Froment's sign is a special test of the wrist. It tests for palsy of the ulnar nerve the action of adductor pollicis. Froment's maneuver can refer to cogwheel effect from contralateral arm movements seen in Parkinson's disease. To perform the test, a patient is asked to hold an object a flat object such as a piece of paper, between their thumb and index finger; the examiner attempts to pull the object out of the subject's hands. A normal individual will be able to maintain a hold on the object without difficulty. However, with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the flexor pollicis longus of the thumb to maintain grip pressure causing a pinching effect. Clinically, this compensation manifests as flexion of the interphalangeal joint of the thumb; the compensation of the affected hand results in a weak pinch grip with the tips of the thumb and index finger, with the thumb in obvious flexion. Note that the flexor pollicis longus is innervated by the anterior interosseous branch of the median nerve.
Anterior interosseous branch comes off more proximally than the wrist, in evaluating lacerations near the wrist. Simultaneous hyperextension of the thumb MCP joint is indicative of ulnar nerve compromise; this is known as Jeanne's Sign. It is named after Jules Froment
Ulnar tunnel syndrome
Ulnar tunnel syndrome known as Guyon's canal syndrome or Handlebar palsy, is caused by entrapment of the ulnar nerve in the Guyon canal as it passes through the wrist. Symptoms begin with a feeling of pins and needles in the ring and little fingers before progressing to a loss of sensation and/or impaired motor function of the intrinsic muscles of the hand which are innervated by the ulnar nerve. Ulnar tunnel syndrome is seen in regular cyclists due to prolonged pressure of the Guyon's canal against bicycle handlebars. Another common cause of sensory loss in the ring and pink finger is due to ulnar nerve entrapment at the Cubital Tunnel near the elbow, known as Cubital Tunnel Syndrome. Ulnar tunnel syndrome may be characterized by the location or zone within the Guyon's canal at which the ulnar nerve is compressed; the nerve divides into a deeper motor branch in this area. Thus, Guyon's canal can be separated into three zones based on which portion of the ulnar nerve are involved; the resulting syndrome results in either muscle weakness or impaired sensation in the ulnar distribution.
Zone 2 type syndromes are most common. Initial line of treatment is with cortisone injections. There have been trials with gloves; the most radical treatment option is surgery to relieve tension in the volar carpal ligament which forms the roof of Guyon's canal, thereby reducing compression on the ulnar nerve. Jean Casimir Félix Guyon Ulnar claw Josh. "The influence of glove and hand position on pressure over the ulnar nerve during cycling". Clinical Biomechanics. 26: 642–8. Doi:10.1016/j.clinbiomech.2011.03.003. PMID 21458120. Maimaris, C. British Journal of Sports Medicine. 24: 245–6. Doi:10.1136/bjsm.24.4.245. PMC 1478904. PMID 2097022. Rehak, David C.. "Cyclist's Hands: Overcoming overuse injuries". Hughston Health Alert. Hughston Clinic. Bledsoe, Jim. "Cycling injuries - handlebar palsy". Sports Injury Bulletin. US patent 6845514, Joseph, "Protective device for the median and ulnar nerves", issued January 25, 2005
Pathology is the study of the causes and effects of disease or injury. The word pathology refers to the study of disease in general, incorporating a wide range of bioscience research fields and medical practices. However, when used in the context of modern medical treatment, the term is used in a more narrow fashion to refer to processes and tests which fall within the contemporary medical field of "general pathology," an area which includes a number of distinct but inter-related medical specialties that diagnose disease through analysis of tissue and body fluid samples. Idiomatically, "a pathology" may refer to the predicted or actual progression of particular diseases, the affix path is sometimes used to indicate a state of disease in cases of both physical ailment and psychological conditions. A physician practicing pathology is called a pathologist; as a field of general inquiry and research, pathology addresses four components of disease: cause, mechanisms of development, structural alterations of cells, the consequences of changes.
In common medical practice, general pathology is concerned with analyzing known clinical abnormalities that are markers or precursors for both infectious and non-infectious disease and is conducted by experts in one of two major specialties, anatomical pathology and clinical pathology. Further divisions in specialty exist on the basis of the involved sample types and physiological systems, as well as on the basis of the focus of the examination. Pathology is a significant field in medical research; the study of pathology, including the detailed examination of the body, including dissection and inquiry into specific maladies, dates back to antiquity. Rudimentary understanding of many conditions was present in most early societies and is attested to in the records of the earliest historical societies, including those of the Middle East and China. By the Hellenic period of ancient Greece, a concerted causal study of disease was underway, with many notable early physicians having developed methods of diagnosis and prognosis for a number of diseases.
