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175 results found

  • How does diabetes affect recovery after trigger finger surgery?

    Functional outcomes of trigger finger release in non-diabetic and diabetic patients. Stirling, P. H. C., P. J. Jenkins, A. D. Duckworth, N. D. Clement and J. E. McEachan (2020) Level of Evidence: 2b Follow recommendation: ๐Ÿ‘ ๐Ÿ‘ Type of study: Prognostic Topic: Trigger finger surgery - diabetes and functional recovery This retrospective study assessed the effect of diabetes on functional recovery following surgery for trigger finger (A1 pulley release). Functional recovery was measured through the QuickDASH questionnaire, and the presence of diabetes was self-reported by participants. A total of 192 participants were recruited at baseline and they were assessed pre-surgery and one year post-surgery. The results showed that 25% (n = 49) of the participants reported diabetes (no information was provided on number of participants with Type 1 or Type 2 diabetes). Participants' function at baseline was significantly worst in diabetic subjects (16 points worse). However, improvements in functional outcome following surgery were similar in both the diabetic (13 points improvement) and non-diabetic participants (9 points improvement). Clinical Take Home Message: Based on what we know today, clients affected by trigger finger and diabetes may have greater disability than clients without diabetes. It may be worth checking with the client if they are compliant with their diabetes medications (e.g. metformin) and if they have had a check up with their GP recently. The functional outcomes of A1 pulley release are similar between clients with and without diabetes. This synopsis is a nice addition to the one written on the effect of diabetes on functional recovery following distal radius fracture. URL: Available through EBSCO Health Databases for PNZ members. Abstract We compared the functional outcomes, health-related quality of life, and satisfaction in diabetic and non-diabetic patients undergoing A1 pulley release for trigger finger in 192 patients. Preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), EuroQol-5 dimensions, and satisfaction scores were collected prospectively over a 6-year period. These patients had a mean follow-up of 14 months (range 11?40) after surgery. There were 143 patients (143 trigger fingers) without diabetes and 49 patients (49 trigger fingers) with diabetes. We found overall QuickDASH improvement was the same in both groups (-4.5 points). Patient satisfaction rates were comparable in both groups (90% versus 96%), and no significant difference in postoperative health-related quality of life was observed. No complications were reported in either group. We conclude from this study that A1 pulley release leads to similar functional improvement and high patient satisfaction at one year postoperatively in diabetic and non-diabetic patients.

  • What is the differential diagnosis for this case? - Wrist pain

    Level of Evidence: 5 Follow recommendation: ๐Ÿ‘ Type of study: Diagnostic Topic: What is the differential diagnosis? โ€“ 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 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. X-ray images are shown below. What is it?

  • Do you know which hand muscles were originally called earthworms?

    The lumbricals are not the workhorse of digital extension and do not relax their own antagonist. Crowley, J. S., M. Meunier, R. L. Lieber and R. A. Abrams (2020) Level of Evidence: 5 Follow recommendation: ๐Ÿ‘ Type of study: Anatomical Topic: Lumbricals' action - Action and interaction This is biomechanical study on the role of lumbricals in the hand. The major points of this article are reported below: - Lumbricals are not able to produce enough force to counteract flexor digitorum profondus (FDP) or superficialis (FDS) at the pipj or dipj. This is due to their small cross sectional area when compared to FDP or FDS. - Lumbricals are weak mcpj flexors compared to the interossei muscles as their cross sectional area is 1/15 of the interossei - Lumbricals present the greatest number of muscle spindles (used for proprioception) among all the muscles of the upper limb Considering these facts, it is hypothesised that lumbricals have a proprioceptive role important for finger dexterity. Clinical Take Home Message: Based on what we know today, the lumbricals are more likely to have a sensory function rather than a force or movement generating capability in healthy clients. A possible exception is the presence of paradoxical flexion following laceration or avulsion of FDP. Knowing that lumbricals are also involved in proprioception may direct us to include a dexterity treatment component in those clients presenting with a grade III or IV lumbrical strain or tear. This injury may occur in climbers following a forced middle or ring finger extension while having the other fingers curled in your hand (Fall while on a mono or small ledge holds). URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract That the lumbrical muscles are the workhorse of digital extension and that they can relax their own antagonist have been time-honored principles. However, we believe this dogma is incorrect and an oversimplification. We base our assertion on anatomy, innervation, and the notion that muscle architecture is the most important determinant of muscle function. Wang and colleagues proposed the lumbrical to be a sophisticated tension monitoring device. We elaborate on their well-supported thesis, further proposing that the lumbricals also function as a constant tension spring within the closed loop composed of the digital flexors and the extensor mechanism.

