175 results found
- Resistance training or stretching to improve range of movement?
Strength training is as effective as stretching for improving range of motion: A systematic review and meta-analysis. Afonso, J., et al. (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Resistance training and stretching - Range of movement improvements This is a systematic review and meta-analysis assessing the effectiveness of resistance training and stretching exercises on joint range of movement. Eleven RCTs were included in the systematic review, for a total of 452 participants. Participants included had a wide age range, health status (healthy and persistent pain). All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Resistance training exercises were compared to stretching exercises. Efficacy of intervention was assessed through active and passive range of movement of lower and upper limb joints. Interventions duration ranged betwee 5 and 16 weeks, with a maximum training frequency of 5 and a minimum of 2. The assessment time points varied significantly, and they ranged from 6 to 24 weeks. Moderate quality evidence showed that stretching or resistance training provided similar range of movement improvements by the end of the training regime. 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, resistance training or stretching interventions appear to be equally effective in improving range of movement. Either intervention can be used if the goal of treatment is to improve range of movement in our clients. However, if resistance training is well tolerated, it may be the best option. Thus, the international guidelines for physical activity advise on the implementation of resistance training across all ages. Stretching is only mentioned as an adjunct to aerobic and resistance training for pregnant women. Open access URL: https://osf.io/preprints/metaarxiv/2tdfm/ Abstract Background: Range of motion (ROM) is an important feature of sports performance and health. Stretching is usually prescribed to improve promote ROM gains, but evidence has suggested that strength training (ST) also improves ROM. However, it is unclear if its efficacy is comparable to stretching. Objective: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of ST and stretching on ROM. Protocol: INPLASY: 10.37766/inplasy2020.9.0098. Data sources: Cochrane Library, EBSCO, PubMed, Scielo, Scopus, and Web of Science were consulted in early October 2020, followed by search within reference lists and consultation of four experts. No constraints on language or year. Eligibility criteria (PICOS): (P) humans of any sex, age, health or training status; (I) ST interventions; (C) stretching interventions (O) ROM; (S) supervised RCTs. Data extraction and synthesis: Independently conducted by multiple authors. Quality of evidence assessed using GRADE; risk-of-bias assessed with RoB 2. Results: Eleven articles (n = 452 participants) were included. Pooled data showed no differences between ST and stretching on ROM (ES = -0.22; 95% CI = -0.55 to 0.12; p = 0.206). Sub-group analyses based on RoB, active vs. passive ROM, and specific movement-per-joint analyses for hip flexion and knee extension showed no between-protocol differences in ROM gains. Conclusion: ST and stretching were not different in improving ROM, regardless of the diversity of protocols and populations. Barring specific contra-indications, people who do not respond well or do not adhere to stretching protocols can change to ST programs, and vice-versa.
- Distal forearm fracture - is bone density screening required?
