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  • Can antidepressants prevent the onset of persistent pain following acute musculoskeletal injuries?

    Tolerability and efficacy of duloxetine for the prevention of persistent musculoskeletal pain after trauma and injury: A pilot three-group randomized controlled trial. Beaudoin, F. L., Gaither, R., DeLomba, W. C. and McLean, S. A. (2022) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic Topic: Duloxetine - Acute musculoskeletal pain This is a pilot randomised double-blind placebo-controlled trial assessing the tolerability and efficacy of duloxetine (an antidepressant) in reducing the likelihood of pain. A total of 65 participants completed the study. Participants were recruited in the emergency department and were randomised to receive either a placebo pill, 30 mg, or 60 mg of duloxetine per day for two weeks. Tolerability was assessed by determining the number of participants reporting side effects and comparing them between placebo and active drugs. Pain intensity was assessed on the numerical rating scale. Participants were followed up for six weeks. The results showed that there was no difference in adverse events across groups. For pain intensity, there was a statistically significant but not clinically relevant difference between the 60 mg duloxetine and placebo groups. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, 60 mg/daily of duloxetine for 2 weeks does not appear to provide clinically relevant benefits over placebo alone for people with acute musculoskeletal injuries. There is a trend favouring duloxetine over placebo, however, future studies powered for effectiveness need to be completed before routinely prescribing this medication in clinical practice. Considering that depression and anxiety are common after elbow/wrist/hand/finger injury, it is possible that duloxetine may be appropriate for a subgroup of patients. URL: https://doi.org/10.1097/j.pain.0000000000002782 Abstract This study investigated the tolerability and preliminary efficacy of duloxetine as an alternative nonopioid therapeutic option for the prevention of persistent musculoskeletal pain (MSP) among adults presenting to the emergency department with acute MSP after trauma or injury. In this randomized, double-blind, placebo-controlled study, eligible participants (n = 78) were randomized to 2 weeks of a daily dose of one of the following: placebo (n = 27), 30 mg duloxetine (n = 24), or 60 mg duloxetine (n = 27). Tolerability, the primary outcome, was measured by dropout rate and adverse effects. Secondary outcomes assessed drug efficacy as measured by (1) the proportion of participants with moderate to severe pain (numerical rating scale ≥ 4) at 6 weeks (pain persistence); and (2) average pain by group over the six-week study period. We also explored treatment effects by type of trauma (motor vehicle collision [MVC] vs non-MVC). In both intervention groups, duloxetine was well tolerated and there were no serious adverse events. There was a statistically significant difference in pain over time for the 60 mg vs placebo group (P = 0.03) but not for the 30 mg vs placebo group (P = 0.51). In both types of analyses, the size of the effect of duloxetine was larger in MVC vs non-MVC injury. Consistent with the role of stress systems in the development of chronic pain after traumatic stress, our data indicate duloxetine may be a treatment option for reducing the transition from acute to persistent MSP. Larger randomized controlled trials are needed to confirm these promising results. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • What is the differential diagnosis for this posterior elbow pain?

    Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. The patient was a 25 years old, who presented with sudden onset of left elbow swelling and pain whilst performing resisted elbow extension exercises at the gym. Active range of movement of the elbow was possible and there was no obvious deformity. There was tenderness on palpation across the whole elbow. X-rays are shown below. What is it?

  • Botulinum for Raynaud's phenomenon: Does it help?

    Botulinum toxin for the treatment of intractable raynaud phenomenon. Gallegos, J. E., D. C. Inglesby, Z. T. Young and F. A. Herrera (2020). Level of Evidence: 4 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Therapeutic Topic: Raynaud's phenomenon - Botox This is narrative review on the use of botulinum injection therapy in people with Raynaud's Phenomenon (RP). This condition is characterised by painful vasocontriction of vessels within the hand, which may lead to ulceration and digit loss in severe cases (see picture below). Several vasodilation medications have been trialled with varies degrees of success. These medications appear to counteract the excessive sympathetic activity leading to vasocontriction. Botulinum toxins injections have been trialled in small studies and appear to be effective in clients who do not respond to more traditional pharmacological approaches. It has been suggested that Botulinum toxin injections are effective in RP by preventing the recruitment of vessels' smoot muscles. Following a Botulinum injection, follow ups should be completed at 1, 3, 6 months. Common transient complications include pain at the site of injection and intrinsic muscle weakness. Rare complications may include generalised muscle weakness, dyaphagia, troubles breathing, and fatigue. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, Raynaud's phenomenon unresponsive to mainstream medical management may benefit from Botulinum toxin injections. It is important to monitor potential complications such as intrinsic muscle weakness through grip strength after these injections (50% of grip strength comes from the intrinsic muscles of the hand) and reassure clients about this transient impairment. Other rare symptoms include difficulty breathing and they require urgent medical attention. URL: https://doi.org/10.1016/j.jhsa.2020.07.009 Abstract Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Is eccentric training the best treatment for tennis elbow?

