Capsular and retinaculum thickening in type II mucopolysaccharidosis: a novel MRI finding

Mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage diseases caused by a deficiency of glycosaminoglycan (GAG) catalytic enzymes, resulting in an accumulation of unprocessed or partly degraded GAGs in different tissues, including bones and joints. Notably, skeletal and joint abnormalities may be the first complaint that prompts patients to seek medical attention, especially in the milder forms of the disease. To our knowledge, there are no prior imaging reports that have documented capsuloligamentous thickening in patients with MPS on MRI. In this study, we present four cases of patients with clinically and genetically confirmed diagnosis of type II MPS, encompassing seven MRI examination of different joints, including cervical spine, hip, wrist, knee, and shoulder. All of the patients were male, aged between 14 and 35 years, and exhibited varying degrees of joint stiffness in the clinical examination and carpal tunnel syndrome in cases of the wrist joint was affected. None of the patients had a history of surgical procedures on the affected joint, other metabolic or deposit diseases, or sports activity practice. The MRI revealed significant capsuloligamentous and retinaculum thickening, up to eight times greater than the normal capsular thickness reported in the literature.

Carpal tunnel syndrome prediction with machine learning algorithms using anthropometric and strength-based measurement

OBJECTIVES

Carpal tunnel syndrome (CTS) stands as the most prevalent upper extremity entrapment neuropathy, with a multifaceted etiology encompassing various risk factors. This study aimed to investigate whether anthropometric measurements of the hand, grip strength, and pinch strength could serve as predictive indicators for CTS through machine learning techniques.

METHODS

Enrollment encompassed patients exhibiting CTS symptoms (n = 56) and asymptomatic healthy controls (n = 56), with confirmation via electrophysiological assessments. Anthropometric measurements of the hand were obtained using a digital caliper, grip strength was gauged via a digital handgrip dynamometer, and pinch strengths were assessed using a pinchmeter. A comprehensive analysis was conducted employing four most common and effective machine learning algorithms, integrating thorough parameter tuning and cross-validation procedures. Additionally, the outcomes of variable importance were presented.

RESULTS

Among the diverse algorithms, Random Forests (accuracy of 89.474%, F1-score of 0.905, and kappa value of 0.789) and XGBoost (accuracy of 86.842%, F1-score of 0.878, and kappa value of 0.736) emerged as the top-performing choices based on distinct classification metrics. In addition, using variable importance calculations specific to these models, the most important variables were found to be wrist circumference, hand width, hand grip strength, tip pinch, key pinch, and middle finger length.

CONCLUSION

The findings of this study demonstrated that wrist circumference, hand width, hand grip strength, tip pinch, key pinch, and middle finger length can be utilized as reliable indicators of CTS. Also, the model developed herein, along with the identified crucial variables, could serve as an informative guide for healthcare professionals, enhancing precision and efficacy in CTS prediction.

How Does ChatGPT Use Source Information Compared With Google? A Text Network Analysis of Online Health Information

BACKGROUND

The lay public is increasingly using ChatGPT (a large language model) as a source of medical information. Traditional search engines such as Google provide several distinct responses to each search query and indicate the source for each response, but ChatGPT provides responses in paragraph form in prose without providing the sources used, which makes it difficult or impossible to ascertain whether those sources are reliable. One practical method to infer the sources used by ChatGPT is text network analysis. By understanding how ChatGPT uses source information in relation to traditional search engines, physicians and physician organizations can better counsel patients on the use of this new tool.

QUESTIONS/PURPOSES

(1) In terms of key content words, how similar are ChatGPT and Google Search responses for queries related to topics in orthopaedic surgery? (2) Does the source distribution (academic, governmental, commercial, or form of a scientific manuscript) differ for Google Search responses based on the topic's level of medical consensus, and how is this reflected in the text similarity between ChatGPT and Google Search responses? (3) Do these results vary between different versions of ChatGPT?