Rate of bone mineral density testing and subsequent fracture-free interval after distal forearm fracture in the medicare population. Parikh, K., D. Reinhardt, K. Templeton, B. Toby and J. Brubacher (2021). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Bone mass density post forearm fractures - Prognosis for fragility fractures This is a retrospective study assessing the rate of Bone Mass Density (BMD) scans performed after distal forearm fractures (e.g. radius fracture) and whether this testing was effective in reducing the risk of further fractures. A total of 37,473 participants who had not been previously screened for BMD were included. Of these, 80% were female and 85% of the total sample were older than 65 years old. The results show that out of the total, 26% of the people over 65 were screened for bone fragility through BMD. Also, the results showed that those females who had undergone BMD testing after a distal forearm fracture had a lower risk of any other fracture. More precisely, females who underwent a BMD scan had 1.5 extra years of life without a fracture (see picture below). Due to the retrospective nature of the study, it is not possible to determine causality between BMD testing and reduction of fragility fractures. Several factors such as medication prescription for osteoporosis, referral to physiotherapy to reduce risk of fall, or a combination of these and other variables may be responsible for a reduction in risk following BMD 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, getting a BMD assessment following a distal forearm fracture may reduce the risk of fragility fractures in our older female clients. It may therefore be worth to ask our clients (especially older females) if they have had a bone density scan in recent years. In addition, we could screen our clients through tools such as the FRAX. Hand therapist can also assess lower limb strength and balance in people with distal radius fracture through simple tests such as the Chair Stand Test and the Timed up and Go test. Recently, a mobile app called Nymbl has been sponsored by ACC and can be used by our older clients to keep active and reduce their risk of falls. If clients are provided with medications such as bisphosphonate, hand therapists should encourage them to take them as prescribed and provide educational resources on osteoporosis (e.g. NIH, NOF, IOF). For further information on our key role in fragility fracture screening, see this synopsis. URL: https://doi.org/10.1016/j.jhsa.2020.11.020 Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Distal forearm fractures are prevalent among the Medicare population. Many patients who sustain these fractures have poor bone health and are at increased risk for subsequent fractures. We sought to determine the rate of bone mineral density (BMD) testing and subsequent fragility fracture-free interval after distal forearm fractures in the Medicare population. Methods: We examined the 5% Medicare Standard Analytic File dataset using the PearlDiver Application from 2005 to 2014 to identify patients with distal forearm fractures based on International Classification of Diseases–Ninth Revision and Current Procedural Terminology codes. We queried these records to determine the incidence and timing of BMD testing after fracture and the number of patients who went on to hip or vertebral fractures. Survival curves were generated using Kaplan-Meier analysis with hip or vertebral fracture as the end point. Results: A total of 37,473 patients with distal forearm fractures were identified who did not have BMD testing within the 2 years before fracture. Only 9,605 of this unscreened cohort underwent testing after the fracture (26%) and only 2,684 underwent testing within 6 months (7%). The patients least likely to be tested were males (9%), those aged over 85 years (12%), and those less than 65 years (22%). Twenty percent of these patients sustained a subsequent hip or vertebral fracture (n = 7,326). Patients who underwent testing after fracture had a longer fracture-free interval compared with patients without BMD testing (819 vs 579 days). When separated by sex and controlling for comorbidities, males with BMD testing had a worsened fracture-free interval whereas females had an improved fracture-free interval. Conclusions: Bone mineral density testing is underused nationwide in patients sustaining distal forearm fractures despite current guidelines. Orthopedic surgeons should ensure proper testing of patients because this may be an important time point for intervention.
- Answer for - What is the differential diagnosis for this case? - Forearm pain
Acute bilateral compartment syndrome of the forearms. Wrafter, P., O. Kelly and M. O’Shaughnessy (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. A diagnosis of bilateral forearm compartment syndrome was made, possibly secondary to rhabdomyolysis. Rhabdomyolysis is a pathology leading to muscle break down. This condition is often caused by unaccustomed overexertion, dehydration and myotoxic medications (medications toxic to muscle), which include statins and angiotensin inhibitors. The patient was treated with bilateral forearm fasciotomy, which relieved pressure and lead to a good overall recovery. 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: Compartment syndrome may be considered as a differential diagnosis in clients who report: taking statins or angiotensin inhibitors, recently having overexerted themselves, being dehydrated, or consuming alcohol. Objectively they would present with swollen painful muscles, which cause extreme pain when stretched. If acute compartment syndrome is suspected, clients should immediately be referred to ED. URL: https://www.jhandsurg.org/article/S0363-5023(18)31003-7/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract A 43-year-old woman presented to our emergency department with severe bilateral forearm pain. On examination, both forearms were tense and swollen and the patient had excruciating pain, made much worse on passive extension of the fingers. The pain did not resolve with analgesia. The symptoms and clinical examination were highly suspicious for compartment syndrome. However, there was no history of trauma, strenuous physical activity, or any other obvious factor that might have precipitated the onset of a compartment syndrome. The serum creatinine kinase at presentation was greater than 37,000. The patient, however, did have a history of hypertension and was taking losartan, an angiotensinogen II antagonist that has been associated with rhabdomyolysis. The patient was brought to surgery for emergency fasciotomies and made an excellent recovery after surgery. The etiology of this patient’s bilateral compartment syndrome is uncertain but may be a manifestation of drug-induced rhabdomyolysis.
