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How to Human Blog

  • Hand in Hand: Structure, Function, and Carpal Tunnel Syndrome

    Justine Smith

    The human hand is a marvel of biological engineering—finely tuned for both strength and precision. It enables everything from forceful grips to delicate manipulations, thanks to its complex interplay of bones, joints, muscles, tendons, nerves, and blood vessels. Understanding this intricate structure is essential, especially when exploring conditions like carpal tunnel syndrome, which can severely impact hand function.

    Figure 1 Nail anatomy (Lane et al., 2023)

    Bones: The Framework of Dexterity

    The skeletal architecture of the hand begins with the carpal bones, a cluster of eight small bones forming the wrist. These bones are arranged in two rows and act as the foundation for hand movement. The proximal row includes the scaphoid, lunate, triquetrum, and pisiform, articulating with the radius and ulna of the forearm. The distal row connects to the five metacarpal bones, which extend into the palm and link to the phalanges, or finger bones.

    Each finger—except the thumb—has three phalanges (proximal, middle, and distal), while the thumb has only two. These bones not only support movement but are integral to hand stability and function.

    Figure 2 Carpal anatomy (Lane et al., 2023)

    Figure 3 Osseous anatomy of the hand (Lane et al., 2023)

    Joints: Points of Precision

    The hand’s range of motion depends on numerous joints. Intercarpal joints allow slight gliding between carpal bones, while carpometacarpal (CMC) joints connect the wrist to the metacarpals. Notably, the thumb’s saddle-shaped CMC joint enables its unique oppositional movement, which is critical for gripping and pinching.

    Further along the digits, interphalangeal (IP) joints—including proximal (PIP) and distal (DIP) joints—enable finger flexion and extension. The thumb contains a single IP joint due to its two-phalange structure.

    Figure 4 Carpometacarpal, metacarpophalangeal, and interphalangeal joint anatomy (Lane et al., 2023)

    Muscles and Tendons: The Engines of Movement

    Two major groups of muscles power hand movement: extrinsic muscles, which originate in the forearm, and intrinsic muscles, which reside within the hand itself.

    • Extrinsic flexors like the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) enable finger bending.
    • Extensors help straighten the fingers and are housed in compartments under the extensor retinaculum, a stabilizing band at the wrist.
    • Intrinsic muscles include the thenar and hypothenar muscles, lumbricals, and interossei, which fine-tune finger movements, especially for grasping and manipulating objects.

    Tendons run through pulley systems in fibrous sheaths that allow for smooth gliding during movement. In the carpal tunnel—a narrow passageway at the wrist—these tendons share space with the median nerve, making the area vulnerable to compression.

    Figure 5 Digital extensor mechanism (Lane et al., 2023)

    Nerve Supply: The Control Center

    Three main nerves power the hand:

    • The ulnar nerve governs fine motor control in the ring and small fingers.
    • The median nerve supplies sensation to the thumb, index, middle, and part of the ring finger. It also innervates the thenar muscles—crucial for thumb movement.
    • The radial nerve primarily controls wrist and finger extension.

    Compression of the median nerve within the carpal tunnel can lead to carpal tunnel syndrome, a condition marked by numbness, tingling, and weakness in the hand—especially affecting thumb function.

    Blood Supply: Keeping the Hand Alive

    The hand’s rich vascular network is supported by the radial and ulnar arteries, which form both dorsal and palmar arches. These arches distribute blood to the fingers through digital arteries, ensuring that the hand’s many tissues receive necessary oxygen and nutrients.

    Figure 6 Schematic drawing of the vascular supply of the hand (Abzug et al., 2023)

    Bone Development and Growth Plates

    In children, the hand bones undergo a process known as endochondral ossification, where cartilage gradually transforms into bone. This occurs in growth zones called physes, or growth plates, which are susceptible to injury. Damage to these areas can lead to long-term issues like growth arrest or deformity if not managed promptly.

    Fractures involving the growth plate (physeal fractures) are particularly common in children and must be treated with urgency and precision. Fortunately, younger bones have a high capacity for remodeling, especially when diagnosed early.

    Functional Development: More Than Just Mechanics

    Beyond structure, the hand is both an executive tool and a sensory organ. Even before birth, fetuses begin using their hands to explore their environment. In infancy, reflexive grasping evolves into intentional, skilled hand use. Over time, children develop prehension—the ability to grasp objects—followed by refined haptic perception, allowing them to identify textures, shapes, and sizes purely through touch.

    As they grow, children shift from relying on feedback-driven movement to more anticipatory control. By the age of 4 to 7, most children can match objects by feel alone, and by 11 months, many begin to develop a preferred hand—a precursor to dominant-hand use in adulthood.

