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Bertini A, Lenti S, Libelli G, Ronco R, Oliveri S, Montemagno K, Priori A, Bocci T. When the diagnosis is in the patient's hand and in the neurologist's eye. Neurol Sci 2024:10.1007/s10072-024-07626-1. [PMID: 38833097 DOI: 10.1007/s10072-024-07626-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/25/2024] [Indexed: 06/06/2024]
Abstract
The objective of this study was to encompass current knowledge about pathophysiological mechanisms of those specific hand postures or deformities caused by central nervous system disorders. In the era of high-resolution neuroimaging and molecular biology, clinicians are progressively losing confidence with neurological examination. Careful hand observation is of key importance in order to differentiate neurological from non-neurological conditions, central from peripheral aetiologies, and organic from functional disorders. Localizing the potential anatomical site is essential to properly conduct subsequent exams. We provided a practical guide for clinicians to recognize hand patterns caused by central nervous system disorders, avoiding mimicking conditions, thus optimizing and prompting the diagnostic pathway.
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Affiliation(s)
- Alessandro Bertini
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
- Clinical Neurology Unit, Department of Health Sciences, Azienda Socio-Sanitaria Territoriale Santi Paolo E Carlo, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
| | - Sveva Lenti
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
- Clinical Neurology Unit, Department of Health Sciences, Azienda Socio-Sanitaria Territoriale Santi Paolo E Carlo, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
| | - Giorgia Libelli
- Neurology Unit, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Riccardo Ronco
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
- Clinical Neurology Unit, Department of Health Sciences, Azienda Socio-Sanitaria Territoriale Santi Paolo E Carlo, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
| | - Serena Oliveri
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
- Clinical Neurology Unit, Department of Health Sciences, Azienda Socio-Sanitaria Territoriale Santi Paolo E Carlo, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
| | - Kora Montemagno
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
| | - Alberto Priori
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
- Clinical Neurology Unit, Department of Health Sciences, Azienda Socio-Sanitaria Territoriale Santi Paolo E Carlo, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy
| | - Tommaso Bocci
- "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy.
- Clinical Neurology Unit, Department of Health Sciences, Azienda Socio-Sanitaria Territoriale Santi Paolo E Carlo, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy.
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Imran N, Liaqat S, Sattar A. Clenched Fist Syndrome in an Adolescent Girl. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20201208-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hill EJ, Kahn LC, Sterni LM, Mackinnon SE, Felder JM. Median Neuropathy After Blood Draw Mimics Painful Clenched Fist Syndrome in a Child. Hand (N Y) 2020; 15:NP31-NP36. [PMID: 30957563 PMCID: PMC7076620 DOI: 10.1177/1558944719837674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background: Clenched fist syndrome is a rare disorder, often attributed to a conversion disorder without anatomic basis. Here, we review the literature surrounding clenched fist syndrome and challenge the assumption it is always psychiatric in origin, via description of a case of clenched fist syndrome responsive to surgical nerve decompression. Methods: An unusual case of clenched fist syndrome is reviewed and discussed. Results: A child presenting with clenched fist syndrome failed conservative measures consisting of formal hand therapy, multidisciplinary pain management, and psychiatric treatment. On clinical examination, she had findings consistent with median nerve entrapment. After undergoing surgical decompression of the median nerve in the forearm and carpal tunnel, the clenched fist resolved immediately. Conclusions: Nerve compression may be an unrecognized factor underlying some cases of clenched fist syndrome. Evaluation by a hand surgeon or a hand therapist skilled in the detection of peripheral nerve entrapment or injury should be considered as part of the workup for this rare disorder.
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Affiliation(s)
- Elspeth J.R. Hill
- Washington University School of Medicine, Saint Louis, MO, USA,Elspeth J. R. Hill, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 1150 Northwest Tower, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
| | - Lorna C. Kahn
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Lynne M. Sterni
- Washington University School of Medicine, Saint Louis, MO, USA
| | | | - John M. Felder
- Washington University School of Medicine, Saint Louis, MO, USA
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Meiwandi A, Papadakis M. The clenched fist syndrome: case report of a clinical rarity of special interest for psychiatrists and hand surgeons. BMC Psychiatry 2019; 19:349. [PMID: 31703662 PMCID: PMC6839091 DOI: 10.1186/s12888-019-2348-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Clenched Fist Syndrome (CFS) is a type of a psychiatric disorder, in which the patients show flexion finger contractures. Although no organic etiology can be identified, the syndrome in most cases presents with pain and paradoxical stiffness. CASE PRESENTATION We, herein, report the case of a 52-year old woman with a 6-month history of progressive hand flexion contracture and intermittent numbness in the first 3 fingers, mimicking carpal tunnel syndrome. On examination, all digits, including the thumb, were held in a tight flexion at the metacarpal and interphalangeal joints. Passive digital extension was painless in all fingers. Physical examination did not reveal any joint tenderness, joint or tendon sheath swelling. X ray was performed and did not show any abnormalities. Neurological examination did not reveal any organic etiology. CONCLUSIONS CFS is believed to be a conversion disorder, i.e. unconsciously motivated and produced, whereas others consider it a factitious disorder, i.e. unconsciously motivated but consciously produced. Surgical treatment is not indicated, as it can worsen the symptoms. The related literature is discussed. We conclude that CFS should always be considered in patients with unexplainable flexion hand contractures, especially in the presence of a positive psychiatric history.
