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Triceps brachii hypertrophy is substantially greater after elbow extension training performed in the overhead versus neutral arm position. Maeo, S., et al. (2022) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic Topic: Triceps extensions - Overhead vs neutral shoulder This is a within-subject quasi-experimental study assessing the amount of hypertrophy and exercise load required during two different triceps exercises. In particular, overhead triceps extensions were compared to shoulder-neutral triceps extensions (see figure below). Participants performed one exercise in one limb and the other exercise in the contralateral limb. Which arm did which exercise was alternated when participants were recruited. A total of 21 healthy participants were included and they trained twice a week for 12 weeks performing 10 repetitions per set for five sets with two minutes interset rest. Exercise intensity started at 50% of 1 repetition maximum (1RM) during the first session followed by 60% and 70% in the second and third sessions. After that, 70% of 1RM was utilised. The results showed that in the overhead triceps extension position, 1RM at baseline was on average 34-39% lower compared to in neutral shoulder position. In addition, training in the overhead position lead to greater muscle hyperthropy (5-10%) compared to training in the neutral position. 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 overhead triceps position requires a lower level of loading, compared to the neutral triceps extension, and provides greater levels of hypertrophy following 12 weeks of training. This appears to be true also if we account for the weight of the forearm (1.7% of body weight), which adds to the external resistance in the overhead position. This is useful to know when treating triceps tendinopathies. Thus, lower tendon loads may be beneficial in the initial stages of resistance training. In terms of triceps tendon loading, have a look at this other synopsis to determine how you can progress the exercises for your patients. Open Access URL: https://doi.org/10.1080/17461391.2022.2100279 Abstract The biarticular triceps brachii long head (TBLong) is lengthened more in the overhead than neutral arm position. We compared triceps brachii hypertrophy after elbow extension training performed in the overhead vs. neutral arm position. Using a cable machine, 21 adults conducted elbow extensions (90−0°) with one arm in the overhead (Overhead-Arm) and the other arm in the neutral (Neutral-Arm) position at 70% one-repetition maximum (1RM), 10 reps/set, 5 sets/session, 2 sessions/week for 12 weeks. Training load was gradually increased (+5% 1RM/session) when the preceding session was completed without repetition failure. 1RM of the assigned condition and MRI-measured muscle volume of the TBLong, monoarticular lateral and medial heads (TBLat+Med), and whole triceps brachii (Whole-TB) were assessed pre- and post-training. Training load and 1RM increased in both arms similarly (+62−71% at post, P = 0.285), while their absolute values/weights were always lower in Overhead-Arm (-34−39%, P < 0.001). Changes in muscle volume in Overhead-Arm compared to Neutral-Arm were 1.5-fold greater for the TBLong (+28.5% vs. +19.6%, Cohen's d = 0.61, P < 0.001), 1.4-fold greater for the TBLat+Med (+14.6% vs. +10.5%, d = 0.39, P = 0.002), and 1.4-fold greater for the Whole-TB (+19.9% vs. +13.9%, d = 0.54, P < 0.001). In conclusion, triceps brachii hypertrophy was substantially greater after elbow extension training performed in the overhead versus neutral arm position, even with lower absolute loads used during the training. 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

Biceps disorder rehabilitation for the athlete: A continuum of moderate- to high-load exercises. Borms, D., I. Ackerman, P. Smets, G. Van den Berge and A. M. Cools (2017). Rehabilitation exercises for athletes with biceps disorders and slap lesions: A continuum of exercises with increasing loads on the biceps. Cools, A. M., et al. (2014) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic Topic: Triceps tendon - Gradual loading These are two cross-sectional studies assessing the activation of triceps brachii during upper limb exercises. The aim was to identify which exercises should be included in the early/middle phase vs later phase rehabilitation of clients presenting with a triceps brachii pathology. A total of 62 healthy participants were included in these studies. Of these, 50% were females. Participants were excluded if they were performing resistance training of their upper limb for more than 5 hours a week and if they were competitive overhead athletes. Many different exercises were assessed. The weight utilised in the exercises was based on the participants' body weight. The percentage of triceps brachii activation was based on a maximum isometric voluntary contraction (MVC) of the triceps (EMG). In the exercises described, biceps activation ranged from a minimum of 15% of MVC to 50% of MVC. For your ease of use, I have created the table below. 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 exercises described above can be utilised to gradually load triceps brachii during the early/middle and later phases of rehabilitation. These exercises may be appropriate for distal triceps brachii tendinopathies (after an initial rest has been provided), which could be detected through the overhead active resisted elbow extension. Progression beyond the exercises shown above may include overhead triceps extensions followed by shoulder-neutral triceps extensions. Borms et al. (2017) URL: https://doi.org/10.1177/0363546516674190 Cools, A. M., et al. (2014) URL: https://doi.org/10.1177/0363546514526692 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

