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
The spinal cord is a long, tubular structure made up of nervous tissue, that extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column. It encloses the central canal of the spinal cord; the brain and spinal cord together make up the central nervous system. In humans, the spinal cord begins at the occipital bone where it passes through the foramen magnum, meets and enters the spinal canal at the beginning of the cervical vertebrae; the spinal cord extends down to between the second lumbar vertebrae where it ends. The enclosing bony vertebral column protects the shorter spinal cord, it is around 45 cm in men and around 43 cm long in women. The spinal cord has a varying width, ranging from 13 mm thick in the cervical and lumbar regions to 6.4 mm thick in the thoracic area. The spinal cord functions in the transmission of nerve signals from the motor cortex to the body, from the afferent fibers of the sensory neurons to the sensory cortex, it is a center for coordinating many reflexes and contains reflex arcs that can independently control reflexes.
It is the location of groups of spinal interneurons that make up the neural circuits known as central pattern generators. These circuits are responsible for controlling motor instructions for rhythmic movements such as walking; the spinal cord is the main pathway for information connecting the brain and peripheral nervous system. Much shorter than its protecting spinal column, the human spinal cord originates in the brainstem, passes through the foramen magnum, continues through to the conus medullaris near the second lumbar vertebra before terminating in a fibrous extension known as the filum terminale, it is about 45 cm long in men and around 43 cm in women, ovoid-shaped, is enlarged in the cervical and lumbar regions. The cervical enlargement, stretching from the C5 to T1 vertebrae, is where sensory input comes from and motor output goes to the arms and trunk; the lumbar enlargement, located between L1 and S3, handles sensory input and motor output coming from and going to the legs. The spinal cord is continuous with the caudal portion of the medulla, running from the base of the skull to the body of the first lumbar vertebra.
It does not run the full length of the vertebral column in adults. It is made of 31 segments from which branch one pair of sensory nerve roots and one pair of motor nerve roots; the nerve roots merge into bilaterally symmetrical pairs of spinal nerves. The peripheral nervous system is made up of these spinal roots and ganglia; the dorsal roots are afferent fascicles, receiving sensory information from the skin and visceral organs to be relayed to the brain. The roots terminate in dorsal root ganglia, which are composed of the cell bodies of the corresponding neurons. Ventral roots consist of efferent fibers that arise from motor neurons whose cell bodies are found in the ventral gray horns of the spinal cord; the spinal cord are protected by three layers of tissue or membranes called meninges, that surround the canal. The dura mater is the outermost layer, it forms a tough protective coating. Between the dura mater and the surrounding bone of the vertebrae is a space called the epidural space; the epidural space is filled with adipose tissue, it contains a network of blood vessels.
The arachnoid mater, the middle protective layer, is named for its spiderweb-like appearance. The space between the arachnoid and the underlying pia mater is called the subarachnoid space; the subarachnoid space contains cerebrospinal fluid, which can be sampled with a lumbar puncture, or "spinal tap" procedure. The delicate pia mater, the innermost protective layer, is associated with the surface of the spinal cord; the cord is stabilized within the dura mater by the connecting denticulate ligaments, which extend from the enveloping pia mater laterally between the dorsal and ventral roots. The dural sac ends at the vertebral level of the second sacral vertebra. In cross-section, the peripheral region of the cord contains neuronal white matter tracts containing sensory and motor axons. Internal to this peripheral region is the grey matter, which contains the nerve cell bodies arranged in the three grey columns that give the region its butterfly-shape; this central region surrounds the central canal, an extension of the fourth ventricle and contains cerebrospinal fluid.
The spinal cord is elliptical in cross section, being compressed dorsolaterally. Two prominent grooves, or sulci, run along its length; the posterior median sulcus is the groove in the dorsal side, the anterior median fissure is the groove in the ventral side. The human spinal cord is divided into segments. Six to eight motor nerve rootlets branch out of right and left ventro lateral sulci in a orderly manner. Nerve rootlets combine to form nerve roots. Sensory nerve rootlets form off right and left dorsal lateral sulci and form sensory nerve roots; the ventral and dorsal roots combine to form one on each side of the spinal cord. Spinal nerves, with the exception of C1 and C2, form inside the intervertebral foramen; these rootlets form the demarcation between the peripheral nervous systems. The grey column, in the center of the cord, is shaped like a butterfly and consists of cell bodies of interneurons, motor neurons, neuroglia cells and unmyelinated axons; the anterior and posterior grey column present as projections of the grey matter and are known as the horns of the spinal cord.
