Search Results

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

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

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

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 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 recent 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. What is it?

Driving performance following a wrist fracture: A pilot study using a driving simulator Stinton, S., Pappas, E., Edgar, D., & Moloney, N. (2019) Level of Evidence: 3b Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Preventative Topic: Return to driving - Radius fracture ORIF This is a pilot study assessing patients' fitness to drive after a distal radius fracture. All distal radius fractures were treated through open reduction and internal fixation (ORIF). The ORIF group (n = 6) was compared to a healthy uninjured group (n = 16). All the participants were assessed through a driving simulator. The ORIF group was assessed at two time points (5/52 and 7/52 post surgery) while the control group was assessed at one time point only. The results of this study need to be considered in the context of a few limitations. The sample size was small and it is possible that a larger study would provide different results. In addition, the validity of the driving simulator has not been assessed and we are not sure whether the results obtained from this test are able to identify people at higher risk of a car accident. At the first assessment point (5/52 post surgery), the results showed that the ORIF group spent a greater proportion of time out of their lane (ORIF: 13% vs Control: 0.2%), which represents a risky driving behaviour. Also at the first assessment point (5/52 post surgery), the time spent over the speed limit was lower for the ORIF group (3%) compared to the control group (16%), suggesting that the ORIF group had a safer driving behaviour. At the second assessment point (7/52 post surgery), the ORIF group was no different compared to the control group, suggesting that their driving behaviour had normalised. 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, five weeks after distal radius fracture ORIF, patients are slower and less accurate in keeping to their lane when driving compared to their peers. At seven weeks, such differences no longer existed. We should therefore encourage our patients to practice driving in a safe environment (e.g. empty parking lot) before driving on the road, which may help in improving car control. In addition, patients may check with their insurance company requirements before engaging in driving. Open Access URL: https://doi.org/10.1177/1758998319887526 Abstract Introduction: Driving performance, as assessed using a driving simulator, after distal radius fracture has not been previously studied. Our aims were to undertake a pilot study to assess feasibility via: (i) acceptability of driving simulation for this assessment purpose, (ii) recruitment and retention, (iii) sample size calculation. Preliminary evaluations of differences in driving performance between individuals recovering from distal radius fracture and controls were conducted to confirm if the methodology provided meaningful results to aid in justification for future studies. Methods: Driving performance of 22 current drivers (aged 21–81 years), recruited by convenience sampling, was assessed using a driving simulator. The fracture group included those recovering from distal radius fracture managed with open reduction and internal fixation using a volar plate. The control group were uninjured individuals. Assessment was performed approximately five weeks post-surgery and follow-up assessment two weeks later. Acceptability outcome measures included pain and simulator sickness scores, feasibility measures included retention rates and measures of driving performance included time spent speeding, time spent out of the lane, standard deviation of lateral position and hazard reactions. Results: The assessment was completed by 91% of participants; two participants dropped out secondary to simulator sickness. Retention rates were 83%. Preliminary results suggest those with distal radius fracture spent more time out of the lane and less time speeding. Conclusion: This method was sensitive, acceptable and feasible according to the parameters of this pilot study. The results from this small sample suggest that between-group differences in driving performance are measurable using driving simulation five weeks following distal radius fracture. 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

Metacarpal fractures in the national football league: Injury characteristics, management, and return to play. Sharareh, B., et al. (2022) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Prognostic Topic: Metacarpal fracture - Surgery vs conservative treatment for return to sport This is a retrospective study describing common metacarpal fractures as well as return to sport in the National Football League (NFL) players. The data were obtained from a database of NFL injuries recorded between 2012 and 2018. A total of about 19,000 participants (including repeated measures) were included in the analysis. Across the years, a total of 208 metacarpal fractures were recorded. Only three players sustained two separate injuries within these seven years. There were no refractures. The average return to sport time was three weeks. Return to sport was delayed in those player who had a thumb metacarpal fracture. There was no correlation between age, position, type of fracture, conservative/surgical management of fractures and return to sport time. 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, in professional NFL players with metacarpal fracture II to IV, return to sport can happen at three weeks without evidence of refracture. However, the use of protective splints is required. Given these findings, it is possible that our clients may benefit from an early return to sport without significant risks following a metacarpal fracture. Also, remember that tenderness on palpation is not a reliable way of assessing fracture healing and it is unlikely to be useful in determining when people can return to work/sport. URL: https://doi.org/10.1016/j.jhsa.2022.01.011 Abstract Purpose: This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes. Methods: NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded. Results: There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position. Conclusions: Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. 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