The medical practices of the Romans and those of the Byzantines continued from these Greek roots, but, as with many areas of scientific inquiry, growth in understanding of medicine stagnated some after the Classical Era, but continued to develop throughout numerous cultures. Notably, many advances were made in the medieval era of Islam, during which numerous texts of complex pathologies were developed based on the Greek tradition. So, growth in complex understanding of disease languished until knowledge and experimentation again began to proliferate in the Renaissance and Baroque eras, following the resurgence of the empirical method at new centers of scholarship. By the 17th century, the study of microscopy was underway and examination of tissues had led British Royal Society member Robert Hooke to coin the word "cell", setting the stage for germ theory. Modern pathology began to develop as a distinct field of inquiry during the 19th Century through natural philosophers and physicians that studied disease and the informal study of what they termed “pathological anatomy” or “morbid anatomy”.
However, pathology as a formal area of specialty was not developed until the late 19th and early 20th centuries, with the advent of detailed study of microbiology. In the 19th century, physicians had begun to understand that disease-causing pathogens, or "germs" existed and were capable of reproduction and multiplication, replacing earlier beliefs in humors or spiritual agents, that had dominated for much of the previous 1,500 years in European medicine. With the new understanding of causative agents, physicians began to compare the characteristics of one germ’s symptoms as they developed within an affected individual to another germ’s characteristics and symptoms; this realization led to the foundational understanding that diseases are able to replicate themselves, that they can have many profound and varied effects on the human host. To determine causes of diseases, medical experts used the most common and accepted assumptions or symptoms of their times, a general principal of approach that persists into modern medicine.
Modern medicine was advanced by further developments of the microscope to analyze tissues, to which Rudolf Virchow gave a significant contribution, leading to a slew of research developments. By the late 1920s to early 1930s pathology was deemed a medical specialty. Combined with developments in the understanding of general physiology, by the beginning of the 20th century, the study of pathology had begun to split into a number of rarefied fields and resulting in the development of large number of modern specialties within pathology and related disciplines of diagnostic medicine; the term pathology comes from the Ancient Greek roots of pathos, meaning "experience" or "suffering" and -logia, "study of". The modern practice of pathology is divided into a number of subdisciplines within the discrete but interconnected aims of biological research and medical practice. Biomedical research into disease incorporates the
Cheiralgia paraesthetica is a neuropathy of the hand caused by compression or trauma to the superficial branch of the radial nerve. The area affected is on the back or side of the hand at the base of the thumb, near the anatomical snuffbox, but may extend up the back of the thumb and index finger and across the back of the hand. Symptoms include numbness, burning or pain. Since the nerve branch is sensory there is no motor impairment, it may be distinguished from de Quervain syndrome because it is not dependent on motion of the hand or fingers. The most common cause is thought to be watchband, it is associated with the use of handcuffs and is therefore referred to as handcuff neuropathy. Other injuries or surgery in the wrist area can lead to symptoms, including surgery for other syndromes such as de Quervain's; the exact etiology is unknown, as it is unclear whether direct pressure by the constricting item is alone responsible, or whether edema associated with the constriction contributes. Symptoms resolve on their own within several months when the constriction is removed.
In some cases surgical decompression is required. The efficacy of cortisone and laser treatment is disputed. Permanent damage is possible; this neuropathy was first identified by Robert Wartenberg in a 1932 paper. Recent studies have focused on handcuff injuries due to the legal liability implications, but these have been hampered by difficulties in followup as large percentages of the study participants have been inebriated when they were injured. Diagnostically it is subsumed into compression neuropathy of the radial nerve as a whole, but studies and papers continue to use the older term to distinguish it from more extensive neuropathies originating in the forearm. Radial neuropathy
An ulnar claw known as claw hand, or'Spinster's Claw' is a deformity or an abnormal attitude of the hand that develops due to ulnar nerve damage causing paralysis of the lumbricals. A claw hand presents with a hyperextension at the metacarpo-phalangeal joints and flexion at the proximal and distal inter-phalangeal joints of the 4th and 5th fingers; the patients with this condition can make a full fist but when they extend their fingers, the hand posture is referred to as claw hand. The ring- and little finger can not extend at the proximal interphalangeal joint; this can be confused with the "Hand of benediction", caused by proximal median nerve damage. Patients exhibiting an ulnar claw are very unable to spread or pull together the fingers against resistance; this occurs because the ulnar nerve innervates the palmar and dorsal interossei of the hand. Patients with this deficit will become easy to identify over time as the paralysed first dorsal interosseous muscle atrophies, leaving a prominent hollowing between the thumb and forefinger.
