an inflammatory disorder that primarily affects the synovial joints of the hands, feet, and cervical spine. Affected joints become swollen, stiff, and painful. Although it is known that RA is an autoimmune disease in which the body’s immune system mistakenly attacks healthy tissue, the cause of RA remains unknown. Immune cells from the blood enter joints and the synovium causing cartilage breakdown, swelling, and inflammation of the joint lining. Breakdown of cartilage causes bones to rub against each other causing pain. RA is more common in women than men and the age of onset is usually 40–50 years of age.

Rheumatologists can diagnose RA on the basis of symptoms such as joint inflammation and pain, X-ray and MRI imaging, and blood tests. Arthrography is a type of medical imaging of joints that uses a contrast agent, such as a dye, that is opaque to X-rays. This allows the soft tissue structures of joints—such as cartilage, tendons, and ligaments—to be visualized. An arthrogram differs from a regular X-ray by showing the surface of soft tissues lining the joint in addition to joint bones. An arthrogram allows early degenerative changes in joint cartilage to be detected before bones become affected.

There is currently no cure for RA however, rheumatologists have a number of treatment options available. Early stages can be treated with rest of the affected joints by using a cane or by using joint splints that minimize inflammation. When inflammation has decreased, exercise can be used to strengthen the muscles that surround the joint and to maintain joint flexibility. If joint damage is more extensive, medications can be used to relieve pain and decrease inflammation. Anti-inflammatory drugs such as aspirin, topical pain relievers, and corticosteroid injections may be used. Surgery may be required in cases in which joint damage is severe.

In Summary: Joints and Skeletal Movement

The structural classification of joints divides them into bony, fibrous, cartilaginous, and synovial joints. The bones of fibrous joints are held together by fibrous connective tissue the three types of fibrous joints are sutures, syndesomes, and gomphoses. Cartilaginous joints are joints in which the bones are connected by cartilage the two types of cartilaginous joints are synchondroses and symphyses. Synovial joints are joints that have a space between the adjoining bones. The functional classification divides joints into three categories: synarthroses, amphiarthroses, and diarthroses. The movement of synovial joints can be classified as one of four different types: gliding, angular, rotational, or special movement. Gliding movements occur as relatively flat bone surfaces move past each other. Angular movements are produced when the angle between the bones of a joint changes. Rotational movement is the movement of a bone as it rotates around its own longitudinal axis. Special movements include inversion, eversion, protraction, retraction, elevation, depression, dorsiflexion, plantar flexion, supination, pronation, and opposition. Synovial joints are also classified into six different categories on the basis of the shape and structure of the joint: planar, hinge, pivot, condyloid, saddle, and ball-and-socket.


Common Congenital Hand Differences

Syndactyly (Webbed Fingers)

Syndactyly, derived from the Greek syn meaning together and dactylos meaning digit, is a failure of differentiation in which the fingers fail to separate into individual appendages. The syndactyly can be simple (only soft tissue is conjoined) or complex (bone, nail elements and soft tissues are conjoined).

The normal hand develops during the 5th to 8th week of gestation. Fingers start to develop joined together because of a substance (denominated AERMF) that is present in every one of us. This substance should disappear during the 6th to 8th week of gestation to allow finger separation, when the substance fails to disappear syndactyly occurs. Syndactyly is twice as common in boys as in girls, it occurs in 1 of 2000 live births and most commonly the long and ring fingers are conjoined. This difference can be part of many genetic syndromes, thus an evaluation by a specialized physician is important to rule out these associations.

Syndactyly can be treated with an operation depending on each case the hand surgeon will decide the appropriate treatment. The goal of the surgery is to allow independent movement to each finger, in order to obtain a good result each finger must have all the bones and soft tissues complete. Timing of the procedure is decided in an individual basis ranging from 3 months to 1 year, but prompt evaluation by the hand specialist is always crucial.

When surgery is decided to be used, the hand surgeon completes a thorough preoperative planning, a series of incisions (zig-zag pattern) are made to separate the digits and almost always skin graft will be used to cover the site where the separation is performed. Sometimes these skin grafts can get a darker color than the child’s own skin because of the cicatrization process. Usually, after surgery the hand is immobilized in a splint and dressing changes are only done 2 to 4 weeks later to allow proper skin healing.

