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Rupture of the triceps tendon – A case series. Jaiswal, A., Kacchap, N. D., Tanwar, Y. S., Kumar, D. and Kumar, B. (2016) 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 25 years old, who presented with sudden onset of left elbow swelling and pain whilst performing resisted elbow extension exercises at the gym. Active range of movement of the elbow was possible and there was no obvious deformity. There was tenderness on palpation across the whole elbow. X-rays are shown below. The patient underwent surgery and the partial triceps tendon rupture was repaired. Following surgery the patient was immobilised for three weeks after which a gradual range of movement exercise program was initiated. Resistance training was introduced three months post-surgery. At one year, there were no functional limitations, however, objective testing revealed a 10 degrees elbow flexion limitation. 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, distal triceps tendon partial/full ruptures can occur due to a fall onto an outstretched arm or gym exercises superseding tissue capacity. Objective testing may reveal bruising, a palpable defect (full ruptures), and weakness in resisted elbow extension . If surgical repair is indicated, return to work is faster compared to a distal biceps tendon repair . Remember that elbow extension weakness may be caused by a low cervical spine (C7) radiculopathy and this condition needs to be considered as a differential diagnosis. Open Access URL : https://doi.org/10.1016/j.cjtee.2016.06.006 Abstract Triceps rupture is the least common among all tendon injuries. The usual mechanism of injury is a fall on an outstretched hand, although direct contact injuries have also been reported to cause this injury. The diagnosis of acute triceps tendon rupture may be missed, which can result in prolonged disability and delayed operative management. We presented three cases of acute triceps tendon rupture each at different site showing the spectrum of injury to the muscle and mechanism of injury and management were also discussed. 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

Nico's blog, which was written for PhysioTutors Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of blog : Diagnostic Topic : Elbow assessment The elbow is the middle-earth of the upper limb, placed above the realm of the hand and below the realm of the shoulder. As per Tolkien’s Lord of The Ring, the scientific literature is full of magical tests with 100% sensitivity and specificity. So how can we decide how to assess our clients? Let’s walk through a few steps that you may find useful in clinical practice 💪. Easy steps First of all, the subjective assessment is our greatest friend. Knowledge of whether the client presents with a traumatic or non-traumatic condition halves the number of tests that we can perform. At the same time, observation will guide us in determining whether it is safe to perform any tests. For example, if the person is complaining of a traumatic injury associated with bruising and deformity, is it likely that the best thing we can do is refer them for an x-ray (Bunshah et al., 2015). In contrast, if the presentation is traumatic but we feel comfortable moving into active range of movement assessment, the elbow extension test may be useful in determining whether we require an x-ray (Appelboam et al., 2008). This is a good screening test, if it’s negative, you can be reasonably confident that they do not have a fracture. Physiotutors have created a helpful video about this test that you should watch! You have now determined whether the client needs an x-ray before proceeding with the physical assessment! Well done! Next, you could further exclude special tests by determining the location and type of symptoms they present with. What is the location of pain, pins and needles, numbness, and/or weakness? If you can answer these questions, the number of special tests will reduce to 0 or 2-3. Zero if pain is widespread and it is not following any specific pattern that you can think of. In this case, after your appointment, you can brainstorm with yourself and your colleagues. On the other hand, if you have a differential diagnosis in mind, you can get through your classic active, passive range of movement testing followed by a few special tests. How good are special tests though? Not so good. As covered in a previous synopsis, the diagnostic accuracy of special tests for the elbow is poor (Zwerus et al., 2018). This means that solely based on the results of special tests for the elbow, we cannot make a diagnosis. Is this surprising? I don’t think so. Often the problem is that we do not have a gold standard against which to compare special test results. For instance, common extensor tendon origin tendinopathy (e.g. tennis elbow) does not have a diagnostic gold standard. Ultrasound and MRI imaging can detect changes within the tendon but not all tendinopathies are symptomatic. In other instances, there is just not enough research to be confident about the results of an isolated special test (e.g., hook test for distal biceps rupture ). This does not mean that we cannot use these tests, we just need to be aware of the limitations and reduce our expectations. This last point means that our subjective and clinical reasoning need to have greater importance compared to special tests when making a diagnosis. For those of you who like numbers, it simply means that the change in diagnostic probability should be much more affected by subjective and general objective examination compared to isolated results from special tests! For a list of special tests for the elbow, have a look at the table by Zwerus et al. (2018) . On a final note, be aware of studies showing 100% specificity or sensitivity. They often obtain those results because there is a disproportionate number of participants with or without the condition studied. These results are more likely to come from a Harry Potter book rather than reality - ✨ The magic of statistics ✨ References Distal triceps tendinopathies. Lappen, S., et al. (2020) https://doi.org/10.1007/s11678-020-00601-0 Triceps tendon rupture: An uncommon orthopaedic condition. Bunshah, J. J., Raghuwanshi, S., Sharma, D. and Pandita, A. (2015). http://dx.doi.org/10.1136/bcr-2014-206446 Distal biceps tendon repair and reconstruction. Srinivasan, R., Pederson, W., & Morrey, B. (2019) http://dx.doi.org/ 10.1016/j.jhsa.2019.09.014 Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. Appelboam, A., et al. (2008). https://doi.org/10.1136/bmj.a2428 Physical examination of the elbow, what is the evidence? A systematic literature review. Zwerus, E. L., et al. (2018). http://dx.doi.org/10.1136/bjsports-2016-096712 Disclaimer: This blog was written by one clinician only and it reflects their interpretation. Readers should come to their own conclusions by reading the original articles.