    Setting the Stage for Carpal Tunnel Syndrome

    With this complex yet elegant design, the human hand is vulnerable to a variety of conditions—especially where multiple systems converge. One such vulnerable site is the carpal tunnel, through which the median nerve and flexor tendons pass. When pressure builds up in this narrow space—due to swelling, repetitive motion, or anatomical anomalies—carpal tunnel syndrome (CTS) can develop.

    Next time, we’ll explore how this condition affects the finely tuned harmony of the hand, who’s at risk, and how modern medicine addresses it—especially in growing children.

    References:

    Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2023). Clinically oriented anatomy (9th ed.). Wolters Kluwer.

    Netter, F. H. (2023). Atlas of human anatomy (8th ed.). Elsevier.

  • Mastering life-saving memory-aiding techniques – an example

    Justine Smith

    Let’s look at the following task.

    You need to memorise the names of the bones in the human hand. What to do to achieve it quickly?

    The best technique depends on your learning style, but the most effective ones are usually:

    Mnemonic Acronyms or Phrases (Acronyms/Reverse Acronyms)

    These are widely used in anatomy because they’re quick, memorable, and easy to recall under exam pressure.

    Carpal Bones (wrist, proximal and distal rows):

    There are 8 carpal bones:

    • Proximal row (lateral to medial): Scaphoid, Lunate, Triquetrum, Pisiform
    • Distal row (lateral to medial): Trapezium, Trapezoid, Capitate, Hamate

    Mnemonic Example:

    “Some Lovers Try Positions That They Can’t Handle”

    Each first letter corresponds to a carpal bone:

    • Scaphoid
    • Lunate
    • Triquetrum
    • Pisiform
    • Trapezium
    • Trapezoid
    • Capitate
    • Hamate

    Make it personally vivid or funny to improve recall.

    Memory Palace (Method of Loci)

    Use this if you’re more visual-spatial and need to learn locations and relationships between bones.

    Example:

    1. Visualize a hallway with 8 rooms (or stops).
    2. Associate each room with an exaggerated image:
      • Room 1: A scarf (for Scaphoid) wrapped around a wrist
      • Room 2: A glowing moon (Lunate) on the floor
      • Room 3: A triangle shaped sculpture (Triquetrum)
      • Room 4: A cat purring loudly (Pisiform)
      • Room 5: A gymnast on a trapeze (Trapezium)
      • Room 6: A puzzle (pieces fitting perfectly like Trapezoid)
      • Room 7: A cap worn on a statue (Capitate)
      • Room 8: A hammer smashing something (Hamate)

    Then mentally walk through this “palace” when recalling.

    Peg Method (Rhyme-Based Association)

    This can be adapted if you want to learn both names and order, especially useful for numbered bones like metacarpals or phalanges.

    Example pegs:

    • 1 is a bun: imagine a bun with a scaphoid inside.
    • 2 is a shoe: shoe made of lunate, etc.

    Less common for anatomy, but good if you’re already familiar with peg systems.

    Best Pick for Most Students:

    Acronym + Spatial Diagram Sketching

    Start with mnemonic phrases like “Some Lovers Try Positions That They Can’t Handle”, then reinforce it by drawing hand diagrams repeatedly, labelling each bone. This builds both verbal and spatial memory.

    RegionElementsMnemonic
    Carpals8 named bones“Some Lovers Try Positions That They Can’t Handle”
    MetacarpalsThumb to Little (I–V)“Tall Individuals Make Real Leaders”
    Phalanges OrderProximal → Middle → Distal“Please Make Dinner”
    Thumb PhalangesProximal → Distal only“Thumbs Prefer Dessert”

    References:

    Iftikhar, N. (2019). Important Joints: Hand and Wrist Bones. [online] Healthline. Available at: https://www.healthline.com/health/wrist-bones.

    National Library of Medicine (2018). How do hands work? [online] Nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK279362/.

  • Thyroid Homeostasis

    Edith Renata

    Thyroid hormones (TH) are essential for a wide array of physiological processes, including growth, development, differentiation, and metabolism. The body’s ability to maintain flexible homeostatic equilibria of TH in response to environmental challenges is a key indicator of a healthy state. While traditional understanding focused on a proportional negative feedback control between the thyroid and pituitary glands, recent research indicates a more complex and dynamic system. This updated view highlights that homeostatic equilibria are governed by intricate inter-relationships between thyroid hormones and pituitary thyrotropin (TSH), displaying significant individuality, a hierarchical structure based on thyroid state, and adaptive conditionality.

    Homeostatic Control of the Thyroid-Pituitary Axis

    A basic understanding of thyroid control, mediated by pituitary TSH, has been extensively utilised in the diagnosis of thyroid disorders. As a result, TSH measurement, despite being an indirect marker of thyroid homeostasis, has become a central component of modern thyroid function testing.