Radial Club Hand

Radial club hand is a longitudinal deficiency of a bone, the radius, in the forearm this congenital difference occurs in 1 of 30,000 to 100,000 live births. It consists of an absent or incomplete radius, absent or incomplete thumb, deviation of the wrist toward the thumb’s side (radial) and some degree of neuromuscular deficiency. Sometimes the problem may appear in both upper extremities. Many mechanisms have been implicated in cause of this difference, irradiation, environmental factors and nutrition among others have been studied but the real cause is still unknown. As other congenital differences radial club hand can be associated with other genetic syndromes such as VACTER, Holt-Oram Syndrome, TAR syndrome and Fanconi’s anemia.

The child with this difference must undergo a thorough evaluation including heart, spine, and kidneys, where other anomalies can be present. After these related problems have been ruled out or treated the hand surgeon will start treating the child with splints, casting and non–surgical manipulation to avoid or improve contractures.

Between 6 months and 1 year some patients with this problem will require a surgical procedure. This surgery is known as a “Centralization/radialization of carpus on ulnar epiphysis”. With this surgery the hand specialist relocates the hand over the existing normal bone “the ulna” making the hand to be aligned with this normal bone. This procedure corrects the deformity and in some cases allows movement of the wrist. Usually, the patient will be immobilized with a cast for four to 6 weeks after surgery. In some occasions, this surgery must be accompanied by other procedures to further straighten the arm and to allow correct movement of the hand.

Generally the affected arm will be shorter than the normal one. When this difference is too severe the hand surgeon can perform a lengthening procedure around 6 and 8 years of age. The other important component of this difference is the absence or underdevelopment of the thumb. Hand surgeons can improve this problem with a procedure called “pollicization” this means to make the thumb out of the index finger. The thumb is the most important finger of the hand and because grasping is one of the most important functions humans have, the reconstruction of a thumb may provide a better function to the hand in selected cases. Usually the results of these procedures are advantageous the decision to proceed with them depends on each individual case.

Camptodactyly/Clynodactyly

Camptodactyly is the term that describes a flexion deformity of one of the fingers the finger with this difference is bent and cannot be straightened. Camptodactyly can be caused by problems in the tendons the ligaments or the bones of the finger. This difference presents in approximately 1% of the population, the cause of this difference is not known but it can be associated with other congenital differences or syndromes this is why prompt assessment by a specialist is required.

An experienced hand surgeon must examine the hand of the child in order to initiate appropriate treatment. Usually camptodactyly can be managed without surgery, passive stretching exercises or finger splinting may correct the deformity. Some surgical procedures can be indicated by the hand specialist when the flexion contracture of the finger is larger than 30°. Surgical procedures depend on each case individually, but tendon excisions and transfers can be performed to correct this difference. Although correction can be obtained, the risk of residual flexion is always present.

Clinodactyly refers to the curving of the fifth (little) finger toward the fourth (ring) finger. This difference occurs because of a misshaped bone of the fifth finger. This minor difference can be found in a completely normal child, but it’s also a common finding in patients with Down and Klinefelter syndrome. This difference does not require any treatment, finger and hand function is normal.

Congenital Trigger Finger

Trigger finger refers to a difference in which the digit, almost exclusively the thumb in children, locks or catches when it’s flexed and extended. Apparently this is a condition that develops after birth and is present at 1 year of age in as much as 3.3 per 1000 live births. In one third of the cases the condition can be present bilaterally.

The tendon that allows flexion of the thumb glides through a series of pulleys before getting to the tip of the finger. When one of the pulleys (A1) is too tight or the tendon gets swollen the movement is not smooth and the tendon starts to lock or catch in its trajectory. The symptoms can progress to the point where the thumb is completely locked and contractures may develop, often a nodule (Notta’s nodule) can be palpated at the base of the finger.

Hand surgeons must evaluate this condition early on in order to initiate prompt treatment and avoid contractures. In 30% of the patients, the trigger finger recovers spontaneously. Usually depending on the age of presentation the treatment will change, between one and three years of age surgery is usually considered if the condition is still present.

The surgical procedure when indicated consists of opening the pulley that causes the tight passage for the tendon. Usually this requires a small incision on the base of the finger the child is immobilized for one week with a soft bandage after which they return to normal activities. The risk of recurrence is minimal but appropriate surgical technique is important because of the close relation with important nerves of the finger and the pulley.