Dislocations of the elbow – An instructional review. Reichert, I. L. H., Ganeshamoorthy, S., Aggarwal, S., Arya, A. and Sinha, J. (2021) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Elbow dislocation - Treatment This is an expert opinion on the assessment and conservative/surgical treatment of elbow dislocations. Following shoulder dislocations, elbow dislocations are the most common dislocations in adults. Simple dislocations are defined by the presence of no or small fractures and stability of the elbow post-reduction. Following simple elbow dislocations, It is possible to have ongoing instability due to ligament lesions and these require repair. The most common mechanism of trauma for elbow dislocation is a valgus hyperextension injury, which leads to posterior dislocation, which can cause damage to the lateral collateral ligament (LCL) +/- lateral ulnar collateral ligament (LUCL). Posterolateral instability can occur with partial or complete disruption of the LUCL. In more severe dislocations, damage to the LCL is followed by disruption of the anterior and posterior capsule followed by the medial collateral ligaments (anterior bundle) and in extreme cases the common flexor origin. Imaging pre- and post-reduction is required and the presence of the 'drop sign', which is identified by a gap between ulnar and humeral joint spaces, indicates ongoing instability, likely requiring surgical repair. Conservative treatment of simple elbow dislocations includes the provision of a posterior elbow split for two weeks followed by a progressive range of movement home exercise program. Weekly x-rays are required to identify displacement or re-positioning of fracture fragments. If surgical treatment is required, a posterior elbow splint can be provided for comfort, however, active assisted range of movement should be started within 24-48 hrs post-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, the 'drop sign' on lateral elbow x-ray suggests the presence of significant ligament injury. These cases may require surgical repair. In all elbow dislocations, it is important to assess not only the stability post-reduction but also the presence of neurovascular lesions. If you are interested in elbow dislocations, you can read more about the ligaments providing biomechanical restrain to the elbow, how to test for postero-lateral rotatory instability, differentiating between simple and complex elbow dislocations, and what is the best treatment for simple dislocations. Remember, that the outcome of these injuries is dependent on achieving joint stability and initiating range of movement early. The sequelae of elbow stiffness are significant not only from a physical but also from a mental health perspective. URL: https://doi.org/10.1016/j.jcot.2021.101484 Abstract Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications 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

Medical cannabis in hand surgery: A review of the current evidence. Yang, A., Townsend, C. B. and Ilyas, A. M. (2023) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Therapeutic Topic: Hand and upper limb pain - Medical cannabis This is a narrative review on the efficacy of medical cannabis for hand and upper limb persistent pain conditions/post-surgical analgesia. Cannabis's active ingredients include THC and cannabidiol. THC is the one with psychoactive effect. For the treatment of pain, cannabidiol has been utilised in several experiments. The used of medical cannabis might be appropriate for several different conditions, however, post-surgery its use appears problematic due to the interaction of THC/cannabidiol with anaesthesia and other drugs. Considering these side effects and the lack of studies reporting clinically relevant benefits, its use in acute post-operative settings is not advised. Some evidence has suggested that medical cannabis may be useful for neuropathic pain and may reduce opioid use, however, further research in the hand and upper limb will need to confirm these initial findings. 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 use of medical cannabis following hand and upper limb surgery is advised against due to side effects caused by its interaction with anaesthesia. For persistent hand and upper limb pain, there is very little published evidence on the benefits of medical cannabis despite encouraging findings showing clinically relevant reductions in pain when topical cannabidiol (6.2 mg/ml) is applied in people with symptomatic thumb OA. URL: https://doi.org/10.1016/j.jhsa.2022.11.008 Abstract Acute and chronic pain management remains an ongoing challenge for hand surgeons. This has been compounded by the ongoing opioid epidemic in the United States. With the increasing legalization of medical and recreational cannabis throughout the United States and other countries, previous societal stigmas about this substance keep evolving, and recognition of medical cannabis as an opioid-sparing pain management alternative is growing. A review of the current literature demonstrates a strong interest from patients regarding the use of medical cannabis for pain control. Current evidence demonstrates its efficacy and safety for chronic musculoskeletal and neuropathic pain. However, definitive conclusions regarding the efficacy of cannabis for pain control in hand and upper extremity conditions require continued investigation. The purpose of this article is to provide a general review of the mechanism of medical cannabis and a scoping review of the current evidence for its efficacy, safety, and potential applicability in hand and upper extremity conditions. 