Dominique Mouraux

Functional and outcome evaluation of the hand and wrist

The first evaluation of the upper extremity and hand, performed by the surgeon at the outpatient clinic, is fundamental to understanding the patients problem, determining the best treatment options, and, in the case of a surgical indication, assessing the preoperative status. In addition to recording the patients symptoms and complaints, the surgeon evaluates anatomic integrity, stability, mobility, trophicity, strength, and sensibility. In many patients, especially patients with severe handicaps or those who anticipate long delays in rehabilitation, in litigation problems, or as part of prospective clinical research, this classic evaluation is not sufficient. The authors recommend that to accommodate these patients, a laboratory of functional evaluation of the hand should be established. The evaluation, performed by independent reviewers, ideally includes techniques allowing objective measurements of kinematics, strength, sensibility, and global hand function and dexterity. Pain assessment using the VAS is indispensable. The results may be presented as scores based on to the patients problem. The researchers should analyze precisely how the scores were constructed. Questionnaires are part of the evaluation armamentarium. As with other tools, questionnaires allow us to understand better what our patients experience. They do not replace physical examination. Questionnaires also could be used for routine screening in a general upper limb practice, even before the patient sees the hand surgeon. The choice of the questionnaire is important; the reviewer should make sure that the patient understands all questions, that the questions are not redundant, and that they do apply to the patient. Generic health status instruments such as the SF-36 allow comparison across a variety of health problems, including mental and physical conditions, but are not sensitive to upper extremity disability. The DASH questionnaire seems a better choice, allowing a standardized outcome evaluation. Dedicated questionnaires have been developed for specific conditions (eg, carpal tunnel syndrome). As discussed by Amadio, questionnaires are easier to perform than physical testing, can be self-administered, and require no special equipment, saving the cost of an examiner, avoiding the complexities of scheduling a follow-up examination, and eliminating the possibility of observer bias. The patient is less likely to offer polite but incorrect responses. Questionnaires are especially useful when patients perceptions are important to assess. Questionnaires also could be used in longitudinal studies to assess improvement or aggravation. The use of questionnaires is therefore especially indicated in studies involving a large number of patients, when observer bias and costs are concerns, and when the main outcome measurements are satisfaction, symptoms, or functional status. Amadio has pointed out that questionnaires are not the best tool to measure anatomic or physiologic impairments.

Tolerance of Upper Extremity Pneumatic Tourniquets and their Effect on Grip Strength

This study was undertaken to evaluate tourniquet tolerance in healthy people. An arm tourniquet was inflated to 100 mmHg above systolic blood pressure for 21 minutes. We measured pain and grip strength before, during and at various times after deflation. We tested 40 subjects (20 women and 20 men) with an average age of 38 (range 22–58) years. Eight individuals did not tolerate the tourniquet for this length of time and the test was stopped. Visual analogical scale had a globally linear increase during tourniquet application. We noted a sensation of well-being just after deflation, quickly replaced by pain in the tested limb due to limb reperfusion. We also noted a significant loss of strength in the tested limb, which completely recovered by 48 hours. We also observed a significant loss of strength in the contralateral hand, which also recovered by 48 hours. The possible reasons for these temporary losses of strength in both the ipsilateral and contralateral limbs are discussed.

Biased visuospatial perception in complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a chronic pain condition associating sensory, motor, trophic and autonomic symptoms in one limb. Cognitive difficulties have also been reported, affecting the patients’ ability to mentally represent, perceive and use their affected limb. However, the nature of these deficits is still a matter of debate. Recent studies suggest that cognitive deficits are limited to body-related information and body perception, while not extending to external space. Here we challenge that statement, by using temporal order judgment (TOJ) tasks with tactile (i.e. body) or visual (i.e. extra-body) stimuli in patients with upper-limb CRPS. TOJ tasks allow characterizing cognitive biases to the advantage of one of the two sides of space. While the tactile TOJ tasks did not show any significant results, significant cognitive biases were observed in the visual TOJ tasks, affecting mostly the perception of visual stimuli occurring in the immediate vicinity of the affected limb. Our results clearly demonstrate the presence of visuospatial deficits in CRPS, corroborating the cortical contribution to the CRPS pathophysiology, and supporting the utility of developing rehabilitation techniques modifying visuospatial abilities to treat chronic pain.

