Hand Grip Exercises for Strength and Endurance
(one must solve for g (y) if the left-hand function f (x) and the integral kernel K(x, y) are known) is the so-called ''ill-conditioned problem'' (Press et al., 1992) in the Hadamard sense. This means, that small errors in the experimental data (represented here by f (x)) can cause arbitrary large deviations in the solution if no special precautions (the so-called ''regularization techniques'') are taken. However, this very interesting topic cannot be discuss at this point, and interested readers are referred to literature references in Press et al. (1992).
Best results are achieved by massive debridement with wide exposure. Debridement is repeated and delayed primary closure performed only when the wound is clean. Mobilization commences early. With such a regime, 64 of patients regain normal hand function, but 16 still require amputation.
A gravity drainage tube was removed from the dorsal surgical wound 5 days after surgery, and a long-arm thumb splint was reapplied until the sutures were removed 12 days after surgery. A nonremovable thumb spica splint was worn for 3 weeks. The patient's digital sensation had not improved. The patient returned in 1 week with increasing pain and swelling of the hand and fingers, further restricting finger movement. He was given two steroid dose packs and additional narcotic analgesics. One week later his pain increased despite no change in his exam. He was placed in a transcutaneous electrical nerve stimulation (TENS) unit, which improved his pain tolerance during the day. Just over 6 weeks after his surgery, the patient was taken to the operating room for removal of the pins. Two weeks later the swelling significantly decreased and the fingers were supple. The radiocarpal motion was noncrepitant, and the roentgenograms continued to be normal except for periartic-ular osteopenia. Pain...
A 45-year-old right hand dominant railroad worker fell at work onto his right hand. He developed pain in the wrist, a painful snapping sensation, and weakness of pinch and grip strength in that hand. He was treated with an extended period of splinting and nonsteroidal antiinflammatory medications without success. Subsequent radiographs demonstrated a scapholunate dissociation with dorsal intercalated segment instability (DISI) deformity. Wrist arthrogram demonstrated a disruption in the scapholunate interosseous ligament. The patient was referred for further treatment 9 months after the injury.
The patient has 25 degrees of ulnar drift at the index through small finger metacarpophalangeal (MP) joints. An extension deficit at the MP measures 45 degrees. The arc of motion of the digits at the MP is 20 degrees. The proximal interphalangeal (PIP) joint of the index and long fingers demonstrates a 30-degree flexion contracture with pain and crepitus with range of motion. Key pinch strength is 30 N and grip strength is 70 N at position II using the Jamar dynamometer.
The patient has 25 degrees of ulnar drift at the index through small finger metacarpophalangeal (MP) joints. An extension deficit at the MP measures 50 degrees (Fig. 73-1). The arc of motion of the digits at the MP joint is 20 degrees. Key pinch strength is 30 N and grip strength is 70 N at position II using the Jamar dynamometer. There is relative preservation of joint motion at the proximal interphalangeal (PIP) joint and wrist articulations without significant collapse or deformity.
The radial, ulnar and median nerves are all essential for normal hand function. The radial nerve innervates the wrist and finger extensors. The ulnar nerve innervates the adductor of the thumb and most of (he interossei and lumbricals. The median nerve innervates the bulk of the flexor muscles in the forearm and the opponens and abductor muscles of the thumb.
Several authors support accepting apex dorsal angulation up to 70 degrees, whereas others tolerate only 20 degrees. Hunter and Cowen found that angulations as large as 70 degrees could be tolerated with no compromise of hand function. Other published reports suggest patient dissatisfaction with angulation greater than 20 to 30 degrees secondary to the loss of knuckle prominence and palmar discomfort when grasping objects that abut the flexed metacarpal head. As a practical compromise, most surgeons prefer apex dorsal angulations for the ring and small metacarpal necks to be less than 30 to 40 degrees, with no malrotation and no pseudoclawing (MP hyperextension with PIP extensor deficit). Delayed presentation or loss of reduction may necessitate accepting 70 degrees of angulation and then treating the rare symptomatic patient with a corrective osteotomy.