Aplasias / Duplications / Hypoplasias

Other examples of common differences that are treated at our center are duplications, aplasias and hypoplasias. All of these congenital differences arise from errors during the genetic development of the hand. Hand surgeons can actively participate, explaining, treating and counseling parents when one of these stressful events occurs. Absences (aplasias) are described by level, as in amelia (absent limb) and adactyly (absent digit(s). Another important absence occurs when a central portion of the hand is missing. Often functional without treatment, cosmetic considerations must be addressed, and may be improved with surgical procedures performed by trained hand surgeons. Duplications and hypoplasia (undergrowth), can also require treatment. In order to improve function or esthetical appearance hand surgeons should be consulted in order to obtain the best results.


Performing Passive Range of Motion Exercises to Major Extremities

Step by Step Instructions

This is a set of step by step instructions based on the clinical skills portion of a CNA exam although they can also be followed in a real world setting. In this particular case, the patient is simply lying in bed and needs passive assistance.

Step 1: Perform your opening duties.

  • Knock on the door.
  • Perkenalkan diri anda.
  • Explain your title.
  • Identify the patient.
  • Describe the skill.
  • Obtain permission.
  • Close the privacy curtain.
  • Perform handwashing.

Step 2: Prepare the patient.

  • Raise the entire bed height to a comfortable working position if desired.
  • Place the patient supine (flat) in the bed.
  • Adjust them towards the center of the bed if necessary.
  • Move everything out of the way in order to perform the exercises properly (blanket, bedside table, etc.).

Step 3: Ensure all of these precautions are taken during the exercises.

  • Support each joint while performing the exercises by cupping underneath extremities and gently lifting rather than gripping an extremity from above in a claw-like fashion.
  • Move all joints slowly and gently without overextending and causing pain. Only move to the point of resistance.
  • If pain does occur, perform the next exercise by stopping movement below the pain threshold as to not cause pain again.
  • Describe each exercise to the patient immediately before performing them.
  • Only perform exercises on sides and joints that are listed in the care plan or physician orders. (example: “left shoulder only” would exclude the right shoulder).
  • Repeat exercises only as many times as directed in the care plan (example: three reps).

Step 4: Flexion and extension (up and down motion) of the shoulder.

  • Straighten the patient’s arm flush against their side and lay it flat on the bed.
  • Cup underneath the patient’s elbow with one hand and cup underneath their wrist with your other hand.
  • Raise their arm at the shoulder joint above their head and towards the head of the bed as if they were needing to ask a question.
  • Gently lower the arm back down to its original position on the bed.
  • Repeat as necessary.

Starting position

Asking a question

Step 5: Abduction and adduction (side to side motion) of the shoulder.

  • Straighten the patient’s arm flush against their side and lay it flat on the bed.
  • Cup underneath the patient’s elbow with one hand and cup underneath their wrist with your other hand.
  • Move the arm sideways and away from their body at the shoulder joint as if they were making a snow angel.
  • Gently move the arm back to its original position on the bed.
  • Repeat as necessary.

Starting position

Snow angel

Step 6: Flexion and extension (up and down motion) of the elbow.

  • Keep the patient’s elbow on the bed with their palm facing up throughout this exercise.
  • Straighten the patient’s arm flush against their side and lay it flat on the bed.
  • Cup underneath the patient’s wrist with your hand.
  • Lift their lower arm straight up and bring it towards their shoulder by bending it at the elbow joint as if they were flexing their bicep muscle.
  • Gently move the arm back to its original position on the bed.
  • Repeat as necessary.

Starting position

Bicep flex

Step 7: Flexion and Extension (up and down motion) of the wrist.

  • Keep the patient’s elbow on the bed with their palm facing up throughout this exercise.
  • Straighten the patient’s arm flush against their side and lay it flat on the bed.
  • Cup underneath the patient’s forearm with one hand.
  • Lift their lower arm straight up by bending it at the elbow joint.
  • With your other hand, curl their fingers into a fist and gently grip their fist.
  • Bend their fist forward to the point of resistance without causing pain as if they were knocking on a door.
  • Then bend their fist backwards to the point of resistance without causing pain as if they were twisting the throttle of a motorcycle.
  • Return the fist back to its original position.
  • Repeat as necessary.
  • After all of the reps are done, gently place the patient’s lower arm back onto the bed.

Knocking on a door

Revving a motorcycle

Step 8: Flexion and extension (up and down motion) of the hip and knee.

  • Straighten the patient’s leg flush against the bed.
  • Cup underneath their knee with one hand.
  • Cup underneath their ankle with your other hand.
  • Lift their thigh (upper leg) up from the bed by bending at the hip joint while simultaneously keeping the calf (lower leg) straight by bending at the knee joint. This motion should bring their knee towards their chest as if they were climbing up a step.
  • Return the leg back to its original position.
  • Repeat as necessary.

