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PM & R : the Journal of Injury,... Jul 2010To determine if ultrasound (US) localization is equivalent to surface landmark localization to identify botulinum toxin injection targets for forearm muscle spasticity.
OBJECTIVE
To determine if ultrasound (US) localization is equivalent to surface landmark localization to identify botulinum toxin injection targets for forearm muscle spasticity.
DESIGN
Observational.
SETTING
Outpatient spasticity clinic in a tertiary care center.
SUBJECTS
Eighteen patients with upper-extremity flexor spasticity that interferes with function were included. Individuals with severe fixed contractures or traumatic injury of the involved forearm were excluded.
METHODS
Flexor pollicis longus, flexor carpi radialis, pronator teres, and flexor digitorum superficialis (FDS) were identified by 2 separate localization techniques: the method of Delagi et al for flexor carpi radialis, pronator teres, and flexor pollicis longus; and a surface landmark technique by Bickerton et al to identify the 4 muscle bellies of FDS. Proximodistal and lateral (radial) coordinates were recorded relative to a landmark line from the medial epicondyle to pisiform bone, and percentage of landmark line distance was calculated. After surface measurements were collected, the best point for injection was determined by using real-time US with a 12-MHz linear transducer. US measurements were recorded by using the same landmark line system.
RESULTS
Localization techniques were compared by using the Wilcoxon signed rank test. One-sample t-tests compared surface-mapped lateral coordinates to US-derived lateral coordinates with controls for multiple testing. Significant differences were observed between surface and US proximodistal and lateral coordinates for several flexor muscles.
CONCLUSIONS
US should be considered as an adjunct for localization in patients with upper-limb spasticity. US can improve accuracy of toxin placement and help to avoid injection into vascular and nerve structures.
Topics: Adult; Botulinum Toxins, Type A; Female; Forearm; Humans; Injections; Male; Middle Aged; Muscle Spasticity; Muscle, Skeletal; Neuromuscular Agents; Ultrasonography
PubMed: 20659720
DOI: 10.1016/j.pmrj.2010.05.002 -
Clinical Biomechanics (Bristol, Avon) Oct 2010Carpal tunnel release and conservative interventions are widely used in clinical therapies of carpal tunnel syndrome. The efficacy of these treatment and interventions...
BACKGROUND
Carpal tunnel release and conservative interventions are widely used in clinical therapies of carpal tunnel syndrome. The efficacy of these treatment and interventions mainly lies in the exploitation of the mechanical properties of carpal tunnel. This study investigated the structural mechanics of the transverse carpal arch using cadaveric hands.
METHODS
Paired force was applied to the insertion sites of the transverse carpal ligament at both the distal (hamate-trapezium) and proximal (pisiform-scaphoid) levels of the carpal tunnel. The two pairs of forces were simultaneously applied in an inward or outward direction when the transverse carpal ligament was intact and transected. Transverse carpal arch and carpal tunnel compliance in response to the forces were analyzed. Three-way repeated measures ANOVA were used to examine the effect of the transverse carpal ligament status (intact/transected), the level of the carpal tunnel (distal/proximal) and the force application direction (inward/outward) on the biomechanics of the transverse carpal arch.
FINDINGS
Transverse carpal ligament plays a stabilizing role in resisting outward deformation of the carpal tunnel. The carpal tunnel at the proximal level is more flexible than the carpal tunnel at the distal level. The carpal tunnel is more compliant under the inward force application than under the outward force application.
INTERPRETATION
The understanding of carpal tunnel mechanics potentially helps to improve the existing strategies and to develop alternatives for the treatment of carpal tunnel syndrome.
Topics: Biomechanical Phenomena; Carpal Bones; Female; Hamate Bone; Humans; In Vitro Techniques; Ligaments, Articular; Male; Middle Aged; Trapezium Bone
PubMed: 20579787
DOI: 10.1016/j.clinbiomech.2010.05.011 -
BMJ Case Reports Apr 2010
Topics: Female; Fractures, Bone; Humans; Middle Aged; Pisiform Bone; Radiography; Splints; Wrist Injuries
PubMed: 22736214
DOI: 10.1136/bcr.07.2009.2132 -
BMJ Case Reports 2009Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. We present a 35-year old tennis player suffering tremendous pain (visual analogue scale (VAS) rating of...
Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. We present a 35-year old tennis player suffering tremendous pain (visual analogue scale (VAS) rating of 9/10) at the flexor carpi ulnaris tendon with adjacent calcification in close proximity to the pisiform bone. Sclerosing therapy using polidocanol under power and laser Doppler guidance was initiated, with immediate decrease of capillary blood flow by 25% with resolution of the neovascularisation in power Doppler. Immediately following sclerosing, the patient's reported pain level on the VAS was reduced from 9/10 to 4/10. Following a short period of rest, eccentric training of the forearm muscle was initiated over 12 weeks with functional complete recovery and complete resolution of wrist pain.
