Carpal tunnel syndrome impairs thumb opposition and circumduction motion

Opposition Transfer Using the Extensor Indicis Muscle and the Extensor Pollicis Brevis Tendon

Purpose

This study aimed to introduce a novel technique using the extensor pollicis brevis and extensor indicis proprius tendons as power sources for thumb opposition reconstruction in cases of severe carpal tunnel syndrome (CTS) associated with thenar muscle atrophy. Furthermore, the efficacy of this novel method and the traditional Camitz technique was compared.

Methods

Patients with severe CTS and thumb opposition dysfunction who underwent surgery using the novel technique (n = 7 and 9 surgeries) or the Camitz technique (n = 8 and 8 surgeries) were included in the analysis. The pre- and postoperative palmar abduction angle, thumb-ring finger opposition angle, and Kapandji score were assessed. The repeated measures analysis of variance and the Mann-Whitney U test were used for statistical analysis.

Results

The novel technique was associated with a significant postoperative improvement in palmar abduction angle, thumb-ring finger opposition angle, and Kapandji score. In particular, the thumb-ring finger opposition angle of patients who underwent surgery using this technique was superior to that of patients who underwent surgery using the Camitz technique. Therefore, the novel technique was highly effective in improving thumb pronation.

Conclusion

The novel technique using the extensor pollicis brevis and extensor indicis proprius tendons is promising for thumb opposition reconstruction in severe CTS cases. Unlike the traditional Camitz technique, this approach promotes stable thumb opposition function without requiring a pulley, thereby yielding satisfactory outcomes. Nevertheless, further studies with a larger sample size should be conducted to validate these findings.

Type of study/level of evidence

Therapeutic 4; Surgical technique.

Association between three-dimensional motion analysis of the thumb and clinical parameters in patients with carpal tunnel syndrome

We analysed the relationship between motor dysfunction of the thumb and the clinical parameters of carpal tunnel syndrome using three-dimensional motion analysis. This single-centred, prospective study included 65 hands in 51 patients with idiopathic carpal tunnel syndrome and 30 healthy hands. Three-dimensional thumb kinematics were acquired using a motion capture system with a retroreflective surface-based marker method. The trajectory area of thumb tip, adduction and abduction of the trapeziometacarpal joints and metacarpophalangeal joints were correlated with the clinical parameters. There was no significant correlation between the results of motion analysis values and patient-reported outcomes measures. Thumb movement disorder associated with carpal tunnel syndrome affected specific activities of daily living based on the pinching movements, such as 'writing' and 'buttoning clothes' among the patient-reported outcome measure items.Level of evidence: III.

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.

Pedicled Pronator Quadratus Transposition for Functional Opponensplasty: A Cadaveric Anatomical Study for Feasibility

BACKGROUND

Techniques on opponensplasty for chronic carpal tunnel syndrome have been described previously. A novel pronator quadratus (PQ) transposition for chronic carpal tunnel syndrome is described. In addition, the relationship of the distal perforating branch of the radial artery to the surrounding tissue is detailed to optimize further use of the PQ flap for clinical applications.

METHODS

Ten cadaver hands underwent PQ dissection, and the perforating branch of the radial artery was identified. Measurements were taken from the radiocarpal joint and the radial styloid to the distal perforating branch. Finally, a proposed surgical technique of PQ transposition with proximal radius periosteum to the first metacarpophalangeal joint and anterior interosseous nerve transfer was performed.

RESULTS

The average distance of the perforating branch from the radiocarpal joint was 10 ± 1.05 mm, and the average distance from the radial styloid was 17.1 ± 1.6 mm. Pronator quadratus transposed with a layer of radius periosteum demonstrated anatomical feasibility.

CONCLUSIONS

The distal perforating branch of the radial artery predictably perfuses the PQ muscle, which may be used in the future as a means of opponensplasty for chronic carpal tunnel syndrome.

Innovative Quantitative Assessment of Hand Function in Carpal Tunnel Syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) compromises fine sensorimotor function during activities of daily living and affects a large number of individuals with high burden costs for society. The purpose of this study was to quantitatively characterize fine movement skills in CTS patients preoperatively and at 1 month postoperatively by means of a sensor-engineered glove, in order to provide new insights for evaluative and finally therapeutic purposes.