  • Are your clients with symptomatic hand OA at greater risk of cardiovascular disease?

    Hand osteoarthritis in relation to mortality and incidence of cardiovascular disease: Data from the Framingham heart study. Haugen, I. K., Ramachandran, V. S., Misra, D., Neogi, T., Niu, J., Yang, T., . . . Felson, D. T. (2015) Level of Evidence: 2b Follow recommendation: ๐Ÿ‘ ๐Ÿ‘ ๐Ÿ‘ Type of study: Prognostic Topic: Symptomatic hand OA - Mortality prediction This is a prospective cohort study assessing the risk of cardiovascular disease and associated mortality in people with symptomatic hand OA. A total of 1,348 participants were included at baseline (1948-1953) and followed up for 60 years (2008-2011). Participants' offspring were included as well in this study. Participants were 50 to 75 years old at baseline. Participants were divided into two groups: participants with symptomatic and radiographic evidence of hand OA, and participants with radiographic hand OA only. The results showed that participants with symptomatic hand OA were at least twice as likely to present with a significant cardiovascular condition (e.g. coronary heart disease) during the course of their life compared to the rest of the sample. People with radiographic but not symptomatic hand OA were at no greater risk that the rest of the population. 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, people with symptomatic hand OA are at least 2 times more likely to develop cardiovascular disease. We should therefore encourage our clients with this condition to keep as active as possible. Remember that previous research showed a relation between grip strength and mortality and walking and mortality. Have a look at the recent WHO 2020 guidelines on physical activity, which will give you an idea of the level and type of exercise that we should recommend to our clients. Clients who do not present with symptomatic hand OA but x-ray evidence of OA do not seem to be at greater risk then other people to develop cardiovascular disease. Open Access URL: Abstract Objectives: To study whether hand osteoarthritis (OA) is associated with increased mortality and cardiovascular events in a large community based cohort (Framingham Heart Study) in which OA, mortality and cardiovascular events have been carefully assessed. Methods: We examined whether symptomatic (โ‰ฅ1 joint(s) with radiographic OA and pain in the same joint) and radiographic hand OA (โ‰ฅ1 joint(s) with radiographic OA without pain) were associated with mortality and incident cardiovascular events (coronary heart disease, congestive heart failure and/or atherothrombotic brain infarction) using Cox proportional hazards models. In the adjusted models, we included possible confounding factors from baseline (eg, metabolic factors, medication use, smoking/alcohol). We also adjusted for the number of painful joints in the lower limb and physical inactivity. Results: We evaluated 1348 participants (53.8% women) with mean (SD) age of 62.2 (8.2) years, of whom 540 (40.1%) and 186 (13.8%) had radiographic and symptomatic hand OA, respectively. There was no association between hand OA and mortality. Although there was no significant relation to incident cardiovascular events overall or a relation of radiographic hand OA with events, we found a significant association between symptomatic hand OA and incident coronary heart disease (myocardial infarction/coronary insufficiency syndrome) (HR 2.26, 95% CI 1.22 to 4.18). The association remained after additional adjustment for pain in the lower limb or physical inactivity. Conclusions: Symptomatic hand OA, but not radiographic hand OA, was associated with an increased risk of coronary heart disease events. The results suggest an effect of pain, which may be a possible marker of inflammation.