- Can botulinum 💉 help with Raynaud's phenomenon?
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: 👍 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. Hand therapist may monitor potential complications such as intrinsic muscle weakness through grip strength after the injections (50% of grip strength comes from the intrinsic muscles of the hand) and reassure clients about this transient impairment. Hand therapist may also monitor for other symptoms (e.g. difficulty breathing), which although rare requires medical attention. URL: https://www.jhandsurg.org/article/S0363-5023(20)30406-8/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. 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.
- RA? - To glove or not to glove, that is the question
Clinical and cost effectiveness of arthritis gloves in rheumatoid arthritis (A-GLOVES): randomised controlled trial with economic analysis. Hammond, A., et al. (2021). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Rheumatoid Arthritis - Gloves This is a randomised, multicentre, double-blind, placebo controlled trial assessing the effectiveness of compression gloves on pain in participants with rheumatoid arthritis (RA) affecting the hand. Participants (N = 206) were included if they were diagnosed with rheumatoid arthritis by a Rheumatology consultant and if they had difficulty sleeping due to hand pain or using their hands during the day. Importantly, participants were excluded if they had previously tried arthritis gloves. Pain was assessed through the numerical rating scale (NRS) at baseline and 12 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either wear arthritis gloves providing between 23 to 32 mmHg of compression (real gloves), or loose fitting gloves providing 15 to 25 mmHg of compression (placebo gloves). Participants were advised to wear the gloves for most of the day but less than 24 hours per day. Participants in both groups were also provided with joint protection advice and hand exercises. The results showed that participants in all groups used the gloves for an average of 5 hours during the day and 6 hours at night. Both groups had minor improvements in pain (1 point out of 10) at 12 weeks, which was not statistically or clinically different between groups. The arthritis gloves increased the cost of care by £129 without providing any significant benefit. 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, arthritis gloves do not provide any additional benefit than loose fitting gloves. Providing gloves is more pricey and the expense does not appear to be justified. Instead of providing gloves, it may be more useful to use those resources (money) for an additional session of hand therapy where we can provide them with exercise interventions which have been shown to be effective through the SARAH trial (See previous synopsis with links to free online course). Open access URL: https://doi.org/10.1186/s12891-020-03917-8 Abstract Arthritis (or compression) gloves are widely prescribed to people with rheumatoid arthritis and other forms of hand arthritis. They are prescribed for daytime wear to reduce hand pain and improve hand function, and/or night-time wear to reduce pain, improve sleep and reduce morning stiffness. However, evidence for their effectiveness is limited. The aims of this study were to investigate the clinical and cost effectiveness of arthritis gloves compared to placebo gloves on hand pain, stiffness and function in people with rheumatoid arthritis and persistent hand pain.
- Is joint position sense impaired in people with symptomatic thumb OA?
Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study. Ouegnin, A. and K. Valdes (2020). Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Aetiologic Topic: Symptomatic thumb osteoarthritis - Proprioception This is a multicentre case-control study assessing differences on proprioception (joint position test) in participants with thumb OA (cases) and healthy participants (controls). A total of 29 participants were included in the study. Thumb OA was diagnosed through clinical examination (e.g. positive grind test) and confirmed through x-ray in some participants but not all. Proprioception (joint position sense) was assessed through a hand held goniometer by asking participants to reproduce a specific thumb position (30 degrees of abduction) after moving the thumb through the full range of abduction. The difference between the target angle and the angle reproduced (error) was recorded. The results showed that participants with thumb OA presented with an average error of 10 degrees while the healthy participants presented with 1 degree error in joint repositioning. This finding was statistically and potentially clinically significant. There are however, a couple of limitations in this study. First, not all participants with thumb OA were matched to a healthy participant. In some cases, when thumb OA was unilateral, the controlateral thumb of the same participant was assessed. This leads to the second limitation, which is a statistical one. For the data analysis, an independent t-test was used, although this test can only be utilised when the two groups (thumb OA and controls) do not include the same participants. 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, clients with thumb OA may present with proprioception deficit. It is possible that these impairments may contribute to functional deficits. Currently, there is no evidence supporting the use of specific proprioceptive training and other multidisciplinary approaches, supported by higher quality evidence, may be implemented first. URL: http://www.sciencedirect.com/science/article/pii/S0894113018302904 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study has a descriptive-comparative, cross-sectional design. Introduction Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA). Purpose of the Study This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test. Methods The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non–CMC OA group with the healthy control group. Results The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96. Conclusions Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.
- Physical activity: Is it going to help our clients with depression?
Customary physical activity and odds of depression: A systematic review and meta-analysis of 111 prospective cohort studies. Dishman, R. K., C. P. McDowell and M. P. Herring (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Mental health - Physical activity This is a systematic review and meta-analysis assessing the effectiveness of physical activity in reducing symptoms of depression. Hundred and eleven observational studies were included in the systematic review, for a total of 1,404 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was based on some aspects of the GRADE approach, although the evidence was classified as "good", "acceptable", or "poor". Studies were included if physical activity was quantified and comparable to a guideline threshold. The results showed that there is moderate quality evidence showing that physical activity, when performed according to international guidelines, reduces the odds of presenting with depression by 20%. Importantly, there is a dose-response between physical activity and symptoms of depression. A limitation of this study is the inclusion of observational studies, which limits the extrapolation of causality between physical activity and depression. 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, physical activity has the potential to reduce depression symptoms. Interesting, effectiveness appears to be dependent on exercise dosage, which needs to follow international guidelines. The type of activity does not appear to matter as long as we meet a sufficient intensity and volume of exercise. Among the many forms of exercise available, a previous meta-analysis has shown that yoga, can reduce depression (see contraindications of yoga classes with a significant amount of meditation). Considering the relationship between depressive symptoms and upper limb recovery as well as mental health and post surgical satisfaction, it may be worthwhile encouraging our clients to follow the international guidelines for physical activity. URL: http://bjsm.bmj.com/content/early/2021/01/04/bjsports-2020-103140.abstract Available through EBSCO Health Databases for PNZ members. Abstract Objective: To explore whether physical activity is inversely associated with the onset of depression, we quantified the cumulative association of customary physical activity with incident depression and with an increase in subclinical depressive symptoms over time as reported from prospective observational studies. Design: Systematic review and meta-analysis. Data sources MEDLINE, PsycINFO, PsycARTICLES and CINAHL Complete databases, supplemented by Google Scholar.Eligibility criteria Prospective cohort studies in adults, published prior to January 2020, reporting associations between physical activity and depression.Study appraisal and synthesis Multilevel random-effects meta-analysis was performed adjusting for study and cohort or region. Mixed-model meta-regression of putative modifiers. Results: Searches yielded 111 reports including over 3 million adults sampled from 11 nations in five continents. Odds of incident cases of depression or an increase in subclinical depressive symptoms were reduced after exposure to physical activity (OR, 95% CI) in crude (0.69, 0.63 to 0.75; I2=93.7) and adjusted (0.79, 0.75 to 0.82; I2=87.6) analyses. Results: were materially the same for incident depression and subclinical symptoms. Odds were lower after moderate or vigorous physical activity that met public health guidelines than after light physical activity. These odds were also lower when exposure to physical activity increased over time during a study period compared with the odds when physical activity was captured as a single baseline measure of exposure. Conclusion: Customary and increasing levels of moderate-to-vigorous physical activity in observational studies are inversely associated with incident depression and the onset of subclinical depressive symptoms among adults regardless of global region, gender, age or follow-up period.
