Intrinsic contracture of the hand: diagnosis and management

Intrinsic contracture of the hands in sarcoid myopathy

Hand involvement in sarcoidosis is rare and it presents as tenosynovitis, dactylitis, nodules and osteoarticular bony destruction. We describe an unusual presentation of progressive intrinsic muscle contracture of both hands in a 42-year-old woman with sarcoid myopathy who presented with painful swelling and weakness of all four extremities. Her systemic symptoms improved with oral corticosteroids, but the hand muscle contracture remained after resolution of myositis. Serial soft tissue releases of intrinsic muscle contracture improved hand function markedly. This case highlights that surgery is a viable option to treat intrinsic muscle contracture in patients with chronic sarcoid myopathy complicated with severe muscle contracture.

Striatal hand deformities in Parkinson's disease ‐ hand surgical perspectives

Background

The knowledge about striatal hand deformities (SHD) in Parkinson's disease (PD), has recently increased but need more attention due to their early impact on dexterity. The focus of clinical studies has been on the staging of SHD severity and neurological features. However, a hand surgical perspective has not been considered.

Objectives

Our purpose was to examine SHD in patients with PD using hand surgical assessment methods and the recommended staging of SHD.

Methods

In this observational study, a specialist in neurological physiotherapy examined 100 consecutive PD patients and identified 35 with suspected SHD, who were then examined by two hand surgeons. Their hands were clinically evaluated for severity of SHD, according to a previous proposed staging, focusing on metacarpophalangeal (MCP) joint flexion, presence of intrinsic and extrinsic tightness, as well as other hand deformities.

Results

Three kinds of deformities were identified among 35 included patients: surgical diagnoses unrelated to PD (n = 5), SHD (n = 23), and PD related hand deformities with increased extrinsic tightness (n = 10); three of these 10 patients had also contralateral SHD, thus are included in SHD group. In addition to previously described MCP joint flexion, swan neck deformity and z‐thumb deformity, we found in most hands finger “clefting,” abduction of the little finger and/or an increased intrinsic tightness, indicating pathology of intrinsic muscles of the hand involved in SHD.

Conclusions

SHD diagnosed with a modified staging method, including features of intrinsic and extrinsic hand deformities, should be considered in PD to implement early and more accurate treatment.

Clinical assessment of upper limb hypertonia in central neurological diseases

The clinical assessment of a hypertonic upper limb in central neurological diseases should be analytical, systematic (shoulder, elbow, extrinsic and intrinsic hand) and focused on the patient or caregiver's wishes and on the expected objectives (esthetic, hygienic, functional). Nerve blocks can help to separate mixed contractures, show the existence of antagonist muscles or find a starter muscle in dystonia patterns. The etiology (especially the evolving nature of the disease), general health condition (especially in older adults), associated deficits (cerebellar, sensory and cognitive; hemineglect) are considered together to arrive at a contract with patients and/or caregivers.

Ultrasound-guided ethyl alcohol injection to the deep branch of the ulnar nerve to relieve hand spasticity in stroke patients: A case series

Hand spasticity with a flexor pattern is a common problem affecting stroke patients and can result in pain, contractures, esthetic concerns, skin maceration, and overall loss of function. Poststroke (≥6 months) hemiparetic adult patients having a Modified Ashworth Scale (MAS) score of ≥1 for metacarpophalangeal flexion and thumb adduction spasticity were selected to receive an ultrasound-guided 20% ethyl alcohol block performed perineurally at the level of the deep branch of the ulnar nerve. Their MAS scores were evaluated pretreatment at 1 month and the change in MAS scores was assessed using Wilcoxon’s test. The threshold for statistical significance was set at p < 0.05. The mean MAS score for the flexor muscles of the 5 MCP joints and for thumb adduction was reduced from 3.3 ± 0.5 at pretreatment to 0.9 ± 0.5 at 1 month after the injection for the 10 patients. One month after the injection, the MAS scores were significantly reduced compared with those at pretreatment (p < 0.001), without complications. These are encouraging results showing that ultrasound-guided alcohol blocks of the deep branch of the ulnar nerve are safe and can help chronic stroke patients with metacarpophalangeal flexion and thumb adduction spasticity at 1 month.