An ulnar claw may follow an ulnar nerve lesion which results in the partial or complete denervation of the ulnar two lumbricals of the hand. Since the ulnar nerve innervates the 3rd and 4th lumbricals, which flex the MCP joints, their denervation causes these joints to become extended by the now unopposed action of the long finger extensors; the lumbricals and interossei extend the IP joints of the fingers by insertion into the extensor hood. The combination of hyperextension at the MCP and flexion at the IP joints gives the hand its claw like appearance; the ulnar nerve innervates the ulnar half of the flexor digitorum profundus muscle. If the ulnar nerve lesion occurs more proximally, the flexor digitorum profundus muscle may be denervated; as a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand. This is called the "ulnar paradox" because one would expect a more proximal and thus debilitating injury to result in a more deformed appearance. Put, as reinnervation occurs along the ulnar nerve after a high lesion, the deformity will get worse as the patient recovers - hence the use of the term "paradox".
A simple way to remember this is:'the closer to the Paw, the worse the Claw'. The ulnar nerve runs from the shoulder to the hand, damage to it results in the Ulnar claw, it is linked to palsy, a result of peripheral neuropathy. There is a range of ways. Leaning on the elbow can lead to long-term wear and tear due to the prolonged pressure of the weight of the upper body. Symptoms resulting from leaning on the nerve can include tingling fingers. Common occupations such as cyclist and desk jobs prolong movement and elbow leaning; these activities involve pressure to the palms. When using a pizza cutter or similar hand tools which require downward pressure during use, applying upper body weight to push down on the tool over time can cause damage to the nerve. Older males are more to have ulnar mononeuropathy than females without regard to BMI. 95% of females with a BMI less than a 22.0 have a higher risk of ulnar nerve damage from a lack of adipose “cushion”, external compression at the elbow is a more important cause of ulnar mononeuropathy among females than males.
Both males and females with high grip strength, such as string musicians, are more susceptible to ulnar mononeuropathy, as are those who experience severe or sustained compression of the ulnar nerve. Treatments excluding surgery can include occupational therapy rehabilitation. Range of motion can be regained by using hand splints to stretch the impaired hand and to prevent overstretching. Using splints will initiate flexion in the metacarpophalangeal joints while allowing extensions and flexion in the interphalangeal joints, thus increasing range of motion. Beneficial exercise will be any that strengthens the interosseous lumbricals. By exercising individual fingers and thumb in adduction and abduction motion in pronation position, interosseous muscles will gain strength. Exercises to strengthen lumbricals, strengthen flexion in the metacarpophalangeal joint, extension in the interphalangeal joints are beneficial. Repetitive motion of pronation and supination are effective exercises for rehabilitation.
Exercising pronation and supination with a handle or screwdriver attachment will help stimulate the nerves. A lateral pinch and recurring grip can be applied for supination and pronation. Preventive therapy is recommended to preserve the function of the fingers; this may include physical exercise, proper bodily function and myofascial release. Exercises are focused on the forearm muscles, such as the extensor carpi ulnaris. Massaging the forearm muscles alleviates the tightness that occurs with muscles exertion. Stretching allows the muscles more flexibility, decreasing interference with the innervations of the ulnar nerve to the fingers; the so-called "Hand of Benediction" is caused by median nerve lesions. The hand will show hyper-extension of the metacarpophalangeal joints from the unopposed extensor digitorum as well as weakened extension and flexion of the Interphalangeal joints of the 2nd and 3
Ape hand deformity
Ape hand deformity known as simian hand, is a deformity in humans who cannot move the thumb away from the rest of the hand. It is an inability to abduct the thumb. Abduction of the thumb refers to the specific capacity to orient the thumb perpendicularly to the ventral surface of the hand. Opposition refers the ability to "swing" the first metacarpal such that the tip of the thumb may touch the distal end of the 5th phalanx and if we put the hand on the table as the palm upward the thumb can not point to the sky; the Ape Hand Deformity is caused by damage to the distal median nerve, subsequent loss of opponens pollicis muscle function. The name "ape hand deformity" is misleading, it can occur with an injury of the median nerve either at the elbow or the wrist, impairing the thenar muscles and opponens pollicis muscle. Ape hand deformity is one aspect of median nerve palsy, caused by deep injuries to the arm and wrist area. Ape hand caused by ulnar nerve lesions. Recurrent branch of the median nerve Median nerve palsy
Nonsteroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs are a drug class that reduce pain, decrease fever, prevent blood clots and, in higher doses, decrease inflammation. Side effects depend on the specific drug, but include an increased risk of gastrointestinal ulcers and bleeds, heart attack and kidney disease; the term nonsteroidal distinguishes these drugs from steroids, which while having a similar eicosanoid-depressing, anti-inflammatory action, have a broad range of other effects. First used in 1960, the term served to distance these medications from steroids, which where stigmatised at the time due to the connotations with anabolic steroid abuse. NSAIDs work by inhibiting the activity of cyclooxygenase enzymes. In cells, these enzymes are involved in the synthesis of key biological mediators, namely prostaglandins which are involved in inflammation, thromboxanes which are involved in blood clotting. There are two types of NSAID available: COX-2 selective. Most NSAIDs are non-selective, inhibit the activity of both COX-1 and COX-2.