    The concept of a feedback control loop between the thyroid and the pituitary was first proposed in 1940 and experimentally confirmed by 1950. Early models posited an inverse linear correlation between TSH and T4, which was later revised to a log-linear relationship and adopted as the standard model. However, current knowledge suggests this simplistic log-linear concept requires reconsideration due to the inherent complexity of the underlying system.

    More detailed analyses reveal that the TSH-FT4 relationship is curvilinear and exhibits a damped response in the middle portion of the euthyroid range, with steeper gradients observed at the hypothyroid or hyperthyroid extremes. This non-linear characteristic facilitates a dampened response, which is more effective at maintaining the controlled parameter at a stable level with minimal fluctuation. This adaptable response is thought to originate from the integrated action of multiple feedback loops operating at various levels of biological organisation.

    The integrated control system of thyroid homeostasis incorporates several major feedback loops:

    • Negative Feedback Control: Thyroid hormones exert a repressive action on pituitary TSH and hypothalamic TRH.

    • Positive Stimulatory Control: TRH actively stimulates TSH secretion.

    • Ultrashort Feedback: TSH is involved in a feedback loop that suppresses its own secretion.

    • Feedforward Control: TSH directly influences deiodinase activity, thereby regulating the conversion of T4 to T3.

    Molecular Mechanisms Involved in Feedback Control 

    The complexity and non-proportional nature of thyroid homeostasis are underpinned by various molecular mechanisms:

    • Thyroid Hormone Receptors (TRs): Both T3 and T4 (after its conversion to T3) bind to specific intracellular TR receptors, leading to the repression of several genes, including TSHβ and, to a lesser extent, α-subunit. The TRβ2 isoform, found in the central nervous system, hypothalamus, and pituitary, exhibits up to a 10-fold enhanced sensitivity to thyroid hormones compared to TRβ1, which allows central tissues to anticipate T3/T4 oversupply before it affects less sensitive peripheral tissues.

    • Deiodinases: These enzymes are crucial for regulating T3 conversion and provide a sophisticated mechanism for sensitive responses to changes in FT4 within the feedback loop. Specifically, type 2 deiodinase (D2) ubiquitination is critical for hypothalamic negative feedback regulation and is expressed non-uniformly across different tissues. D2 facilitates the conversion of the pro-hormone thyroxine (T4) into its active metabolite, T3, particularly in glial cells and tanycytes in the hypothalamus, while type 3 deiodinase (D3) inactivates both T4 and T3. This local enzymatic activity can result in tissue-specific states of hypothyroidism or thyrotoxicosis, even when systemic euthyroidism is maintained.

    • Thyroid Hormone Transporters: T3 and T4 do not freely diffuse across cell membranes but are actively transported by specialised proteins such as MCT8, MCT10, and OATP1C1. Intracellular trafficking also involves internal binding substrates (IBS) of thyroid hormones. These transporters are essential components of the feedback control system.

    • TRH and TSH: Thyrotropin-releasing hormone (TRH) functions as a potent defensive mechanism against thyroid hormone undersupply, stimulating pituitary TSH secretion and modulating its bioactivity. TSH stimulation of thyroid hormone production is vital, as the basal capacity of the thyroid gland is limited without it. Tissue-specific glycosylation of TSH also contributes to targeted signalling. Long feedback control of TRH release by TH involves both hypophysiotropic TRH neurons and tancytes, which can adjust the set point and integrate energy metabolism and thyroid function.

    • Pulsatility of TSH Secretion: TSH is secreted in a pulsatile manner, with rapid oscillations superimposed on a circadian rhythm that typically peaks shortly after midnight. This pulsatile release may be advantageous by preventing homologous desensitisation of the thyrotropin receptor. Furthermore, a direct link between TSH and deiodinase activity may partly explain the circadian rhythm observed in T3 levels that parallels TSH.

    • Non-Classical Thyroid Hormones: Emerging research suggests an active physiological role for less recognised non-classical thyroid hormones, including reverse triiodothyronine (rT3), 3,5-diiodothyronine (T2), iodothyroacetates, and thyronamines. Some of these molecules, such as 3,5-T2, TRIAC, and TETRAC, exert thyromimetic effects at TR-β receptors, leading to TSH-suppressive actions, which implies their role as important modulators of the overall control system.

    • Other Modulating Influences: A multitude of physiological and pathophysiological factors, including age, body mass index (BMI), genetic polymorphisms, and conditions like non-thyroidal illness (NTI) syndrome, modulate the relationship between TSH and thyroid hormones and influence the position of the set point in both health and disease.

    Consequences for Thyroid Function Testing and Treatment 

    The traditional paradigm of TSH as the sole and primary diagnostic parameter for thyroid function is increasingly being challenged.

    • Limitations of TSH Measurement: TSH is fundamentally an indirect measure of thyroid hormone homeostasis and a controlling element, not a simple, isolated statistical parameter. Its interpretation is complicated by its non-proportional (non-log-linear) and conditional relationship with thyroid hormones, as well as its high degree of individuality. Consequently, the same TSH value can be considered “normal” for one individual but “pathological” for another.

