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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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Typically, Dupuytren's contracture first presents as a thickening or nodule in the palm, which initially can be with or without pain. Later in the disease process, there is painless increasing loss of range of motion of the affected fingers. The earliest sign of a contracture is a triangular “puckering” of the skin of the palm as it passes over the flexor tendon just before the flexor crease of the finger, at the metacarpophalangeal (MCP) joint. Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected. The disease begins in the palm and moves towards the fingers, with the metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.
In Dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren's contracture decreases a person's ability to hold objects. People may report pain, aching and itching with the contractions. Normally, the palmar fascia consists of collagen type I, but in Dupuytren sufferers, the collagen changes to collagen type III, which is significantly thicker than collagen type I.
People with severe involvement often show lumps on the back of their finger joints (called “Garrod's pads”, “knuckle pads”, or “dorsal Dupuytren nodules”) and lumps in the arch of the feet (plantar fibromatosis or Ledderhose disease). In severe cases, the area where the palm meets the wrist may develop lumps. Severe Dupuytren disease may also be associated with frozen shoulder (adhesive capsulitis of shoulder), Peyronie's disease of the penis, increased risk of several types of cancer, and risk of early death, but more research is needed to clarify these relationships.
Plantar fibromatosis is most frequently present on the medial border of the sole, near the highest point of the arch. The lump is usually painless and the only pain experienced is when the nodule rubs on the shoe or floor. The overlying skin is freely movable, and contracture of the toes does not occur in the initial stages.
The typical appearance of plantar fibromatosis on magnetic resonance imaging (MRI) is a poorly defined, infiltrative mass in the aponeurosis next to the plantar muscles.
Only 25% of patients show symptoms on both feet (bilateral involvement). The disease may also infiltrate the dermis or, very rarely, the flexor tendon sheath
Finger injuries are usually diagnosed with x-ray and can get to be considerably painful. The majority of finger injuries can be dealt with conservative care and splints. However, if the bone presents an abnormal angularity or if it is displaced, one may need surgery and pins to hold the bones in place.
Arthritis of the hand is common in females. Osteoarthritis of the hand joints is much less common than rheumatoid arthritis. As the arthritis progresses, the finger gets deformed and lose its functions. Moreover, many patients with rheumatoid arthritis have this dysfunction present in both hands and become disabled due to chronic pain. Osteoarthritis is most common at the base of thumb and is usually treated with pain pills, splinting or steroid injections.
Carpal tunnel syndrome is a common disorder of the hand. This disorder results from compression of an important nerve in the wrist. Disorders like diabetes mellitus, thyroid or rheumatoid arthritis can narrow the tunnel and cause impingement of the nerve. Carpal tunnel syndrome also occurs in people who overuse their hand or perform repetitive actions like using a computer key board, a cashiers machine or a musical instrument. When the nerve is compressed, it can result in disabling symptoms like numbness, tingling, or pain in the middle three fingers. As the condition progresses, it can lead to muscle weakness and inability to hold objects. The pain frequently occurs at night and can even radiate to the shoulder. Even though the diagnosis is straightforward, the treatment is not satisfactory.
Dupuytren's contracture is another disorder of the fingers that is due to thickening of the underlying skin tissues of the palm. The disorder results in a deformed finger which appears thin and has small bumps on the surface. Dupuytren's contracture does run in families, but is also associated with diabetes, smoking, seizure recurrence and other vascular disorders. Dupuytren's does not need any treatment as the condition can resolve on its own. However, if finger function is compromised, then surgery may be required.
Ganglion cysts are soft globular structures that occur on the back of the hand usually near the junction of the wrist joint. These small swellings are usually painless when small but can affect hand motion when they become large. The cysts contain a jelly like substance and usually do disappear on their own. If the ganglion cyst is not bothersome, it should be left alone. Just removing the fluid from the cyst is not curative because fluid will come back in less than a week. Surgery is often done for large cysts but the results are poor. Recurrences are common, and there is always the possibility of nerve or joint damage.