PubMed: 21686666
DOI: 10.1136/bcr.08.2008.0714 -
Journal of Anatomy May 2008The immunohistochemical labelling patterns of the extracellular matrix at the insertion of the flexor carpi ulnaris tendon and the entheses at both ends of the...
The immunohistochemical labelling patterns of the extracellular matrix at the insertion of the flexor carpi ulnaris tendon and the entheses at both ends of the pisometacarpal and pisohamate ligaments were compared in order to relate the molecular composition of the attachment sites to their mechanical environment. Tissue was obtained from elderly dissecting room cadavers and labelled with a panel of monoclonal antibodies directed against collagens, glycosaminoglycans, proteoglycans and matrix proteins. All entheses were fibrocartilaginous and labelled positively for molecules typically associated with articular cartilage (type II collagen, chondroitin 6 sulphate, aggrecan and link protein). Labelling for type II collagen was most conspicuous at the attachment of the flexor carpi ulnaris tendon. In the ligaments, type II collagen labelling was always greater at the pisiform end. Matrilin 1 was universally present at all five entheses examined and fibromodulin labelling was most intense around the tidemark. Fibromodulin may thus be involved in anchorage and/or the control of mineralization at the hard-soft tissue interface of entheses. The greater prominence of fibrocartilage at the pisiform enthesis of the flexor carpi ulnaris tendon than at any ligament attachment may relate to the marked change in the tendon insertional angle that occurs with wrist movements. We also suggest that the more fibrocartilaginous character of the proximal compared with the distal ends of the ligaments relates to the fact that the pisiform is anchored in position and is thus at the centre of rotation of any movement of ligaments attached to it.
Topics: Aged; Aged, 80 and over; Aggrecans; Chondroitin Sulfates; Collagen; Extracellular Matrix; Extracellular Matrix Proteins; Fibromodulin; Glycosaminoglycans; Humans; Immunohistochemistry; Ligaments, Articular; Pisiform Bone; Proteoglycans; Tendons
PubMed: 18399959
DOI: 10.1111/j.1469-7580.2008.00887.x -
British Journal of Sports Medicine Dec 2007Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. Recent research revealed the role of a neurovascular ingrowth at the point of pain in various...
BACKGROUND
Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. Recent research revealed the role of a neurovascular ingrowth at the point of pain in various tendinopathic locations, such as at the Achilles and patellar tendon, in plantar fasciitis as well as in supraspinatus and tennis elbow tendinopathy. However, beyond the elbow no such neovascularisation has been reported to date.
METHODS
We present a 35-year old tennis player suffering tremendous pain (visual analogue scale (VAS) rating of 9/10) at the flexor carpi ulnaris tendon with adjacent calcification in close proximity to the pisiform bone. The patient was assessed with power Doppler and laser Doppler quantification of neovascularisation at the point of pain.
RESULTS
Power Doppler and laser Doppler quantification of neovascularisation at the point of pain identified higher capillary blood flow at three points over the painful vs the non-painful tendon (146/240/232rU vs 93/74/70rU at the non-affected side). Sclerosing therapy using polidocanol under power and laser Doppler guidance was initiated, with immediate decrease of capillary blood flow by 25% with resolution of the neovascularisation in power Doppler. Immediately following sclerosing, the patient's reported pain level on the VAS was reduced from 9/10 to 4/10. Following a short period of rest, eccentric training of the forearm muscle was initiated over 12 weeks with functional complete recovery and complete resolution of wrist pain.
CONCLUSION
Sclerosing therapy using polidocanol under power- and laser-Doppler guidance can decrease capillary blood flow by 25% with resolution of the neovascularisation. Subsequent eccentric training of the forearm muscle over 12 weeks can result in complete resolution of wrist pain.
Topics: Adult; Exercise Therapy; Feasibility Studies; Humans; Male; Pain Measurement; Polidocanol; Polyethylene Glycols; Sclerosing Solutions; Tendinopathy; Tennis; Treatment Outcome; Ultrasonography; Wrist Injuries
PubMed: 17496066
DOI: 10.1136/bjsm.2007.036558 -
The Journal of Bone and Joint Surgery.... Feb 2007Disorders of the pisotriquetral joint are well recognised as the cause of pain on the ulnar side of the wrist. The joint is not usually examined during routine...