Starting position

Climbing a step

Step 9: Flexion and extension (up and down motion) of the ankle.

  • Straighten the patient’s leg flush against the bed.
  • Cup underneath their calf (lower leg) with one hand.
  • Raise the leg up slightly off of the bed.
  • Gently grasp the top of their foot with your other hand.
  • Bend their foot forward and down towards the bed at the ankle joint as if they were pushing on a gas pedal.
  • Then bend their foot backwards at the ankle joint bringing their toes up towards their knee.
  • Return the foot back to its original position
  • Repeat as necessary.
  • After all of the reps are done, gently place the patient’s leg back onto the bed.

Pushing on a gas pedal

Toes up towards the knee

Step 10: Perform your closing duties.

  • Place the call bell either in the bed with the patient or within their reach.
  • Adjust the head of the bed if desired.
  • Keep the entire bed height in the lowest position.
  • Make sure the bed alarm is on if necessary.
  • Open the privacy curtain if desired.
  • Ask the patient if they are comfortable and if they need anything else before you go.
  • Check to make sure everything is clean and in its proper place.
  • Adjust the lights if needed.
  • Ask about the door being left open or closed.
  • Perform hand hygiene.

Evolution of clinically orientated diagnostic criteria

As discussed above, the first widely accepted diagnostic criteria (Griggs) were biased heavily towards pathological features, which is not surprising given that most of the literature to that date concerned pathology. The criteria stated ‘even without a typical history, a diagnosis of inclusion body myositis can be made solely on the basis of muscle biopsy if all of the pathological features are present (inflammation, vacuoles, amyloid deposits, and 15- to 18-nm tubulofilaments’ 5 . Conversely, they appreciated that diagnostic problems could arise if the patient has ‘typical features of the disease including an inflammatory myopathy [but] does not show vacuolated muscle fibres, intracellular amyloid deposits or 15- to 18-nm tubulofilaments’. They suggested that confirmation of the diagnosis might then require study of additional sections from the biopsy, or repeating the biopsy. However, two decades of clinical experience has clearly shown that the canonical pathological features may indeed be absent, even on repeat study, when long-term follow-up of patients leaves the clinician in no doubt about the correct diagnosis 9, 10 .

Since 1995 (the Griggs criteria), there have been several proposals for revised diagnostic criteria, the most recent coming from a European Neuromuscular Centre (ENMC) Workshop in 2011 (Table 2) 31 . The general drift has been for increased importance to be given to specific clinical features, allowing a diagnosis of IBM in the absence of what have previously been considered to be essential pathological features.

Knee extension weakness ≥ hip flexion weakness and/or finger flexion weakness > shoulder abduction weakness

sCK no greater than 15× ULN

Endomysial inflammatory infiltrate

Protein accumulationa a Demonstration of amyloid or other protein accumulation by established methods (e.g. for amyloid Congo red, crystal violet, thioflavin T/S, for other proteins p62, SMI-31, TDP-43). Current evidence favours p62 in terms of sensitivity and specificity, but the literature is limited and further work required.
or 15- to 18-nm filaments

Knee extension weakness ≥ hip flexion weakness and finger flexion weakness > shoulder abduction weakness

sCK no greater than 15× ULN

One or more, but not all, of:

Endomysial inflammatory infiltrate

Upregulation of MHC class I

Protein accumulationa a Demonstration of amyloid or other protein accumulation by established methods (e.g. for amyloid Congo red, crystal violet, thioflavin T/S, for other proteins p62, SMI-31, TDP-43). Current evidence favours p62 in terms of sensitivity and specificity, but the literature is limited and further work required.
or 15- to 18-nm filaments

Knee extension weakness ≥ hip flexion weakness or finger flexion weakness > shoulder abduction weakness

sCK no greater than 15× ULN

One or more, but not all, of:

Endomysial inflammatory infiltrate

Upregulation of MHC class I

Protein accumulationa a Demonstration of amyloid or other protein accumulation by established methods (e.g. for amyloid Congo red, crystal violet, thioflavin T/S, for other proteins p62, SMI-31, TDP-43). Current evidence favours p62 in terms of sensitivity and specificity, but the literature is limited and further work required.
or 15- to 18-nm filaments

  • a Demonstration of amyloid or other protein accumulation by established methods (e.g. for amyloid Congo red, crystal violet, thioflavin T/S, for other proteins p62, SMI-31, TDP-43). Current evidence favours p62 in terms of sensitivity and specificity, but the literature is limited and further work required.