Nearly half of patients with chronic tendinopathy may have a neuropathic pain component, with significant differences seen between different tendon sites: a prospective cohort of more than 300 patients. Wheeler, P. C. (2022) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Symptoms prevalence Topic : Neuropathic pain - Tennis elbow This is a cross-sectional study assessing the presence of neuropathic pain in people with tendinopathy. In this synopsis, we focused on tennis elbow. A total of 39 participants with lateral elbow tendinopathy were included in the study. The diagnosis was made by a sports medicine consultant, and other diagnoses such as upper limb entrapment neuropathies were excluded. To assess the presence of neuropathic pain, the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). Other clinical outcomes such as average and worst pain were assessed. The results showed that 50% of participants with tennis elbow presented with neuropathic pain characteristics (e.g. burning pain, pins and needles, allodynia). In addition, greater levels of neuropathic pain presented with higher levels of pain. 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, a large proportion of patients with lateral elbow tendinopathy present with neuropathic pain characteristics. In addition, these people have greater levels of pain intensity. In clinical practice, it is important to differentiate between lateral elbow tendinopathy and peripheral entrapment neuropathies such as radial tunnel syndrome or cervical radiculopathies. Cervical radiculopathies can also present with upper limb peripheral symptoms (e.g. burning, pins and needles) without neck pain. Although this cervical radiculopathy presentation is rare, we need to keep it in mind as a differential diagnosis . A full neurological assessment would be useful to screen for these conditions. Open access URL : http://dx.doi.org/10.1136/bmjsem-2021-001297 Abstract OBJECTIVES: Identifying the prevalence of neuropathic pain components in patients with chronic tendinopathy conditions using the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire. METHODS: Patients with chronic tendinopathy and 'tendon-like' conditions treated within a single hospital outpatient clinic specialising in tendinopathy were identified. Pain scores, plus global function patient-reported outcome measures (5-Level version of EuroQol-5 Dimension and Musculoskeletal Health Questionnaire (MSK-HQ)), were completed and compared with the S-LANSS questionnaire. RESULTS: 341 suitable patients with chronic tendinopathy and potentially similar conditions were identified. Numbers: lateral elbow tendinopathy (39), greater trochanteric pain syndrome (GTPS; 112), patellar tendinopathy (11), non-insertional Achilles tendinopathy (40), insertional Achilles tendinopathy (39), plantar fasciopathy (100). 68% were female, with a mean age of 54.0±11.3 years and a mean symptom duration of 38.1±33.7 months.There was a mean S-LANSS score of 11.4±6.4. Overall, 47% of patients scored 12 or greater points on S-LANSS, indicating the possible presence of neuropathic pain. The highest proportion was in patients with plantar fasciopathy (61%), the lowest in those with GTPS (33%). Weak correlations were found between the S-LANSS score and MSK-HQ score, the numerical rating scale (0-10) values for 'average pain' and for 'worst pain', but not with the MSK-HQ %health value. CONCLUSION: S-LANSS identified nearly half of patients with chronic tendinopathy as possibly having a neuropathic pain component. This is of unclear clinical significance but worth further study to see if/how this may relate to treatment outcomes. These results are from a single hospital clinic dealing with patients with chronic tendinopathy, without a control group or those with shorter symptom duration. However, this reinforces the probability of neuropathic pain components in at least some patients with chronic tendinopathy. 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