    • Controversy over Reference Ranges: There is ongoing debate regarding the appropriate reference limits for TSH, particularly its upper limit used to define subclinical hypothyroidism. Conventional methods for establishing these ranges may be insufficient, leading to exploration of more personalised and multivariate approaches for TSH referencing. Furthermore, circadian and ultradian rhythms of TSH levels can reduce diagnostic accuracy unless reference intervals are adjusted or blood sampling is restricted to specific times, such as morning.

    • Subclinical Thyroid Dysfunction: Current definitions of subclinical hypothyroidism and hyperthyroidism, which are based on abnormal TSH levels while FT3 and FT4 remain within their reference ranges, may not consistently and accurately classify disease states. Patients diagnosed with subclinical hypothyroidism, for instance, are identified as a heterogeneous population comprising both truly dysfunctional and truly euthyroid subjects.

    • Challenges in L-T4 Treatment: The assumption that a patient’s own pituitary gland is a reliable determinant for establishing the correct dosage of L-T4 treatment has been challenged. In athyreotic patients receiving L-T4, the intricate inter-relationships between FT3, FT4, and TSH are not rigidly fixed but are instead conditionally and homeostatically determined. Three significant phenomena have been observed in L-T4-treated patients:

        1. A dissociation between FT3 and FT4 concentrations.

        2. A discernible disjoint between TSH and FT3 levels. Approximately 15% of athyreotic patients may experience a chronically low-T3 state, even if their TSH levels are normalised.

        3. An L-T4-related conversion inefficiency. This means that increasing the L-T4 dose may not always resolve T3 deficiency and could, in fact, impede its attainment. Rodent models further suggest that these disequilibria may indicate widespread tissue hypothyroidism in various organs, despite normal TSH levels.

    • Re-evaluating TSH’s Role: The sources propose that the use of TSH, while valuable in certain situations, should be relegated to a supporting role that more accurately reflects its conditional interaction with peripheral thyroid hormones. It is underscored that the measurement and consideration of FT3 and conversion efficiency are equally important, especially in scenarios where TSH and FT3 levels diverge.

    • Need for Standardisation and New Biomarkers: The discussion around measuring free thyroid hormones is re-opened, and the identification of suitable biomarkers is encouraged. While TSH assays are traceable to a single WHO standard, methods for FT4 and particularly FT3 urgently require equivalent standardisation and harmonisation to play a clinically acceptable role within an integrated diagnostic concept.

    Summary and Future Outlook

    The concept of thyroid homeostasis offers fresh perspectives for optimizing the interpretation of thyroid function tests and mitigating the inappropriate diagnostic reliance on an isolated statistical interpretation of TSH. TSH is not considered a precise marker of euthyroidism nor is it optimal for fine-tuning thyroid control, and TSH levels defined for optimum health may not be applicable to many L-T4-treated patients. The observed disjoint between FT3 and TSH concentrations in athyreotic patients indicates that T4 monotherapy may be insufficient to adequately meet their therapeutic needs, as FT3 levels become unstably dependent on exogenous T4 supply.

    Homeostatic principles advocate for a more personalised approach to diagnosis and a consideration of thyroid function within a more conditional, adaptive context, thereby challenging the isolated interpretation and disease-defining value of TSH measurements. Future research should prioritise exploring multivariate reference limits, personalised set point reconstructions, and the additional clinical value of FT3 in defining thyroid status and assessing the adequacy of thyroid hormone replacement therapy. Furthermore, the potential adverse effects and long-term risks associated with the unphysiological FT3-FT4 ratio, FT3-TSH disjoint, and impaired deiodinase activity seen with current L-T4 replacement warrant careful investigation. This supports the potential role of combined T3 and T4 treatment for selected patients who exhibit poor conversion efficiency. It remains general good clinical practice to interpret laboratory test results in conjunction with a comprehensive clinical assessment of the patient’s history and symptoms.

    Hypothyroid treatment

    The sources indicate that while T3 is crucial for physiological processes, it is not as widely considered in hypothyroid treatment as TSH for several reasons, primarily stemming from historical diagnostic practices and the perceived limitations in its measurement and interpretation:

    • Historical Reliance on TSH: The discovery that pituitary Thyrotropin (TSH) responds inversely and with exaggerated sensitivity to underlying thyroid hormone concentrations greatly influenced clinical thyroid testing. This led to TSH becoming the central and dominant parameter in contemporary thyroid function testing, largely due to its ease of measurement and cost-effectiveness. The clinical community embraced TSH as a simple and efficient diagnostic tool, which inadvertently obscured the complex relationship between TSH and the hormonal milieu. It was widely assumed that the patient’s own pituitary gland would reliably determine the adequate dosage of L-T4 treatment, making TSH a sufficient target for therapy.