Ensures that the digit remains well opposed to the splint and maintains flexion of the PIP joint blocked at 10 to 20 degrees greater than the point of demonstrable instability. Although McElfresh et al allowed up to 60 degrees of flexion to obtain stability, most accept a maximum of 30 degrees. This guideline prevents the chance of irreversible flexion contracture and delegates cases requiring greater than 30 degrees to other treatments. Lateral radiographs within the splint confirm this optimal point of flexion where the articular surfaces are absolutely congruent, for the PIP joint may become incongruous slowly, gradually, and subtly with extension. Some embark on immediate active range of motion, whereas others allow 1 week of rest. After 1 week of mobilization and radiographic and clinical confirmation of sustained congruity at rest and in maximum flexion, the degree of flexion is reduced by one third and the joint reassessed by a lateral radiograph. If radiographs demonstrate...
The Austin Flint murmur, as originally described in 1862,310 consisted of an apical presystolic murmur observed in two patients with considerable aortic regurgitation and no evidence of mitral stenosis at autopsy. Since its original description, the timing of this murmur has been extended to include a middiastolic component. It is heard best at the apex and has many of the qualities of the murmur of mitral stenosis. It is introduced by an S3 rather than by an opening snap, however, and S1 is of normal or decreased amplitude. Maneuvers or pharmacologic agents that increase the degree of aortic regurgitation, such as hand grip or vasoconstricting drugs, will increase the intensity of the rumble, whereas vasodilating agents such as amyl nitrite will decrease its intensity. In most cases of severe aortic regurgitation, particularly when the regurgitation is acute, the presystolic component of the Austin Flint murmur is lost. In this situation, there is marked elevation of the LV...
No wrist swelling or obvious deformity was noted. There was point tenderness dor-sally over the triquetrum. Range of motion was diminished in all planes. A painful clunk was palpable with radial-ulnar deviation. Compression of the triquetrum with a radially directed force elicited pain. Excessive laxity was present with lunotriquetral (LT) ballottement when compared with the contralateral wrist. Grip strength was reduced 20 compared with the contralateral, nondominant side. He was neurovascularly intact.
A 48-year-old right hand dominant mechanic presented for evaluation of right ulnar-sided wrist pain. Two weeks earlier he had slipped in his shop and landed on a dorsiflexed wrist. The primary impact was to the hypothenar eminence. Subsequently, he developed intermittent ulnar-sided wrist pain, exacerbated by radial-ulnar deviation. Grip strength was diminished, and he felt his wrist give way when torquing heavy tools. These symptoms reduced his work productivity and prevented him from participating in his weekly bowling league.
A 52-year-old right hand dominant carpenter and avid golfer presented with complaints of pain well localized to the right extensor muscle mass just distal to the elbow joint that had persisted for 6 months. He describes the pain as aching in character with burning that radiates along the anatomic course of the forearm extensor muscles. He has noticed a slowly enlarging mass over the dorsal proximal forearm and complains of weakness in grip strength and diminished endurance. He has no complaints of sensory loss to the hand or forearm. He denies any history of trauma.
The thumb provides 40 of hand function. Maintenance of a sensate, mobile thumb of normal length and power is important. Good cosmesis and quick rehabilitation are also desirable. Thus replantation of traumatic thumb amputations at all levels should be attempted. If the amputated part is inadequate, a hallux or second toe transfer can be performed, or the index finger can be pollicized.
Malunion becomes significant when it interferes with hand function. The most common deformity is rotational, as this is the most difficult to judge clinically without being able to take the digit through a full range of motion. If the resulting rotational or angular malunion is sufficient to hinder hand function, osteotomy after fracture healing can be performed secondarily.
Ganglions rarely interfere with hand function, but on occasion, particularly after strenuous activity, they may become painful. 2. Treatment. In the early posttraumatic condition, splinting may be attempted with the deformity reversed (PIP flexed and DIP extended) for a 6-week period. Surgical correction is necessary if hand function is sufficiently impaired.
Severe wrist synovitis and bony destruction are amenable to surgical therapy the degree of involvement dictates the choice of a synovectomy and ulnar head resection (dorsal stabilization procedure), a total wrist arthroplasty, or wrist fusion. Total wrist arthroplasty retains wrist motion while providing pain relief. Wrist synovitis can attenuate and rupture extensor tendons. Wrist synovectomy is indicated in the presence of persistent boggy, dorsal swelling to prevent rupture of extensor tendons. Implants continue to play an important role in the management of thumb and MCP joint disease. Critical to success are soft-tissue balancing and prolonged dynamic postoperative splinting to prevent recurrence of ulnar drift. This procedure results in pain relief with only a slight decrease in grip strength. Although fusions are not indicated for finger MCP joints, they are often useful in advanced proximal PIP joint disease to reestablish a functional hand. Cemented PIP...
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