    Stop using eccentric exercises as the gold standard treatment for the management of lateral elbow tendinopathy. Stasinopoulos, D. (2022) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Eccentric training - Tennis elbow This is an expert opinion on tennis elbow treatment. The author suggests that there are other beneficial treatments beyond eccentric training. These include resistance training approaches involving concentric and isometric exercises. In addition, they suggest that full kinetic chain exercises should be utilised (e.g. shoulder resistance training). Considering that proprioceptive impairments have been identified in people with lateral epicondylalgia, they also suggest utilising position sense training. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, there is a reasonable amount of research suggesting that any form of resistance training is beneficial for tennis elbow. In addition, the use of other interventions such as blood flow restriction training may be useful in the treatment of this condition. Proprioception training may also be useful in the early stages of tennis elbow as it has been found to be impaired compared to healthy controls. Upper limb resistance training including the shoulder has been trialled in people with lateral epicondylalgia but does not appear to provide better outcomes than isolated elbow exercises. If you are interested in more research about tennis elbow, have a look at the full tennis elbow database. URL: https://doi.org/10.3390/jcm11051325 No Abstract available publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • What are the risk factors for re-rupture of flexor tendon repair?

    Risk factors for reoperation after flexor tendon repair: A registry study. Svingen, J., Wiig, M., Turesson, C., Farnebo, S. and Arner, M. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Prognostic Topic: Flexor tendon repair - Factors associated with re-rupture This is a retrospective study assessing factors associated with re-rupture of flexor tendon following repair of zone I-III. A total of 1,372 participants were included. The variables recorded included age, sex, type of injury, time between injury and surgery, income, educational level, type and number of fingers involved. Details about post-surgical rehabilitation were missing from 60% of the cohort. Of those who had recorded post-surgical rehabilitation, more than 70% of participants underwent early mobilisation, whilst 20% underwent early passive mobilisation. The remaining 10% had a variable post-surgical rehabilitation. Reoperation for tendon rupture occurred in 6% of cases and greater odds of rupture were associated with being male, being older than 25, and having lesions of both FDS and FDP, or FPL. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, being male, older than 25, and having injured both FDS and FDP, or FDL increases the likelihood of a re-rupture following flexor tendon repair zone I-II. In addition, existing evidence suggests that greater social deprivation is associated with worse outcomes for our clients. Knowledge of these factors provides us with opportunities to provide better care for our patients. URL: https://doi.org/10.1177/17531934221101563 Abstract The aim of this study was to identify risk factors for reoperations after Zones 1 and 2 flexor tendon repairs. A multiple logistic regression model was used to identify risk factors from data collected via the Swedish national health care registry for hand surgery (HAKIR). The studied potential risk factors were age and gender, socio-economics and surgical techniques. Included were 1372 patients with injuries to 1585 fingers and follow-up of at least 12 months (median 37 IQR 27–56). Tendon ruptures occurred in 80 fingers and tenolysis was required in 76 fingers. Variables that affected the risk of rupture were age >25 years (p < 0.001), flexor pollicis longus tendon injuries (p < 0.001) and being male (p = 0.004). Injury to both finger flexors had an effect on both rupture (p = 0.005) and tenolysis (p < 0.001). Understanding the risk factors may provide important guidance both to surgeons and therapists when treating patients with flexor tendon injuries. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Are depression and anxiety common after hand injury?