- What is the differential diagnosis for this case? - Forearm pain
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. What is it? 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.
- What are the repercussions of smoking in clients with a distal radius fracture?
A matched comparison of postoperative complications between smokers and nonsmokers following open reduction internal fixation of distal radius fractures. Galivanche, A. R., et al. (2021). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Distal radius fracture – Smoking and prognosis This is a retrospective study assessing the effect of smoking on post surgical complications in participants undergoing open reduction and internal fixation (ORIF) for distal radius fracture. A total of 16,158 participants was included in the study. Of these, 3,062 (19%) we're smokers. Participants' average age ranged between 50 to 58. Complications were measured 30 days after surgery and included infections, re-operation, readmission, cardiovascular events, and mortality. The statistical analyses took into account demographic and comorbidity information to reduce the contribution of confounding factors to the overall results. The results showed that although mortality was not different between smokers and non smokers, all the other complications were more likely in smokers. In particular, the prevalence of any adverse event was 4% in smokers and 3% in non smokers. Clinical Take Home Message: Based on what we know today, smoking not only increases the risk of post surgical infections but also increases the chance of other complications (e.g. re-operation) following distal radius fracture. Hand therapist may therefore ask their clients about their smoking status and whether they are interested in quitting. If they are, a previous synopsis provides information on some of the evidence-based advice to help clients quit smoking. URL: http://www.sciencedirect.com/science/article/pii/S0363502320305712 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts. Results: In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28–2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22–2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04–3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26–2.39), reoperation (OR, 2.07; 95% CI, 1.13–3.78), and readmission (OR, 1.83; 95% CI, 1.20–2.79). There was no difference in 30-day mortality rate. Conclusions: Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.
- Diagnostic tests for occult scaphoid fractures?
Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway. Kodumuri, P., A. McDonough, V. Lyle, Z. Naqui and L. Muir (2020). Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Scaphoid fractures - Physical tests This is a retrospective study on the specificity and sensitivity of physical tests for occult schapoid fractures. 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. Only participants (n = 920) presenting with a negative x-ray for scaphoid fracture (occult fracture) were included in the present study. The diagnostic tests utilised were: tenderness on palpation at the snuff box or scaphoid tubercle, pain on axial compression of the thumb, pinch test, and ulnar deviation. The pinch test simply consisted in a tip to tip pinch between the thumb and index. The test was deemed positive when it caused pain in the client (see table 1 below). MRI was used as the gold standard against which the physical tests were assessed. The results showed that the absence of tenderness on palpation of the snuff box, moderately reduced the probability of an occult scaphoid fracture (see table 2 below - I calculated likelihood ratios for you, which are useful in assessing the diagnostic ability of a test). Tenderness on palpation of the snuff box increased the probability of an occult scaphoid fracture by a small degree (see table 2 below). The combination of multiple tests did not improve diagnostic accuracy. There was however a flaw within the study. When all the physical tests were negative, participants were not referred for an MRI, which is the gold standard against which all the tests were supposed to be assessed against (Thanks Dr. Steve White for pointing out this limitation and having a look at my likelihood ratio calculations). Table 2. Test specificity, sensitivity, and likelihood ratios (I calculated the LR+ and LR-, they were not provided in the article) 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, assessment of snuff box tenderness may be the most useful test for excluding an occult scaphoid fracture. However, given the limitations of the study analysed, it may be still worth repeating a hand x-ray at two weeks to exclude the presence of an occult scaphoid fracture. If you would like more information, look at the previous synopsis on scaphoid fractures requiring surgery. URL: https://doi.org/10.1177/1753193420979465 Available through EBSCO Health Databases for PNZ members. Abstract We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent (n=602) with a low clinical suspicion were discharged and 35% (n=320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666.