METHODS

We evaluated three search queries relating to orthopaedic conditions: "What is the cause of carpal tunnel syndrome?," "What is the cause of tennis elbow?," and "Platelet-rich plasma for thumb arthritis?" These were selected because of their relatively high, medium, and low consensus in the medical evidence, respectively. Each question was posed to ChatGPT version 3.5 and version 4.0 20 times for a total of 120 responses. Text network analysis using term frequency-inverse document frequency (TF-IDF) was used to compare text similarity between responses from ChatGPT and Google Search. In the field of information retrieval, TF-IDF is a weighted statistical measure of the importance of a key word to a document in a collection of documents. Higher TF-IDF scores indicate greater similarity between two sources. TF-IDF scores are most often used to compare and rank the text similarity of documents. Using this type of text network analysis, text similarity between ChatGPT and Google Search can be determined by calculating and summing the TF-IDF for all keywords in a ChatGPT response and comparing it with each Google search result to assess their text similarity to each other. In this way, text similarity can be used to infer relative content similarity. To answer our first question, we characterized the text similarity between ChatGPT and Google Search responses by finding the TF-IDF scores of the ChatGPT response and each of the 20 Google Search results for each question. Using these scores, we could compare the similarity of each ChatGPT response to the Google Search results. To provide a reference point for interpreting TF-IDF values, we generated randomized text samples with the same term distribution as the Google Search results. By comparing ChatGPT TF-IDF to the random text sample, we could assess whether TF-IDF values were statistically significant from TF-IDF values obtained by random chance, and it allowed us to test whether text similarity was an appropriate quantitative statistical measure of relative content similarity. To answer our second question, we classified the Google Search results to better understand sourcing. Google Search provides 20 or more distinct sources of information, but ChatGPT gives only a single prose paragraph in response to each query. So, to answer this question, we used TF-IDF to ascertain whether the ChatGPT response was principally driven by one of four source categories: academic, government, commercial, or material that took the form of a scientific manuscript but was not peer-reviewed or indexed on a government site (such as PubMed). We then compared the TF-IDF similarity between ChatGPT responses and the source category. To answer our third research question, we repeated both analyses and compared the results when using ChatGPT 3.5 versus ChatGPT 4.0.

RESULTS

The ChatGPT response was dominated by the top Google Search result. For example, for carpal tunnel syndrome, the top result was an academic website with a mean TF-IDF of 7.2. A similar result was observed for the other search topics. To provide a reference point for interpreting TF-IDF values, a randomly generated sample of text compared with Google Search would have a mean TF-IDF of 2.7 ± 1.9, controlling for text length and keyword distribution. The observed TF-IDF distribution was higher for ChatGPT responses than for random text samples, supporting the claim that keyword text similarity is a measure of relative content similarity. When comparing source distribution, the ChatGPT response was most similar to the most common source category from Google Search. For the subject where there was strong consensus (carpal tunnel syndrome), the ChatGPT response was most similar to high-quality academic sources rather than lower-quality commercial sources (TF-IDF 8.6 versus 2.2). For topics with low consensus, the ChatGPT response paralleled lower-quality commercial websites compared with higher-quality academic websites (TF-IDF 14.6 versus 0.2). ChatGPT 4.0 had higher text similarity to Google Search results than ChatGPT 3.5 (mean increase in TF-IDF similarity of 0.80 to 0.91; p < 0.001). The ChatGPT 4.0 response was still dominated by the top Google Search result and reflected the most common search category for all search topics.

CONCLUSION

ChatGPT responses are similar to individual Google Search results for queries related to orthopaedic surgery, but the distribution of source information can vary substantially based on the relative level of consensus on a topic. For example, for carpal tunnel syndrome, where there is widely accepted medical consensus, ChatGPT responses had higher similarity to academic sources and therefore used those sources more. When fewer academic or government sources are available, especially in our search related to platelet-rich plasma, ChatGPT appears to have relied more heavily on a small number of nonacademic sources. These findings persisted even as ChatGPT was updated from version 3.5 to version 4.0.

CLINICAL RELEVANCE

Physicians should be aware that ChatGPT and Google likely use the same sources for a specific question. The main difference is that ChatGPT can draw upon multiple sources to create one aggregate response, while Google maintains its distinctness by providing multiple results. For topics with a low consensus and therefore a low number of quality sources, there is a much higher chance that ChatGPT will use less-reliable sources, in which case physicians should take the time to educate patients on the topic or provide resources that give more reliable information. Physician organizations should make it clear when the evidence is limited so that ChatGPT can reflect the lack of quality information or evidence.

The Effect of Proprioceptive Training on Hand Function and Activity Limitation After Open Carpal Tunnel Release Surgery: A Randomized Controlled Study

OBJECTIVE

To investigate the effect of proprioceptive training on hand function and activity limitation in patients undergoing open carpal tunnel release surgery.

DESIGN

Randomized controlled study.

SETTING

A university hospital.

PARTICIPANTS

Thirty patients were included in the study and randomized to proprioceptive training (PT) and conventional rehabilitation (CR) groups.

INTERVENTION

One week after surgery, both groups received CR for 6 weeks. All participants were asked to perform home-based exercises daily in 3 sets with 10 repetitions. For the PT group, a 6-step PT program was conducted starting from Week 6. Both groups received face-to-face interventions twice a week for 12 weeks.