    • Complexity and Individuality of Homeostasis: The long-held, simpler concept of a log-linear relationship between TSH and Free T4 (FT4) has been challenged by more recent studies. Research now shows the TSH-FT4 relationship is curvilinear and damped in the middle portion of the euthyroid range, with steeper gradients at the extremes, allowing for a more flexible and robust defense of the thyroid state. TSH is understood to be an indirect measure and a controlling element, not a simple isolated statistical parameter. TSH values are highly individual; the same TSH value might be considered “normal” for one person but “pathological” for another. This individuality and the complex, conditional nature of thyroid homeostasis complicate relying solely on TSH as a precise marker of euthyroidism or for fine-tuning treatment.

    • Limitations in L-T4 Monotherapy and T3 Stability: In patients treated with L-Thyroxine (L-T4) monotherapy, the intricate inter-relationships between Free Triiodothyronine (FT3), FT4, and TSH are often not fixed as in healthy individuals but are conditionally determined. The sources highlight several issues in L-T4-treated patients:

        ◦ A dissociation between FT3 and FT4 concentrations.

        ◦ A discernible disjoint between TSH and FT3 levels. Approximately 15% of athyreotic patients (those without a thyroid gland) receiving L-T4 may experience a chronically low-T3 state, even if their TSH levels are normalised.

        ◦ An L-T4-related conversion inefficiency, meaning that increasing the L-T4 dose may not resolve T3 deficiency and could even hinder its attainment.

        ◦ Rodent models suggest that these observed disequilibria may indicate widespread tissue hypothyroidism in various organs (e.g., brain, liver, skeletal muscle) despite normal TSH levels.

        ◦ L-T4 treatment, which lacks the approximately 10% naturally secreted T3 component, is described as an “unphysiological treatment modality,” where homeostatic responses differ from normality.

        ◦ The quality of life for a substantial portion of hypothyroid patients on levothyroxine may be reduced, even with normal TSH levels.

    • Lack of Standardization for FT3 Measurement: While TSH assays are traceable to a single WHO standard, methods for FT4 and especially FT3 urgently require equivalent standardisation and harmonisation to be clinically acceptable in an integrated diagnostic concept. This lack of standardisation significantly limits the widespread clinical utility and reliability of FT3 measurements compared to TSH.

    • Limited Human Data on Tissue T3: There is a general lack of corresponding data on tissue T3 levels in humans, which hinders a full understanding of T3 adequacy at the cellular level despite circulating hormone levels.

    In light of these findings, the sources advocate for TSH to be scaled back to a supporting role, emphasizing that the measurement and consideration of FT3 and conversion efficiency are equally important, especially when TSH and FT3 levels diverge. This approach pushes for a more personalised and adaptive context for diagnosing and treating thyroid dysfunction, moving away from an isolated interpretation of TSH measurements.

    References:

    • Hoermann, R., Midgley, J.E.M., Larisch, R. and Dietrich, J.W. (2015) ‘Homeostatic Control of the Thyroid–Pituitary Axis: Perspectives for Diagnosis and Treatment’, Frontiers in Endocrinology, 6, p.177. doi: 10.3389/fendo.2015.00177.

        ◦ This primary source was instrumental in detailing the complexities of the thyroid-pituitary axis, the limitations of TSH as a sole diagnostic marker, and the issues arising from L-T4 monotherapy, particularly concerning T3 stability and conversion efficiency.

    • McAninch, E.A. and Bianco, A.C. (2014) ‘Thyroid hormone signaling in energy homeostasis and energy metabolism’, Annals of the New York Academy of Sciences, 1311, pp. 77–87. doi: 10.1111/nyas.12374.

        ◦ This source provided supporting context on the physiological roles of thyroid hormones, particularly T3, in energy homeostasis, cellular metabolism, and the activity of deiodinases at the tissue level, reinforcing the idea that T3’s actions are highly regulated at the cellular and organismal levels.

  • Academic Skills

    Gerard Stewart

    Whether you’re starting a research paper or polishing a university essay, understanding how to find and use credible academic sources is essential. By the end of this guide, you’ll have the tools to confidently navigate the world of academic research and referencing.