Together, the gr
An analgesic or painkiller is any member of the group of drugs used to achieve analgesia, relief from pain. Analgesic drugs act in various ways on the central nervous systems, they are distinct from anesthetics, which temporarily affect, in some instances eliminate, sensation. Analgesics include paracetamol, the nonsteroidal anti-inflammatory drugs such as the salicylates, opioid drugs such as morphine and oxycodone; when choosing analgesics, the severity and response to other medication determines the choice of agent. Analgesic choice is determined by the type of pain: For neuropathic pain, traditional analgesics are less effective, there is benefit from classes of drugs that are not considered analgesics, such as tricyclic antidepressants and anticonvulsants. Topical nonsteroidal anti-inflammatory drugs provided pain relief in common conditions such as muscle sprains and overuse injuries. Since the side effects are lesser, topical preparations could be preferred over oral medications in these conditions.
Each different type of analgesic has its own associated side effects. Analgesics are classified based on their mechanism of action. Paracetamol known as acetaminophen or APAP, is a medication used to treat pain and fever, it is used for mild to moderate pain. In combination with opioid pain medication, paracetamol is now used for more severe pain such as cancer pain and after surgery, it is used either by mouth or rectally but is available intravenously. Effects last between four hours. Paracetamol is classified as a mild analgesic. Paracetamol is safe at recommended doses. Nonsteroidal anti-inflammatory drugs, are a drug class that groups together drugs that decrease pain and lower fever, and, in higher doses decrease inflammation; the most prominent members of this group of drugs, aspirin and naproxen, are all available over the counter in most countries. These drugs have been derived from NSAIDs; the cyclooxygenase enzyme inhibited by NSAIDs was discovered to have at least 2 different versions: COX1 and COX2.
Research suggested most of the adverse effects of NSAIDs to be mediated by blocking the COX1 enzyme, with the analgesic effects being mediated by the COX2 enzyme. Thus, the COX2 inhibitors were developed to inhibit only the COX2 enzyme; these drugs are effective analgesics when compared with NSAIDs, but cause less gastrointestinal hemorrhage in particular. After widespread adoption of the COX-2 inhibitors, it was discovered that most of the drugs in this class increase the risk of cardiovascular events by 40% on average; this led to the withdrawal of rofecoxib and valdecoxib, warnings on others. Etoricoxib seems safe, with the risk of thrombotic events similar to that of non-coxib NSAID diclofenac. Morphine, the archetypal opioid, other opioids all exert a similar influence on the cerebral opioid receptor system. Buprenorphine is a partial agonist of the μ-opioid receptor, tramadol is a serotonin norepinephrine reuptake inhibitor with weak μ-opioid receptor agonist properties. Tramadol is structurally closer to venlafaxine than to codeine and delivers analgesia by not only delivering "opioid-like" effects but by acting as a weak but fast-acting serotonin releasing agent and norepinephrine reuptake inhibitor.
Tapentadol, with some structural similarities to tramadol, presents what is believed to be a novel drug working through two different modes of action in the fashion of both a traditional opioid and as an SNRI. The effects of serotonin and norepinephrine on pain, while not understood, have had causal links established and drugs in the SNRI class are used in conjunction with opioids with greater success in pain relief. Dosing of all opioids may be limited by opioid toxicity, but opioid-tolerant individuals have higher dose ceilings than patients without tolerance. Opioids, while effective analgesics, may have some unpleasant side-effects. Patients starting morphine may experience vomiting. Pruritus may require switching to a different opioid. Constipation occurs in all patients on opioids, laxatives are co-prescribed; when used appropriately and other central analgesics are safe and effective, risks such as addiction and the body's becoming used to the drug can occur. The effect of tolerance means.