  • A surgeon's opinion on thumb OA ๐Ÿ’‰

    Trapeziometacarpal joint arthritis: A personal approach to its treatment. Davis, T. R. C. (2020) Level of Evidence: 5 Follow recommendation: ๐Ÿ‘ Type of study: Therapeutic Topic: Thumb OA - Surgeon's point of view This is a surgeon's opinion on treatment of thumb osteoarthritis (OA). I particularly enjoyed the open minded approach that this surgeon has about thumb OA. They recognise the limitations of their own approach and they are ready to change their practice in light of new evidence, which will inevitably arise in the future. The approach suggested is to delay surgery (e.g. trapeziotomy) as much as possible. This is based on evidence suggesting that a limited proportion of the pain is correlated with radiographic findings and that a flare in pain may resolve within 6 months to a year. Furthermore, conservative treatments may help in the resolution or reduction of pain. More importantly, they recognise the significant impact of psychological factors in the exacerbation of pain (which is the driver for surgery) and the potential effect of other conservative interventions in the management of thumb OA. Cortisone injections are suggested as an additional treatment option. They report being happy to provide more than 3 injections if the benefits last for more than 6 months. A final point was made on the lack of evidence suggesting greater effectiveness of trapeziotomy alone vs trapeziotomy plus suspension arthroplasty. No differences have been identified between these approaches at short and long term in randomised controlled trials. 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, thumb OA should be initially treated conservatively. Conservative treatments should last between 6 to 12 months and consider other factors contributing to pain other than radiographic evidence of thumb OA. Psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery and should be taken into account more than the degree of "degeneration" of the joint (up to 75% of people with radiographic evidence of thumb OA do not have pain). Have a look at conservative treatments for hand OA (e.g. manual therapy/exercise, illusory resizing, mental health component), we can make a difference! URL: Available through EBSCO Health Databases for PNZ members. Abstract Many hand surgeons have fixed beliefs on how trapeziometcarpal (TMC) osteoarthritis should be treated. However, not all hand surgeons share the same fixed beliefs, so different factions of hand surgeons can hold contradictory beliefs. Many retain their fixed beliefs, rather than reconsidering them, when the best available evidence challenges them. The problem causing this heterogeneity of fixed beliefs is the lack of high-quality evidence that can withstand critical appraisal and cannot be ignored or simply dismissed by those with rigid contradictory beliefs. This article examines some of the dogmas surrounding the treatment of TMC osteoarthritis.

  • Diabetic clients are at much higher risk of amputation following a washout procedure

    Factors affecting suboptimal outcomes in hand infections. Botma, N., McGuire, D., Koller, I., & Solomons, M. (2020) Level of Evidence: 4 Follow recommendation: ๐Ÿ‘ ๐Ÿ‘ Type of study: Prognostic Topic: Revision surgery following infection โ€“ Diabetes This is a non-peer reviewed prospective study assessing the risk factors for the development of complications following a hand washout procedure. A total of 674 participants diagnosed with a hand infection were included in the study. The results showed that being diabetic increased the risk of a second infection by at least twofold. In people with diabetes, delayed presentation to ED (i.e. more than 1 week) increased the odds of amputation due to sepsis by 6 times. 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, diabetes is a risk factor for the development of a secondary infection following a washout procedure. A prompt referral to ED is warranted given the substantial risk of sepsis and potential amputation in clients with diabetes. This synopsis is a nice addition to a previous synopsis on risk factors for hand infection. URL: Available through EBSCO Health Databases if you have access (PNZ) No abstract available.

  • Can type 2 diabetes contribute to the development of lateral epicondylalgia?

    The impact of type 2 diabetes on the development of tendinopathy. Cannata, F., Vadalร , G., Ambrosio, L., Napoli, N., Papalia, R., Denaro, V., & Pozzilli, P. (2020) Level of Evidence: 5 Follow recommendation: ๐Ÿ‘ Type of study: Prognostic Topic: Lateral epicondylalgia โ€“ Risk factors This is a narrative review assessing the connection between type 2 diabetes and tendinopathy, and exploring the potential treatment pathways. Type 2 diabetes is associated with chronic hyperglycemia (high levels and significant fluctuations of glucose in the bloodstream - especially if not treated) and poses several risks for tendons. In particular, it reduces the loading threshold at which tendons enter a degenerative phase, and it reduces the ability of tendon to heal due to tenocytes oxidative stress and impairment of stem cells activity. This is not to mention the effect that hyperglycemia has on connective and vascular tissue. Thus, glycation of connective tissue makes it more stiff and less resilient to loading. Vascular impairments lead to a reduction of neoangiogenesis (formation of new vessels), which is fundamental for tendon healing. Management of people presenting with type 2 diabetes and tendinopathy includes both local treatment (reduction in loading during the acute phase and gradual resistance training) and other interventions aiming at weight-loss (i.e. exercise, diet, and pharmacological, +/- surgical). Interventions aiming at weight loss have shown to reduce symptoms in both weight-bearing and non-weight-bearing tissues. Finally, resistance training and aerobic exercises are fundamental interventions in the management of type 2 diabetes and should be undertaken under the supervision of a health professional. Clinical Take Home Message: Based on what we know today, clients with type 2 diabetes may be predisposed to develop lateral epicondylalgia. When assessing clients with Type 2 diabetes, hand therapists should investigate whether they are compliant with medications (e.g. metformin) and encourage clients to take part in supervised resistance and/or aerobic training exercises (as per international guidelines). This article is a nice addition to what we already know on the risk factors for lateral epicondylalgia. URL: Available through EBSCO Health Databases for PNZ members. Abstract Tendinopathy is a chronic and often painful condition affecting both professional athletes and sedentary subjects. It is a multiโ€etiological disorder caused by the interplay among overload, ageing, smoking, obesity (OB) and type 2 diabetes (T2D). Several studies have identified a strong association between tendinopathy and T2D, with increased risk of tendon pain, rupture and worse outcomes after tendon repair in patients with T2D. Moreover, consequent immobilization due to tendon disorder has a strong impact on diabetes management by reducing physical activity and worsening the quality of life. Multiple investigations have been performed to analyse the causal role of the individual metabolic factors occurring in T2D on the development of tendinopathy. Chronic hyperglycaemia, advanced glycation endโ€products, OB and insulin resistance have been shown to contribute to the development of diabetic tendinopathy. This review aims to explore the relationship between tendinopathy and T2D, in order to define the contribution of metabolic factors involved in the degenerative process and to discuss possible strategies for the clinical management of diabetic tendinopathy.