    Psychological sequelae of hand injuries: An integrative review. Maddison, K., Perry, L. and Debono, D. (2022) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Symptoms prevalence Topic: Psychological results of hand injuries - Depression and anxiety This is a narrative review assessing the prevalence and risk factors for depression and anxiety following hand injuries. A total of nine articles with retrospective and prospective designs were included. Only participants with injuries from the elbow down were included. Of those presenting with depression 15-30% presented with severe symptoms. Depression tended to resolve in 50% of cases in the subacute stage. Anxiety was reported in 15-40% of people after injury. Factors that appeared to be associated with depression and anxiety were pain intensity, persistent pain, reduced social function, and unemployment. One of the limitations of the studies included was the lack of a control group assessing the presence of anxiety and depression in people without hand injuries. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, depression and anxiety are common post elbow/wrist/hand/finger injury. There is also an association between these psychological factors and pain intensity, persistent pain, and social participation. We also know that given the same type of injury, greater levels of depression significantly increase levels of pain. Acknowledging these issues and providing patients with as much advice as possible (e.g. taking part in regular exercise) may help them cope with their recovery. If you are interested in the effects of mental health on upper limb injury and recovery, have a look at the full database. URL: https://doi.org/10.1177/17531934221117429 Abstract This integrative review investigated reports of psychological impact and sequelae of traumatic hand injuries. A systematic search using Medline, PsychINFO, PubMed, EMBASE, CINAHL and hand-searching methods was conducted from 2008 to 2020. Nine included articles with a total of 503 participants were reported in prospective cross-sectional or longitudinal cohort studies. Depression and anxiety were common, affecting between 7% and 71% and between 23% and 71% of patients, respectively. Post-traumatic stress disorder affected between 3% and 95% of patients. Factors reported predicting psychological sequelae of hand injuries included injury severity, pain, limb dysfunction, negative perceptions of injured limbs, suboptimal coping mechanisms and limited social support. Symptoms persisted for protracted periods of follow-up but broadly attenuated after 3 months. We conclude that the high prevalence and enduring nature of psychological symptoms demonstrate an urgent need for further research to optimize treatment. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Can a fatiguing test be useful when assessing myotomes?

    Does your bedside neurological examination for suspected peripheral neuropathies measure up? Bender, C., Dove, L. and Schmid, A. B. (2022) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Diagnostic Topic: Neurological testing - Peripheral neuropathies This is an expert opinion on neurological testing for peripheral neuropathies. Six recommendations are provided based on the available evidence: 1 - Assess light touch sensation in the upper limb in a circular pattern. This will allow you to differentiate between a dermatomal vs a peripheral nerve numbness presentation. 2 - Test small fibre neuropathy through pin-prick in a circular pattern 3 - If there are motor or sensory deficits in both upper limbs, do not consider that "normal". 4 - When performing myotome testing, fatigue may incur more quickly in the affected muscles compared to other myotomes. Instead of a single maximal strength test, repeated testing may be required. 5 - Reflex testing is independent of patients' pain, use them. 6 - Monitor progress/deterioration as accurately as possible. Have a look at: Video 2 for sensory testing Video 5 for motor and reflex testing Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, light touch, pin-prick, myotomes, and reflex testing may be useful in the assessment of people with peripheral neuropathies. Light touch, myotome, and reflex testing assess the gross integrity of nerves and they may be affected when there are moderate/large entrapment neuropathies. If the entrapment is mild, you may only identify impairments on pin-prick (small fibre neuropathy). Pin-prick can be easily tested with a neuropen, which consistently delivers 40g of pin-prick (This is what I use in the clinic). If clients report muscle fatigue and you are testing myotomes, you may want to perform a few repetitions and compare their endurance to unaffected muscles of the same limb. In terms of dermatomes remember that they are inconsistent across people and the best you could do is differentiate between a radicular presentation vs a peripheral nerve entrapment. URL: https://doi.org/10.2519/jospt.2022.11281 Abstract Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination, and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits, but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our viewpoint is based on neuroscientific principles. We highlight six challenges for clinicians when conducting neurological examinations, and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Freshwater and saltwater lacerations, are they at high risk of infection?

    Rapidly progressive soft tissue infection of the upper extremity with aeromonas veronii biovar sobria. Lujan-Hernandez, J., Schultz, K. S., & Rothkopf, D. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Diagnostic/Therapeutic Topic: Freshwater laceration – Infection This is a case report on Aeromonas infection following a laceration in fresh water. The patient was a 20 years old male who had been experiencing pain in the forearm following a laceration injury while swimming in a freshwater reservoir. They were not immunocompromised and the injury had been treated in ED a few hours (2 hrs) prior to the worsening of symptoms. Objectively, they presented with pain in the distal forearm, erythema around the wound site, pain with passive wrist extension, and purulent discharge from the wounds attended two hours prior. They had no fever. X-ray investigations revealed a small air sack within the volar forearm. Blood tests revealed the presence of a high white blood cells count. The patient was immediately treated with a wide-spectrum series of antibiotics and went through two washouts with the wound left open for primary healing. The symptoms resolved after a few weeks of discharge and there were no hand or upper limb impairments at 6 or 12 months. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, lacerations or wounds contaminated with fresh or saltwater should be followed closely. This is particularly true for those clients working/spending time in high-risk environments (e.g. fisherman, aquarist). The risk of severe repercussions if an infection is not treated is high. Post-washout we should monitor our smoking/diabetic clients as they are at greater risk (15-20%) of developing an additional infection. X-rays and US are the primary investigations to be utilised if suspecting an infection. URL: https://doi.org/10.1016/j.jhsa.2020.02.003 Abstract Aeromonas veronii, a bacterium found in freshwater, is an unusual pathogen in healthy patients. We present a case report of a rare, aggressive subtype in a young, immunocompetent individual. History of injury in an aquatic environment and culture data are key for identification of the causal agent and should dictate acute clinical management and antibiotic therapy. Coverage should include cephalosporins, quinolones, or sulfas if Aeromonas is suspected, and adjusted depending on culture and sensitivity. Early surgical exploration, incision and drainage, and appropriate antimicrobial therapy are the cornerstones for successful treatment of these aggressive, sometimes life-threatening infections. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Are people with normal nerve conduction studies less likely to benefit from carpal tunnel surgery?