MAIN OUTCOME MEASURES

The outcome measures included the Purdue Pegboard Test (PPT), the joint position sense test (JPST), the Boston Carpal Tunnel Questionnaire, and the Patient-Specific Functional Scale. In total, 3 assessments were performed (at 1, 6 and 12 weeks postoperatively).

RESULTS

In the PT group, the results for PPT were statistically significant (P<.05). Although there was a greater decrease in the absolute angular error value (JPST) of the PT group compared to the CR group, the difference was nonsignificant (P>.05). Similar reductions in activity limitation were seen in both groups (PT: 176%, CR: 175%). Symptom severity decreased by 40% in the PT group vs 32% in the CR group. The effect sizes were larger for the changes between the second and third assessments in the PT group compared to the CR group in all parameters tested.

CONCLUSION

When applied after carpal tunnel release surgery, PT may potentially to improve hand functions, reduce activity limitation, increase participation in activities of daily living, and thus improve quality of life.

Late Onset of Severe Demyelinating Peripheral Neuropathy in a 62-Year-Old African American Woman

ABSTRACT

Hereditary neuropathies are typically associated with an early onset of symptoms, but same types of neuropathies may also manifest late, after the age 50 years. A 62-year-old African American woman presented with a 6-year history of gait unsteadiness and has been using a walker since the age 57 years after an unwitnessed fall. Gradual worsening of walking difficulties was later followed by decreased dexterity. The family history was negative for neuromuscular disorders, including neuropathy. On examination, the patient had both distal and proximal weakness with distal sensory loss to all modalities and hyporeflexia. Charcot Marie Tooth Examination Score was 12. Previous electrodiagnostic testing at the age 60 years showed severe sensorimotor demyelinating polyneuropathy with bilateral severe carpal tunnel syndrome. Genetic testing showed a homozygous pathogenic mutation in SH3TC2 gene (c.2860C>T; p.Arg954*), associated with CMT4C. CMT4C is the most common recessive demyelinating sensorimotor polyneuropathy and overall comprises 0.4%-1.7% of all patients with Charcot-Marie-Tooth disease. It is more common in French Canadians and Spanish Roma and in recent natural history study; only 1 of 56 patients was African American. This report demonstrates sporadic occurrence of CMT4C in other ethnic groups as well.

[Rare nerve compression neuropathies]

UNCOMMON NERVE COMPRESSION SYNDROMES

In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

Effect of pronator teres muscle botulinum neurotoxin type-A injection on proximal median nerve entrapment

PURPOSE

We aimed to evaluate the effect of botulinum neurotoxin type-A (Btx-A) injection into the pronator teres muscle in proximal median nerve entrapment (PMNE).

METHODS

Intramuscular injection of 30 IU Btx-A into the pronator teres muscle was performed in 12 patients (14 extremities) diagnosed with PMNE. The injection was made under nerve stimulator control. One patient with thoracic outlet syndrome was excluded from the study and not included in the clinical evaluation. Grip and pinch strength, 2-point discrimination, Q-DASH score, and pain on VAS were evaluated and compared before and 6-8 months after injection. The patients were contacted again by phone after the first and fifth years and asked about PMNE symptomatology.

RESULTS

None of the patients had complications. No significant difference in pinch strength was observed following Btx-A injection, but there was significant improvement in grip strength, 2-point discrimination, and Q-DASH and VAS pain scores.

CONCLUSION

The outcomes of our study were promising: Btx-A injection improved symptoms in patients with PMNE.

LEVEL OF EVIDENCE

Level IV.

Minimal Clinically Important Differences in Hand Pain Intensity (Numerical Pain Rate Scale) and Related-Function (Boston Carpal Tunnel Questionnaire) in Women With Carpal Tunnel Syndrome

OBJECTIVE

To calculate the minimal clinically important differences (MCIDs) for hand pain intensity and the Boston Carpal Tunnel Questionnaire (BCTQ) in a sample of women with carpal tunnel syndrome (CTS).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

A Hospital Rehabilitation Unit.

PARTICIPANTS

One hundred twenty women with clinical and electromyographic diagnosis of CTS who were randomly assigned into 2 groups (N=120).

INTERVENTIONS

One group received 3 sessions of manual physical therapy (n=60) and the other group received surgery (n=60).

MAIN OUTCOME MEASURES

Mean and the worst pain intensity (numerical pain rate scale, 0-10 points) and functional status and symptoms' severity subscales of the BCTQ questionnaire were assessed before and 1 month after treatment. The Global Rating of Change (GROC) was used as the anchor variable for determining the MCID.