Intrinsic plus hand: Painful Finger flexion and extension

Intrinsic plus hand describes a rare and painful contracture of the intrinsic hand muscles with excessive flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. Resulting from many causes to include trauma and neurologic injury, intrinsic plus hand can involve any number of fingers. Emergency department (ED) assessment should include evaluation for cerebrovascular injury, infection, compartment syndrome, and deep vein thrombosis (DVT). Conservative splinting is generally unsuccessful and ultimately requires operative intervention. We highlight the case of a 61-year-old otherwise healthy male who awoke to a painful and mildly swollen left hand with his fingers held in a contracted position. Evaluation in the ED found no active range of motion in the digits, severe pain with any passive motion, and a negative upper extremity ultrasound for DVT. Ultimately, orthopedic and neurology consults in the ED agreed upon a diagnosis of intrinsic plus hand.

Assessment of the Passive Tension of the First Dorsal Interosseous and First Lumbrical Muscles Using Shear Wave Elastography

PURPOSE

Quantitative evaluation of passive tension of the intrinsic muscles of the hand is necessary to assess contracture of the intrinsic muscles accurately. The aim of this study was to evaluate the shear modulus, which is related to passive muscle tension, of the first dorsal interosseous (FDI) and first lumbrical (FL) muscles using shear wave elastography.

METHODS

Subjects were 18 healthy males. The shear modulus of the FDI and FL muscles was assessed at several proximal interphalangeal (PIP), distal interphalangeal (DIP), metacarpophalangeal (MCP), and wrist joint positions. The position in which the MCP joint was flexed 60° past 0° with PIP-DIP joint extension and that in which the MCP joint was extended 30° past 0° with PIP-DIP joint flexion were respectively defined as the slack and stretched positions. We analyzed whether the shear modulus was affected by finger position (slack or stretched), wrist position (30° flexion past 0° and 30° extension past 0°), and muscle (FDI or FL).

RESULTS

Shear modulus in the stretched position was significantly higher than that in the slack position. The shear modulus of the FL muscle at 30° wrist extension was significantly higher than that at 30° flexion. The shear modulus of the FL muscle was significantly higher than that of the FDI muscle in the stretched position with the wrist at 30° flexion and extension, and in the slack position with the wrist at 30° extension.

CONCLUSIONS

The shear modulus of the FDI and FL muscles increased with MCP joint extension and PIP-DIP joint flexion. The difference in the muscle characteristics between the FDI and FL muscles should be considered when evaluating or treating contractures of the intrinsic muscles.

CLINICAL RELEVANCE

Shear wave elastography can evaluate the condition of the intrinsic muscles of the hand quantitatively.

Transcutaneous high-frequency alternating current for rapid reversible muscle force reduction below pain threshold

OBJECTIVE

The development of non-invasive, quickly reversible techniques for controlling undesired muscle force production (e.g. spasticity) could expand rehabilitation approaches in those with pathology by increasing the type and intensity of exercises that can be performed. High-frequency alternating current (HFAC) has been previously established as a viable method for blocking neural conduction in peripheral nerves. However, clinical application of HFAC for nerve conduction block is limited due to the invasiveness of surgical procedures and the painful onset response. This study aimed to examine the use of transcutaneous HFAC (tHFAC) at various stimulation frequencies to address these shortfalls.

APPROACH

Ten individuals participated in the study. Surface electrodes were utilized to apply tHFAC (0.5-12 kHz) to the median and ulnar nerves. Individual pain threshold was determined by gradual increase of stimulation amplitude. Subjects then performed a force-matching task by producing grip forces up to the maximal voluntary contraction level with and without application of tHFAC below the pain threshold.

MAIN RESULTS

Pain threshold current amplitude increased linearly with stimulation frequency. Statistical analysis showed that both stimulation frequency and charge injected per phase had significant effects (p   <  0.05) on grip force reduction. At the group level, application of tHFAC below pain threshold reduced grip force by a maximum of 40.7%  ±  8.1%. Baseline grip force trials interspersed between tHFAC trials showed consistent grip force, indicating that fatigue was not a factor in force reduction.