    1. What Makes a Source Credible?
      Not all sources are created equal. Credible sources are typically written by experts, backed by evidence, and published by reputable organizations or academic publishers. Learn to evaluate sources by asking:
    • Who is the author?
    • Is it peer-reviewed?
    • Is the information current and relevant?
    1. How to Find Reliable Academic Sources
      Knowing where to look is just as important as knowing what to look for. University libraries, online academic databases (like JSTOR, Google Scholar, or PubMed), and institutional repositories are great starting points. Understanding search strategies will help you find high-quality materials efficiently.
    2. Referencing: Getting It Right
      Referencing isn’t just about avoiding plagiarism—it’s about showing academic integrity and giving credit to others’ ideas. Whether you’re using APA, MLA, or Harvard style, consistency and accuracy are key. Learn the rules of your required citation style and apply them carefully throughout your work.
    3. Quoting, Summarising, and Paraphrasing: Know the Difference
      Quoting involves copying a passage word for word with quotation marks. Summarising means giving a brief overview of a larger text. Paraphrasing is rewording someone else’s idea in your own words. Each serves a different purpose, and knowing when to use which is essential for strong academic writing.
    4. How to Paraphrase Effectively
      Effective paraphrasing means more than just changing a few words—it’s about truly understanding the original idea and expressing it in your own voice. Practice by reading a passage, setting it aside, and then writing the idea in your own words. Always follow up with proper citation.

    By mastering these skills, you’ll not only improve your academic writing but also build confidence in your ability to research and engage critically with scholarly material.

  • Dupuytren’s Contracture: Recurrence, Outcomes, and Future Directions

    Edith Renata

    Lets start with definition

    Dupuytren’s contracture (DC) is a progressive fibroproliferative disorder of the palmar fascia, characterized by nodules, cords, and eventual flexion contractures of the fingers. Its management presents persistent challenges—not only due to its progressive nature but also because of the variability in treatment outcomes and recurrence definitions. Recent research has aimed to clarify these issues, contributing to more standardized clinical care.

    Dupuytren’s contracture is named after Baron Guillaume Dupuytren (1777–1835), a renowned French surgeon. He was the first to describe and surgically treat the condition in detail in 1831.

    How Dupuytren's Contracture Affects the Hand

    Figure 1 Trigger finger from Dupuytren’s (Rella, 2019)

    Using the Delphi method, a structured communication process, an international panel of 21 experts from ten countries defined recurrence as:

    “An increase in joint contracture in any treated joint of at least 20 degrees at one year post-treatment compared to six weeks post-treatment”

    How to recognize it

    Key features of this definition include:

    • Focus on angular measurement (contracture) rather than the presence of nodules or cords.
    • Use of the six-week post-treatment measurement as a baseline, rather than intraoperative metrics.
    • Emphasis on joint-specific recurrence rather than global recurrence across the hand.
    • This provides a more objective and reproducible benchmark for comparing treatment modalities and enables clinicians to better understand long-term outcomes.

    One of the most critical developments in the field has been the consensus-based definition of recurrence, presented by Kan et al. in PLOS ONE (2017). Historically, recurrence rates for DC have varied dramatically across studies—from as low as 0% to nearly 100%—due in large part to the lack of a unified definition.

    A recent letter published in the New England Journal of Medicine critically examined the trial results from Dias et al., which compared collagenase injections with limited fasciectomy. The trial had concluded that collagenase was “not noninferior” to surgery, prompting debate.

    In response, Blazar and Atroshi argued that:

    • Collagenase injections showed superior short-term functional outcomes.
    • Surgeons had more experience with surgery than with collagenase, possibly biasing results.

    While recurrence rates were similar (17.2% for collagenase vs. 13.8% for surgery), reintervention was higher in the collagenase group—possibly due to differing thresholds for action, rather than actual treatment failure.

    Moreover, the complication profile favored collagenase:

    • Surgery carried risks including nerve damage (14.2%), infection, CRPS, and even amputation.
    • In contrast, collagenase avoided many of these risks and required less downtime from work or daily activities.

    The Importance of Accurate Diagnosis

    Another key point raised by Rayan and Porembski is the potential misclassification of non-Dupuytren’s palmar fibromatosis as Dupuytren’s disease in clinical trials. Non-Dupuytren’s fibromatosis:

    • Lacks genetic predisposition
    • Is often non-progressive
    • May not recur after treatment

    Their concern is that inclusion of such patients may artificially skew trial outcomes, particularly recurrence and complication rates.

    With a standardized recurrence definition and more comparative data on treatments, clinicians can now better tailor interventions to individual patient needs. However, challenges remain:

    • There is still no objective biomarker or imaging standard to detect early recurrence.
    • Long-term data comparing treatments beyond the 1-year mark is limited.
    • Patient-reported outcomes, while valuable, are still underutilized in determining success.

    As the field continues to evolve, studies like Kan et al.’s consensus on recurrence and the ongoing debates around collagenase efficacy and diagnosis accuracy reflect a broader move toward evidence-based, patient-centered care in Dupuytren’s disease. By aligning treatment goals, recurrence definitions, and patient expectations, we move closer to more consistent and meaningful outcomes.

    References:

    Blazar P, Atroshi I. Letter to the Editor. N Engl J Med. 2025;392(4):414–416. DOI:https://doi.org/10.1056/NEJMc2415164.