RESULTS

A change of 1.5 and 2.5 points in mean and the worst pain intensity represents the MCID for Numerical Pain Rating Scale, whereas a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for each subscale of the BCTQ. All variables showed acceptable discrimination between patients classified as "improved" and those classified as "stable/not improved" (area under the curve≥0.72). Mean pain intensity (Youden index, 0.53; sensitivity: 73.3%; specificity: 80%) and symptoms' severity (Youden index, 0.69; sensitivity: 90%; specificity: 77.8%) showed the best discriminative ability expressed as a percentage of prediction. Participants classified as "improved" had significantly greater improvements in pain intensity, functional status, and symptoms' severity compared with those classified as "stable/not improved".

CONCLUSION

A change of 1.5 and 2.5 points in mean and the worst pain and a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for pain intensity and BCTQ in women with CTS 1 month after treatment.

Provocative changes in nerve conductions: Fact or fiction?

At times electrodiagnostic medical consultants (EMCs) are asked to perform studies in both a neutral position, and then again after the patient is in a provocative position that exacerbates symptoms, to assess for measurable electrophysiologic changes. While this approach might seem initially appealing, particularly when standard studies are not effective at diagnosis, empiric studies in several conditions have been unimpressive. Studies in median neuropathy at the wrist, thoracic outlet syndrome, piriformis syndrome, and radial tunnel syndrome have failed to demonstrate reproducible changes in nerve conduction studies in positions that exacerbate symptoms. Furthermore, there is lack of a plausible pathophysiologic mechanism for producing both measurable and rapidly reversible electrophysiologic changes after just a few minutes, or less, of compression. Axon loss and demyelination would not be rapidly reversible, and positional changes of 2 min or less (the durations generally studied) would be insufficient to produce measurable nerve ischemia. Last, we have gained a greater appreciation for how much nerves move within limbs with changes in joint position; this movement can lead to misleading changes in nerve conduction studies. It is thus appropriate to conclude that testing nerve conduction in provocative or symptomatic positions adds no value to electrodiagnostic testing.

A Cadaveric Comparison of Approaches for Exposure of the Volar Distal Radius: Is There a Utilitarian Approach?

BACKGROUND

It remains unclear whether exposure for planned fixation of distal radius fractrues is superior with any given approach, and whether a single utilitarian approach exists that permits reliable complete exposure of the volar distal radius.

METHODS

A cadaveric study was performed using 10 matched specimens. Group 1 consisted of 3 radially based approaches (standard flexor carpi radialis [FCR], standard FCR with radial retraction of FCR and flexor pollicis longus [FPL] tendons, extended FCR). Group 2 consisted of 2 ulnarly based approaches (volar ulnar, extended carpal tunnel). The primary outcome was total width of exposed distal radius at the watershed line. Mann-Whitney U and Wilcoxon rank testing was used to identify differences.

RESULTS

The standard FCR approach exposed 29 mm (90%), leaving on average 3 mm (10%) of the ulnar corner unexposed. Retracting the FCR and FPL tendons radially allows for an extra 1 mm of volar ulnar corner exposure. Finally, converting to an extended FCR approach provided 100% exposure in all specimens. The volar ulnar exposure however provided exposure to only 9 mm (37%), leaving 20 mm (62.5%) left unexposed radially. The extended carpal tunnel provided exposure to 21 mm (65%), leaving 11 mm (35%) radially unexposed. Differences between each group were statistically significant (P < .05).

CONCLUSIONS

The extended FCR approach exposed 100% of the volar distal radius in our study and may serve as a utilitarian volar surgical approach for exposure and fixation of distal radius fractures. Additional knowledge of the limitations of alternative approaches can be helpful in surgical planning.

Multiple nodules with a linear distribution on the palm and wrist

A 33-year-old woman presented with a 15-year history of multiple asymptomatic subcutaneous nodules on the left palm and wrist, which had slowly enlarged and increased in number. Physical examination showed scattered, nontender, smooth flesh-coloured nodules on the left palm and wrist in a linear distribution.

Comparative study of trimming and resection of diseased finger superficial flexor tendons in gouty carpal tunnel syndrome

BACKGROUND

Hyperuricemia can lead to synovial hyperplasia in the wrist. In severe cases, it can lead to the deposition of gouty stone in the carpal tunnel, resulting in increased pressure in the carpal tunnel and compression of the median nerve to cause carpal tunnel syndrome (CTS), which is called gouty carpal tunnel syndrome (GCTS). As for the surgical treatment of gouty carpal tunnel syndrome, scholars have different opinions on whether it is necessary to remove the superficial flexor tendon. The purpose of this study was to compare the clinical efficacy of trimming and resection of the diseased superficial flexor tendon in the treatment of gouty carpal tunnel syndrome.