METHODS

Forty-one CTS patients and 41 age- and gender-matched healthy controls (HC) were analyzed by adopting the engineered glove Hand Test System (HTS), which previously demonstrated its reliability and sensitivity to detect hands dysfunction in several neurological diseases. A sub-group of 11 CTS subjects was re-tested 1 month after surgery. Three parameters-touch duration (TD), inter-tapping interval (ITI), and movement rate (MR)-were considered to characterize hand function.

RESULTS

The affected hand of CTS patients generally showed worst finger opposition performances than HC. Comparing the dominant hand, all parameters were able to significantly discriminate CTS patients from HC. Considering the nondominant hand, the best performing parameter in discriminating CTS from HC was TD. The follow-up assessment at 1 month after surgery showed that considered parameters were able to monitor patients' recovery. In particular, the TD parameter recorded at the 3 different assigned task modalities resulted significantly enhanced.

CONCLUSIONS

Results of this pilot study proved the validity of the parameters obtained through the sensor-engineered glove to assess objectively hand functional status and surgical outcomes in CTS.

Effect of the position of the interphalangeal joint on movements of the trapeziometacarpal joint during thumb opposition

The Kapandji test is a simple method to score thumb opposition; however, the position of the interphalangeal joint of the thumb during this test has not been described. We aimed to quantitatively examine the effect of the thumb interphalangeal joint position on movements of the trapeziometacarpal joint during thumb opposition using the Kapandji test. The Kapandji test was carried out in 20 healthy participants during thumb interphalangeal joint extension and flexion. Movements of the joints and the activity of thenar muscles were recorded using motion capture and electromyography, respectively. We found that interphalangeal joint extension increased the trapeziometacarpal joint movement and thenar muscle activity compared with interphalangeal joint flexion, which contributed to thumb opposition at Kapandji Positions 0-6. These findings suggest the position of the thumb interphalangeal joint affects the trapeziometacarpal joint during thumb opposition, and assessment of thumb opposition using the Kapandji test is best done with the thumb interphalangeal joint in extension.

A Detailed Comparison of Preoperative Complaints in Severe Carpal Tunnel Syndrome versus Recurrent Carpal Tunnel Syndrome Using the Boston Carpal Tunnel Questionnaire

Background: The Boston Carpal Tunnel Questionnaire (BCTQ) has a symptom severity scale (SSS) with 11 questions and a functional status scale (FSS) with 8 questions. The final score for each scale is the sum divided by the number of questions and ranges between 1 and 5. A score of 1 indicates they have no complaints and 5 indicates high severity and functional loss. Unfortunately, this single digit score does not permit a detailed analysis of the symptoms and functional status. The aim of this study is to conduct an in-depth comparison of preoperative complaints using the BCTQ between patients with severe carpal tunnel syndrome (SCTS) and recurrent carpal tunnel syndrome (RCTS). Methods: This is a retrospective cohort study on the preoperative status of 37 patients with SCTS and 18 patients with RCTS using the BCTQ. The questions in the SSS and FSS were classified into four groups based on the responses of patients, namely a low complaint (LC) (1-1.99), moderate complaint (MC) (2-2.99), high complaint (HC) (3-3.99), and severe complaint (SC) (4-5) groups. The patients in the SCTS and RCTS groups were compared to find differences in age, gender, hand dominance, and responses to questions in the SSS and FSS. Results: The age of patients in the SCTS group (76.06 years) was significantly higher compared to the RCTS group (51.11 years). There was no significant difference between the two groups with regard to gender or hand dominance. The top question with SC or HC response in the SCTS group was problems in grasping small objects (SSS) and fastening buttons (FSS) and in the RCTS group was tingling in the hand (SSS) and difficulty with opening a jar (FSS). Conclusions: An in-depth analysis of the BCTQ allowed us to compare and understand differences in symptoms and function between patients with SCTS and RCTS. Level of Evidence: Level III (Therapeutic).

Three-dimensional analysis of thumb motion recovery after carpal tunnel release

This study quantified recovery of thumb motion in patients with carpal tunnel syndrome after carpal tunnel release using three-dimensional motion analysis with a retroreflective surface-based marker method. Eighteen hands from 14 patients who underwent carpal tunnel release for idiopathic carpal tunnel syndrome were included. The angular movements of the three joints of the thumb, the path length of the thumb tip and the area enclosed by the perimeter path of the thumb tip were measured during circumduction. The range of joint movement, including abduction/adduction of the trapeziometacarpal joint, and flexion/extension of the interphalangeal and metacarpophalangeal joints and the path length of the thumb tips, improved significantly 1 year after surgery. The quantification of thumb kinematics helps to better understand motor dysfunction in carpal tunnel syndrome, assess the severity of the condition and decide on treatment.Level of evidence: IV.