    Bumbasirevic, M., Palibrk, T., Lesic, A. and Djurasic, L. (2011). Baron Gijom Dipitren, Guillaume Dupuytren (1777-1835). Acta chirurgica iugoslavica, 58(3), pp.15–19. doi:https://doi.org/10.2298/aci1103015b.

    Kan, H.J., Verrijp, F.W., Hovius, S.E.R., van Nieuwenhoven, C.A. and Selles, R.W. (2017). Recurrence of Dupuytren’s contracture: A consensus-based definition. PLOS ONE, 12(5), p.e0164849. doi:https://doi.org/10.1371/journal.pone.0164849.

    Lurati, A.R. (2017). Dupuytren’s Contracture. Workplace Health & Safety, 65(3), pp.96–99. doi:https://doi.org/10.1177/2165079916680215.

    Rella, M. (2019). Dupuytren’s Contracture: Treatment Options You Need to Know About. [online] CreakyJoints. Available at: https://creakyjoints.org/living-with-arthritis/treatment-and-care/medications/dupuytrens-contracture-treatment/ [Accessed 23 Jun. 2025].

  • The Unsung Hero of Learning: Why Tests and Quizzes are More Than Just Assessments

    Justine Smith

    In the realm of education, tests and quizzes are often viewed primarily as evaluative tools – instruments to measure student comprehension or gauge teaching effectiveness. However, a growing body of psychological research consistently demonstrates that testing is a powerful intervention that actively enhances learning, a phenomenon termed “the testing effect” or “test-enhanced learning”. This systematic review integrates findings from hundreds of studies, revealing the profound importance of incorporating retrieval practice into classroom settings, not merely as a means of assessment, but as a fundamental learning strategy.

    The Robust Impact of Retrieval Practice

    Over the last century, numerous studies have shown that engaging in retrieval practice – actively recalling information from memory, often through quizzes or tests – significantly boosts long-term retention of studied knowledge and facilitates the mastery of new information. Compared with passive strategies like re-reading or concept mapping, testing proves to be a more effective approach. A comprehensive meta-analysis involving data from 48,478 students across 222 independent studies concluded that overall, testing (quizzing) raises student academic achievement to a medium extent (g = 0.499). This is a noteworthy effect, considering that in educational interventions, an effect size of 0.20 standard deviations is often considered large.

    The benefits of testing are particularly evident for long-term retention, with studies consistently showing greater recall after longer intervals (e.g., a week or more) when testing is employed, compared to repeated studying. This “backward testing effect” consolidates previously studied information, making it a robust phenomenon across various educational materials and settings, from laboratory experiments to real classrooms.

    Beyond Rote Memorisation: Fostering Deeper Learning and Transfer

    A common criticism levelled against testing is that it acts as a “drill-and-kill” strategy, only promoting “inert knowledge” that cannot be applied to new problems. However, research refutes this narrow view. The findings indicate that testing is not solely beneficial for remembering facts but also promotes conceptual learning and facilitates knowledge application in problem-solving scenarios. For instance, it can enhance comprehension by encouraging knowledge organisation and integration, and support knowledge transfer to aid in solving new problems in unfamiliar contexts.

    Moreover, the “testing effect” can transfer to untested knowledge, meaning that quizzing on some material can also benefit the retention of related, untried information. This transferability is particularly relevant in classrooms where lecture content and textbook sections are often semantically coherent.

    The Critical Role of Feedback and Repetition

    The effectiveness of testing is significantly amplified by the provision of corrective feedback. Studies show that offering feedback following quizzes significantly increases learning gains compared to not providing it. This is because feedback provides additional exposure to the correct information and helps learners rectify their misunderstandings. Interestingly, delayed feedback can sometimes be even more beneficial than immediate feedback, as it prompts the learner to retrieve their original thought process, which further strengthens memory.

    Furthermore, the number of test repetitions matters: there is a positive relationship between the frequency of testing and learning gains, indicating that the more often class content is quizzed, the greater the learning benefits. Multiple retrieval opportunities, especially when spaced over time and across various contexts, lead to superior long-term retention compared to a single test.

    Tests as Catalysts for Future Learning: The Forward Testing Effect

    Beyond consolidating past learning, testing also possesses a “forward testing effect,” whereby testing on studied information can facilitate the acquisition of new, subsequent information. This occurs because interim testing can influence focused attention, reduce mind-wandering, and improve the integration of information during subsequent learning sessions. It can also prime students to activate relevant mental models and identify key concepts to focus on during instruction. This effect is noted across various educational materials and age groups, emerging early in human life.

    Flexibility in Format and Context

    The benefits of test-enhanced learning are not confined to a single format or setting. Testing generalises across a variety of test formats, including matching, fill-in-the-blank, short answer, multiple-choice, cued recall, and free recall, with different formats offering comparable benefits depending on the context. For instance, while some theories suggest more effortful recall tests should be superior, recognition tests (like multiple-choice) have been shown to be equally effective, sometimes even improving recall for untested, related information. This is practically significant, as multiple-choice questions are often quicker to administer and score, especially with technology.

