[Clinical anatomical study on the treatment of carpal tunnel syndrome with classic Acupotomy]

OBJECTIVE

To explore the safety of classic Acupotomy in the treatment of carpal tunnel syndrome.

METHODS

Twenty six adult specimens (15 males and 11 females), aged 60 to 95(82.54±6.94) years old, were selected from 10% formalin antiseptic fixation. There were 52 sides(two of them could not be tested). The study period was from November 2017 to May 2018. The specimens were collected from the body donation center of the school of basic medicine, Peking University. The operation of releasing the transverse carpal ligament on the human body specimen was simulated by the classic acupotomy, and the distance from the four points to the surrounding anatomical structure was measured to calculate the direct injury rate to the nerve and blood vessels, and the shortest distance between the acupotomy and the nerve and blood vessels was defined as ≥2 mm as safety.

RESULTS

In the experimental operation, the direct injury rate of nerve and blood vessel was 14% and 12% respectively. There was significant difference in the rate of direct nerve injury between the four injection points (P<0.05). There was no significant difference in the rate of direct vascular injury between the four injection points (P>0.05). Among the four points, there was a statistically significant difference in the safety of nerves(P<0.05), and the safety of point 1 and point 3 of radial injection was higher than that of point 2 and point 4 of ulnar injection(P<0.05). There was significant difference in the safety of blood vessels between the four points(P<0.05), and the safety of radial point 1 was higher than that of ulnar point 2 and point 4 (P<0.05).

CONCLUSION

The safety of the classic Acupotomy for carpal tunnel syndrome is related to the location of the needle entry point, and the safety of theradial proximal end of the needle is the highest.

Ergonomic Considerations in the Incidence of CTS in College of Dentistry, King Khalid University, Abha - Kingdom of Saudi Arabia

PURPOSE

Ergonomics in dentistry poses some challenges to dentists and may require considerable concentration and attention to detail. This research enables early recognition and prevention of common ergonomic-related conditions, such as carpel tunnel syndrome, back pain and neck pain. The purpose of this study was to determine the prevalence of ergonomic-related problems concerning carpel tunnel syndrome (CTS) and to know the efficacy of independent and combined clinical tests used in diagnosing it.

MATERIALS AND METHODS

Initially the participants were instructed to complete a self-administered questionnaire regarding the severity of symptoms of their hands on a hand-wrist diagram and a visual analogue scale. The principle investigator evaluated all questionnaires independently and four clinical tests were used on both hands in a systematic (non-randomised) order for subjects who had symptoms. Those with residual symptoms that exceeded beyond 1 min interval were identified and controlled for the statistical analyses.

RESULTS

The most common symptom noted in the study group was tingling and numbness of fingers (66.46%) followed by neck pain (66.34%). 29.26% of subjects reported moderate difficulty in typing and driving vehicles, whereas 26.82% subjects felt moderate difficulty in grasping and carrying shopping bags. 61.94% of subjects with symptoms spent more than 1 h daily of their free time on mobile phones or other smart devices. Individually, in our study the Tinsel's sign stood out as ineffective in ruling out CTS when compared with Phalen's test. Combination tests like Phalen's test and compression tests are confirmatory to CTS diagnosis and 66.34 % of the research group were hence diagnosed for CTS.

CONCLUSIONS

A positive criteria for CTS, neck and shoulder pain is identified in our study as being due to long-term use of mobile devices. Further, combination tests like Phalen's with pressure provocation tests proved accurate in conforming CTS. Future research is needed to confirm the diagnostic utility of these independent and combined clinical tests in less prevalent settings, including general dental practitioners and occupational worksites.

TRIAL REGISTRATION

The current study is registered in King Khalid University, College of dentistry ethical committee SRC/REG/2016-17/107.

You're the Flight Surgeon

Warneke JA, Pavelites JJ. You're the flight surgeon: Raynaud's phenomenon/hand arm vibration syndrome. Aerosp Med Hum Perform. 2020; 91(5):459-461.

[Mode of median nerve irritation under different wrist forcing postures observed by ultrasonography and foot pressure measurement system]