Biomechanical Evaluation of Opponensplasty for Low Median Palsy: A Cadaver Study

Purpose

Impaired thumb opposition associated with advanced carpal tunnel syndrome may be treated by opponensplasty at the time of open carpal tunnel release. However, it is unclear which opponensplasty technique achieves the greatest functional improvement. This study aimed to compare the biomechanics of thumb opposition after Camitz, modified Camitz, and Burkhalter opponensplasties.

Methods

We used 6 fresh-frozen cadaveric arms. Each procedure was reproduced on each arm: Camitz opponensplasty, modified Camitz opponensplasty involving palmaris longus transfer routed around the flexor carpi ulnaris pulley, and Burkhalter opponensplasty. Arms were fixed with the wrist in 0° flexion and the forearm in neutral pronosupination, and sensors were placed on the thumbnail, radial styloid, and dorsal aspect of the second metacarpal head. The donor tendon was pulled using a mechanical testing machine with a maximum force of 25 N, and the locations of the sensors in thumb opposition were recorded. The first web space and thumb pronation angles were measured for each procedure and compared.

Results

The mean first web space and pronation angles produced using 25 N were 55° and 20°, 57° and 26°, and 53° and 29° for the Camitz, modified Camitz, and Burkhalter opponensplasties, respectively. The first web space angle was significantly larger after modified Camitz opponensplasty compared with Burkhalter opponensplasty with 25 N loading. Camitz opponensplasty resulted in a significantly smaller pronation angle compared with modified Camitz and Burkhalter opponensplasties with 25 N loading.

Conclusions

The modified Camitz opponensplasty produces a relatively balanced biomechanical outcome in terms of the first web space and pronation angles. Conversely, Burkhalter opponensplasty has been shown to be a favorable technique for improving pronation.

Clinical relevance

Modified Camitz opponensplasty with a pulley offers effective restoration of thumb opposition, including pronation. On the other hand, Burkhalter opponensplasty represents a suitable option not only for patients with high median palsy and injury to the palmar aponeurosis but also for those who require improved pronation.

Device Development for Detecting Thumb Opposition Impairment Using Carbon Nanotube-Based Strain Sensors

Research into hand-sensing is the focus of various fields, such as medical engineering and ergonomics. The thumb is essential in these studies, as there is great value in assessing its opposition function. However, evaluation methods in the medical field, such as physical examination and computed tomography, and existing sensing methods in the ergonomics field have various shortcomings. Therefore, we conducted a comparative study using a carbon nanotube-based strain sensor to assess whether opposition movement and opposition impairment can be detected in 20 hands of volunteers and 14 hands of patients with carpal tunnel syndrome while avoiding existing shortcomings. We assembled a measurement device with two sensors and attached it to the dorsal skin of the first carpometacarpal joint. We measured sensor expansion and calculated the correlation coefficient during thumb motion. The average correlation coefficient significantly increased in the patient group, and intrarater and interrater reliability were good. Thus, the device accurately detected thumb opposition impairment due to carpal tunnel syndrome, with superior sensitivity and specificity relative to conventional manual inspection, and may also detect opposition impairment due to various diseases. Additionally, in the future, it could be used as an easy, affordable, and accurate sensor in sensor gloves.

Maximum Palmar Abduction Angle of the Trapeziometacarpal Joint in Healthy Subjects Can Be Evaluated Accurately Using a Radiograph-Based Measurement Technique

In carpal tunnel syndrome, the abductor pollicis brevis, which is the primary muscle for the palmar abduction of the thumb, is almost inevitably impaired. The active palmar abduction of the thumb may be a better indicator of thumb disability. The authors aimed to establish a simple and accurate method to measure the angle of active palmar abduction of the thumb and to determine the maximum angle values in healthy women. Twenty-five women 20 to 21 years old with no disorder of the hand participated in this study voluntarily. Three measurement methods were tested. The first method was designed according to the Japanese Orthopaedic Association and the second method was designed according to the American Society of Hand Therapists; both use photographs to perform measurement calculations. In the third method, 2 orthopedic surgeons measured the same angle as that described in the second method on hand radiographs. Intra- and interobserver reliability were assessed for each method and described as interclass correlation coefficients. The first and third methods had strong inter- and intraobserver reliability. The second method had strong intraobserver reliability but medium interobserver reliability. The measurement obtained with the first method was significantly different from the values obtained by the second and third methods (almost double). Therefore, the authors regarded the third method as the most appropriate approach for measuring active palmar abduction of the thumb, which, in healthy individuals, yielded maximum values of 45.3°±6.4° and 44°±7° for the left hand and the right hand, respectively. [Orthopedics. 2020; 43(2):e95-e101.].