Perspectives on climate change: Can hand surgery go carbon neutral? Dickson, K., Cooper, K. and Gardiner, M. D. (2022). Level of Evidence: N/A Follow recommendation: N/A Type of study: N/A Topic: Carbon neutral - Hand Therapy We are all familiar with the detrimental effects of carbon emissions on the environment and population health. There is substantial evidence that increasing levels of greenhouse gases contribute to climate change and that greater levels of carbon emissions/pollutants contribute to a worsening of health conditions. A recent analysis has shown that the healthcare contributes to an increase in green-house effects largely due to staff commuting. When looking specifically at hand therapy/surgery, the prescription medical equipment (e.g. splinting), imaging, and referrals to other health professionals all contribute, albeit to a lower extent, to carbon emissions. It may be useful for individual businesses to quantify their carbon footprint and start by reducing our emissions where possible. 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, hand therapy contributes to a significant amount of carbon footprint, especially due to the commute of clinicians. If changing our commuting habits is not possible (e.g. remote clinic locations or limited public transport), we may still be able to reduce our carbon footprint by being more aware of what we consume (provide to clients). For example, splinting may be reserved only for those conditions that really require it (e.g. use splinting for thumb OA parsimoniously). As a matter of fact, the creation of splints/thermoplastic materials at a commercial level does have a carbon footprint. Reducing unnecessary referrals or surgeries may be helpful too. Considering that several interventions (e.g. surgery/PRP/cortisone injections for tennis elbow) are not more effective than a placebo, we could probably do without them. URL: https://doi.org/10.1177/17531934221096786 No Abstract 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

Posterolateral rotatory instability of the elbow: Part I. Mechanism of injury and the posterolateral rotatory drawer test. Camp, C. L., Smith, J. and O'Driscoll, S. W. (2017) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic Topic: Posterolateral rotatory instability – Drawer test This is an expert opinion on the mechanism of injury and objective testing for posterolateral rotatory instability (PLRI) of the elbow. PLRI is often caused by a fall onto an outstretched arm, leading to varus loading of the elbow associated with internal rotation of the humerus on a fixed forearm. The lateral collateral ligament (LCL) of the elbow is typically involved as it limits varus movement of the elbow and posterior displacement of the radial head in relation to the humerus. Subjectively, patients often present with a painful laxity (instability). Objectively, we could perform the posterolateral rotatory drawer test, which is performed with the patient in supine. Whilst stabilising the humerus and the forearm, an anteroposterior force is applied to the proximal aspect of the radius. As you can see in the video below, increase laxity in the affected side compared to the unaffected side, suggests a lesion of the LCL. Further tissue involvement (e.g., Medial collateral ligament) may be present depending on the trauma severity. Unfortunately, we do not currently have information about the sensitivity and specificity of this test. 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, posterolateral rotatory instability of the elbow often presents following a fall onto an outstretched hand. A posterolateral rotatory drawer test may be useful in making a diagnosis. Unfortunately, like many other orthopaedic tests for the elbow, we don't have information regarding the diagnostic accuracy of the posterolateral rotatory drawer test. Open Access URL: https://doi.org/10.1016/j.eats.2016.10.016 Abstract Posterolateral rotatory instability (PLRI) is the most commonly encountered pattern of elbow instability. It is the result of disruption of the lateral collateral ligament complex leading to a posterolateral rotatory subluxation of the ulna and radial head. A number of examination maneuvers have been described to assist in clinical identification of PLRI. Despite this, some inconsistency in the description of these techniques remains in the orthopaedic literature. This Technical Note details the mechanism of injury and patient presentation, and emphasizes the primacy of the posterolateral rotatory drawer test in the assessment of PLRI while providing video instruction on how it should be performed. 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