METHODS

Clinical data were collected from May 2016 to July 2021 from 10 patients (13 affected wrists) diagnosed with gouty carpal tunnel syndrome and classified into two groups according to the surgical modality: the diseased portion of the gout-eroded superficial finger tendon was trimmed in 9 wrists, and the diseased superficial finger flexor tendon was excised in 4 wrists. Values related to flexion and extension functions, 2-PD, DASH, BCTQ, VAS and recurrence in the affected fingers were compared between the two groups as well as before and after surgery in each group.

RESULTS

All affected limbs used were cleared of gouty stones, finger numbness improved, no skin necrosis occurred, and all incisions healed at stage I. At follow-up (13.58 ± 5.53 months), there was no significant difference between groups in flexion and extension function, 2-PD, DASH, BCTQ, and VAS with respect to the affected fingers, and patients in both groups improved significantly before and after surgery. Treatment of only one wrist involved trimming to remove lesion-affected portions of tendon, which reappeared 1 year after surgery, and there was one case of poor recovery from greater piriformis muscle atrophy in both procedures.

CONCLUSION

Regarding surgical treatment of patients with gouty carpal tunnel syndrome in which the gouty stone has invaded the superficial flexor tendons of the fingers, the diseased superficial flexor tendons can be selectively excised, and the postoperative mobility of the affected fingers may not be impaired.

Carpal Tunnel Syndrome in Athletes Who Compete in Wheelchair Sport: A Scoping Review

ABSTRACT

The purpose of this review was to understand the research on carpal tunnel syndrome in athletes who compete in wheelchair sport. Eight articles were identified using the search strategy. The most common sport evaluated was wheelchair basketball ( N = 4). Most athletes were male and were diagnosed with a spinal cord injury. Different clinical and electrodiagnostic criteria have been used to diagnose carpal tunnel syndrome. Two studies incorporated ultrasound into the clinical evaluation of median nerve pathology. The duration of disability and wheelchair use were associated with increased risk of carpal tunnel syndrome in four studies. There was no association between training load and the prevalence of carpal tunnel syndrome. No study has explored the functional implications of carpal tunnel syndrome on sports participation and performance. No study has assessed the prevention and treatment of carpal tunnel syndrome in individuals who compete in wheelchair sport. This review provides an understanding of the important diagnostic tools, and demographic and training risk factors to consider when evaluating para-athletes for carpal tunnel syndrome and highlights areas for future research.

Feasibility and usability of a virtual-reality-based sensorimotor activation apparatus for carpal tunnel syndrome patients

PURPOSE

This study aimed to assess the usability of a virtual reality-assisted sensorimotor activation (VRSMA) apparatus for individual digit rehabilitation. The study had two main objectives: Firstly, to collect preliminary data on the expectations and preferences of patients with carpal tunnel syndrome (CTS) regarding virtual reality (VR) and an apparatus-assisted therapy for their affected digits. Secondly, to evaluate the usability of the VRSMA apparatus that was developed.

METHODS

The VRSMA system consists of an apparatus that provides sensory and motor stimulation via a vibratory motor and pressure sensor attached to a button, and a virtual reality-based visual cue provided by texts overlaid on top of a 3D model of a hand. The study involved 10 CTS patients who completed five blocks of VRSMA with their affected hand, with each block corresponding to the five digits. The patients were asked to complete a user expectations questionnaire before experiencing the VRSMA, and a user evaluation questionnaire after completing the VRSMA. Expectations for VRSMA were obtained from the questionnaire results using a House of Quality (HoQ) analysis.

RESULTS

In the survey for expectations, participants rated certain attributes as important for a rehabilitation device for CTS, with mean ratings above 4 for attributes such as ease of use, ease of understanding, motivation, and improvement of hand function based on clinical evidence. The level of immersion and an interesting rehabilitation regime received lower ratings, with mean ratings above 3.5. The survey evaluating VRSMA showed that the current prototype was overall satisfactory with a mean rating of 3.9 out of 5. Based on the HoQ matrix, the highest priority for development of the VRSMA was to enhance device comfort and usage time. This was followed by the need to perform more clinical studies to provide evidence of the efficacy of the VRSMA. Other technical characteristics, such as VRSMA content and device reliability, had lower priority scores.