    Carpal tunnel decompression in patients with normal nerve conduction studies. Mackenzie, S. P., et al. (2020) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Prognostic Topic: Carpal tunnel decompression – Outcomes in patients with and without nerve conduction impairments This study assessed the effectiveness of carpal tunnel decompression in patients with and without objective impairments on median nerve conduction studies (NCS). Changes in function were assessed through the QuickDASH before and after surgery. Patients were selected for surgery only if they clinically presented with the following three characteristics: paraesthesia in the median nerve distribution at the hand, positive Tinel’s and/or Phalen’s test, and symptoms reduction after a steroid injection. The results showed that both groups of patients presented with clinically and statistically significant improvements at one year on the QuickDASH questionnaire. There was no clinically significant difference between groups in function. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, median nerve impairments identified by nerve conduction study may not predict clinical improvements following carpal tunnel decompression. We can therefore reassure our patients that at one-year post carpal tunnel release, they are likely to experience notable improvements independently of their test results. Did you know that the presence of carpal tunnel syndrome is largely influenced by genetics? If you would like to know more about carpal tunnel syndrome assessment and treatment, head over to the database. URL: https://doi.org/10.1177/1753193419866646 Abstract Some patients present with typical clinical features of carpal tunnel syndrome despite normal nerve conduction studies. This study compared the preoperative and 1-year postoperative QuickDASH scores in patients with normal and abnormal nerve conduction studies, who underwent carpal tunnel decompression. Of the 637 patients included in the study, 19 had clinical features of carpal tunnel syndrome but normal nerve conduction studies, and underwent decompression after failure of conservative management. Preoperative QuickDASH scores were comparable in both groups (58 vs 54.8). However, there were significant differences between the normal and abnormal nerve conduction study groups in the QuickDASH at 1 year (34.9 vs 21.5) and change in QuickDASH postoperatively (23.1 vs 33.4). Patients with normal nerve conduction studies had comparable preoperative disability scores compared with those with abnormal studies. Although they had a significant improvement in QuickDASH at 1 year, this was significantly less than those with abnormal nerve conduction studies. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Answer - What is the differential diagnosis for this ulnar-volar wrist pain?

    Posttraumatic arthrosis and triquetral nonunion associated with pisotriquetral subluxation in adolescent female softball players. Wallace, D. R. and Floyd, W. E. (2022) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic/Therapeutic This is the answer to last week's Sherlock Handy. The patient was a 19 years old, right-handed, female softball player. They had been gradually developing pain since a fall onto an outstretched hand seven years prior. Despite a course of conservative management that included hand therapy and six weeks of casting, they had been unable to return to batting. Objectively, they presented with pain at the pisotriquetral joint. X-rays are shown below. Surgery was performed and intraoperatively there was evidence of pisotriquetral osteoarthritis associated with a triquetrum fracture non-union. A pisiform excision was performed. Three months post-surgery, the patient was back playing softball without pain and remained asymptomatic at the two years follow-up. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical take home message: Based on what we know today, pisotriquetral impaction syndrome may be the result of an old fracture of the pisiform/triquetrum. This presentation may be associated with pisotriquetral osteoarthritis even in young clients. If conservative treatment fails, pisiform excision may be a useful treatment. If you are interested in another case of ulnar-sided wrist pain, have a look at this synopsis. URL: https://doi.org/10.1016/j.jhsa.2021.07.032 Abstract Impaction fracture subluxation of the pisotriquetral joint producing arthrosis and ulnar triquetral osteochondral nonunion is a cause for ulnar wrist pain in batting athletes. Two cases of adolescent female softball players managed successfully with pisiform and triquetral fragment excision are reported. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Early vs delayed motion following scapholunate ligament repair: Is it feasible?