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Affiliation(s)
- Abdulwares Meiwandi
- 0000 0000 9024 6397grid.412581.bDepartment of Plastic, Reconstructive, Aesthetic and Hand Surgery, Helios University Hospital Wuppertal, Witten-Herdecke University, Wuppertal, Germany
| | - Marios Papadakis
- Division of Surgery II, Witten-Herdecke University, Wuppertal, Germany.
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Abstract
BACKGROUND The clenched fist syndrome/psycho-flexed hand, first described in the early 1980s, has not yet entered the major psychiatric textbooks. Curiously, the phenomenon has been illuminated mainly in journals and textbooks on hand surgery. There is a need to examine, describe, and understand this syndrome from a psychiatric perspective. CASE PRESENTATION We present a case we encountered in an intensive care unit. A 60-year-old white man with schizophrenia, cerebrovascular disease, diabetes mellitus type 2, and peripheral neuropathy, developed rather acutely bilateral clenched fists in the aftermath of a traumatic dislocated hip fracture that was operated on. He later died due to complications from the surgical procedure. CONCLUSIONS While this was a complex case with some clinical uncertainty regarding the cause of our patient's symptoms, we conclude that psychological processes were central to the development of his clenched fists. The phenomenon of clenched fists and our case are discussed with reference to the accumulated literature on psychogenic hand disorders and the International Statistical Classification of Diseases and Related Health Problems, 10th version. The nosological status appears to be obscure. This case presentation is a first step in increasing the understanding of this syndrome from a psychiatric perspective.
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Affiliation(s)
- Trygve Nissen
- Division of Mental Health and Addictions, University Hospital of North Norway, N-9291, Tromsø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway
| | - Rolf Wynn
- Division of Mental Health and Addictions, University Hospital of North Norway, N-9291, Tromsø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway.
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Factitious disorders in the hand-Main diagnostic traps highlighted with 3 cases. HAND SURGERY & REHABILITATION 2017; 37:110-113. [PMID: 29292110 DOI: 10.1016/j.hansur.2017.10.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/10/2017] [Accepted: 10/18/2017] [Indexed: 11/20/2022]
Abstract
Every doctor can be confronted, during his career, with patients presenting symptoms they created themselves. Because it is easily accessible, the hand is a favored target organ for these self-inflicted injuries. The diagnosis of factitious disorder of the hand is very difficult, rarely suggested and widely under-estimated. The real issue is detecting it early on to develop a cohesive diagnostic and therapeutic approach. The three clinical cases reported in this article illustrate the difficulty of caring for this pathology at all stages, from diagnosis to treatment. These disorders must be distinguished from malingering. A psychiatrist must be part of the treatment team. The prognosis of factitious disorders is poor. It is vital to maintain contact with the patient once the diagnosis is established. The risk is that the patient consults with other professionals, restarting a new cycle. The featured clinical cases were chosen to remind surgeons that factitious disorders of the hand are a recognized psychiatric disease. It must be evoked in the context of an unusual injury with a vague history. Everything possible must be done to confirm the diagnosis and avoid surgery.