Measurement of thumb pronation and palmar abduction angles with a small motion sensor: a comparison with Kapandji scores

The Kapandji score is used widely to record thumb opposition and is the only alternative to angular measurements. We aimed to verify the extent to which the Kapandji score reflects the angle of pronation. We recruited volunteers with unaffected upper limbs (33 hands) and patients with carpal tunnel syndrome (20 hands). We attached a small gyroscope to the thumb metacarpal and measured the pronation and palmar abduction angles at each position of the Kapandji score in both groups. The Kapandji score showed a strong ceiling effect, and the increase in angle size at each Kapandji score levelled off around a score of 6 in both groups. A Kapandji score greater than 6 does not necessarily reflect thumb opposition. Level of Evidence: III.

Quantitative evaluation of hand motor function using a gyrosensor in mild and moderate carpal tunnel syndrome

INTRODUCTION

The objective of this study was to determine whether patients with carpal tunnel syndrome (CTS) manifest changes in early-stage motor function and to investigate the utility of a gyrosensor for quantitative evaluation of motor function.

METHODS

Angular velocity signal was measured during finger tapping in 52 patients with mild-to-moderate CTS and 45 controls. Four finger-tapping performance (FTP) values-root-mean-squared (RMS) velocity, RMS angle, peak power, and total power-were derived from the signal.

RESULTS

All FTP values were significantly lower in patients with CTS than in controls (P = 0.001 or P < 0.001). There were no significant differences between the mild and moderate CTS subgroups.

DISCUSSION

FTP measurement with a gyrosensor represents a valuable tool for the evaluation of median nerve motor function in patients with CTS. It facilitates the detection of subclinical motor dysfunction in patients with early stage CTS. Muscle Nerve 59:465-469, 2019.

A new method of measuring the thumb pronation and palmar abduction angles during opposition movement using a three-axis gyroscope

Background

Thumb opposition is vital for hand function and involves pronation and palmar abduction. The improvement of pronation is often used as one of the evaluation items of the opponensplasty method for severe carpal tunnel syndrome. However, most of the studies used substitution evaluation methods for measurement of the pronation angle. Thus, there is still no appropriate method for measuring thumb pronation angle accurately in carpal tunnel syndrome patients.

In recent reports, a wearable gyroscope was used to evaluate upper extremity motions and it can be possibly used for accurate measurement of the thumb pronation angle along the three-dimensionally moving bone axis.

Thus, we investigated the reliability of measuring thumb pronation using a gyroscope and evaluated whether this method can be used to detect opposition impairment.

Methods

The participants were volunteers with unaffected upper limbs (32 hands) and patients with carpal tunnel syndrome (27 hands). The pronation and palmar abduction angles during opposition movements were measured using a three-axis gyroscope that included a three-axis accelerometer. The gyroscope was fixed onto the first metacarpal bone and the thumb phalanx.

Results

The pronation and palmar abduction angles of the metacarpal bone and the palmar abduction angles of the phalanx significantly decreased in the carpal tunnel syndrome group. The pronation angle of the metacarpal bone during opposition movement peaked later than the palmar abduction angle in all hands.

Conclusions

We were able to measure the thumb pronation and palmar abduction angles using the three-axis gyroscope, and this tool was able to detect impairments of thumb opposition due to carpal tunnel syndrome. This could be a tool for measuring thumb and finger angles and for detecting impairments caused by various diseases.

Dynamic Functional Assessment of Hand Motion Using an Animation Glove: The Effect of Stenosing Tenosynovitis

BACKGROUND

The aim of the present study is to determine whether an animation glove can be utilized to provide a reliable and reproducible assessment of dynamic hand function and whether this assessment is altered in the setting of hand pathology.

METHODS

Ten subjects without known hand pathology and 11 subjects with known stenosing tenosynovitis were assessed on tasks involving hand function at varied speeds, including forceful and gradual making of a fist and the quick and slow grip of a baseball using an animation glove to record range of motion and measures of velocity (CyberGlove II).