When safe to do so, the dosage may need to be increased to maintain effectiveness against tolerance, which may be of particular concern regarding patients suffering with chronic pain and requiring an analgesic over long periods. Opioid tolerance is addressed with opioid rotation therapy in which a patient is switched between two or more non-cross-tolerant opioid medications in order to prevent exceeding safe dosages in the attempt to achieve an adequate analgesic effect. Opioid tolerance should not be confused with opioid-induced hyperalgesia; the symptoms of these two conditions can appear similar but the mechanism of acti
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
The lymphatic vessels are thin-walled vessels structured like blood vessels, that carry lymph. As part of the lymphatic system, lymph vessels are complementary to the cardiovascular system. Lymph vessels are lined by endothelial cells, have a thin layer of smooth muscle, adventitia that bind the lymph vessels to the surrounding tissue. Lymph vessels are devoted to the propulsion of the lymph from the lymph capillaries, which are concerned with absorption of interstitial fluid from the tissues. Lymph capillaries are larger than their counterpart capillaries of the vascular system. Lymph vessels that carry lymph to a lymph node are called afferent lymph vessels, those that carry it from a lymph node are called efferent lymph vessels, from where the lymph may travel to another lymph node, may be returned to a vein, or may travel to a larger lymph duct. Lymph ducts drain the lymph into one of the subclavian veins and thus return it to general circulation. Lymph flows away from the tissues to lymph nodes and to either the right lymphatic duct or the largest lymph vessel in the body, the thoracic duct.
These vessels left subclavian veins respectively. The general structure of lymphatics is based on that of blood vessels. There is an inner lining of single flattened epithelial cells composed of a type of epithelium, called endothelium, the cells are called endothelial cells; this layer functions to mechanically transport fluid and since the basement membrane on which it rests is discontinuous. The next layer is that of smooth muscles that are arranged in a circular fashion around the endothelium, which by shortening or relaxing alter the diameter of the lumen; the outermost layer is the adventitia. The general structure described here is seen only in larger lymphatics; the smallest vessels lack both the outer adventitia. As they proceed forward and in their course are joined by other capillaries, they grow larger and first take on an adventitia, smooth muscles; the lymphatic conducting system broadly consists of two types of channels—the initial lymphatics, the prelymphatics or lymph capillaries that specialize in collection of the lymph from the ISF, the larger lymph vessels that propel the lymph forward.
Unlike the cardiovascular system, the lymphatic system has no central pump. Lymph movement occurs despite low pressure due to peristalsis and compression during contraction of adjacent skeletal muscle and arterial pulsation; the lymphatic circulation begins with blind ending permeable superficial lymph capillaries, formed by endothelial cells with button-like junctions between them that allow fluid to pass through them when the interstitial pressure is sufficiently high. These button-like junctions consist of protein filaments like platelet endothelial cell adhesion molecule-1, or PECAM-1. A valve system in place here prevents the absorbed lymph from leaking back into the ISF. There is another system of semilunar valves that prevents back-flow of lymph along the lumen of the vessel. Lymph capillaries have many interconnections between them and form a fine network. Rhythmic contraction of the vessel walls through movements may help draw fluid into the smallest lymphatic vessels, capillaries. If tissue fluid builds up the tissue will swell.
As the circular path through the body's system continues, the fluid is transported to progressively larger lymphatic vessels culminating in the right lymphatic duct and the thoracic duct. The system collaborates with white blood cells in lymph nodes to protect the body from being infected by cancer cells, viruses or bacteria; this is known as a secondary circulatory system. The lymph capillaries drain the lymph to larger contractile lymphatics, which have valves as well as smooth muscle walls; these are called the collecting lymphatics. As the collecting lymph vessel accumulates lymph from more and more lymph capillaries in its course, it becomes larger and is called the afferent lymph vessel as it enters a lymph node. Here the lymph is removed by the efferent lymph vessel. An efferent lymph vessel may directly drain into one of the lymph ducts, or may empty into another lymph node as its afferent lymph vessel. Both the lymph ducts return the lymph to the blood stream by emptying into the subclavian veins The functional unit of a lymph vessel is known as a lymphangion, the segment between two valves.
Since it is contractile, depending upon the ratio of its length to its radius, it can act either like a contractile chamber propelling the fluid ahead, or as a resistance vessel tending to stop the lymph in its place. Lymph vessels act as reservoirs for plasma and other substances including cells that have leaked from the vascular system and transport lymph fluid back from the tissues to the circulatory system. Without functioning lymph vessels, lymph cannot be drained and edema results; the afferent lymph vessels enter at all parts of the periphery of the lymph node, after branching and forming a dense plexus in the substance of the capsule, open into the lymph sinuses of the cortical part. It carries unfiltered lymph into the node. In doing this th
X-rays make up X-radiation, a form of electromagnetic radiation. Most X-rays have a wavelength ranging from 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 100 eV to 100 keV. X-ray wavelengths are shorter than those of UV rays and longer than those of gamma rays. In many languages, X-radiation is referred to with terms meaning Röntgen radiation, after the German scientist Wilhelm Röntgen who discovered these on November 8, 1895, credited as its discoverer, who named it X-radiation to signify an unknown type of radiation. Spelling of X-ray in the English language includes the variants x-ray, X ray. Before their discovery in 1895 X-rays were just a type of unidentified radiation emanating from experimental discharge tubes, they were noticed by scientists investigating cathode rays produced by such tubes, which are energetic electron beams that were first observed in 1869. Many of the early Crookes tubes undoubtedly radiated X-rays, because early researchers noticed effects that were attributable to them, as detailed below.