  • I like to move it move it...physically fit, physically, physically, physically fit

    World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Bull, F. C., Al-Ansari, S. S., Biddle, S., Borodulin, K., Buman, M. P., Cardon, G., . . . Willumsen, J. F. (2020) Level of Evidence: 1a Follow recommendation: ๐Ÿ‘ ๐Ÿ‘ ๐Ÿ‘ ๐Ÿ‘ Type of study: Preventative, Therapeutic Topic: Pregnancy and older adults - Physical activity guidelines I am publishing again this synopsis because I think it did not get enough attention when I first published it at the beginning of the year. More information on why I think it's important in the clinical take home message below. These are the updated guidelines for physical activity from the World Health Organisation (WHO). Importantly, they included updated information for pregnant women and older adults. The results showed that regular physical activity provides several benefits (e.g. reducing the likelihood of gestational diabetes in pregnant women). For older adults, at least three sessions per week including balance and strength training, have been advised. The table below presents a nice summary. Some extra information is provided below, specifically for pregnant women. Clinical Take Home Message: Based on what we know today, physical activity appears to be necessary across all life stages. Although this statement makes sense and is well known, it is rarely reiterated in clinical practice. Several of our older clients such as those with distal forearm/wrist fractures may particularly benefit by being reminded about the need to perform structured resistance and aerobic training (if they cannot attend the gym, Nymbl - a mobile app - has been sponsored by ACC for older adults in NZ and it can be used to keep them active and reduce their risk of falls). Thus, lack of physical exercise seems to be associated with greater frailty. In addition, older clients with a distal radius fracture are 5 times more likely to have another fracture in the following year compared to their healthy peers. You may be thinking that physical activity advice is appropriate for your older clients only. I would argue that we see several mothers postpartum for De Quervain syndrome, who are at risk of gestational diabetes, post partum depression, and future osteoporosis. The current physical activity guidelines suggest that physical activity during pregnancy and post partum are safe and may reduce the risk of all these conditions. Also, resistance training has been previously suggested to improve bone mass density if performed for a long enough period. Overall, I think I am not asking enough questions about physical activity to my clients, I will try to ask more in the future. What about you? Open Access URL: Abstract Objectives: To describe new WHO 2020 guidelines on physical activity and sedentary behaviour. Methods: The guidelines were developed in accordance with WHO protocols. An expert Guideline Development Group reviewed evidence to assess associations between physical activity and sedentary behaviour for an agreed set of health outcomes and population groups. The assessment used and systematically updated recent relevant systematic reviews; new primary reviews addressed additional health outcomes or subpopulations. Results: The new guidelines address children, adolescents, adults, older adults and include new specific recommendations for pregnant and postpartum women and people living with chronic conditions or disability. All adults should undertake 150โ€“300โ€‰min of moderate-intensity, or 75โ€“150โ€‰min of vigorous-intensity physical activity, or some equivalent combination of moderate-intensity and vigorous-intensity aerobic physical activity, per week. Among children and adolescents, an average of 60โ€‰min/day of moderate-to-vigorous intensity aerobic physical activity across the week provides health benefits. The guidelines recommend regular muscle-strengthening activity for all age groups. Additionally, reducing sedentary behaviours is recommended across all age groups and abilities, although evidence was insufficient to quantify a sedentary behaviour threshold. Conclusion: These 2020 WHO guidelines update previous WHO recommendations released in 2010. They reaffirm messages that some physical activity is better than none, that more physical activity is better for optimal health outcomes and provide a new recommendation on reducing sedentary behaviours. These guidelines highlight the importance of regularly undertaking both aerobic and muscle strengthening activities and for the first time, there are specific recommendations for specific populations including for pregnant and postpartum women and people living with chronic conditions or disability. These guidelines should be used to inform national health policies aligned with the WHO Global Action Plan on Physical Activity 2018โ€“2030 and to strengthen surveillance systems that track progress towards national and global targets.