    Similarly, the mode of administration (e.g., paper-and-pen, clicker response systems, online platforms) does not significantly modulate the testing effect, implying that the benefits stem from the act of retrieval itself rather than the specific technology used. The location of administration also matters: quizzes administered in the classroom tend to be more beneficial than those taken outside, likely due to instructor supervision and mandatory engagement. Furthermore, post-class quizzes are more effective at enhancing learning than pre-class quizzes.

    Importantly, test-enhanced learning is effective across all levels of education – from elementary school to university/college – and generalises across a wide range of academic subjects. This highlights its broad applicability in diverse educational contexts.

    Addressing Concerns: Low-Stakes, Motivation, and Individual Differences

    Despite the clear advantages, testing often faces resistance due to concerns about test anxiety and the perception that it is burdensome. However, research indicates that low-stakes or no-stakes quizzes are crucial for promoting learning without inducing excessive anxiety. Such practice tests can be framed as learning opportunities, alleviating pressure and allowing students to focus on the retrieval process. Indeed, low-stake interim testing has been shown to minimally influence test anxiety, and some findings even suggest that frequent tests can reduce test anxiety over time.

    Testing also plays a vital role in motivation and metacognition. Frequent tests can motivate learners to sustain or enhance their study efforts, provide diagnostic feedback on learning gaps, and induce higher test expectancy. Crucially, testing helps students develop more accurate assessments of what they know and don’t know, improving their metacognitive awareness.

    Concerns that testing might exacerbate individual differences in academic performance are also mitigated by evidence. Studies suggest that students with lower working memory capacity or inferior learning abilities can benefit equally or even more from retrieval practice than those with high ability, potentially narrowing rather than widening achievement gaps. Furthermore, male and female students appear to benefit from testing to a comparable extent.

    The Underlying Mechanisms

    The efficacy of test-enhanced learning is supported by three main theoretical accounts:

    • Additional Exposure: Testing, especially with corrective feedback, provides re-exposure to the learned material, which aids retention.

    • Transfer-Appropriate Processing: The similarity of mental operations required during initial tests and final assessments enhances recall performance.

    • Motivation: Frequent testing motivates learners to invest more effort in subsequent learning, leading to improved outcomes.

    While the “retrieval effort” theory (suggesting that more difficult retrieval tasks lead to greater benefits) has received mixed support in classroom settings, the other three theories consistently provide a robust explanation for the observed effects.

    Practical Recommendations for a Learning-Centric Classroom

    The implications of this research are clear and offer concrete strategies for educators and students alike:

    For Course Designers:

    • Incorporate frequent, low-stakes quizzes throughout the course, using various formats (multiple-choice, short-answer, fill-in-the-blank) to provide regular retrieval practice.

    • Provide corrective feedback promptly after quizzes to enhance learning gains and clarify misconceptions.

    • Design cumulative assessments that include prior material, spacing out practice to improve long-term retention.

    • Utilise pretesting before new units to prime students’ learning and highlight key concepts.

    • Dedicate time at the end of lectures for students to recall and articulate key points (e.g., “minute papers” or the PUREMEM method).

    • Employ questioning techniques in class that allow for sufficient “wait time” (3-5 seconds) for all students to retrieve information, or use cooperative learning activities like “think-pair-share” to engage more learners.

    • Communicate the benefits of testing to students explicitly, helping them understand that tests are learning tools, not just evaluative measures.

    For Students:

    • Engage in self-testing regularly using flashcards, practice questions, or by trying to recall information without looking at notes.

    • Space out study sessions over time rather than cramming, and interleave different topics during practice.

    • Seek and utilise feedback on practice tests to identify and address knowledge gaps.

    • Actively try to retrieve information during study, even if it feels more difficult than re-reading.

    In conclusion, the evidence overwhelmingly supports the notion that testing is an indispensable learning tool. By embracing quizzes and tests as integral components of the learning process, educators can significantly enhance student attainment, foster deeper understanding, and cultivate lasting knowledge, transforming the classroom into a more effective and engaging learning environment.

    References:

    Brame, C.J. and Biel, R. (2015). Test-Enhanced Learning: The Potential for Testing to Promote Greater Learning in Undergraduate Science Courses. CBE—Life Sciences Education, [online] 14(2), p.es4. doi:https://doi.org/10.1187/cbe.14-11-0208.

    Yang, C., Luo, L., Vadillo, M.A., Yu, R. and Shanks, D.R. (2021). Testing (quizzing) boosts classroom learning: A systematic and meta-analytic review. Psychological Bulletin, [online] 147(4), pp.399–435. doi:https://doi.org/10.1037/bul0000309.

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