General anxiety is associated with problematic initial recovery after carpal tunnel release. Ryan, C., Miner, H., Ramachandran, S., Ring, D. and Fatehi, A. (2022). Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Therapeutic Topic: Carpal tunnel release recovery - The role of anxiety This is a retrospective study assessing the association between pre-operative mental health and a problematic initial recovery following carpal tunnel release. Problematic recovery was defined as unchanged post-operative pain, persistent or new nerve symptoms, stiffness, wound issues, or kinesiophobia. A total of 156 patients were included, out of which 38 were classified as having a problematic initial recovery. The results showed that greater levels of preoperative anxiety were associated with a greater likelihood of a problematic initial recovery following carpal tunnel release. 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, greater preoperative anxiety is associated with a greater chance of a problematic initial recovery following carpal tunnel release. These findings are in line with other upper limb research showing that we have the opportunity to improve recovery in those people with anxiety/depression/or pain catastrophising prior to or following surgery for upper limb conditions. URL: https://doi.org/10.1097/CORR.0000000000002115 Abstract BACKGROUND: Carpal tunnel release can stop the progression of idiopathic median neuropathy at the wrist (carpal tunnel syndrome). Intermittent symptoms tend to resolve after surgery, but loss of sensibility can be permanent. Both pathophysiology (severe neuropathy) and mental health (symptoms of despair or worry) contribute to problematic recovery after carpal tunnel release, but their relative associations are unclear. QUESTION/PURPOSE: Is problematic initial recovery after carpal tunnel release associated with psychologic distress rather than with disease severity? METHODS: We retrospectively studied 156 patients who underwent in-office carpal tunnel release between November 2017 and February 2020, and we recorded their symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD]) and depression (Patient Health Questionnaire), signs of severe median neuropathy (loss of sensibility, thenar muscle atrophy, and palmar abduction weakness), and problematic recovery. The initial recovery (first 2 weeks) was categorized as problematic if the patient was upset about persistent numbness, experienced unsettling postoperative pain, developed hand stiffness, or experienced wound issues-all of which are routinely recorded in the medical record by the treating surgeon along with signs of severe median neuropathy. Twenty-four percent (38 of 156) of patients had a problematic initial recovery characterized by distress regarding persistent numbness (16% [25 of 156]), unsettling pain (8% [12 of 156]), hand stiffness (5% [8 of 156]), or wound issues (1% [2 of 156]); 6% (9 of 156) of patients had more than one issue. Associations between problematic initial recovery and age, gender, symptoms of anxiety and depression, disease severity, specific exam findings, and insurance were evaluated using t-tests, Mann-Whitney tests, and chi-square tests, with the plan to perform logistic regression if at least two variables had an association with p < 0.10. RESULTS: The only factor associated with problematic initial recovery was greater symptoms of anxiety (median GAD score 1.5 [interquartile range 0 to 7.8] for problematic initial recovery compared with a median score of 0 [IQR 0 to 2] for nonproblematic recovery; p = 0.04), so we did not perform a logistic regression. Physical examination findings consistent with severe median neuropathy were not associated with problematic initial recovery. CONCLUSION: The finding that problematic initial recovery after carpal tunnel release was related to symptoms of anxiety and not to the severity of median neuropathy highlights the need to study the ability of efforts to ameliorate anxiety symptoms before carpal tunnel release as an effective intervention to reduce unplanned visits and additional tests, therapy, and repeat surgery, while improving patient-reported outcomes and experience. 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