Disorders of the pisotriquetral joint are well recognised as the cause of pain on the ulnar side of the wrist. The joint is not usually examined during routine arthroscopy because it is assumed to have a separate joint cavity to the radiocarpal joint, although there is often a connection between the two. We explored this connection during arthroscopy and in fresh-frozen cadaver wrists and found that in about half of the cases the pisotriquetral joint could be visualised through standard wrist portals. Four different types of connection were observed between the radiocarpal joint and the pisotriquetral joint. They ranged from a complete membrane separating the two, to no membrane at all, with various other types of connection in between. We recommend that inspection of the pisotriquetral joint should be a part of the protocol for routine arthroscopy of the wrist.
Topics: Adolescent; Adult; Age Distribution; Aged; Arthroscopy; Child; Female; Humans; Male; Middle Aged; Pisiform Bone; Sex Distribution; Synovial Membrane; Triquetrum Bone; Wrist Joint
PubMed: 17322435
DOI: 10.1302/0301-620X.89B2.18540 -
Journal of Anatomy Nov 1997The ulnar tunnel is located at the proximal part of the hand radial to the pisiform bone and to the proximal part of the carpal tunnel. Inside it lie the ulnar nerve and...
The ulnar tunnel is located at the proximal part of the hand radial to the pisiform bone and to the proximal part of the carpal tunnel. Inside it lie the ulnar nerve and artery. Compression of the ulnar nerve in this tunnel is often reported. Cysts, occupational trauma, fractures and muscle variations are among the main causes (Schjelderup, 1964; Kleinert & Hayes, 1971). Damage to the ulnar nerve and artery during the endoscopic decompression of the carpal tunnel has been reported recently (Agee et al. 1992; Nath et al. 1993; De Smets & Fabry, 1995). The structures within the ulnar tunnel are closely related to the medial part of the flexor retinaculum, in particular the ulnar artery which is located lateral to the ulnar nerve. During a study of this region we found a rare disposition of the contents of this tunnel. We believe that knowledge of this variation is important for the surgical anatomy of this region.
Topics: Adult; Humans; Male; Ulnar Artery; Ulnar Nerve; Wrist
PubMed: 9449081
DOI: 10.1046/j.1469-7580.1997.19140615.x -
Genes & Development Dec 1993Hox A11 is one of the expanded set of vertebrate homeo box (Hox) genes with similarities to the Drosophila homeotic gene, Abdominal-B (Abd-B). These Abd-B-type Hox genes...
Hox A11 is one of the expanded set of vertebrate homeo box (Hox) genes with similarities to the Drosophila homeotic gene, Abdominal-B (Abd-B). These Abd-B-type Hox genes have been shown to be expressed in the most caudal regions of the developing vertebrate embryo and in overlapping domains within the developing limbs, suggesting that these genes play important roles in pattern formation in both appendicular and axial regions of the body. In this report whole-mount in situ hybridization in mouse embryos gave a precise description of Hox A11 gene expression in the developing limbs and in the axial domain of the developing body. In addition, we generated a targeted mutation in Hox A11 and characterized the resulting phenotype to begin to dissect developmental functions of the Abd-B subfamily of Hox genes. Hox A11 mutant mice exhibited double homeotic transformations, with the thirteenth thoracic segment posteriorized to form an additional first lumbar vertebra and with the sacral region anteriorized, generating yet another lumbar segment. Furthermore, skeletal malformations were observed in both forelimbs and hindlimbs. In mutant forelimbs, the ulna and radius were misshapen, the pisiform and triangular carpal bones were fused, and abnormal sesamoid bone development occurred. In mutant hindlimbs the tibia and fibula were joined incorrectly and malformed at their distal ends. Also, an enlarged sesamoid developed ventral to the tibiale bone. Both heterozygous and homozygous mice displayed mutant phenotypes adding an additional level of complexity to the Hox code hypothesis.
Topics: Animals; Base Sequence; Embryonic and Fetal Development; Extremities; Gene Expression; Genes, Homeobox; Limb Deformities, Congenital; Mice; Mice, Inbred C57BL; Mice, Mutant Strains; Molecular Sequence Data; Mutation; Phenotype
PubMed: 7902826
DOI: 10.1101/gad.7.12a.2318 -
Journal of Anatomy Feb 1992Anatomical variations of the muscles and nerves around the wrist are common. Knowledge of such variations is derived from 2 sources: anatomical dissections and...
Anatomical variations of the muscles and nerves around the wrist are common. Knowledge of such variations is derived from 2 sources: anatomical dissections and clinically reported cases. We present a case of duplication of the tendon of flexor carpi ulnaris with splitting of the ulnar nerve. The ulnar slip of the tendon was inserted into the pisiform bone and the radial slip into the proximal phalanx of the ring finger. The anatomical literature and the clinically reported cases of variations of the flexor carpi ulnaris are reviewed.
Topics: Adult; Fingers; Humans; Male; Nerve Compression Syndromes; Tendons; Ulnar Nerve; Wrist
PubMed: 1452475
DOI: No ID Found