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 necessary to fix basal fractures of the ulnar styloid after anterior plate fixation of distal radius fractures? A randomized controlled trial. Afifi, A. and Mansour, A. (2022) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Distal radius fractures - Ulnar styloid fixation This randomised controlled study assessed whether ulnar styloid fracture fixation leads to better outcomes in distal radius fracture open reduction internal fixation (ORIF). A total of 86 participants undergoing distal radius fracture ORIF with an associated distal unlar styloid fracture were included. Potential participants were excluded if there was objective DRUJ laxity (ballottement test) identified intra-operatively (see figure below). In the control group, only the radius fracture was fixated whilst in the experimental group the radius and the ulnar styloid fractures were fixated (k-wire). To assess treatment outcomes, the QuickDASH was collected at 24 months. Post-operatively, participants were kept in a Plaster of Paris slab for 2 weeks during which elbow and hand motion was allowed. A hand therapist provided rehabilitation, which included active mobilisation of the elbow, forearm, hand, and finger joints. Resistance exercises were initiated when bony union was achieved. The results showed that there were no differences between the two groups at the 24 months follow-up. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, in absence of DRUJ instability, fixating a distal radius ulnar styloid fracture does not lead to better outcomes during distal radius fracture open reduction internal fixation. This is one of the few randomised controlled trials in hand and upper limb surgery and the authors should be congratulated for carrying it out. If you are interested in more research concerning distal radius fractures, have a look at the full database where you can find synopses on mobilisation, the effect of catastrophising on stiffness, and complex regional pain syndrome. URL: https://doi.org/10.1177/17531934221140730 Abstract The purpose of this study was to investigate the necessity for surgical fixation of basal fractures of the ulnar styloid without distal radioulnar joint (DRUJ) instability, after stabilization of associated distal radial fractures using an anterior plate. This single-centre, prospective, randomized controlled trial, conducted between 2015 to 2021, included 43 patients in each study arm who were randomized to either fixation (Group A) or non-operative treatment (Group B) of the ulnar styloid. The mean follow-up period was 24 months (SD 5.2) in Group A and 23.9 months (SD 5.5) in Group B. At the final follow-up, patients were evaluated by the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the Modified Mayo Wrist Score (MMWS), the visual analogue scale (VAS) for pain, the grip strength, wrist range of motion. The DASH score was 6 (SD 2.6) in Group A and 6 (SD 2.4) in Group B; the MMWS was 87 (SD 5.6) in Group A and 87 (SD 5.6) in Group B; and the grip strength was 88% (SD 9.4) in Group A and 87% (SD 7.7) in Group B. In conclusion, fixation of basal ulnar styloid fractures is not mandatory if the DRUJ is stable after rigid fixation of the associated fracture of the distal radius. 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

Os centrale – a rare cause of wrist pain: A review. Nazifi, O., Griffiths, J. A. and Flores, D. M. A. (2023) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic This is the answer to last week's Sherlock Handy. The patient was assessed radiographically for a suspected triquetrum fracture, which was confirmed with further investigations. However, during the radiographic assessment of the patient, an additional bone or fracture was identified between the scaphoid, trapezium, trapezoid, and capitate. Considering the presentation of ulnar wrist pain only, the authors concluded that this was an "os centrale" which is a vestigial bone of the wrist. In the literature, symptomatic "os centrale" cases have been reported and excision often revealed avascular necrosis of this bone. 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, "os centrale" is a rare vestigial bone that can in some instances cause pain due to avascular necrosis. Avascular necrosis has been reported in other carpal/wrist bones such as the trapezoid and the distal ulna. Differentiating between an os centrale and a fracture may be difficult if the client reports a history of trauma. URL: https://doi.org/10.1177/17531934221129761 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

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 assessed radiographically for a suspected triquetrum fracture, which was confirmed with further investigations. However, during the radiographic assessment of the patient, an additional bone or fracture was identified between the scaphoid, trapezium, trapezoid, and capitate. Considering the presentation of ulnar wrist pain only, what do you think it is?