Tendinitis is disorder when tendons of the hands become inflamed. Tendons are thick fibrous cords that attach small muscles of the hand to bones. A Tendon is useful for generation of power to bend or extend the finger. When repetitive action is performed, tendons often get inflamed and present with pain and difficulty for moving the finger. In most cases, tendinitis can be treated with rest, ice and wearing splints. In some cases, an injection of corticosteroid may help. Tendinitis is primarily a disorder from overuse but if not treated properly, can become chronic.
Trigger finger is a common disorder which occurs when the sheath through which tendons pass, become swollen or irritated. Initially, the finger may catch during movement but symptoms like pain, swelling and a snap may occur with time. The finger often gets locked in one position and it may be difficult to straighten or bend the finger. Trigger finger has been found to be associated with diabetes, gout and rheumatoid arthritis.
Stenosing tenosynovitis often presents with a painful and swollen thumb with limited range of motion, or a ring finger or middle finger with similarly limited motion. There is often a feeling of catching when the thumb is flexed. In the ring and middle fingers, often a nodule can be felt when you press the area of the hand where the palm meets the finger.
Plantar fascial fibromatosis, also known as Ledderhose's disease, Morbus Ledderhose, and plantar fibromatosis, is a relatively uncommon non-malignant thickening of the feet's deep connective tissue, or fascia. In the beginning, where nodules start growing in the fascia of the foot the disease is minor . Over time walking becomes painful. The disease is named after Dr. Georg Ledderhose, a German surgeon who described the condition for the first time in 1894. A similar disease is Dupuytren's disease, which affects the hand and causes bent hand or fingers.
As in most forms of fibromatosis, it is usually benign and its onset varies with each patient. The nodules are typically slow growing and most often found in the central and medial portions of the plantar fascia. Occasionally, the nodules may lie dormant for months to years only to begin rapid and unexpected growth. Options for intervention include radiation therapy, cryosurgery, treatment with collagenase clostridium histolyticum, or surgical removal only if discomfort hinders walking.
Stenosing tenosynovitis (also known as trigger finger or trigger thumb) is a painful condition caused by the inflammation (tenosynovitis) and progressive restriction of the superficial and deep flexors fibrous tendon sheath adjacent to the A1 pulley at a metacarpal head. Repetitive forceful compression, tensile stress, and resistive flexion, causes inflammation, swelling, and microtrauma, that results in thickening (commonly a nodular formation) of the tendon distal to the pulley and stenosis of the tendon sheath leading to a painful digital base, limitation of finger movements, triggering, snapping, locking, and deformity progressively.
Patients report a popping sound at the proximal interphalangeal joint (PIP), morning stiffness with/without triggering, delayed and sometimes painful extension of the digit, and when more advanced, a locking position that requires manipulation to extend the affected finger. This condition more commonly affects the middle and ring fingers (occasionally the thumb), and the flexor rather than extensor tendons in the hand.
In rheumatic trigger finger (or in diabetes), more than one finger may be involved. Cases of stenosing peroneal tenosynovitis, have been reported where the patient presents with pain over the lateral malleolus, both with active and passive range of motion and no physical of radiographic evidence of instability.
Garrod's pads (also known as "violinist's pads") are a cutaneous condition characterized by calluses on the dorsal aspect of the interphalangeal joints, i.e. the back side of the finger joints. They are often seen in violin, viola, and cello players, along with fiddler's neck and other dermatologic conditions peculiar to string musicians. Although Garrod’s pads are conventionally described as appearing on the proximal interphalangeal joint, Rimmer & Spielvogel document an instance on the distal interphalangeal joint of a cellist.
Garrod's pads are named after Archibald Garrod who first documented them in 1904 in association with Dupuytren's contracture. H.A. Bird described them as an incidental finding in a professional violinist and proposed that they arise in such cases due to repeated extreme tension of the extensor tendons over the interphalangeal joints. Bird noted that violin players use the left hand for a markedly different task than the right hand, with the extensor tendons in the left hand subjected to considerable tension, and that Garrod’s pads only arise on the left hand in such cases. This unilateral finding differentiates the occupational hazard of Garrod’s pads from more significant disorders. Among violinists and violists, Garrod’s pads apparently arise as a protective mechanism for the skin and subcutaneous tissues above the tendons; Bird notes that they do not protect against external trauma unlike most calluses.
