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Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic Have a think about this case study. Leave a diagnostic comment if you like. The patient was a 53 years old office worker who had undergone trapeziectomy with ligament reconstruction and tendon interposition. They did not present with comorbidities. Seven hours after they were discharged, they presented to ED with excruciating pain in their hand. Upon objective examination, the fingers had no capillary refill. Following assessment of a vascular surgeon, they were put on antibiotics, steroids, and aspirin. They were discharged after two days. Seven days after surgery, their hand appeared as shown in the picture below. They were assessed by another team of surgeons and there was no evidence of infection or joint range of movement limitations. What's the problem?

Effects of multidirectional elastic tape on pain and function in individuals with lateral elbow tendinopathy: A randomised crossover trial. Hill, C. E., Heales, L. J., Stanton, R. and Kean, C. O. (2023) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Lateral epicondylalgia – Kinesio taping This is a randomised crossover trial assessing the effects of multidirectional elastic tape on pain-free grip strength and pressure pain threshold in individuals with lateral elbow tendinopathy. A total of 27 participants were included in the study. The tensioned (experimental) tape was applied as shown in the image below. The placebo tape was applied without tension. These conditions were also compared to a "no tape" condition. Pain-free grip strength and pressure pain thresholds were measured immediately before and after the application of taping/no taping. The results showed that the "tensioned" kinesio tape provided no additional benefit compared to the placebo application or no tape. In terms of pain-free grip strength or pressure pain threshold. There were, however, individual variations showing that 7 participants (26%) experienced an increase in pain-free grip strength with the experimental condition. 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, tensioned multidirectional elastic tape does not appear to improve pain-free grip strength or pressure pain threshold in individuals with lateral elbow tendinopathy. This is in line with previous evidence showing that "inhibitory" Kinesio taping is no more effective than a placebo for lateral epicondylalgia (LE). If you are interested in lateral epicondylalgia, have a look at the whole collection. Open Access URL: https://doi.org/10.1177/02692155231152817 Abstract OBJECTIVE: To investigate the effects of multidirectional elastic tape on pain and function in individuals with lateral elbow tendinopathy. STUDY DESIGN: Randomised crossover trial. SETTING: Biomechanics laboratory. SUBJECTS: 27 participants (11 females, mean (SD) age: 48.6 (11.9) years) with clinically diagnosed lateral elbow tendinopathy of at least six weeks' duration. INTERVENTIONS: Tensioned multidirectional elastic tape applied over the wrist, compared to control tape (untensioned), and no tape conditions. MAIN MEASURES: Pain-free grip strength and pressure pain threshold were recorded at three timepoints for each condition: baseline, post-application, and following an exercise circuit. Change scores were calculated as the post-application or post-exercise value minus baseline. Repeated-measure analyses of variance were used to examine differences between conditions. RESULTS: There were no statistically significant differences in pain-free grip strength between conditions (flexed position: F(2,52) = 0.02, p = 0.98; extended position: F(2,52) = 2.26, p = 0.12) or across timepoints (post-application vs post-exercise) (flexed position: F(1,26) = 0.94, p = 0.34; extended position: F(1,26) = 0.79, p = 0.38). Seven participants (26%) increased pain-free grip strength above the minimal detectable change following application of multidirectional elastic tape. There were no statistically significant differences in pressure pain threshold between conditions (affected lateral epicondyle: F(1.51,39.17) = 0.54, p = 0.54) or across timepoints (affected lateral epicondyle: F(1,26) = 0.94, p = 0.34). CONCLUSION: Tensioned multidirectional elastic tape may not immediately improve pain-free grip strength or pressure pain threshold in our lateral elbow tendinopathy population; however, individual variation may exist. 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

Development and validation of a prognostic nomogram for open elbow arthrolysis: The Shanghai Prediction model for Elbow Stiffness Surgical Outcome. Liu, W., et al. (2022) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Prognostic Topic: Post-traumatic elbow stiffness - Is arthrolysis going to be successful? This is a prognostic study aiming to develop a model to predict the outcome of surgery for post-traumatic stiffness of the elbow. The type of surgery investigated was open arthrolysis. A total of 551 patients were retrospectively identified amongst a cohort of Chinese people presenting with post-traumatic elbow stiffness. A successful surgical outcome was defined as presenting with more than 120° (functional elbow range) post-surgery. Several potential predictors were included. The results showed that higher BMI, longer duration of stiffness, poorer baseline ROM, more severe pain, and more severe OA of the elbow lead to poorer functional recovery after open elbow arthrolysis. The model had a good prediction performance although further validation is required. To calculate the probability of your patients having a successful surgery, you can use the nomogram in the figure below or use the online tool that I created for you. