Hand surgery & rehabilitation最新文献

Objectives: The "psychopathological hand" or "psychogenic hand", long regarded as a clinical curiosity, remains underdiagnosed today and is sometimes confused with other hand conditions. The aim of this article is to reframe the psychopathological hand syndrome within the field of functional neurological disorders, in order to clarify its clinical, pathophysiological and therapeutic specificities.

Methods: A narrative review of the literature was conducted using international medical databases and reference works in functional neurology, psychiatry and hand surgery. The main data were synthesized along four axes: historical aspects, diagnostic and clinical criteria, comorbidities and pathophysiological models, therapeutic strategies and organization of care.

Results: Functional neurological disorders of the hand are characterized by anatomo-clinical inconsistencies, symptom variability, and frequent presentations such as functional dystonias, tremors, paresis or atypical pain. They occur in a context of vulnerability due to early trauma, heightened bodily vigilance, and psychiatric or somatic comorbidities. From a neurofunctional perspective, they reflect a disorganization of the networks of agency, interoception and emotion. Treatment is based on a positive diagnosis announcement, recovery by combined action, psychotherapeutic support and multidisciplinary coordination.

Conclusion: The psychopathological hand constitutes a localized manifestation of a functional neurological disorder and should no longer be regarded as a marginal entity. Its recognition as a specific functional disorder helps to avoid inappropriate treatments and paves the way for integrated care strategies and a better structuring of specialized pathways.

Background: Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Anterograde ultrasound-guided carpal tunnel release is now a widely adopted technique. However, identifying the distal limit of the transverse carpal ligament (TCL) on a longitudinal view remains challenging. This study investigates whether the 'V'-shaped structure seen on longitudinal ultrasound can serve as a reliable landmark for complete TCL release.

Materials and methods: Ten fresh cadaveric upper limbs were examined. Four anatomical landmarks were identified and marked under ultrasound guidance, including the distal end of the 'V'-shaped structure seen on longitudinal view. An ultrasound-guided anterograde release of the transverse carpal ligament was then performed, advancing the instrument to the distal end of the V-shaped sonographic image. A final anatomical dissection verified the correspondence between ultrasound landmarks and underlying structures, particularly the superficial palmar arch.

Results: The distal end of the 'V'-shaped structure was consistently located distal to Kaplan's line and trapezium-hook of hamate line. It averaged 6.8 mm from the superficial palmar arch. In 5 of 10 cases, this distance was ≤5 mm, and in one case, the section came into contact with the superficial palmar arch without causing injury.

Conclusion: The 'V'-shaped structure extends beyond the anatomical limits of the carpal tunnel. Despite its proximity to the superficial palmar arch, no vascular injury occurred. These findings support the need for continuous ultrasound guidance and highlight that the 'V' sign does not represent the true distal limit of the carpal tunnel. Larger in vivo studies are required to confirm these results and establish consistent longitudinal ultrasound landmarks for safe carpal tunnel release.

Purpose: This study evaluated the accuracy of leading AI models, ChatGPT-4o and Gemini 1.5 Pro, in providing management recommendations for CTS in patient scenarios against American Academy of Orthopedic Surgery (AAOS) guidelines.

Methods: Treatment ratings for CTS patient scenarios from the AAOS Appropriate Use Criteria for Management of Carpal Tunnel Syndrome Pathology were compared with ratings provided by ChatGPT and Gemini 1.5 Pro using a scale from 1 to 9, with discrepancies in treatment rating calculated by contrasting scores with AAOS ratings. Spearman correlations and paired t-tests (α < .05) were conducted to assess consensus, while heatmaps were employed to display the findings.

Results: A total of 810 paired scores were generated across 135 patient scenarios. Compared to AAOS guidelines, ChatGPT-4o under-recommended steroid injection (mean error -2.7 ± 1.2; P < .001) and carpal tunnel release (mean error -1.8 ± 1.7; P < .001) while over-recommending electrodiagnostic studies (mean error 4.5 ± 3.8; P < .001). Gemini 1.5 Pro demonstrated a similar pattern, under-recommending steroid injection (mean error -2.4 ± 1.4; P < .001) and carpal tunnel release (mean error -1.8 ± 1.3; P < .001) but showing a less pronounced over-recommendation for electrodiagnostic studies (mean error 3.7 ± 3.2; P < .001). Gemini 1.5 Pro outperformed ChatGPT-4o in alignment with AAOS guidelines, with a stronger Spearman correlation (Rho = 0.782 vs. 0.53, P < 0.001).

Conclusions: Gemini 1.5 Pro showed a stronger overall alignment with AAOS guidelines, indicating a more refined diagnostic approach. Ultimately, these platforms are bound by the limitations of algorithmic biases, posing a risk for misdiagnosis.

Level of evidence: Level III - Non-Experimental Study.