Patients with Dupuytren's contracture are four times more likely to have coexisting Garrod's pads.
Volkmann's contracture is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful.
Any fracture in elbow region or upper arm may lead to Volkmann's ischemic contracture, but it is especially associated with supracondylar fracture of the humerus.
Volkmann's contracture results from acute ischaemia and necrosis of the muscle fibres of the flexor group of muscles of the forearm, especially the flexor digitorum profundus and flexor pollicis longus. The muscles become fibrotic and shortened.
The condition is caused by obstruction on the brachial artery near the elbow, possibly from improper use of a tourniquet, improper use of a plaster cast, or compartment syndrome. It is also caused by fractures of the forearm bones if they cause bleeding from the major blood vessels of the forearm.
On weightbearing projectional radiography, pes cavus can be diagnosed and graded by several features, the most important being medial peritalar subluxation, increased calcaneal pitch (variable) and abnormal "talar-1st metatarsal angle" (Meary's angle). Medial peritalar subluxation can be demonstrated by a medially rotated talonavicular coverage angle.
As with certain cases of flat feet, high arches may be painful due to metatarsal compression; however, high arches— particularly if they are flexible or properly cared-for—may be an asymptomatic condition.
People with pes cavus sometimes—though not always—have difficulty finding shoes that fit and may require support in their shoes. Children with high arches who have difficulty walking may wear specially-designed insoles, which are available in various sizes and can be made to order.
Individuals with pes cavus frequently report foot pain, which can lead to a significant limitation in function. The range of complaints reported in the literature include metatarsalgia, pain under the first metatarsal, plantar fasciitis, painful callosities, ankle arthritis, and Achilles tendonitis.
There are many other symptoms believed to be related to the cavus foot. These include shoe-fitting problems, lateral ankle instability, lower limb stress fractures, knee pain, iliotibial band friction syndrome, back pain and tripping.
Foot pain in people with pes cavus may result from abnormal plantar pressure loading because, structurally, the cavoid foot is regarded as being rigid and non-shock absorbent and having reduced ground contact area. There have previously been reports of an association between excessive plantar pressure and foot pathology in people with pes cavus.
Classification of radial dysplasia is practised through different models. Some only include the different deformities or absences of the radius, where others also include anomalies of the thumb and carpal bones. The Bayne and Klug classification discriminates four different types of radial dysplasia. A fifth type was added by Goldfarb et al. describing a radial dysplasia with participation of the humerus. In this classification only anomalies of the radius and the humerus are taken in consideration. James and colleagues expanded this classification by including deficiencies of the carpal bones with a normal distal radius length as type 0 and isolated thumb anomalies as type N.
Type N: Isolated thumb anomaly
Type 0: Deficiency of the carpal bones
Type I: Short distal radius
Type II: Hypoplastic radius in miniature
Type III: Absent distal radius
Type IV: Complete absent radius
Type V: Complete absent radius and manifestations in the proximal humerus
The term absent radius can refer to the last 3 types.
The following factors may be involved in causing this deformity:
- Inherent laxity of the knee ligaments
- Weakness of biceps femoris muscle
- Instability of the knee joint due to ligaments and joint capsule injuries
- Inappropriate alignment of the tibia and femur
- Malunion of the bones around the knee
- Weakness in the hip extensor muscles
- Gastrocnemius muscle weakness (in standing position)
- Upper motor neuron lesion (for example, hemiplegia as the result of a cerebrovascular accident)
- Lower motor neuron lesion (for example, in post-polio syndrome)
- Deficit in joint proprioception
- Lower limb length discrepancy
- Congenital genu recurvatum
- Cerebral palsy
- Multiple sclerosis
- Muscular dystrophy
- Limited dorsiflexion (plantar flexion contracture)
- Popliteus muscle weakness
- Connective tissue disorders. In these disorders, there are excessive joint mobility (joint hypermobility) problems. These disorders include:
- Marfan syndrome
- Ehlers-Danlos syndrome
- Benign hypermobile joint syndrome
- Osteogenesis imperfecta disease
Radial dysplasia, also known as radial club hand or radial longitudinal deficiency, is a congenital difference occurring in a longitudinal direction resulting in radial deviation of the wrist and shortening of the forearm. It can occur in different ways, from a minor anomaly to complete absence of the radius, radial side of the carpal bones and thumb. Hypoplasia of the distal humerus may be present as well and can lead to stiffnes of the elbow. Radial deviation of the wrist is caused by lack of support to the carpus, radial deviation may be reinforced if forearm muscles are functioning poorly or have abnormal insertions. Although radial longitudinal deficiency is often bilateral, the extent of involvement is most often asymmetric.