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, The Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) is a valid and convenient model, which can be utilised to predict the outcome of open arthrolysis of the elbow. It can be adopted in combination with clinical reasoning to counsel patients about surgical options (i.e. open arthrolysis) to reduce elbow stiffness. Considering that elbow stiffness can lead to mental health issues such as depression, it is an important impairment to resolve. In terms of conservative treatment, stretching or resistance training appear to be useful to regain range of movement. URL: https://doi.org/10.1302/0301-620x.104b4.bjj-2021-1326.r2 Abstract AIMS: The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow. METHODS: We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation. RESULTS: BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome. CONCLUSION: The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of 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

Prevalence and associated factors of primary elbow osteoarthritis in the Japanese general elderly population: A Japanese cohort survey randomly sampled from a basic resident registry. Nakayama, K., et al. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Symptoms prevalence study Topic: Elbow osteoarthritis – Prevalence This is a cross-sectional study that assessed the prevalence of asymptomatic and symptomatic primary elbow osteoarthritis (PEOA) in Japan. A total of 318 participants over the age of 50 (range 50 to 89 years old) took part in the study. The prevalence of PEOA was reported to be 25%. Men had a higher rate of PEOA (27%) compared to women (23%). Despite this high prevalence, symptomatic PEOA was identified in 1% of the cohort. Factors associated with the presence of PEOA were older age and greater body mass index (BMI). In addition, long-term use of vibrating tools was shown to be a risk factor for severe radiographic PEOA. Other factors such as smoking, heavy manual labour, and participation in overhead sports were not associated with PEOA. 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, primary elbow OA identified through radiographs appears to be highly prevalent in people over the age of 50. However, only 1% of people over 50 present with symptomatic primary elbow osteoarthritis. Interestingly, higher BMI appears to be associated with greater prevalence of primary elbow osteoarthritis. Considering the the elbow is not a weighbearing joint, it is likely that this condition may be the result of low-grade inflammation or the presence of genetic factors that contribute to both greater BMI and OA. If you would like to know more about the conservative treatment for elbow OA, have a look at this synopsis. URL: https://doi.org/10.1016/j.jse.2021.07.015 Abstract Background: The epidemiology of primary elbow osteoarthritis (PEOA) remains unknown. We aimed to evaluate the prevalence and associated factors of PEOA in a cross-sectional resident cohort from a municipal registry of a Japanese town. Methods: A total of 415 residents over 50 years of age were randomly sampled from a Japanese town and were adjusted for age and gender. Those with diseases that could potentially cause a secondary osteoarthritis of the elbow were excluded. The remaining 318 subjects (150 men and 168 women) underwent bidirectional radiography of the elbow. Subjects were diagnosed with PEOA if one of their elbows was Kellgren-Lawrence (KL) grade 2 or greater. In addition, motion pain and tenderness at the elbow were examined by orthopedic surgeons. Associated factors for the PEOA were statistically analyzed. Results: The prevalence of PEOA was 25.2% (male, 27.3%; female, 23.2%), and the prevalence of symptomatic PEOA was 0.9%. The age-stratified prevalence of PEOA was as follows: 50-59, 6.2% (male, 5.0%; female, 7.3%); 60-69, 15.4% (male, 17.5%; female, 13.7%); 70-79, 29.5% (male, 35.3%; female, 25.0%); and 80-89, 55.9% (male, 55.6%; female, 56.3%). Age and body mass index were revealed as associated factors that increased the prevalence of PEOA with KL grade 2 or greater. The use of vibrating tools was demonstrated as an independent associated factor that increased the prevalence of PEOA with KL grade 4 in addition to the 2 aforementioned factors. Conclusions: The prevalence of PEOA in Japanese subjects was 25.2% for those aged 50-89 years with a mean age of 69.2 years, most of which was asymptomatic OA without motion pain or tenderness at the elbow. Age and body mass index increased the prevalence of PEOA with KL grade 2 or greater. The prevalence of PEOA increased with age, but the disease was self-accommodated by most people. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Is it time to reconsider the indications for surgery in patients with tennis elbow? Karjalainen, T. and Buchbinder, R. (2023) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Lateral epicondylalgia – Therapeutic approaches This is an expert opinion on the clinical implications of recent research findings on tennis elbow. The authors suggest that recovery from tennis elbow is usually good, with a 50% probability of recovery every three to four months, and that failed nonoperative treatment does not necessarily mean that surgery will be effective. It also suggests that biomechanical and social factors may be involved in recovery, and that future studies should explain with higher certainty what contributes most to its development and recovery. It is important to identify subgroups of patients who do not recover spontaneously and treat them with an evidence-based approach. Failure of nonoperative treatment is not an indication for surgery. 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, tennis elbow is a self-limiting condition in most patients, and the prognosis is usually good with most people recovering without treatment. However, there are some factors that can affect recovery, such as mechanical and social factors, which surgery does not modify. Therefore, failed nonoperative treatment should not be used as an indication for surgery unless we can reliably identify people who will recover through it. This is especially true since a recent paper has shown surgery to be no more effective than placebo. People with longstanding symptoms should be informed about the favourable prognosis instead of trying surgery as a first-line treatment. If you would like to get a more complete picture about lateral epicondylalgia, have a look at the whole collection. URL: https://doi.org/10.1302/0301-620X.105B2.BJJ-2022-0883.R1 Abstract Tennis elbow (lateral epicondylitis or lateral elbow tendinopathy) is a self-limiting condition in most patients. Surgery is often offered to patients who fail to improve with conservative treatment. However, there is no evidence to support the superiority of surgery over continued nonoperative care or no treatment. New evidence also suggests that the prognosis of tennis elbow is not influenced by the duration of symptoms, and that there is a 50% probability of recovery every three to four months. This finding challenges the belief that failed nonoperative care is an indication for surgery. In this annotation, we discuss the clinical and research implications of the benign clinical course of tennis elbow. 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

A life dedicated to climbing and its sequelae in the fingers-a review of the literature. Pastor, T., et al. (2022) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Aetiologic Topic: Climbing - Hand OA This is a case study and literature review on the effects of rock climbing on the hands. It is reported that climbers have thicker pulleys, collateral ligaments and capsules, decreased range of motion, and contractures in their fingers. Bone adaptations, such as thick cortices and small medullary canals, have been found in climbers and are positively correlated with climbing years. It is unclear whether these changes are adaptations to mechanical stress or pathological reactions. The study followed an elite climber for 10 years and found that bone thickness and osteophyte size increased over the course of the study. They presented with morning stiffness but no pain. Previous research has also shown that 84% of the climbers present with objective signs of osteoarthritis, with the middle finger being the most susceptible to degeneration. However, the presence of these signs is not always associated with pain. The crimp position, which is used by 90% of climbers, maybe a contributing factor to the development of osteoarthritis. Based on what these authors said, can you tell which column (either left or right) of radiographs belongs to a 52 yrs old climber vs and age and sex match non-climber? Leave a comment with your guess! 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, elite sport climbing can lead to soft tissue and bone adaptations in the fingers. These adaptations appear to increase over time. The middle finger appears to be the most affected digit. It is important to remember that the presence of bony enlargements and/or changes on x-ray, does not equate to pain. Does this mean that you should advise your clients against rock climbing? Probably not, especially considering that taking part in rock climbing is likely to increase their likelihood of meeting the WHO guidelines for physical activity. This in turn increases life span and health span. If you would like to predict the likelihood of developing hand OA in your non-climbing clients, use the prediction model. If you are wondering whether cracking your knuckles causes hand OA, have a look at this other synopsis! Open Access URL: https://doi.org/10.3390/ijerph192417050 Abstract Fingers of sport climbers are exposed to high mechanical loads. This work focuses on the fingers of a 52-year-old active elite climber who was the first in mankind to master 8B (V13), 8B+ (V14) and 8C (V15) graded boulders, bringing lifelong high-intensity loads to his hands. It is therefore hypothesized that he belongs to a small group of people with the highest accumulative loads to their fingers in the climbing scene. Fingers were analyzed by means of ultrasonography, X-rays and physical examination. Soft tissue and bone adaptations, as well as the onset of osteoarthritis and finger stiffness, were found, especially in digit III, the longest and therefore most loaded digit. Finally, this article aims to provide an overview of the current literature in this field. In conclusion, elite sport climbing results in soft tissue and bone adaptations in the fingers, and the literature provides evidence that these adaptations increase over one's career. However, at later stages, radiographic and clinical signs of osteoarthritis, especially in the middle finger, seem to occur, although they may not be symptomatic. 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