Terrible triad injuries are no longer terrible! Functional outcomes of terrible triad injuries: A scoping review. Stambulic, T., Desai, V., Bicknell, R. and Daneshvar, P. (2022) Level of Evidence: 3a Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Terrible triad – Recovery This is a review assessing the recovery of terrible triad injuries. A total of 43 studies were included in the review. Functional outcomes (e.g. QuickDASH), complication rates, and range of movement were recorded at follow-up (average 2-3 years post-surgery). More than 2,000 participants were included across all the studies. The result showed that patients surgically treated for a terrible triad presented with low disability at 2-3 years post-surgery. The re-operation rate for complications was around 8%. In addition, patients recovered a functional range of movement of the elbow. 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, surgical treatment of a "Terrible triad" injury leads to reasonable outcomes in terms of function and range of movement at 2-3 years post-surgery. The re-operation rate for complications is around 8%. Hence, we could call rename this condition the "Manageable triad", which may reduce catastrophic thinking in our clients. Considering the extensive recovery time as well as the lack of complete recovery, it is important to set clients' expectations. In addition, it is likely that clients affected by this condition will develop depression, which could further impair their perceived function. URL: https://doi.org/10.1016/j.xrrt.2022.01.002 Abstract Background: The terrible triad injury (TTI) of the elbow is a combination of a posterolateral dislocation of the elbow joint combined with fractures of the radial head and coronoid process most often caused by a fall on an outstretched hand. The injury pattern was named for its poor outcomes and high complication rates following surgical repair, but increased understanding of elbow anatomy and biomechanics has led to the development of standardized surgical protocols in an attempt to improve outcomes. Most existing literature on terrible triad injuries is from small retrospective cohort studies and surgical techniques to improve outcomes. Therefore, the purpose of this scoping review is to provide an overview of the functional outcomes, prognosis, and complications following current surgical treatment of TTIs. Methods: A scoping review was performed to evaluate the literature. In total, 617 studies were identified and screened by 2 reviewers, with 43 studies included for qualitative analysis. These 43 studies underwent data extraction for functional outcomes using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand score (DASH) and were stratified accordingly. Secondary outcome measures assessed in the study were a range of motion (ROM) and complication rate. Results: The average MEPS was 90 (excellent) from a total of 37 studies with 1609 patients, and the average DASH score was 16 from 16 studies with 441 patients. Another 6 studies with a total of 127 patients reported a mean Q-DASH score of 13. A total of 39 studies consisting of 1637 patients had a mean forearm rotation of 135 degrees, and 36 studies consisting of 1606 patients had a mean flexion-extension arc of 113 degrees. Among the studies, there was a 30% complication rate with a need for revision surgery in 7.8% of cases. The most common complications were radiographic evidence of heterotopic ossification (11%) and ulnar nerve neuropathy (2.6%). Discussion/Conclusions: This study shows that current surgical treatment for terrible triad injuries has resulted in improved outcomes. Based on primary outcome measures using MEPS and DASH scores, almost all of the studies have highlighted good or excellent functional outcomes. This highlighted the marked improvement in outcome scores since the term was coined, suggesting that terrible triad injuries may no longer be so terrible. 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