Closed traumatic ruptures of the finger flexor tendon pulleys are common injuries in sport climbers. In cases of complete rupture, surgical repair using graft material is the current standard to restore pulley function. Although these techniques provide good outcomes, recovery often exceeds six months and graft-related morbidity may occur. Surprisingly, the option of direct suture repair has been little explored, despite its potential advantages. We retrospectively reviewed six cases of isolated closed traumatic pulley rupture and two cases of multiple pulley ruptures treated by direct suture combined with early active postoperative rehabilitation. Postoperative outcomes were assessed using the Buck-Gramcko score and by comparing the postoperative climbing level with the preinjury level. Tendon-bone distance, functional impairment, and hand strength were also evaluated. Ultrasound examination of the repaired pulley was performed in three patients at three years postoperatively. Patients recovered their preinjury climbing level after a mean of 5.8 months (range, 3-8 months), a shorter timeframe than that typically reported after graft-based reconstruction. Ultrasound confirmed pulley continuity and adequate mechanical behavior in the three examined patients. All injured fingers achieved an excellent Buck-Gramcko score. Hand strength was comparable to preoperative measurements, functional complaints were minimal, and tendon-bone distance remained within normal limits. These encouraging clinical results suggest that direct suture repair of flexor tendon pulley ruptures in high-level climbers may represent a valuable alternative to graft-based reconstruction, enabling a faster return to climbing with minimal morbidity.

Introduction: Distal radius malunions in older patients represent a therapeutic challenge due to osteoporotic bone quality and the need to preserve autonomy. Spanning plates, which are widely used in complex distal radius fractures, allow immediate weight-bearing, but their use in corrective osteotomies has not been reported.

Case report: We report the case of a 77-year-old right-handed female patient, dependent on a cane, who presented with a distal radius malunion 3 months after conservative management of a displaced fracture. The deformity resulted in severe functional impairment and loss of independence. Considering her frailty and scheduled tibiotalar arthrodesis, a corrective osteotomy of the distal radius with an autologous bone graft and fixation using a dorsal spanning plate was performed during the same procedure. This strategy allowed for the patients to use a cane immediately after the procedure. Rehabilitation was initiated early, leading to full recovery of finger flexion within 11 days. Five months after plate removal, the patient presented 50 ° flexion, 50 ° extension, and a grip strength of 12 kg; showed complete pain resolution; and had a QuickDASH score of 18.18.

Conclusion: This case highlights the potential use of spanning plates as a temporary fixation method for distal radius corrective osteotomy in frail older patients. This technique allows weight-bearing immediately after surgery, thus preserving autonomy while providing satisfactory functional and radiological outcomes.

Level of evidence: 4:

Background: Several opponensplasty techniques have been employed to address thenar muscle atrophy associated with severe carpal tunnel syndrome (CTS). Although modified Camitz opponensplasty (MCO) using the palmaris longus (PL) tendon is widely used by hand surgeons, alternative tendon transfer donors have been proposed, such as opponensplasty using the flexor digitorum superficialis of the ring finger (OF4). However, it is unclear which surgical technique provides superior outcomes. Hence, this systematic review aims to examine the difference in functional outcomes between MCO and OF4 for restoring thumb opposition in advanced CTS.

Methods: A systematic search using PubMed, MEDLINE, Embase, and Scopus was performed. English-language articles reporting outcomes of opponensplasty for carpal tunnel syndrome were only included. The Mann-Whitney U test was used to compare differences in clinical outcomes.

Results: 301 studies were identified and only 8 eligible studies were collected and reviewed. In both groups, the postoperative outcomes were better than the preoperative ones. Among the outcomes that could be directly compared between groups, no clear differences were found.

Conclusion: Although both surgeries can provide good thumb opposition, the choice of opponensplasty technique should be based on the surgeon's experience and preference unless being performed on a patient with congenital PL tendon deficiency.

Background: Chondrosarcomas are primary bone malignancies, with most lesions of the hand representing low grade chondral tumours (LGCT). Low grade (grade one) chondrosarcomas are defined as Atypical Cartilaginous Tumours by the 2020 World Health Organisation Classification. Grades two and three are termed high-grade chondral tumours (HGCT).

Aim: To establish whether low-grade chondral tumours of the hand can be safely treated with simple curettage and assess recurrence rates.

Methods: Retrospective data was analysed from a tertiary referral hospital for bone tumours in the UK over a 13-year period. 158 patients with histological proven chondral tumours of the hand, requiring curettage, resection or amputation were included.

Results: 13 (8.2%) had HGCT and 145 (91.8%) had LGCT. 136 LGCTs underwent intralesional curettage (98.5%). 8 (5.1%) underwent wide local resection (6 LGCT and 2 HGCT). 14 (8.9%) underwent amputation (5 LGCT and 9 HGCT). All HGCT patients were free from recurrence at a median of 81.7 months. Patients expressing GD2/3 tumour marker antigens were more likely to be HGCT on histology compared with those not expressing GD2/3 and more likely to require extensive surgery.

Conclusion: In contrast to chondrosarcoma occurring in long bones, there is often discordance between histological and radiological appearance in lesions occurring in the small bones of the hand. These lesions may appear aggressive radiologically but prove to be low-grade on histology. We concluded that intralesional curettage was an effective method for managing LGCT of the hand, whilst more extensive surgery can be reserved for higher grade tumours. GD2/3 expression was associated with high-grade lesions.

Evidence level: III.