Objective: To analyze the influence of simulation mouse use motion under different wrist forcing postures on median nerve, tendons and ligaments in the carpal tunnel. Methods: From June to November in 2017, a total of 49 healthy volunteers [aged from 18 to 27 years, 24 males (48 cases of hands) and 25 females (50 cases of hands)] were selected in the Institute of Digitized Medicine and First Affiliated Hospital of Wenzhou Medical University.Three hand postures of the volunteers were simultaneously and continuously measured by using LOGIQ E9 ultrasonic diagnostic apparatus and Zebris foot pressure distribution measurement system.Seventeen parameters of nerves, tendons and ligaments in carpal tunnel were observed under natural (0 N), and two forced (25 and 50 N) states.Double factor variance analysis was performed with generalized estimating equation (GEE). Results: With increasing pressure (0, 25 and 50 N) of hand postures, the distance between median nerve and transverse carpal ligament were all less than 0.2 cm.The differences in both the distance between median nerve and flexor pollicis longus under the hand pressure changes or under the hand posture changes and the top angle of a triangle composed of median nerve, flexor pollicis longus and flexor digitorum superficialis group under the hand pressure changes or under the hand posture changes were all significant under the GEE analysis (all P<0.01). There were no significant changes in all other structural parameters in the carpal tunnel with the increasing of hand pressure (all P>0.05). Conclusions: The influence of the transverse carpal ligament to the median nerve belongs to the mechanism of pressure-induced irritation damage.The influence of flexor pollicis longus to median nerve belongs to the mechanism of tension-induced irritation damage.The influence of flexor digitorum superficialis to median nerve belongs to the mechanism of mixed shear irritation damage.

Validity, Reliability and Responsiveness of the Korean Version of Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire in Patients with Carpal Tunnel Syndrome

BACKGROUND

The Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) is one of the most widely used questionnaires for assessing functional ability of the patients with upper extremity diseases. Carpal tunnel syndrome (CTS) is the most common neuropathic disease in the upper extremities. The aim of this study was to verify the validity, reliability, and responsiveness of Korean version of QuickDASH questionnaire (K-QuickDASH) in the patients with CTS.

METHODS

In total, 83 subjects who underwent open carpal tunnel release (CTR) operation were selected. They fulfilled Korean version of Disabilities of the Arm, Shoulder and Hand questionnaire (K-DASH) and K-QuickDASH at two different time points: before and six months after the surgery. Both criterion-related and construct validities were evaluated using Pearson's correlation coefficient and factor analysis. Internal consistency was estimated using Cronbach's alpha, and test-retest reliability was assessed to verify the reliability of K-QuickDASH using intraclass correlation coefficient (ICC). The standardized response mean and the effect size were analyzed to confirm the responsiveness of the K-QuickDASH in CTS patients.

RESULTS

Significant positive correlation was found between K-QuickDASH and K-DASH. All the questionnaire items were categorized into three factors. Acceptable internal consistency was confirmed in three categories of K-QuickDASH. A high test-retest reliability and responsiveness of K-QuickDASH were detected.

CONCLUSION

K-QuickDASH in Korean patients with CTS was confirmed to have high degree of validity and reliability, and responsiveness after CTR. Therefore, the K-QuickDASH would be a good evaluation tool for evaluating clinical symptoms and determination of treatment outcomes in the patients with CTS.

[Work-related musculoskeletal disorders]

Work-related musculoskeletal disorders. Upper-limb musculoskeletal disorders are painful conditions related to the overuse of periarticular soft tissues. The main musculoskeletal disorders are rotator cuff tendinopathy, epicondylalgia, carpal tunnel syndrome and non-specific pain. Musculoskeletal disorders affect millions of European workers and represent the first problem of health at work in the European Union. They testify to the intensification of working conditions affecting a growing number of workers in the industry and services sectors. Their impact in terms of pain and disruption of career, but also economic costs, make them a priority of health at work. They are multifactorial disorders associated with individual and occupational (biomechanical, psychosocial and factors related to work organization) risk factors. Prevention requires a global and integrated approach focusing on the reduction of the exposure to working constraints, early diagnosis and management and, if necessary, an intervention of stay at work.

[Value of ratio of sensory nerves conductive velocity along palm-median finger/wrist-palm in diagnosing the carpal tunnel syndrome]

OBJECTIVE

To Verify the value of the ratio of sensory nerves conductive velocity along palm-median finger /wrist-palm minus 1 for diagnosis of the mild-moderate carpal tunnel syndrome(CTS).

METHODS

The different value between 1 and the ratio of sensory nerves conductive velocity along palm-median finger/wrist-palm was defined as index-CTS which was used to assess the severity of CTS.The index-CTS of 100 palms from healthy controls and 58 palms from mild-moderate CTS patients were calculated and compared.Multiple regression was used to identify the relative factors of index-CTS.The ROC curve was used to evaluate the sensitivity and specificity of index-CTS at different values.

RESULTS

The value of index-CTS from healthy controls and patients both fitted Gaussian distribution.The mean value were -0.053±0.042 vs 0.055±0.074 in the controls and the patients respectively.The difference was statistically significant between the two groups by T-test(P<0.001). Multiple regression analysis showed that Tinel sign, Phalen sign, laterality, clinical grade, electrical grade were identifiable factors related to index-CTS.When index-CTS was over 0.001 and Ⅳ-DL over 0.395 ms , specificity of diagnosis by both can get 92%, but index-CTS showed more higher sensitivity(98.3% vs 89.7%).