Extensor hood injuries in elite boxers: injury characteristics, surgical technique and outcomes. Matharu, G. S., Gatt, I. T., Delaney, R., Loosemore, M. and Hayton, M. J. (2022) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Diagnostic/Therapeutic Topic: Extensor hood injuries – Boxing This is a prospective study assessing outcomes following extensor hood repairs in professional or international amateur boxers. A total of 45 participants were included in the study. Extensor hood pathology was defined as pain in the metacarpophalangeal joint (mcpj) with acute or gradual onset. The authors report that these presentations often present with tenderness on palpation over the sides of the extensor hood, crepitus on movement, and potentially limitation in mcpj flexion. Upon surgical exploration, a variety of lesions were identified including central splits between the tendon (e.g. extensor digitorum and extensor indicis), pseudobursas, capsular tears, and adherent tissues (e.g. tendon adherent to capsule). Post-surgery, participants underwent assessment and treatment through a hand therapist/physiotherapist and initiated mobilisation exercises within a week. Gentle active range of movement of the mcpj, pipj, dipj was encouraged and progressed. No splinting was provided. At week 4 participants initiated isometric strengthening of gripping and intrinsic muscles, which was progressed until week 8. Following these 8 weeks, progressive impact was resumed until week 12-14 when boxers were able to return to full sparring. A total of 98% of boxers return to their pre-injury boxing level within 8 months (range 1-24 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, extensor hood injuries can be managed surgically with good outcomes in elite and amateur boxers. This type of injury has a faster recovery and greater probability of return to pre-injury level compared to cmcj (II to V) fusion for instability. Following surgery, early active movements should be encouraged followed by strengthening from week 4 post-op. Other common boxing injuries include boxer's elbow, boxer's knuckle, and cmcj instability. URL: https://doi.org/10.1177/17531934221123139 Abstract We describe our experience of managing extensor hood injuries in boxers (57 fingers). The diagnosis was mostly clinical, with imaging only if the diagnosis was equivocal. The middle (61%) and index (26%) digits were most frequently injured. On exploration, 26% had no hood tear, however all required tenolysis from the adherent capsule. Of 42 hood tears, 15 were central splits between adjacent extensor tendons in the index or little fingers,15 tears were on the ulna side of the extensor tendon and 12 tears were on the radial side. A pseudobursa was encountered in 35%, capsular tears in 28% and chondral injury in one patient. Longitudinal curved metacarpophalangeal joint incisions were used, with hood repair performed in flexion using a locked running suture. Mean postoperative metacarpophalangeal joint flexion was 90°. Ninety-eight per cent returned to the same level of boxing at a mean of 8 months (range 1–24) from surgery. One finger was revised for re-rupture 6 months later. A reproducible technique for treating these injuries is described, with patients able to return to boxing with little risk of complications. 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 pain contagious? Innocuous stimulation can be transformed into the pain experience by observational learning. Buglewicz-Przewoźnik, E., Adamczyk, W. M. and Bąbel, P. (2022) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Aetiologic Topic: Allodinia - Observational conditioning This is an experimental study assessing the effect of observing somebody in pain on the likelihood of somebody else experiencing allodynia (non-nociceptive stimulus perceived as painful). A total of 88 healthy participants took part in the study. Participants underwent a procedure to identify an electric current level that they could perceive on the hand without it being perceived as painful (non-nociceptive stimulus). After this threshold was identified, participants were randomised to different procedures (groups). In all procedures, participants received the same non-nociceptive stimulus 15 times and they had to rate the pain experienced on a scale from 0 to 10. The control group was given the stimuli while they were alone in a room. In contrast, the experimental groups were given the stimuli in the room with an actor who received sham stimuli but pretended them to be painful (between 2 and 6/10). The results showed that the control group reported no pain with repeated non-nociceptive stimuli. However, the experimental groups all reported allodynia (pain caused by a non-painful stimulus) (See graphs below). In addition, the likelihood of participants reporting pain was moderately associated with fear of pain (questionnaire). 