  • Are cortisone or hyaluronic acid injections a good idea if trapeziectomy is coming up?

    Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery. Giladi, A. M., Rahgozar, P., Zhong, L., & Chung, K. C. (2018) Level of Evidence: 4 Follow recommendation: ๐Ÿ‘ ๐Ÿ‘ Type of study: Prognostic Topic: 1st cmcj OA injections - Are they safe? This is a retrospective study assessing post-surgical complications in clients who underwent injection therapy vs those who did not, prior to surgery for symptomatic 1st cmcj OA. The surgical procedure was trapeziotomy with or without suspension arthroplasty or fusion. A total of 16,268 participants, took part in this study. Of these, 4,462 (27%) and 252 (1.5%) received at least one cortisone or hyaluronic acid injection respectively prior to surgery. The average time between injection and surgery was 12 months. The results showed that one cortisone injection increased the odds of post surgical infection by 20% while three cortisone injections increased the odds of post surgical infection by 70%. Hyaluronic acid injections increased the risk of post surgical infection by 110%. Unfortunately, the absolute number of participants presenting with post-surgical infections was not provided ( I also contacted the authors but they were unable provide me with the numbers). It is therefore possible that the effect reported is overestimated and potentially not clinically relevant. Clinical Take Home Message: Based on what we know today, cortisone or hyaluronic injections for 1st cmcj OA may not be the best therapeutic options if clients are scheduled for a trapeziotomy in the near future. The risk of post-surgical complications may be higher and other therapeutic interventions may be as effective and less harmful. Considering that the effectiveness of cortisone injections for 1st cmcj OA is not superior to placebo, their use is questionable. The results from this study are not surprising considering that cortisone injections have shown to increase the risk of post surgical infections in other joint (e.g. hip). URL: Available through EBSCO Health Databases for PNZ members. Abstract Truven MarketScanยฎ Databases were used to identify patients with thumb carpometacarpal arthritis who underwent surgical treatment. Pre-operative corticosteroid or hyaluronic acid injections were identified, as were post-operative complications. Multivariable regressions assessed the relationship between injections and complications. Of 16,268 patients, 4462 had steroid injections and 252 received hyaluronic acid injections. Twenty-one per cent (3381 patients) had post-operative complications. Diabetes and smoking increased the odds of complications in all models. Odds of any complication, most notably infectious complications, were increased 20% by corticosteroids (OR 1.2; 95% CI: 1.1 to 1.3). More than three injections increased the odds of a complication by 70% (OR 1.7; 95% CI: 1.3 to 2.1). Hyaluronic acid increased the odds of wound-healing complications by 110% (OR 2.1; 95% CI: 1.3 to 3.4). Corticosteroid and hyaluronic acid injections for thumb carpometacarpal arthritis increase the odds of post-operative complications.

  • Upper limb laceration in fresh water? Keep an eye on it

    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: ๐Ÿ‘ Type of study: Diagnostic/Therapeutic Topic: Fresh water laceration โ€“ 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 experienced while swimming in a fresh water reservoir. They were not immunocompromised and their injury had been attended in ED a few hours (2 hrs) prior to the worsening of symptoms. Objectively, they presented with pain in the 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 washout with the wound left open for primary healing. The symptoms resolved after a few weeks of discharge and the there were no hand or upper limb impairments at 6 or 12 months. Clinical Take Home Message: Lacerations or wounds in fresh or salt water environments should be followed closely in all clients. Particular attention should be paid to 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. The risk of having an additional infection after a washout is 15% higher if clients are smokers or diabetic, and 20% higher if they are both. It is therefore worth investigating whether they are smokers and helping them to quit if they are interested. X-rays and US are the primary investigations to be utilised if suspecting an infection. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. 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.


by Dr Nico Magni

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