SIGNIFICANCE

Our results demonstrate the effectiveness of tHFAC at reducing muscle force when applied below the pain threshold, suggesting its potential clinical viability. Future studies are necessary to further elucidate the mechanism of force reduction before clinical application.

Hand function and recurrence after limited fasciectomy for Dupuytren's contracture: Long-term follow-up

PURPOSE

The aim of this study was to analyze long-term results after limited fasciectomy for Dupuytren's contracture.

METHODS

The study included 34 patients (52 rays), with an average follow-up of 9.5 years (range: 7-13 years). Range of motion, functional status, recurrence, and complications were recorded.

RESULTS

Preoperative metacarpophalangeal joint (MCPJ) contracture (median: 35°, range: 0-90°) improved postoperatively to full extension in all but one patient, with no recurrence at the most recent follow-up. Preoperative proximal interphalangeal joint (PIPJ) contractures (median: 52°, range: 5-100°) were initially corrected, but recurred with time (median: 25°, range 0°-80°). Hand function was assessed using the Disabilities of the Arm, Shoulder and Hand questionnaire. Postoperative hand function improved (median: 0, range: 0-27), compared to preoperative function (median: 20, range: 0-51). Hand function worsened with time (at most recent follow-up: median: 3, range: 0-40), mainly due to PIPJ contracture recurrence, but function remained better than before surgery.

CONCLUSION

Limited fasciectomy is an effective treatment method for MCPJ, with full correction achievable in both the short and long term. Regarding the PIPJ, treatment outcomes seem to be multifactorial. Further clarification is required to distinguish between local recurrence and remaining contracture of the PIPJ.

Impaired Extension of the Digits due to Bilateral Idiopathic Intrinsic Contracture: A Case Report

Idiopathic intrinsic contracture (IIC) with no history of trauma, ischemia, or spasticity is extremely rare. We report herein a case of impaired extension of the digits due to bilateral IICs occurred in a 30-year-old woman with a past medical history of eating disorder and amenorrhea. Although no previous case has been reported in the literature, eight similar cases of IIC have been presented at Japanese domestic conferences. In these eight cases and the present case, resection of the thenar muscle cords and unilateral resection of the lateral band were effective. Since IIC in patients with an eating disorder is a rare condition, it would be treated conservatively at first as tendon sheath inflammation or locking. However, this condition may be resistant to conservative treatment, and surgical treatment should be considered in such cases.

Effects of a warm hand bath on the blood flow in the shoulder, skin and deep body temperature, autonomic nervous activity, and subjective comfort in healthy women: An experimental cross-over trial

AIM

The present study was conducted in order to clarify the effects of a warm hand bath at 40°C for 10 min on the blood flow in the shoulder, skin and deep body temperature, autonomic nervous activity, and subjective comfort in healthy women.

METHODS

The study's participants were 40 healthy adult women who were randomly assigned to either a structured hand bath first and no hand bath second (Group A) or to no hand bath first and a hand bath second (Group B). The blood flow in the shoulder, skin and deep body temperature, autonomic nervous activity, and subjective comfort then were recorded in all the participants.

RESULTS

A repeated-measures ANOVA revealed no significant difference in the blood flow in the right shoulder or deep body temperature between groups. The skin temperature of the hands, forearms, and arms was significantly increased, but not of the face and upper back. The skin temperature of the forearms was maintained at 0.5°C-1°C higher for 30 min in the hand bath group, compared with the no hand bath group. The hand bath group had a significantly higher heart rate while bathing and a significantly lower parasympathetic nerve activity level during bathing. No significant difference was seen in the sympathetic activity level between groups. The hand bath group had a significantly higher subjective comfort level.

CONCLUSION

Hand baths can improve the level of subjective comfort and increase the heart rate and might affect autonomic nervous activity. The skin temperature of the forearms was maintained for 30 min in the hand bath group.