Outcomes and prognostic factors for nerve grafting following high radial nerve injury. Zhu, S., et al. (2023). Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Prognostic Topic: Recovery post radial nerve graft - Prognostic factors This is a retrospective study assessing factors affecting the recovery outcomes following nerve graft for a high radial nerve injuries (distal to the motor branch of the triceps and proximal to the posterior interosseous nerve). A total of 33 patients with severe radial nerve lesions (inability to elicit motor action measured through EMG with nerve conduction studies) were included in the study. Participants were defined as recovered following grafting if they presented with the ability to extend their wrist/fingers at least against resistance. The patients were followed up for at least one year. The results showed that a radial nerve grafting within 6 months, a nerve length defect of less than 5 cm, and the use of three or more donor nerve cables (living nerve tissue used in the transplant) were associated with better recovery. The average time for ECRL and EDC reinnervation after surgery was 9 and 12 months respectively. The study found that the recovery of wrist and finger extension was good but that of thumb extension was poor. Tendon transfer approaches may be more effective in those people presenting with delayed repairs and larger than 5 cm nerve defects. 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, patients with radial nerve grafting of defects smaller than 5 cm, which occur within 6 months of injury, recover well at 9-12 months. A tendon transfer may be more appropriate if patients don't present with these characteristics. Read these other synopses if you are interested in peripheral nervous system lesions have a read of these other synopses on digits' sensory loss and ulnar entrapment at the Guyons' canal. URL: https://doi.org/10.1177/17531934221147651 Abstract In this study, we examined the prognostic factors affecting outcomes following nerve grafting in high radial nerve injuries. Thirty-three patients with radial nerve injuries at a level distal to the first branch to the triceps and proximal to the posterior interosseous nerve were retrospectively studied. After a follow-up of at least 1 year, 24 patients (73%) obtained M3+ wrist extension, 16 (48%) obtained M3+ finger extension and only ten (30%) obtained M3+ thumb extension. Univariate, multivariate and receiver operating characteristic analyses showed that a delay in the repair of less than 6 months, a defect length of less than 5 cm or when grafted with three or more donor nerve cables achieved better recovery. Number of cables used was related to muscle strength recovery but not time to reinnervation. Nerve grafting for high radial nerve injury achieved relatively good wrist extension but poor thumb extension and is affected by certain prognostic factors. 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

Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect. Hohenschurz-Schmidt, D., et al. (2022) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Placebo and nocebo – What are they? This masterclass discusses the negative repercussions associated with the use of fear avoiding language, discarding factors such as the inheritability or socioeconomic contributors to disability, and the higher importance given to biomechanics compared to other factors in rehabilitation settings. The authors explain that these behaviours have the potential to induce nocebo in our patients through learning and expectation mechanisms. From a neurophysiological point of view, these factors act through descending pain modulatory pathways. For example, telling patients that they will experience pain during a certain activity is likely to increase their chance of experiencing pain. Moreover, not recognising the importance of genetic factors in the predisposition to certain diseases, has the potential to reduce patients' self-esteem and self-efficacy. As clinicians, we should aim at modifying false beliefs, and reduce anxiety. Providing positive messages regarding the function and structure of the human body should be the priority. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, we should provide our clients with positive messages and consider factors beyond biomechanics in the assessment and treatment of musculoskeletal conditions. It is important to understand what factors contribute to placebo and nocebo so we can boost the placebo effect during our treatments. Research also showed that pain response is modulated by observing the behavior of other people. If you cringe when your patients show you what they would like to do or have been doing, it is more likely that they will feel pain with that activity. If you are interested in testing your pain science, take this quiz which other hand therapists have completed in research settings. URL: https://doi.org/10.1016/j.msksp.2022.102677 Abstract Introduction: While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects. Purpose: In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects. Implications This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the ‘prism’ of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context. 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