A recent evaluation of published criteria summarized that each proposal includes ‘features’ [comprising clinical (demographic characteristics, temporal aspects and patterns of weakness) and pathological (laboratory studies and muscle pathology)] which through Boolean algebraic combination define ‘categories’ (e.g. definite, probable possible) 25 . The authors assessed the sensitivity and specificity of the published criteria by application through medical records review of 200 patients diagnosed as having IBM by neuromuscular specialists. All published IBM diagnostic categories had high specificities (98–100%), but wide-ranging sensitivities (11–84%). It is noteworthy that poor performance of some categories could be attributed to use of highly specific but insensitive pathological criteria these are easily quantified. It must be added that they also questioned the validity of comparative strength criteria but, as discussed above, there are some concerns about assessment methodology particularly when reviewed retrospectively.

The 2011 ENMC criteria recognize two major categories of patients, those with typical clinical and pathological features (‘clinico-pathologically defined IBM’), and those with typical clinical features but limited pathological changes (‘clinically defined IBM’). A third group (‘probable IBM’) includes patients with a characteristic upper or lower limb pattern of weakness, but not both. Lloyd's analysis showed sensitivities of 84% for probable, 57% for clinically defined and 15% for clinico-pathologically defined IBM 25 . Using the features recorded at presentation, we applied the Griggs and 2011 ENMC diagnostic criteria to a group of 67 patients who, after long-term review by a neuromuscular specialist, were considered to have IBM. At presentation, 88% fulfilled ENMC criteria, but only 27% fulfilled the Griggs criteria 10 . Over a long period of review, no differences were noted in clinical features or outcome, leading us to conclude that ‘we are dealing with a clinically homogenous disorder, irrespective of whether patients are diagnosed on the basis of clinical or histopathological criteria and that IBM can be accurately and reliably diagnosed without fulfilling all of the Griggs histopathological features’ 10 . With respect to rimmed vacuoles, sometimes considered a sine qua non for the diagnosis of IBM, we noted no clinical difference between those with and without vacuoles, but those without vacuoles had had their biopsies undertaken sooner after onset, suggesting that vacuoles appear as a later feature of the disease.

In conclusion, clinically orientated diagnostic criteria can be as specific in diagnosing IBM as conventional pathological criteria, and have substantially greater sensitivity at the time of presentation. This negates the need for more specialized pathological tests (e.g. electron microscopy or amyloid staining) that are time-consuming and not part of the diagnostic repertoire of many laboratories and, more importantly, allows inclusion into trials and studies of patients who are at an earlier stage of their disease. With respect to therapeutic trials, such patients may be more likely to respond to treatments than those with more advanced, ‘end-stage’, disease.


Thumb Muscles

Adductor Pollicis

The adductor pollicis&rsquo primary role is to provide power for pinching. It helps fill the first webspace between the thumb and index finger and weakens with severe cubital tunnel syndrome or other lesions of the ulnar nerve.

Abductor pollicis longus

The abductor pollicis longus passes through the 1st dorsal compartment of the wrist. Tendonitis is common in the 1st dorsal compartment, commonly called De Quervain Syndrome or &ldquoMommy thumb,&rdquo due to its incidence in mothers of young children.


Pengurusan dan Rawatan

How are trigger finger or trigger thumb treated?

For mild cases, the first step is to rest the finger(s) or thumb and limit or avoid the activities that are causing symptoms. Sometimes a splint may be used on the affected finger(s) to keep the joint from moving. If symptoms continue, anti-inflammatory medications, such as ibuprofen, may be prescribed or steroid injection(s) may be considered.

If the condition does not respond to non-surgical treatments or continues to recur, surgery may be recommended. The surgery is done under local anesthesia (you will be awake but may be sedated for comfort) and does not require a hospital stay.

During the surgery, a tiny cut is made in the sheath through which the tendons pass. Cutting the sheath widens the space around the tendons of the affected finger(s) or thumb. This allows the tendon to slide more easily through the sheath. The surgery helps restore the affected finger(s) or thumb’s ability to bend and straighten without pain or stiffness.

Recovery time following surgery is typically only a couple of weeks. However, recovery times vary, depending on your age, general health, and how long the symptoms have been present.


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