CONCLUSION

The current study presents a potential for an individual digit sensorimotor rehabilitation device that is well-liked by CTS patients.

The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study

STUDY DESIGN

Single-blinded, randomized controlled study.

INTRODUCTION

Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders.

PURPOSE OF THE STUDY

This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS.

METHODS

A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome.

RESULTS

We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group.

DISCUSSION

This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients.

CONCLUSIONS

MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.

Evaluation of the treatment of distal radial volar fracture by different methods sparing the pronator quadratus

OBJECTIVE

The traditional volar approach requires the release of the pronator quadratus (PQ) muscle in the treatment of distal radius fractures. However, intraoperative repair of the PQ muscle often fails due to tissue injury and unstable muscle repair. This study compared the outcomes of different methods of sparing the PQ muscle combined with the volar plate in treating distal radius fractures.

METHODS

A total of 95 patients with distal radius fractures sparing the PQ muscle were enrolled with the brachioradialis (BR) splitting approach (group A, 33 people), the volar plating insertion PQ muscle approach (group B, 35 people) and traditional Henry approach without sparing PQ muscle (group C, 27 people). Postoperative internal fixation, fracture healing and postoperative complications were observed in the three groups. The visual analog scale (VAS) of postoperative wrist pain was compared between three groups. The Dienst joint scale was used to evaluate the wrist function of patients, and imaging indexes were used to evaluate the surgical efficacy.

RESULTS

A total of 95 patients with distal radius fractures were followed up for more than one year after surgery. All fractures obtained good union, with no vascular injury, nerve injury or wound infection. Outcomes at three days, one month and three months all showed no significant differences in postoperative imaging indexes among three groups and no significant differences in various indexes among three groups during the same period. The mean operative time in group C was significantly lower than that in groups A and B. There was significant difference in the mean operation time between group A and group B. The amount of mean operative blood loss or mean bone union time in groups A and B was significantly lower than those in group C. No significant difference was shown in mean operative blood loss or mean bone union time between group A and group B. No significant differences in limb function scores, VAS scores and the mean range of motion existed among three groups at the 12-month postoperative follow-up. However, outcomes assessed one week, one month and three months after surgery demonstrated significant differences in the VAS scores and the mean range of motion among three groups, and the group B had lower VAS score and greater the mean range of motion. According to Dienst score, the excellent rate in groups A, B and C was 91.0% (30/33), 94.2% (33/35) and 85.2% (23/27), respectively, at 12 months after surgery. Tendon irritation occurred in 2 cases and joint stiffness in 1 case in group A. In group B, there were 2 cases traumatic arthritis and 2 cases delayed carpal tunnel syndrome and 1 case tendon irritation. In group C, tendon irritation and delayed carpal tunnel syndrome occurred, respectively, in 3 cases.

CONCLUSION

Our results demonstrated that these two different surgical approaches were effective ways to reserve PQ and had good clinical outcomes. The volar plating insertion PQ muscle approach could reduce early postoperative pain, promote early activity and return to normal life, while the BR splitting approach was more advantageous in intraoperative fracture exposure and could shorten the operative time. However, some defects also existed. At 12 months of follow-up, no significant advantage was seen in sparing the PQ muscle. Therefore, surgeons should be aware of their individual characteristics and choose patients carefully.

Median artery persistence in coexistence with a bifid median nerve and interconnections of the median with the ulnar nerve and vice versa

PURPOSE

This report describes a bilateral persistent median artery (PMA) originating from the ulnar artery and terminating at different levels of the upper limb. The PMA coexisted with a bilateral bifid median nerve (MN) and two bilateral interconnections (ICs characterized with the symbol -) of the MN with the ulnar nerve (UN) (MN-UN) and a unilateral reverse IC (UN-MN). Emphasis was given to the artery's developmental background.

METHODS

The PMA was identified in an 80-year-old formalin-embalmed donated male cadaver.

RESULTS

The right-sided PMA terminated at the wrist, posterior to the palmar aponeurosis. Two neural ICs were identified: the UN joined the MN deep branch (UN-MN), at the forearm's upper third, and the MN deep stem joined the UN palmar branch (MN-UN), at the lower third (9.7 cm distally to the 1st IC). The left-sided PMA ended in the palm giving off the 3rd and 4th proper palmar digital arteries. An incomplete superficial palmar arch was identified by the contribution of the PMA, radial, and ulnar arteries. After the MN bifurcation into superficial and deep branches, the deep branches formed a loop, that was penetrated by the PMA. The MN deep branch communicated with the UN palmar branch (MN-UN).