CONCLUSIONS

Rising index-CTS could be the most significant electrophysiological feature in CTS.It can be used as a sensitive marker to assess the extent of conduction block of median nerve in carpal tunnel.

Hand Shape and Carpal Tunnel Syndrome

The literature evaluating external anatomical measurements and carpal tunnel syndrome (CTS) remains inconclusive. The purpose of this study was to compare hand- shape measurements of patients with and without (CTS). A retrospective case - control study of participants with suspected CTS (male/female ratio of 0.69) was performed. Nerve conduction tests (NCT) defined 65 involved hands (CTS) and 73 control hands. The relationship between 3 different hand index ratios (measuring palm length and width) and CTS (defined by NCT) was evaluated using Generalized Estimating Equations model (GEE) with the binary outcome of CTS. Palmar Length/Palmar Width index had the strongest and negative association with CTS with greatest sensitivity and specificity to detect CTS. Hands with more square shape had increased tendency to be diagnosed with CTS. Hand indices that include the shape of the palm may help identify patients with greater likelihood of developing CTS for early screening and prevention.

[Carpal tunnel syndrome with cervical spondylotic radiculopathy: a clinical and electrophysiological study]

OBJECTIVE

To study the clinical and electrophysiological characteristics of carpal tunnel syndrome (CTS) with cervical spondylotic radiculopathy (CSR) and simple-CTS, and compare the effect of double crush with that of simple entrapment on a nerve and investigate the association between CTS and CSR.

METHOD

From January 2011 to August 2014, clinical data from 96 patients with double crush syndrome (DCS, CTS with CSR) and 165 patients with simple-CTS were examined, and the electrophysiologic parameters of median nerve in patients with DCS were compared with that in patients with simple-CTS.

RESULTS

In 96 patients with DCS, most of them were female; neck and shoulder pain or simultaneously accompanied by numbness and pain of upper limb was observed in 34 patients, upper limb symptoms and hand weakness and muscle atrophy were observed in the other 62 patients, 124 median nerves with abnormal conduction were found in these DCS patients, including 68 cases with unilateral abnormalities and 28 cases with bilateral abnormalities. Cervical radiculopathies of the C5-7 mainly involved in patients with DCS.223 median nerves with abnormal conduction found in the 165 patients with simple-CTS, including 107 cases with unilateral abnormalities and 58 cases with bilateral abnormalities. The average sensory nerve conduction velocity (SCV), motor nerve conduction velocity (MCV) and distal motor latency (DML) of median nerve for DCS and simple-CTS were (32±7) m/s vs (35±5) m/s, (55±7) m/s vs (57±5) m/s and (4.6±1.6) ms vs (4.0±0.8) ms, respectively, and their corresponding amplitudes were 6.4 µV vs 9.5 µV, 10.9 mV vs 13.1 mV and 11.3 mV vs 14.1 mV, respectively. The SCV, MCV and DML and their corresponding amplitude of DCS were significantly greater decreased than that of simple-CTS (P<0.01).

CONCLUSION

DCS is a common clinical syndrome, and patients with DCS may have neck and shoulder symptoms in addition to the common manifestations of simple-CTS. Abnormal conduction of median nerve of CTS with CSR is more severe than that of simple-CTS, which neurophysiologically proves the association between CTS and CSR and supports double crush hypothesis.

Sonographic findings in the ulnar nerve according to the electrophysiologic stage of carpal tunnel syndrome

OBJECTIVES

Involvement of the ulnar nerve in patients with carpal tunnel syndrome is controversial. The aim of our study was to evaluate sonographic findings in the ulnar nerve in patients with carpal tunnel syndrome.

METHODS

We performed median and ulnar nerve conduction studies with sonography in 109 hands of 60 patients with clinically suspected carpal tunnel syndrome. Sonographic findings were analyzed with regard to electrophysiologic stages of carpal tunnel syndrome.

RESULTS

We found that the sensory conduction velocity of the ulnar nerve decreased as the electrophysiologic stage of carpal tunnel syndrome increased (P = .038), but there was no change in the cross-sectional area of the ulnar nerve at the wrist. The median-to-ulnar nerve cross-sectional area ratio at the wrist showed a significant correlation with the electrophysiologic stage of carpal tunnel syndrome (Spearman r = 0.431; P < .0001), in addition to the median nerve cross-sectional area at the wrist and the wrist-to- forearm median nerve cross-sectional area ratio.

CONCLUSIONS

In our study, ulnar nerve involvement in patients with carpal tunnel syndrome was shown electrophysiologically but not sonographically. These results suggest that morphologic changes in the ulnar nerve do not occur in carpal tunnel syndrome, although functional changes may occur.