RESULTS

In normal subjects, peak extension and flexion velocity of the index and middle finger was highest in the metacarpophalangeal and lowest in the distal interphalangeal; however, the converse was true in the ring finger. In those subjects with stenosing tenosynovitis, the animation glove was able to detect a triggering event during assessment. Furthermore, there was a significant decrease in the maximum velocity of the proximal interphalangeal joint observed with the slow fist task in both flexion and extension (55%, P < .01) in the affected hand when compared with the unaffected hand.

CONCLUSIONS

The CyberGlove II can be utilized in the dynamic functional analysis of the hand and is able to detect a triggering event in subjects with known stenosing tenosynovitis. Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology.

Carpal tunnel syndrome impairs index finger responses to unpredictable perturbations

The fine-tuning of digit forces to object properties can be disrupted by carpal tunnel syndrome (CTS). CTS' effects on hand function have mainly been investigated using predictable manipulation tasks; however, unpredictable perturbations are commonly encountered during manual tasks, presenting situations which may be more challenging to CTS patients given their hand impairments. The purpose of this study was to investigate muscle and force responses of the index finger to unpredictable perturbations in patients with CTS. Nine CTS patients and nine asymptomatic controls were instructed to stop the movement of a sliding plate by increasing index finger force following an unexpected perturbation. The electrical activity of the first dorsal interosseous muscle and forces exerted by the index finger were recorded. CTS patients demonstrated 20.9% greater muscle response latency and 12.0% greater force response latency compared to controls (p<0.05). The duration of plate sliding was significantly different between groups (p<0.05); the CTS group's duration was 142.2±5.8ms compared to the control group's duration of 133.1±8.4ms. Although CTS patients had increased muscle and force response durations comparatively, these differences were not statistically significant. Findings from this study suggest CTS-induced sensorimotor deficits interfere with accurate detection, processing and response to unpredictable perturbations. These deficits could be accounted for at multiple levels of the peripheral and central nervous systems. Delayed and decreased responses may indicate inefficient object manipulation by CTS patients and may help to explain why CTS patients tend to drop objects.

Evaluating suspected work-related neurologic disorders (clinical diagnosis)

The clinical diagnosis of work-related neurologic disorders is essentially one of exclusion because symptoms and signs are often nonspecific. The clinical reasoning requires a three-step approach: (1) establish the characteristics of the presenting disease; (2) ascertain that observed clinical features are consistent with those caused by the suspected agent(s); and (3) assess occupational exposures. A detailed history is of paramount importance in evaluating patients with suspected work-related neurologic disorders as it is in other clinical contexts, especially because in some circumstances it may represent the only criterion to establish causality. Thus, besides characterization of neurologic symptoms, including their location, quality, timecourse, and possible other associated symptoms, the work environment of the patient should be understood in full detail. In this respect, when a neurotoxin is suspected, then the history collection can be guided by the knowledge of the likely syndromes it produces. Similarly, physical examination should be directed to the target of toxicity/entrapment based on information from the work history. Although specific sites and elements of the nervous system may be affected depending on the offending agent, most neurotoxic disorders are characterized by generalized rather than focal neurologic abnormalities. Laboratory toxicologic tests have limited application for the etiologic diagnosis of neurotoxic disorders, except in cases of acute poisoning and in patients exposed to neurotoxic chemicals with prolonged half-life. In most cases examination takes place after the end of exposure, when the offending chemical is no longer detectable in body fluids. Electrophysiologic studies, in particular evoked potentials, electromyography, and conduction velocities, are important to confirm the organic basis of symptoms, particularly to detect subclinical or early neurologic involvement and to reduce the number of disorders to be considered in the differential diagnoses. In general, imaging studies with computed tomography and magnetic resonance are of limited utility in the evaluation of suspected neurotoxic disorders, except for helping to exclude other causes of the patient's clinical state. Improved conditions and safer practices in the workplace have led to a gradual shift in application of neuropsychologic evaluation from the assessment of severe neurotoxic damage to the evaluation of mild subclinical disturbances, and these tests are nowadays extensively used in screening workers exposed to neurotoxicants. Tools used in the screening of large groups of workers exposed to neurotoxicants may differ from those used in the clinic. Whereas some are obviously impractical, such as physical examination, others, such as, for instance, toxicologic tests, are used for biologic monitoring of exposure to ascertain compliance with occupational exposure limits.