CONCLUSIONS

The PMA should be evaluated as a causative factor of carpal tunnel syndrome. The modified Allen's test and the Doppler ultrasound may detect the arterial flow and the angiography may depict the vessel thrombosis in complex cases. PMA could also be a "salvage" vessel for the hand supply, in radial and ulnar artery trauma.

Pairwise association of upper extremity musculoskeletal conditions: large population investigation from PERSIAN cohort study

BACKGROUND

People with one area of upper extremity musculoskeletal conditions (UEMSCs) may have other. We aim to determine how frequent is the ipsilateral coexistence of common UEMSCs apparent on interview and examination.

METHODS

This is a large population cross-sectional study conducted as part of the PERSIAN cohort study int Mashhad University of Medical Sciences (MUMS). The study aimed to evaluate individuals for symptoms and signs of the following conditions: carpal tunnel syndrome (CTS), lateral epicondylitis (LE), trapeziometacarpal osteoarthritis (TMC OA), DeQuervain's tendinopathy, trigger digit (TD), ganglion cyst, and rotator cuff tendinopathy (RCT). The primary outcomes of the study are (1) to determine the side-specific relative risk of each UEMSC coexisting with the second condition, and (2) to identify predictive factors of each UEMSC using side-specific multivariate logistic regression analysis.

RESULTS

We conducted a study involving 4737 individuals from the staff of MUMS and found significant pairwise associations among UEMSCs on a side-specific basis. Women had more chance of having DeQuervain's disease (β = 6.3), CTS (β = 3.5), ganglion cyst (β = 2.5), TMC OA (β = 2.3), and RCT (β = 2.0). Each condition (dependent variable) was associated with others (predictors) as follows: CTS: RCT (β = 5.9), TMC OA (β = 4.7), TD (β = 2.9), and LE (β = 2.5).

TMC OA

LE (β = 6.4), TD (β = 5.4), RCT (β = 4.3), and CTS (β = 4.1). LE: RCT (β = 8.1), TMC OA (β = 6.4), and CTS (β = 2.5). DeQuervain's disease: TD (β = 13.6), RCT (β = 4.5), and LE (β = 3.8). TD: CTS (β = 8.8), ganglion cyst (β = 7.6), DeQuervain's disease (β = 5.7), and TMC OA (β = 4.3). RCT: LE (β = 5.8), TMC OA (β = 5.5), CTS (β = 5.2), and DeQuervain's disease (β = 4.3). Ganglion cyst: TD (β = 4.8).

CONCLUSION

Our study reports significant increased frequency of the UEMSCs among patients who already have one of the diseases, in a large sample size study. Level of Evidence Level II (Differential Diagnosis/Symptom Prevalence Study).

A Giant Lipoma in the Distal Forearm of a Cadaver

OBJECTIVE

Lipomas are very common tumors which usually prefer the upper limbs and, depending on their size, may cause nerve compression, or may be asymptomatic. The current cadaveric report describes a giant lipoma in the distal forearm area.

CASE REPORT

A large mass (5.1 × 3.2 × 1.6 cm) was identified on the palmar surface of the distal forearm, during dissection of a 63-year-old male cadaver. The mass caused anteromedial displacement and flattening of the median nerve (MN). Despite the lack of information about the subject's medical history, MN compression was assumed on the basis of the lipoma's size, its vicinity to neural structures, and the MN displacement and flattening.

CONCLUSION

The enlarged distal forearm lipoma, located adjacent to the carpal tunnel, displaced and flattened the MN. The cadaveric finding described is clinically relevant for both differential diagnosis and surgical treatment of carpal tunnel syndrome.

Pearls & Oy-sters: Case of Atypical Peripheral Nerve Findings Following Paclitaxel for Breast Cancer

Neuromuscular ultrasound (NMUS) is a valuable tool in establishing a diagnosis of carpal tunnel syndrome (CTS) and can be particularly helpful in patients with clinical CTS but normal nerve conduction studies (NCSs). This case involves the uncommon presentation of enlarged median nerves on NMUS with normal NCS in a patient with breast cancer who developed chemotherapy-induced peripheral neuropathy and CTS after taxane treatment. This case demonstrates that CTS should not be excluded based on electrodiagnostic studies alone, and comorbid CTS should be considered in patients receiving neurotoxic chemotherapy, even in the setting of normal NCS.