Crookes tubes created free electrons by ionization of the residual air in the tube by a high DC voltage of anywhere between a few kilovolts and 100 kV. This voltage accelerated the electrons coming from the cathode to a high enough velocity that they created X-rays when they struck the anode or the glass wall of the tube; the earliest experimenter thought to have produced. In 1785 he presented a paper to the Royal Society of London describing the effects of passing electrical currents through a evacuated glass tube, producing a glow created by X-rays; this work was further explored by his assistant Michael Faraday. When Stanford University physics professor Fernando Sanford created his "electric photography" he unknowingly generated and detected X-rays. From 1886 to 1888 he had studied in the Hermann Helmholtz laboratory in Berlin, where he became familiar with the cathode rays generated in vacuum tubes when a voltage was applied across separate electrodes, as studied by Heinrich Hertz and Philipp Lenard.
His letter of January 6, 1893 to The Physical Review was duly published and an article entitled Without Lens or Light, Photographs Taken With Plate and Object in Darkness appeared in the San Francisco Examiner. Starting in 1888, Philipp Lenard, a student of Heinrich Hertz, conducted experiments to see whether cathode rays could pass out of the Crookes tube into the air, he built a Crookes tube with a "window" in the end made of thin aluminum, facing the cathode so the cathode rays would strike it. He found that something came through, that would cause fluorescence, he measured the penetrating power of these rays through various materials. It has been suggested that at least some of these "Lenard rays" were X-rays. In 1889 Ukrainian-born Ivan Pulyui, a lecturer in experimental physics at the Prague Polytechnic who since 1877 had been constructing various designs of gas-filled tubes to investigate their properties, published a paper on how sealed photographic plates became dark when exposed to the emanations from the tubes.
Hermann von Helmholtz formulated mathematical equations for X-rays. He postulated a dispersion theory before Röntgen made his announcement, it was formed on the basis of the electromagnetic theory of light. However, he did not work with actual X-rays. In 1894 Nikola Tesla noticed damaged film in his lab that seemed to be associated with Crookes tube experiments and began investigating this radiant energy of "invisible" kinds. After Röntgen identified the X-ray, Tesla began making X-ray images of his own using high voltages and tubes of his own design, as well as Crookes tubes. On November 8, 1895, German physics professor Wilhelm Röntgen stumbled on X-rays while experimenting with Lenard tubes and Crookes tubes and began studying them, he wrote an initial report "On a new kind of ray: A preliminary communication" and on December 28, 1895 submitted it to Würzburg's Physical-Medical Society journal. This was the first paper written on X-rays. Röntgen referred to the radiation as "X"; the name stuck.
They are still referred to as such in many languages, including German, Danish, Swedish, Estonian, Japanese, Georgian and Norwegian. Röntgen received the first Nobel Prize in Physics for his discovery. There are conflicting accounts of his discovery because Röntgen had his lab notes burned after his death, but this is a reconstruction by his biographers: Röntgen was investigating cathode rays from a Crookes tube which he had wrapped in black cardboard so that the visible light from the tube would not interfere, using a fluorescent screen painted with barium platinocyanide, he noticed a faint green glow from the screen, about 1 meter away. Röntgen realized some invisible rays coming from the tube were passing through the cardboard to make the screen glow, he found they could pass through books and papers on his desk. Röntgen threw himself into investigating these unknown rays systematically. Two months after his initial discovery, he published his paper. Röntgen discovered their medical use when he made a picture of his wife's hand on a photographic plate formed due to X-rays.
The photograph of his wife's hand was the first photograph of a human body part using X-rays. When she saw the picture, she said "I have seen my death."The discovery of X-rays stimul