Late displacement after lateral condylar fractures of the humerus. Aibara, N., Takagi, T. and Seki, A. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Prognostic Topic: Lateral condyle fracture of the humerus – Predict displacement This is a retrospective study assessing whether it is possible to predict lateral condyle fracture of the humerus displacement in conservatively treated children/teenagers. Lateral condyle fractures of the humerus account for 10-20% of humeral fractures in children. If they are undisplaced, they can be treated conservatively with immobilisation, however, about 15% of them require delayed surgery due to late displacement. The association between age, sex, elbow immobilisation position, initial displacement, fat pad sign, elbow flexion angle, forearm position (neutral/pronation) and the presence of displacement (>= 1 mm on AP or lateral x-ray) was assessed. A total of 62 participants between 1 and 16 years old (average: 5 yrs old) with undisplaced lateral condyle fractures of the humerus at baseline were included in the study. They were all initially treated conservatively. The results showed that 45% of participants presented with fracture displacement (>= 1 mm on AP or lateral x-ray) at 7 days. The results also showed that there was no association between any of the variables considered and the development of a displaced fracture at 7 days. 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, we are currently unable to predict who will develop a displaced lateral condyle fracture of the humerus one week after injury. It is therefore best to repeat a lateral, AP, and internal oblique view seven days post-injury to determine whether surgery is required. After 7 days, the likelihood of fracture displacement appears to plateau. In terms of immobilisation position, there is no evidence that the degree of elbow flexion/extension or forearm supination/pronation will prevent fracture displacement. If you are interested in children/teenagers' elbow conditions, you may also want to read about osteochondritis dissecans. URL: https://doi.org/10.1016/j.jse.2022.06.003 Abstract Background: Nondisplaced or slightly displaced lateral condyle fractures may subsequently displace if treated with cast immobilization alone, and displacement indicates surgery. In this context, placing the forehand in pronation is sometimes recommended, and the prediction of the late displacement based on the presence of the fat pad sign is useful. However, few studies have quantitatively shown the relationships between forearm position during immobilization and late displacement and between the presence of the fat pad sign and late displacement. We investigated the factors that may affect the late displacement and the features of the consequences during the late displacement. Methods: Between October 2003 and July 2020, we observed 62 patients (45 boys and 17 girls). We evaluated the correlation between the factors age, gender, the initial displacement, the presence of a fat pad sign, the flexion angle of the elbow, the forearm position (pronation or neutral), and the late displacement on day 7 after the injury, which means the difference between the displacement on day 0 and that on day 7 in the 62 cases with the minimal displacement. Moreover, of all 62 cases observed, we further investigated those 52 cases that had been treated conservatively for 3 weeks for any resultant effects. We used the Friedman test to evaluate the difference in the late displacement on each day. We acknowledged the P value < .05 as significant. Results: There was no significant correlation between each factor (age, sex, initial displacement, presence of the fat pad sign, flexion angle of the elbow, or forearm position) and displacement on day 7, whereas there was significant progressive displacement until day 7. Conclusion: The present study concluded that late displacement would happen until the 7 postoperative dates, regardless of the splint angle, the fat pad sign, the age, or the gender. Therefore, it is important to follow any case, even with mild-displaced lateral condylar humeral fractures, until day 7 because the late displacement might occur. 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

Evaluation of a convolutional neural network to identify scaphoid fractures on radiographs. Li, T., et al. (2022). Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic: Machine learning – Scaphoid fractures detection on x-ray This is a retrospective study assessing whether machine learning algorithms are able to detect scaphoid fractures on baseline x-rays with acceptable diagnostic accuracy. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. The machine learning model was trained on 930 x-ray images and tested on 100 baseline images. Three surgeons with 3, 13, and 14 years of experience assessed the same 100 x-rays and reached an agreement on each x-ray regarding the presence or not of a scaphoid fracture. The results showed that the surgeons had sensitivity and specificity of 76% and 96% respectively. The machine learning algorithm had similar results with a sensitivity and specificity of 82% and 94%. 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, machine learning is as good at identifying scaphoid fractures on x-ray as experienced surgeons. In the future, it is likely that these algorithms will be implemented in radiology software to aid scaphoid fracture detection. We are experiencing a surge of research showing the usefulness of machine learning for the prediction of treatment responders and the assessment of patients with upper limb conditions. URL: https://doi.org/10.1177/1753193422112709 Abstract This study aimed to develop and evaluate a convolutional neural network for identifying scaphoid fractures on radiographs. A dataset of 1918 wrist radiographs (600 patients) was taken from an orthopaedic referral centre between 2010 to 2020. A YOLOv3 and a MobileNetV3 convolutional neural network were trained for scaphoid detection and fracture classification, respectively. The diagnostic performance of the convolutional neural network was compared with the majority decision of four hand surgeons. The convolutional neural network achieved a sensitivity of 82% and specificity of 94%, with an area under the receiver operating characteristic of 92%, whereas the surgeons achieved a sensitivity of 76% and specificity of 96%. The comparison indicated that the convolutional neural network’s performance was similar to the majority vote of surgeons. It further revealed that convolutional neural network could be used in identifying scaphoid fractures on radiographs reliably, and has potential to achieve the expert-level performance. 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