Decision making in treatment of radial head fractures: Delphi methodology. Surucu, S., et al. (2022) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Radial head fractures - Management This is a Delphi study which aimed at obtaining consensus from a panel of orthopaedic surgeons on the management of radial head fractures. Surgeons' were given a total of 96 clinical scenarios and asked to determine whether they would treat the patients surgically or conservatively. The results showed that there was a high level of agreement for 30 scenarios (32%). The characteristics of the clinical scenarios with high agreement are reported in the tables below. The results showed that if patients were over 80 years old, presented with no block to ROM after aspiration/injection (to exclude pain as a factor limiting ROM), no crepitation with ROM, and no tenderness on DRUJ/interosseous membrane (dorsal forearm) they were suggested to undergo conservative treatment regardless of radial head involvement on imaging. In contrast, those patients presenting with a gap/displacement ≥ 2mm, ≥ 30% radial head involvement with a block to a range of motion, regardless of tenderness over DRUJ or interosseous membrane (dorsal forearm) or crepitation, should be managed surgically. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, in people over 80 yrs old without an elbow ROM limitation, conservative management is the most common approach following a radial head fracture. In contrast, surgical management is preferred in those younger patients presenting with or without ROM limitations in association with crepitus or fracture displacement/large fracture of the radial head. If left untreated these injuries may lead to severe range of movement limitations, pain, and they are likely to lead to post-traumatic elbow osteoarthritis. The type of fractures more likely to undergo surgery are the ones caused by complex elbow dislocations, which are not only associated with fractures but also significant ligament injury. URL: https://doi.org/10.1016/j.jse.2022.10.002 Abstract Background: The treatment of partial, displaced radial head fractures is determined not only by the type of fracture, but also by patient characteristics such as age, occupation, hand dominance, mechanism of injury, and concomitant injuries and comorbidities. The goal of this study was to employ the Delphi method to achieve consensus on the management of patients with radial head fractures, utilizing the experience of the ASES elbow fracture-dislocation multicenter study group and Mayo Elbow Club surgeons. Methods: The initial survey was sent to participants, which included consent to participate in the study and questions about their experience, knowledge, and interest in participating in the Delphi method.We used both open-ended and category-based questions. The second questionnaire generated 76 variables, and individual questions with mean Likert ratings of < 2.0 or > 4.0 were deemed significant and merged to form multifactorial clinical scenarios relating to both nonoperative and operative management, respectively. Results: Of surgeons who responded to the questionnaire; 64% were from the United States, while the remainder were from overseas practices. Years in practice on average were 12.4 years (range, 1-40). Seven of the 76 factors met the criteria of a mean Likert score of <2.0 or >4.0. These factors were; age, block to the range of motion (ROM) after aspiration/injection, crepitation with ROM, tenderness over the distal radioulnar joint (DRUJ) and/or interosseous membrane (dorsal forearm), gap and/or displacement >2mm on imaging, complete loss of contact of the head with rest of radius on imaging, fracture head involvement 30% on imaging. 22 (46%) of the 96 clinical scenarios gained >90% consensus in favor of surgical treatment, whereas 8 (17%) reached >90% consensus in favor of non-operative treatment. Conclusion: Obtaining expert consensus on the treatment of radial head fractures remains challenging. Certain factors such as gap/displacement ≥ 2mm without complete loss of contact, ≥ 30% head involvement with a block to a range of motion regardless of tenderness over DRUJ or interosseous membrane (dorsal forearm) or crepitation when the patient was <80 years of age led to a recommendation of operative treatment in 100% of the surveyed surgeons. Patients greater than 80 years of age with no block to ROM after aspiration/injection, no crepitation with ROM, and no tenderness on DRUJ/interosseous membrane (dorsal forearm) were recommended for non-operative treatment regardless of the size of the radial head involvement on imaging. 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