The incidence is between 1:30,000 and 1:100,000 and it is more often a sporadic mutation rather than an inherited condition. In case of an inherited condition, several syndromes are known for an association with radial dysplasia, such as the cardiovascular Holt-Oram syndrome, the gastrointestinal VATER syndrome and the hematologic Fanconi anemia and TAR syndrome. Other possible causes are an injury to the apical ectodermal ridge during upper limb development, intrauterine compression, or maternal drug use (thalidomide).
Genu recurvatum is a deformity in the knee joint, so that the knee bends backwards. In this deformity, excessive extension occurs in the tibiofemoral joint. Genu recurvatum is also called knee hyperextension and back knee. This deformity is more common in women and people with familial ligamentous laxity. Hyperextension of the knee may be mild, moderate or severe.
The normal range of motion (ROM) of the knee joint is from 0 to 135 degrees in an adult. Full knee extension should be no more than 10 degrees. In genu recurvatum (back knee), normal extension is increased. The development of genu recurvatum may lead to knee pain and knee osteoarthritis.
People usually present with a history of an injury and localized pain. There is often a deformity in the wrist with associated swelling. Numbness of the hand can occur because of compression on the median nerve across the wrist (carpal tunnel syndrome). The wrist deformity often limits motion of the fingers.
Swelling, deformity, tenderness and loss of wrist motion are normal features on examination of a person with a distal radius fracture. Examination should rule out a skin wound which might suggest an open fracture. It is imperative to check for loss of sensation, loss of circulation to the hand, and more proximal injuries to the forearm, elbow and shoulder. The most common associated neurological finding is decreased sensation over the thenar eminence due to associated median nerve injury.
A classic "dinner fork" deformity may be seen in dorsally angulated fractures due to dorsal displacement of the carpus. The reverse deformity may be seen in volarly angulated fractures.
Subacromial bursitis often presents with a constellation of symptoms called impingement syndrome. Pain along the front and side of the shoulder is the most common symptom and may cause weakness and stiffness. If the pain resolves and weakness persists other causes should be evaluated such as a tear of the rotator cuff or a neurological problem arising from the neck or entrapment of the suprascapular nerve. The onset of pain may be sudden or gradual and may or may not be related to trauma. Night time pain, especially sleeping on the affected shoulder, is often reported. Localized redness or swelling are less common and suggest an infected subacromial bursa. Individuals affected by subacromial bursitis commonly present with concomitant shoulder problems such as arthritis, rotator cuff tendinitis, rotator cuff tears, and cervical radiculopathy (pinched nerve in neck).
Impingement may be brought on by sports activities, such as overhead throwing sports and swimming, or overhead work such as painting, carpentry, or plumbing. Activities that involve repetitive overhead activity, or directly in front, may cause shoulder pain. Direct upward pressure on the shoulder, such as leaning on an elbow, may increase pain.
Diagnosing the congenital clasped thumb is difficult in the first three to four months of life, as it is normal when the thumb is clutched into the palm in these first months.
Diagnoses that cause the same flexion or adduction abnormalities of the thumb are:
- Congenital clasped thumb
- Congenital Trigger thumb (flexion of the interphalangeal joint) - Trigger finger
- Spasticity: overstimulation of muscles
Syndrome associated flexion-adduction of the thumb:
- Freeman-Sheldon syndrome (a congenital, heritable affection of the face, the hands, the feet and some joints)
- Distal arthrogryposis
- MASA syndrome
- X-linked hydrocephalus
- Adducted thumb syndrome
- Waardenburg syndrome
- Whistling face syndrome (Freeman-Sheldon syndrome)
- Digitotalar dysmorphism
- Multiple pterygium syndrome
"Infant’s persistent thumb-clutched hand, flexion-adduction deformity of the thumb, pollex varus, thumb in the hand deformity."