Return to work following distal triceps repair. Agarwalla, A., Gowd, A. K., Jan, K., Liu, J. N., Garcia, G. H., Naami, E., . . . Verma, N. N. (2020) Level of Evidence : 4 Follow recommendation : 👍 Type of study : Prognostic Topic : Distal triceps repair - Return to work This is a retrospective study assessing return to work following a distal triceps repair surgery. Distal triceps ruptures have an incident of 1% in the general population. A repair is usually undertaken when the tear is greater than 50% of the tendon. A total of 81 participants with distal triceps repair were included. Patients' average age was 46 ( SD : 11 years ) years old. Return to work outcomes timeframes (in months) were recorded according to work intensity. Work intensity was defined based on the maximum lifting involved. Work intensity was classified as sedentary (max 5kg), light (max 10kg), moderate (max 25kg), and heavy (max 50kg). Pain was assessed through the visual analogue scale (VAS), and function through the quickDASH. All patients followed the same post surgical instructions. These included a limitation to 20deg of elbow flexion (hinge brace) for the fist two weeks followed by a progression to 90deg by weeks six. At six weeks there were no restrictions in active range of movement. At eight weeks clients could start performing isometric triceps resisted exercises. The results showed that all clients in sedentary and light occupations returned to work within one month and three months respectively. Most (80%) of the patients in moderate and heavy occupations returned to work within six months and nine months respectively. The average return to work time reported across all work intensities was 2 months. Clinical Take Home Message : Based on what we know today, we may provide clients with an estimated return to work timeframe of 1 to 9 months, following distal triceps repair, depending on their work intensity. A simple way to remember it is associating the weight they need to lift with the number of weeks. For example if their maximum lifting required is 5 kg, then we expect 5 weeks, 10 kg requires 10 weeks, 25kg requires 25 weeks, and more than that will require up to one year. The average return to work for people undergoing distal triceps repair (2 months) appears to be shorter than the time required for distal biceps repair (3-4 months) . This may be due to the fact that biceps is heavily involved in lifting activities compared to triceps. Unlike distal biceps repair , no major surgical complication were reported URL : https://www.jshoulderelbow.org/article/S1058-2746(19)30836-5/pdf You can ask the authors for the full through ResearchGate . Available through EBSCO Health Databases if you have access ( PNZ ) Abstract Purpose: Evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR). Methods: Consecutive patients undergoing DTR from 2009-2017 at our institution were retrospectively reviewed at a minimum of one year postoperatively. Patients completed a standardized and validated work questionnaire, a visual analog scale for pain (VAS-Pain), Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder, and Hand Score (quick-DASH) and a satisfaction survey. Results: Out of 113 eligible patients who had a DTR, eighty-one patients (71.7%) were contacted. Of which, 74 patients (91.4%) were employed within three years prior to surgery (mean age: 46.0 ± 10.7 years; mean follow-up: 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. 66 patients (89.2%) patients were able to return to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9% by 0.3 ± 0.5 months, 1.8 ± 1.9 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months postoperatively. Fifteen (75%) workers compensation (WC) patients returned to work by 6.5 ± 4.3 months postoperatively, while 100% of non-WC patients returned to work by 1.1 ± 1.6 months (p<0.001). Seventy-one patients (95.9%) were at least somewhat satisfied with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would still have the operation again if presented the opportunity. A single patient (1.4%) required revision distal triceps repair. Conclusions: Approximately 93% of patients that undergo DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher intensity occupations had an equivalent rate of RTW, but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

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

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

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

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

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

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

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

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