Social determinants of health and physical activity are related to pain intensity and mental health in patients with carpal tunnel syndrome. Núñez-Cortés, R., et al. (2023) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Symptoms prevalence Topic: Social risk factors - Carpal tunnel syndrome burden This is a cross-sectional study assessing the effect of social factors (e.g. employment) and physical activity on carpal tunnel syndrome (CTS) disease burden. A total of 86 participants on a waiting list for carpal tunnel release (severe CTS) were included in the study. The social risk factors assessed were employment status and educational level. Physical activity was assessed as high in those people following the World Health Organisation (WHO) guidelines (at least 150 minutes/week of moderate exercise or 75 minutes of vigorous-intensity exercise) and low in those who did not meet the criteria. Carpal tunnel syndrome burden was assessed based on pain, anxiety/depression, and pain catastrophising. The results showed that meeting the WHO guidelines for physical activity was associated with lower levels of pain and depression. Being employed and having a higher educational level were associated with lower anxiety and pain catastrophising respectively. 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, social risk factors and lower physical activity levels are associated with the greater disease burden in carpal tunnel syndrome. Based on these results we should encourage our clients with carpal tunnel syndrome to follow the WHO guidelines for physical activity, which may reduce pain as well as the likelihood of developing or severity depression. In addition, those people who are unemployed and have a lower educational level may require more support from us in terms of the number of sessions that we provide, reduction in attendance barriers (e.g. removal of copayments), referral to free physical activity classes (e.g. green prescription), and additional efforts on our side to reduce pain catastrophising. If left to their own devise, we know that patients with social risk factors tend to have worse outcomes when affected by conditions such as arthritis and flexor tendon repairs. URL: https://doi.org/10.1016/j.msksp.2023.102723 Abstract Background: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy of the upper limb and a frequent cause of disability. Objective To analyze the association between social determinants of health (SDH) and physical activity with pain intensity and mental health in patients with CTS. Design: A cross-sectional study was conducted in patients with CTS awaiting surgery in two public hospitals in Chile. Methods: The SDH collected included: employment status, educational level and monetary income. The level of physical activity was defined according to compliance with WHO recommendations. Outcome measures included: Pain intensity (Visual Analog Scale), Symptoms of anxiety and depression (Hospital Anxiety and Depression Scale), and catastrophic thinking (Pain Catastrophizing Scale). The adjusted regression coefficient (β) for the association between SDH and physical activity with each outcome was obtained using multivariable linear regression models controlling for age, sex, body mass index and symptom duration. Results: Eighty-six participants were included (mean age 50.9 ± 10 years, 94% women). A high level of physical activity was associated with a 12.41 mm decrease in pain intensity (β = −12.41, 95%CI: 23.87 to −0.95) and a 3.29 point decrease in depressive symptoms (β = −3.29, 95%CI: 5.52 to −1.06). In addition, being employed was associated with a 2.30 point decrease in anxiety symptoms (β = −2.30; 95%CI: 4.41 to −0.19) and a high educational level was associated with a 7.71 point decrease in catastrophizing (β = −7.71; 95%CI: 14.06 to −1.36). Conclusion: Multidisciplinary care teams should be aware of the association between SDH and physical activity with physical and mental health. 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

Inflammatory arthritis and the elbow surgeon. Dott, C., Chin, K. and Compson, J. (2021) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic Topic: Elbow inflammatory arthritis – Differential diagnosis This is an expert opinion on the differential diagnosis of inflammatory arthropathies of the elbow. The most common inflammatory arthropathy of the elbow is rheumatoid arthritis (RA). Other less frequent inflammatory arthropathies include psoriatic arthritis, gout, and lupus. Rheumatoid arthritis rarely affects the elbow alone (5%) and more frequently presents as a polyarthropathy (20-65% of cases). It often presents with bilateral symptomatology. With the advent of disease-modifying antirheumatic drugs (DMARDs) the number of patients affected by severe RA has reduced. Psoriatic arthritis tends to present bilaterally and it is present in 25% of people with psoriasis. Another inflammatory arthropathy is gout, and, although rare, it can present as a severely acute elbow mono-arthropathy. An acute elbow gout flare commonly presents at the olecranon bursa. Lupus rarely affects the elbow but it may present as a less severe and reversible arthropathy. All the acute presentations of elbow pain, especially if associated with redness and swelling need to be investigated and septic arthritis needs to be excluded. 