3D augmented reality mirror visual feedback therapy applied to the treatment of persistent, unilateral upper extremity neuropathic pain: a preliminary study

Objective: We assessed whether or not pain relief could be achieved with a new system that combines 3D augmented reality system (3DARS) and the principles of mirror visual feedback. Methods: Twenty-two patients between 18 and 75 years of age who suffered of chronic neuropathic pain. Each patient performed five 3DARS sessions treatment of 20 mins spread over a period of one week. The following pain parameters were assessed: (1) visual analogic scale after each treatment session (2) McGill pain scale and DN4 questionnaire were completed before the first session and 24 h after the last session. Results: The mean improvement of VAS per session was 29% (p < 0.001). There was an immediate session effect demonstrating a systematic improvement in pain between the beginning and the end of each session. We noted that this pain reduction was partially preserved until the next session. If we compare the pain level at baseline and 24 h after the last session, there was a significant decrease (p < 0.001) of pain of 37%. There was a significant decrease (p < 0.001) on the McGill Pain Questionnaire and DN4 questionnaire (p < 0.01). Conclusion: Our results indicate that 3DARS induced a significant pain decrease for patients who presented chronic neuropathic pain in a unilateral upper extremity. While further research is necessary before definitive conclusions can be drawn, clinicians could implement the approach as a preparatory adjunct for providing temporary pain relief aimed at enhancing chronic pain patients’ tolerance of manual therapy and exercise intervention. Level of Evidence: 4.

Arthrodesis of the wrist with bone autograft and Hoffmann external fixation.

We report a series of 29 cases of wrist arthrodesis using a radiometacarpal half-frame or triangular Hoffmann configuration, bone autograft, and relocation of a retinacular rectangular flap under the extensor tendons to prevent adhesions. No splint or plaster cast has been used. Early active motion of the fingers was encouraged. The average duration of follow-up was 4 years. Bone healing was obtained in 27 patients after 104 days on average. All patients regained full finger movements and rotation of the forearm. Nine patients were reassessed on average 7.2 years after the arthrodesis: the VAS for pain at rest was 2.4/10, the DASH score 33/100, the grip strength 75% of the contralateral side on average.

OBJECTIVE EVALUATION OF ELBOW FLEXION STRENGTH AND FATIGABILITY AFTER NERVE TRANSFER IN ADULT TRAUMATIC UPPER BRACHIAL PLEXUS INJURIES

Nerve transfers Oberlin-type are currently used in upper brachial plexus lesions to recover elbow flexion. Is the regained active motion sufficient to resume heavy manual activities? Five adult patients (mean age 37 years) operated of a nerve transfer to recover elbow flexion (transfer of a motor fascicle of the ulnar nerve to the motor branch of the biceps; in three patients, additional transfer from the median to the motor nerve of the brachialis) were clinically and isokinetically evaluated, after a mean follow-up of 47 months. The median Constant-Murley score was 22/100, the DASH 56/100 and the MEPI 60/100. For isokinetic tests the most significant finding was a severe deficit of elbow strength, of about 80%. No patient was able to maintain an isometric contraction during sufficient time to evaluate fatigability. This preliminary study suggests that major functional impairments persist despite early recovery of elbow flexion. These results should be confirmed in a study on a larger group of patients.

Trapeziometacarpal osteoarthrosis: Clinical results and sonographic evaluation of the interposed tissue after trapeziectomy and first metacarpal suspension by external minifixation at a minimal two-year follow-up

Among the surgical options to treat trapeziometacarpal osteoarthrosis, trapeziectomy has been criticized as unable to prevent postoperative collapse of the thumb, causing painful scapho-metacarpal impingement. The implantation of an external minifixator between the first and the second metacarpals for sufficient time has been proposed to maintain the postoperative space created by the bone resection to allow the development of a resistant interposed fibrous tissue. Nineteen patients (16 women, 3 men, mean age 64.5 years) were evaluated at 3.3 years of follow-up after an unilateral trapeziectomy and first metacarpal suspension by external minifixation. Eighty-four percent of the patients were very satisfied with the operation. The mean DASH score was 27.7%, the pain 1.7/10 (Visual Analogue Scale), the opening angle of the first web 58.3° and the Kapandji opposition score 9.5/10. Sonography demonstrated the existence of a strong fibrotic interposed tissue, preventing scapho-metacarpal impingement. The mean height of the trapeziectomy space (8.4mm) was maintained upon active pinch and maximal traction on the thumb. A significant atrophy of thenar muscles was also demonstrated, except for the Abductor pollicis brevis. In conclusion, total trapeziectomy with external minifixation provides acceptable clinical results, stabilizes the base of the thumb and prevents scapho-metacarpal impingement. The study brings also important new information about the nature of the interposed tissue in the trapezial space and about the state of the thenar muscles after trapeziectomy.