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Rodrigues L, Magalhães E, Morello F, Clemente T, Balarini L, Gianordoli A, Serrano E, Gavi M, Valim V, Duque R. EDEMA DE MÃO RECORRENTE, DIAGNÓSTICO DE UMA RARA DOENÇA: SÍNDROME DE SECRÉTAN. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Basaran K, Datli A, Kurt M. An important diagnosis for the hand surgeon: “The clenched fist syndrome”. J Plast Reconstr Aesthet Surg 2014; 67:1304-6. [DOI: 10.1016/j.bjps.2014.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 02/05/2014] [Accepted: 04/29/2014] [Indexed: 11/15/2022]
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Correction of Severe Contracture of Intrinsic Plus Hand with a Modified Ilizarov Mini-Fixator: Correction with an Ilizarov Mini-Fixator for Severe Hand Contracture. J Hand Microsurg 2014; 7:161-5. [PMID: 26078533 DOI: 10.1007/s12593-014-0134-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 05/06/2014] [Indexed: 10/25/2022] Open
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Collet S, Forli A, Carpentier PH, Laviolette F, Imbert B, Blaise S. Le syndrome de Secrétan : mythe ou pathomimie ? ACTA ACUST UNITED AC 2014; 39:67-72. [DOI: 10.1016/j.jmv.2013.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 09/25/2013] [Indexed: 11/25/2022]
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O'Connor EA, Grunert BK, Matloub HS, Eldridge MP. Factitious hand disorders: review of 29 years of multidisciplinary care. J Hand Surg Am 2013; 38:1590-8. [PMID: 23890498 DOI: 10.1016/j.jhsa.2013.04.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/18/2013] [Accepted: 04/24/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To improve our understanding of factitious hand disorders with a review of our experience over 29 years in a multidisciplinary hand center. METHODS A retrospective chart review was performed to identify workers' compensation patients treated for factitious hand disorders in the multidisciplinary hand center between January 1981 and September 2010. Multidisciplinary evaluation at this center involved evaluation by hand surgeons, occupational therapists, and psychologists. Data collected include age, sex, race, educational level, clinical presentation, number of diagnostic tests, number of surgeries, time to referral to the multidisciplinary center, direct cost of care, psychological diagnosis, Minnesota Multiphasic Personality Inventory, treatment modalities, and work status. RESULTS We identified 174 workers' compensation patients with factitious hand disorders. Presentation was used to classify patients into 1 of 4 categories: psychopathological dystonia, factitious edema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation. There were statistically significant differences between the 4 categories in demographics, utilization of medical resources, psychopathology, treatment modalities, and return-to-work status. Patients with factitious wounds were more educated, used more medical resources, demonstrated an angry or hostile profile, and experienced a lower return-to-work rate. Patients with dystonia were less educated, used less medical resources, demonstrated a hypochondriasis or depressed profile, and experienced a higher return-to-work rate. CONCLUSIONS Treatment of factitious hand disorders remains frustrating and costly due to failure or recurrence after traditional approaches. This review is a large-scale examination of the factitious hand disorder population that demonstrates the unique pathology involved in each of the 4 categories. There is a specific association between the category of hand disorder and the underlying pathology and prognosis. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- E A O'Connor
- Medical College of Wisconsin, Milwaukee, WI, USA.
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Petrella L, Belkheyar Z, Oberlin C. The psychoflexed hand: new perspectives in diagnosis, classification and treatment. ACTA ACUST UNITED AC 2013; 32:245-50. [PMID: 23712089 DOI: 10.1016/j.main.2013.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 04/07/2013] [Accepted: 04/18/2013] [Indexed: 11/16/2022]
Abstract
The psychoflexed hand is a rare clinical condition characterized by fixed finger contractures undetermined by organic etiology, often associated with a psychiatric pathology. We report a series of 20 patients (nine males and 11 females, mean aged 56.2 years). We have introduced a new classification of the various possible patterns of finger deformities: 1) Type 1: prevalent flexion contracture at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the last two or three fingers; the thumb and the index are not affected; 2) type 2: prevalent flexion contracture at the PIP and distal interphalangeal (DIP) joints of the last two or three fingers; 3) type 3: flexion contracture of all the long fingers; 4) type 4: flexion contracture of all the fingers of the hand, including the thumb (clenched fist syndrome); 5) type 5: isolated flexus-adductus thumb (the long fingers are not affected); 6) type 6: flexion of digits associated with flexion contractures of other joints of the upper extremity. The treatment was conservative in 14 patients with recent deformities and surgical in six patients. Both forms of treatment were followed by a rigorous rehabilitation program, mostly based on home self-rehabilitation. The correction of the deformities was obtained in all cases and maintained over time.
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Affiliation(s)
- L Petrella
- Université Catholique, Largo A. Gemelli, 00168 Rome, Italy.
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Locking of the metacarpophalangeal joint caused by idiopathic intrinsic muscle atrophy of the hand: report of three cases. Hand (N Y) 2012; 7:431-4. [PMID: 24294165 PMCID: PMC3508021 DOI: 10.1007/s11552-012-9437-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Firoozabadi A, Seifsafari S, Mozafarian K, Bahredar MJ. Psychopathological hand disorders: a rare somatoform reaction to psychological conflicts. Hand (N Y) 2012; 7:181-5. [PMID: 23730238 PMCID: PMC3351522 DOI: 10.1007/s11552-012-9396-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | - M. J. Bahredar
- Institute of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
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