Congenital clasped thumb describes an anomaly which is characterized by a fixed thumb into the palm at the metacarpophalangeal joint in one or both hands.
The incidence and genetic background are unknown. A study of Weckesser et al. showed that boys are twice as often affected with congenital clasped thumb compared to girls. The anomaly is in most cases bilateral (present in both hands).
A congenital clasped thumb can be an isolated anomaly, but can also be attributed to several syndromes.
A muscle contracture is a permanent shortening of a muscle or joint. It is usually in response to prolonged hypertonic spasticity in a concentrated muscle area, such as is seen in the tightest muscles of people with conditions like spastic cerebral palsy.
Contractures are essentially muscles or tendons that have remained too tight for too long, thus becoming shorter. Once they occur, it is often argued that they cannot be stretched or exercised away (they must be released with orthopedic surgery). Most of the physical therapy, occupational therapy, and other exercise regimens targeted towards people with spasticity focuses on trying to prevent contractures from happening in the first place. However, research on sustained traction of connective tissue in approaches such as adaptive yoga has demonstrated that contracture can be reduced, at the same time that tendency toward spasticity is addressed.
Contractures can also be due to ischemia, as in Volkmann's contracture.
Excessive matrix metalloproteinase and myofibroblast accumulation in the wound margins can result in contracture.
Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying coraco-acromial ligament, acromion, coracoid (the acromial arch) and from the deep surface of the deltoid muscle. The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.
Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain.
Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune inflammatory conditions such as rheumatoid arthritis; crystal deposition disorders such as gout or pseudogout; calcific loose bodies, and infection. More commonly, subacromial bursitis arises as a result of complex factors, thought to cause shoulder impingement symptoms. These factors are broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury.
In 1983 Neer described three stages of impingement syndrome. He noted that "the symptoms and physical signs in all three stages of impingement are almost identical, including the 'impingement sign'..., arc of pain, crepitus, and varying weakness." The Neer classification did not distinguish between partial-thickness and full-thickness rotator cuff tears in stage III. This has led to some controversy about the ability of physical examination tests to accurately diagnose between bursitis, impingement, impingement with or without rotator cuff tear and impingement with partial versus complete tears.
In 2005, Park et al. published their findings which concluded that a combination of clinical tests were more useful than a single physical examination test. For the diagnosis of impingement disease, the best combination of tests were "any degree (of) a positive Hawkins-Kennedy test, a positive painful arc sign, and weakness in external rotation with the arm at the side," to diagnose a full thickness rotator cuff tear, the best combination of tests, when all three are positive, were the painful arc, the drop-arm sign, and weakness in external rotation.
Pott's fracture, also known as Pott's syndrome I and Dupuytren fracture, is an archaic term loosely applied to a variety of bimalleolar ankle fractures. The injury is caused by a combined abduction external rotation from an eversion force. This action strains the sturdy medial (deltoid) ligament of the ankle, often tearing off the medial malleolus due to its strong attachment. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus. A fractured fibula in addition to detaching the medial malleolus will tear the tibiofibular syndesmosis. The combined fracture of the medial malleolus, lateral malleolus, and the posterior margin of the distal end of the tibia is known as a "trimalleolar fracture."
An example of Pott's fracture would be in a sports tackling injury. The player receives a blow to the outside of the ankle, causing the ankle to roll inwards (so that the sole of the foot faces laterally). This damages the ligaments on the inside of the ankle and fractures the fibula at the point of contact (usually just above the tibiofibular syndesmosis). A better way to visualize this is the two hands of a clock, with one hand facing 12 and the other facing 6. The vertical line they form represents the fibula of the person's right leg. The lateral force approaches from 3 o'clock, sending the lower hand snapping outwards to point at 5 o'clock.
Bimalleolar fractures are less likely to result in arthritis than trimalleolar fractures.