[APPLICATION OF BUTTERFLY SHAPED LOCKING COMPRESSION PLATE IN COMPLEX DISTAL RADIUS FRACTURES]

OBJECTIVE

To investigate the effectiveness of butterfly shaped locking compression plate for the treatment of complex distal radius fractures.

METHODS

Between June 2011 and January 2013, 20 cases of complex distal radius fractures were treated with butterfly shaped locking compression plate fixation. There were 11 males and 9 females with an average age of 54 years (range, 25-75 years). Injury was caused by falling in 10 cases, by traffic accident in 7 cases, and by falling from height in 3 cases. All of fractures were closed. According to AO classification system, there were 8 cases of type C1, 8 cases of type C2, and 4 cases of type C3. Of them, 9 cases had radial styloid process fracture, 4 cases had sigmoid notch fracture, and 7 cases had both radial styloid process fracture and sigmoid notch fracture. The mean interval between injury and operation was 5.2 days (range, 3-15 days).

RESULTS

All incisions healed by first intention; no complications of infection and necrosis occurred. All cases were followed up 14 months on average (range, 10-22 months). All factures healed after 9.3 weeks on average (range, 6-11 weeks). No complications such as displacement of fracture, joint surface subsidence, shortening of the radius, and carpal tunnel syndrome were found during follow-up. At last follow-up, the mean palmar tilt angle was 10.2° (range, 7-15°), and the mean ulnar deviation angle was 21.8° (range, 17-24°). The mean range of motion of the wrist was 45.3° (range, 35-68°) in dorsal extension, 53.5° (range, 40-78°) in palmar flexion, 19.8° (range, 12-27°) in radial inclination, 26.6° (range, 18-31°) in ulnar inclination, 70.2° (range, 45-90°) in pronation, and 68.4° (range, 25-88°) in supination. According to the Dienst scoring system, the results were excellent in 8 cases, good in 10 cases, and fair in 2 cases, and the excellent and good rate was 90%.

CONCLUSION

Treatment of complex distal radius fractures with butterfly shaped locking compression plate can reconstruct normal anatomic structures, especially for radial styloid process and sigmoid notch fractures, and it can get good functional recovery of the wrist and the distal radioulnar joint.

Quality of information on the Internet about carpal tunnel syndrome: an update

The use of the Internet for health-related information has increased significantly. In 2000, the current authors examined the source and content of orthopedic information on the Internet. At that time, Internet information regarding carpal tunnel syndrome was found to be of limited quality and poor informational value. The purposes of the current study were to reevaluate the type and quality of information on the Internet regarding carpal tunnel syndrome and to determine whether the quality of information available has improved compared with 1 decade ago. The phrase carpal tunnel syndrome was entered into the 5 most commonly used Internet search engines. The top 50 nonsponsored and the top 5 sponsored universal resource locators identified by each search engine were collected. Each unique Web site was evaluated for authorship and content, and an informational score ranging from 0 to 100 points was assigned. Approximately one-third of nonsponsored Web sites were commercial sites or selling commercial products. Seventy-six percent of sponsored sites were selling a product for the treatment of carpal tunnel syndrome. Thirty-eight percent of nonsponsored sites provided unconventional information, and 48% of sponsored sites provided misleading information. Just more than half of nonsponsored sites were authored by a physician or academic institution. The informational mean score was 53.8 points for nonsponsored sites and 14.5 points for sponsored sites. The informational quality on the Internet on carpal tunnel syndrome has improved over the past decade. Despite this progress, significant room exists for improvement in the quality and completeness of the information available.

Pooling job physical exposure data from multiple independent studies in a consortium study of carpal tunnel syndrome

Pooling data from different epidemiological studies of musculoskeletal disorders (MSDs) is necessary to improve statistical power and to more precisely quantify exposure-response relationships for MSDs. The pooling process is difficult and time-consuming, and small methodological differences could lead to different exposure-response relationships. A sub-committee of a six-study research consortium studying carpal tunnel syndrome: (i) visited each study site, (ii) documented methods used to collect physical exposure data and (iii) determined compatibility of exposure variables across studies. Certain measures of force, frequency of exertion and duty cycle were collected by all studies and were largely compatible. A portion of studies had detailed data to investigate simultaneous combinations of force, frequency and duration of exertions. Limited compatibility was found for hand/wrist posture. Only two studies could calculate compatible Strain Index scores, but Threshold Limit Value for Hand Activity Level could be determined for all studies. Challenges of pooling data, resources required and recommendations for future researchers are discussed.

PRACTITIONER SUMMARY

There is a need for standardised measures and measurement protocols of physical exposure for the upper extremity. This study may provide guidance for those planning to conduct an epidemiological study on quantified job physical exposures, or planning to merge physical exposure data from similar studies with some methodologic differences.