These NSAIDs, while reducing inflammation inhibit platelet aggregation and increase the risk of gastrointestinal ulcers/bleeds. COX-2 selective inhibitors have less gastrointestinal side effects, but promote thrombosis and increase the risk of heart attack; as a result, COX-2 selective inhibitors are contraindicated due to the high risk of undiagnosed vascular disease. These differential effects are due to the different roles and tissue localisations of each COX isoenzyme. By inhibiting physiological COX activity, all NSAIDs increase the risk of kidney disease and, through a related mechanism, heart attack; the most prominent NSAIDs are aspirin and naproxen, all available over the counter in most countries. Paracetamol is not considered an NSAID because it has only minor anti-inflammatory activity, it treats pain by blocking COX-2 in the central nervous system, but not much in the rest of the body. NSAIDs are used for the treatment of acute or chronic conditions where pain and inflammation are present.
NSAIDs are used for the symptomatic relief of the following conditions: Aspirin, the only NSAID able to irreversibly inhibit COX-1, is indicated for antithrombosis through inhibition of platelet aggregation. This is useful for the management of arterial thrombosis and prevention of adverse cardiovascular events like heart attacks. Aspirin inhibits platelet aggregation by inhibiting the action of thromboxane A2. In a more specific application, the reduction in prostaglandins is used to close a patent ductus arteriosus in neonates if it has not done so physiologically after 24 hours. NSAIDs are useful in the management of post-operative dental pain following invasive dental procedures such as dental extraction; when not contra-indicated they are favoured over the use of paracetamol alone due to the anti-inflammatory effect they provide. When used in combination with paracetamol the analgesic effect has been proven to be improved. There is weak evidence suggesting that taking pre-operative analgesia can reduce the length of post operative pain associated with placing orthodontic spacers under local anaesthetic.
Combination of NSAIDs with pregabalin as preemptive analgesia has shown promising results for decreasing post operative pain intensity. The effectiveness of NSAID's for treating non-cancer chronic pain and cancer-related pain in children and adolescents is not clear. There have not been sufficient numbers of high-quality randomized controlled trials conducted. NSAIDs may be used with caution by people with the following conditions: Irritable bowel syndrome Persons who are over age 50, who have a family history of GI problems Persons who have had past GI problems from NSAID useNSAIDs should be avoided by people with the following conditions: The widespread use of NSAIDs has meant that the adverse effects of these drugs have become common. Use of NSAIDs increases risk of a range of gastrointestinal problems, kidney disease and adverse cardiovascular events; as used for post-operative pain, there is evidence of increased risk of kidney complications. Their use following gastrointestinal surgery remains controversial, given mixed evidence of increased risk of leakage from any bowel anastomosis created.
An estimated 10–20% of NSAID patients experience dyspepsia. In the 1990s high doses of prescription NSAIDs were associated with serious upper gastrointestinal adverse events, including bleeding. Over the past decade, deaths associated with gastric bleeding have declined. NSAIDs, like all drugs, may interact with other medications. For example, concurrent use of NSAIDs and quinolones may increase the risk of quinolones' adverse central nervous system effects, including seizure. There is an argument over the benefits and risks of NSAIDs for treating chronic musculoskeletal pain; each drug has a benefit-risk profile and balancing the risk of no treatment with the competing potential risks of various therapies is the clinician's responsibility. If a COX-2 inhibitor is taken, a traditional NSAID should not be taken at the same time. In addition, people on daily aspirin therapy must be careful if they use other NSAIDs, as these may inhibit the cardioprotective effects of aspirin. Rofecoxib was shown to produce fewer gastrointestinal adverse drug reactions compared with naproxen.
This study, the VIGOR trial, raised the issue of the cardiovascular safety of the coxibs. A statistically significant increase in the incidence of myocardial infarctions was observed in patients on rofecoxib. Further data, from the APPROVe trial, s