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, rheumatoid arthritis is the most common inflammatory arthritis affecting the elbow. Less common inflammatory arthropathies of the elbow include psoriatic arthritis, gout, and lupus. Acute, non-traumatic, severe elbow pain presentations must be investigated and septic arthritis should be excluded. If the acute non-traumatic presentation is not septic arthritis and it's unilateral, it is likely to be an acute flare of gout. In contrast, if the symptoms are bilaterally and associated with skin lesions, it is more likely to be psoriatic arthritis. These inflammatory arthropathies also affect the periarticular soft tissue and may be mimickers of elbow tendinopathies. It's important to remember that these inflammatory elbow arthropathies are different from elbow osteoarthritis and should therefore be managed accordingly. URL: https://doi.org/10.1016/j.jcot.2021.101492 Abstract The treatment of inflammatory arthritis with disease modifying drugs and biological agents had reduced the number of patients needing surgical treatment. Surgical treatment of patients with inflammatory arthritis is challenging not only due to the factors such as bone stock and status of soft tissue but also due to the comorbidities associated with inflammatory arthritis. Multidisciplinary approach to these patients is recommended to deal with the complex poly-articular involvement and systemic physiological impairment especially when planning surgery. This review will cover the key articular and peri-articular pathologies that can affect the elbow in inflammatory arthritis and discuss the treatment strategies available to the orthopaedic surgeon in their management. From surgical point of view, the rheumatoid elbow can be classified into 4 types: 1) classic soft tissue type with increased joint laxity, malalignment and instability; 2) osteoarthritic type with stiffness, hypertrophic joints (hypertrophic) and preserved alignment; 3) nodular type with subcutaneous nodules and enthesopathies but preserved jointly; 4) mutilans with bone and joint destruction. Surgical managements of the articular problem in each of the subtypes are discussed in this review. On the other hand, the seronegative arthritis such as psoarisis, gout and lupus seems to affect the peri-articular tissue of the elbow more than the joint itself and the disease specific management of the peri-articular soft tissue problems, such as enthesopathies and inflammatory nodules, are also outlined. 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

Neglected posterior dislocation of elbow: A review. Pal, C. P., Mittal, V., Dinkar, K. S., Kapoor, R. and Gupta, M. (2021) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Posterior elbow dislocation - Treatment This is an expert opinion on the assessment and treatment of posterior elbow dislocations that go untreated for 3 weeks or more. A discussion on symptoms, diagnosis, and treatment for this condition is presented. Patients with non-reduced posterior elbow dislocation are usually able to move the elbow through some range, however, this is significantly limited and likely associated with elbow deformity. Range of movement limitations are due to the lack of reduction with or without heterotopic ossification/fracture displacement as well as numbness/tingling/P&N in the ulnar distribution due to ulnar nerve entrapment at the cubital tunnel. Diagnosis requires imaging and in severe cases CT scans. Treatment of neglected posterior dislocations is challenging due to the potential presence of ligament insufficiencies alongside fracture displacement or nerve injuries. Open reduction is almost always required and soft tissue debridement is often required (e.g. triceps tendon). The aim of surgery is to regain a painless, stable elbow with a functional range of movements. Unfortunately, due to the injury complexity, full range of movement is rarely regained in adults. 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, elbow dislocations require assessment and treatment to avoid important sequelae in both children and adults. If left untreated they are associated with severe range of movement limitations, pain, and they are likely to lead to post-traumatic elbow osteoarthritis. If you are interested in reading more about elbow dislocations have a look at these synopses on the "drop sign", differentiating between simple and complex elbow dislocations, what is the best treatment for simple dislocations, and how to test for postero-lateral rotatory instability. URL: https://doi.org/10.1016/j.jcot.2021.04.016 Abstract Untreated traumatic posterior dislocation of the elbow joint, 3 weeks or older, is defined as “neglected posterior dislocation of the elbow”. Around 90% of these are of posterolateral type. These are much more common in the developing and underdeveloped countries. Patients presents with a deformed, stiff and painful elbow with difficulty to perform activities of daily living. The clinical picture looks quite similar to malunited supracondylar fracture of the elbow. Diagnosis is usually confirmed radiographically. CT and MRI scan give additional information and are recommended before embarking on surgery. Treatment is quite challenging due to the significant soft tissue contractures, ligamentous insufficiencies and fibrosis, with possible associated nerve injuries, myositis ossificans, non-compliant patients and the need for long-term postoperative physiotherapy. Goal of surgical treatment is to achieve a painless, stable and mobile elbow with a congruent joint space. We have reviewed the literature and present our view on the prognosis and recommended surgical technique to treat this condition. 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