    Is early active motion after 3-ligament tenodesis noninferior to late active motion? A prospective, multicenter cohort study. Bakker, D., et al. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Scapholunate repair - Delayed vs early mobilisation This is a quasi-experimental (no randomisation) study assessing the effect of early vs delayed mobilisation following scapholunate ligament repair. A total of 108 participants were included and outcomes assessed included upper limb function, pain, range of movement, grip strength, and complications. The early mobilisation group was casted for 3-5 days followed by 24/7 wrist splint wearing and gentle wrist range of movement exercises from week 2 post-surgery. The delayed mobilisation group was casted for 10-16 days followed by 24/7 wrist splint wearing and gentle wrist range of movement exercise from week 5-6 post-surgery. The results showed that there were no differences between groups on function, pain, range of movement, grip strength, or complications at three months. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, early mobilisation of scapholunate repair is feasible and is not associated with worse outcomes. Considering that early mobilisation may provide additional benefits to our clients, it is worth considering as an alternative. If you are interested in outcomes associated with early vs delayed scapholunate repair, have a look at this other synopsis. Open Access URL: https://doi.org/10.1016/j.jhsa.2022.07.002 Abstract Purpose: If early active motion after 3-ligament tenodesis is safe, it may yield more patient comfort and an early return to activities. Therefore, the aim of this study was to investigate whether early active motion is noninferior to late active motion after 3-ligament tenodesis for scapholunate interosseous ligament injuries. Methods: This prospective, multicenter cohort study, using a noninferiority design with propensity score matching, compared a late active motion protocol (immobilization for 10–16 days, wrist therapy in weeks 5–6) with an early active motion protocol (immobilization for 3–5 days, wrist therapy during week 2). Patients who were older than 18 years, had complete baseline information on demographics, and underwent 3-ligament tenodesis were included. The outcome measures were postoperative Patient-Reported Wrist/Hand Evaluation scores, pain, complications, return to work, range of motion, grip strength, and satisfaction with treatment results at 3 months of follow-up. Results: After propensity matching, a total of 108 patients were included. Patient-Reported Wrist/Hand Evaluation and pain scores during physical load following an early active motion protocol were noninferior compared with scores following a late active motion protocol. Furthermore, early active motion did not lead to an increase of complications, differences in range of motion or grip strength, or less satisfaction with the treatment result. An earlier return to work was not observed. Conclusions: Early active motion leads to noninferior results without more complications as compared with late active motion. Based on these findings, early active motion can be considered safe, and might be recommended due to its potential benefits compared with late active motion after 3-ligament tenodesis. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Have you ever heard of the "Cobra" view for US imaging of the elbow?

    Elbow ultrasound. Pierce, J. L. and Nacey, N. C. (2016) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic Topic: Ultrasound imaging – Elbow This is an expert opinion on different ultrasound (US) imaging techniques available to scan the elbow. One of the most interesting appears to be the "cobra" position which is obtained by asking the client to flex the elbow and pronate the forearm while scanning the proximal dorsal forearm in a transverse plane. Pronation and supination of the forearm will reveal the appearance and disappearance of the distal biceps tendon respectively. This approach can be utilised to identify tendinopathies of the distal biceps tendon or partial/full distal biceps tears. Other imaging views can assess the lateral, medial, and posterior aspects of the elbow. Notable pathologies that can be assessed with US include tennis/golfer's elbow, triceps tears, and nerve entrapment lesions due to musculoskeletal or space-invading lesions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the "cobra" position may be useful in US imaging assessment of the distal biceps tendon. This position and imaging approach is similar to what has been described in the biceps palpation-rotation test to assess the presence of distal biceps tendinopathies/partial tears. Another test that can be quite useful to identify the integrity of the distal biceps is the hook test. Unfortunately, like many other orthopaedic tests for the elbow, we don't have information regarding their diagnostic accuracy. If you like to read more about pathologies/assessment/treatment of the distal biceps tendon, have a look at the full database. URL: https://doi.org/10.1007/s40134-016-0182-8 Abstract Purpose of the Review: With high-resolution real-time and dynamic imaging capabilities, ultrasound is an excellent imaging modality for the evaluation of the elbow. With the foundational understanding of elbow anatomy and pathology, ultrasound of the elbow can positively impact clinical care with both diagnostic examination and image-guided injections and treatments. Recent Findings: Although there is a learning curve and image quality is operator-dependent, knowledge of proper patient positioning, ultrasound technique, and tips for eliminating common pitfalls will significantly make an impact on performing and interpreting elbow ultrasound. Summary: Elbow ultrasound is an excellent modality for the diagnosis of elbow joint pathology and image-guided injections and treatments. By understanding the anatomy and learning scanning techniques, ultrasound of the elbow can provide integral clinical value. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

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