Application of deep learning algorithms in automatic sonographic localization and segmentation of the median nerve: A systematic review and meta-analysis

OBJECTIVE

High-resolution ultrasound is an emerging tool for diagnosing carpal tunnel syndrome caused by the compression of the median nerve at the wrist. This systematic review and meta-analysis aimed to explore and summarize the performance of deep learning algorithms in the automatic sonographic assessment of the median nerve at the carpal tunnel level.

METHODS

PubMed, Medline, Embase, and Web of Science were searched from the earliest records to May 2022 for studies investigating the utility of deep neural networks in the evaluation of the median nerve in carpal tunnel syndrome. The quality of the included studies was evaluated using the Quality Assessment Tool for Diagnostic Accuracy Studies. The outcome variables included precision, recall, accuracy, F-score, and Dice coefficient.

RESULTS

In total, seven articles were included, comprising 373 participants. The deep learning and related algorithms comprised U-Net, phase-based probabilistic active contour, MaskTrack, ConvLSTM, DeepNerve, DeepSL, ResNet, Feature Pyramid Network, DeepLab, Mask R-CNN, region proposal network, and ROI Align. The pooled values of precision and recall were 0.917 (95 % confidence interval [CI], 0.873-0.961) and 0.940 (95 % CI, 0.892-0.988), respectively. The pooled accuracy and Dice coefficient were 0.924 (95 % CI, 0.840-1.008) and 0.898 (95 % CI, 0.872-0.923), respectively, whereas the summarized F-score was 0.904 (95 % CI, 0.871-0.937).

CONCLUSION

The deep learning algorithm enables automated localization and segmentation of the median nerve at the carpal tunnel level in ultrasound imaging with acceptable accuracy and precision. Future research is expected to validate the performance of deep learning algorithms in detecting and segmenting the median nerve along its entire length as well as across datasets obtained from various ultrasound manufacturers.

Use of Iontophoresis with Corticosteroid in Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

BACKGROUND

Carpal tunnel syndrome is a neuropathy that affects the median nerve. The aim of this review is to synthesize the evidence and perform a meta-analysis on the effects of iontophoresis in people with carpal tunnel syndrome.

METHODS

The search was carried out using PubMed, Web of Science, Scopus, CINHAL Complete, Physiotherapy Evidence Database, and SciELO. The methodological quality was evaluated using PEDro. A standardized or mean difference meta-analysis (Hedge's g) using a random-effects model was calculated.

RESULTS

Seven randomized clinical trials using iontophoresis for electrophysiological, pain, and functional outcomes were included. The mean of PEDro was 7/10. No statistical differences were obtained for the median sensory nerve conduction velocity (SMD = -0.89; p = 0.27) or latency (SMD = -0.04; p = 0.81), motor nerve conduction velocity (SMD = -0.04; p = 0.88) or latency (SMD = -0.01; p = 0.78), pain intensity (MD = 0.34; p = 0.59), handgrip strength (MD = -0.97; p = 0.09), or pinch strength (SMD = -2.05; p = 0.06). Iontophoresis only seemed to be superior in sensory amplitude (SMD = 0.53; p = 0.01).

CONCLUSIONS

Iontophoresis did not obtain an enhanced improvement compared to other interventions, but no clear recommendations could be made due to the limited number of included studies and the heterogeneity found in the assessment and intervention protocols. Further research is needed to draw sound conclusions.

Carpal arch space increased by volar force applied to the skin surface above the carpal tunnel

BACKGROUND

Carpal arch space augmentation can help decompress the median nerve. The augmentation can be achieved by mechanical manipulations utilizing the biomechanics of the tunnel structure. The purpose of this study was to expand the carpal arch in vitro by applying volar forces on the surface of the wrist.

METHODS

The mechanism was implemented in eight cadaver hands by attaching a volar force transmitter to the palmar surface of the wrist and pulling the transmitter volarly at six force levels (0, 3, 6, 9, 12, and 15 N). Ultrasound images of the cross section at the distal carpal tunnel were collected for morphological analysis.

FINDINGS

The carpal arch height, width, and area were significantly altered by the volarly applied force (P < 0.001). The arch height and area were increased but the arch width was decreased by the force. Pearson's correlation coefficient showed that there was a positive correlation between the arch height and force magnitude; and between the arch area and force magnitude. A negative correlation existed between the arch width and force magnitude (P < 0.001). The magnitude of change of the arch height, width, and area was increased as the force magnitude increased.

INTERPRETATION

This study demonstrated that applying external forces on the wrist skin to increase the carpal arch space was feasible. The magnitude of the force influenced its effect on altering the carpal arch. Study limitations include small sample size and inclusion of male specimens. Future in vivo work is needed for clinical translation feasibility.