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, our clients can present with allodynia if they perform an action/receive a stimulus that appears to have caused pain in somebody else. This suggests that if we communicate pain through body language or we verbally suggest that a specific action will cause pain, they are more likely to report pain or perceive pain in the near future. Pain has been shown to have a learning component and there is growing evidence showing that clients' thoughts about it (e.g. pain catastrophising) are associated with pain intensity. URL: https://doi.org/10.1016/j.jpain.2022.07.015 Abstract Studies indicate that classical and operant conditioning have potential to play a role in the formation of the allodynic effect. Only a few studies have examined the role of observational learning in pain induction. Due to some methodological challenges, evidence that the allodynic effect can be learned through observation is limited. In the present study, healthy participants (n = 88) received two series of innocuous electrocutaneous stimuli: at the beginning of the study and after observation of a model who rated all the stimuli as painful. Participants and the model rated all the stimuli alternately (real-time group), or the participant first observed the model and then rated the stimuli, while the model stayed in (post-hoc+ group) or left (post-hoc- group) the laboratory. There was no model in the control group. The study demonstrated that allodynia can be induced by observational learning. Furthermore, this effect was shown to be similar, regardless of whether stimuli were received during the observation of the model and rated immediately afterwards, or when the observation and stimuli reception were time-separated. The mere presence of the model during the stimuli reception also did not affect the magnitude of this effect. This research may contribute to our understanding of the mechanisms of chronic pain development and assist in the development of suitable treatment for it. Perspective. This article presents study results on the role of observational learning in allodynia induction without tissue injury. The results may contribute to our understanding of the mechanisms of chronic pain development and assist in the development of suitable treatment for it. 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

The effect of diabetes mellitus on the outcome of surgery for cubital tunnel syndrome. Stirling, P. H. C., Harrison, S. J. and McEachan, J. E. (2022) Level of Evidence: 1b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Symptoms prevalence study Topic: Cubital tunnel surgery - diabetes and functional recovery This prospective study assessed the effect of diabetes on functional recovery following surgery for cubital tunnel syndrome. Functional recovery was measured through the QuickDASH questionnaire, and the presence of diabetes was self-reported by participants. A total of 131 participants were recruited at baseline and they were assessed pre-surgery and one-year post-surgery. Of these participants, 22 had diabetes. The results showed that neither group improved to a clinically relevant level on the QuickDASH at 12 months. In addition, the functional improvement in the diabetes group was lower compared to the control. The difference between the two groups was statistically significant at 12 months post-op, but was not clinically relevant. 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 presence of diabetes does not affect recovery, to a clinically meaningful level, after cubital tunnel release. People with diabetes may present with a slower recovery, however, this does not appear to be relevant (QuickDASH minimal clinically important difference ranges between 10 and 18). Similar results have been reported following carpal tunnel release, showing that diabetes has a small effect on recovery. URL: https://doi.org/10.1177/17531934221143500 Abstract The aims of this study were to investigate the effect of diabetes mellitus (DM) on patient-reported outcome measures (PROMs) and satisfaction after surgery for cubital tunnel syndrome (CuTS). Pre- and 1-year postoperative QuickDASH, normal hand, and satisfaction scores were prospectively collected from 107 patients over a 6-year period. Patients without DM reported a significant QuickDASH improvement after surgery (preoperative 34.1 versus postoperative 20.5; p < 0.001), but patients with DM did not (preoperative 46.5 versus postoperative 43.2; p = 0.554). Postoperative QuickDASH (43.2 versus 20.5) and normal hand (65 versus 80) scores were significantly worse in patients with DM. Satisfaction rates were excellent in both groups (88% versus 82%; p = 0.480). Our study showed that surgery for CuTS did not lead to an improvement in QuickDASH score in patients with DM and consequently patients with DM reported worse postoperative PROMs compared with those without. However, lack of improvement in PROMs does not affect patient satisfaction. 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

Hand carpometacarpal joint instability in elite boxers: Injury characteristics, surgical technique, and outcomes. Matharu, G. S., et al. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic/Therapeutic Topic: Cmcj instability – Boxing This is a retrospective study assessing outcomes following fixation of carpometacarpal (cmcj) II to V instability in boxers. A total of 38 elite boxers were included in the study. Carpometacarpal instability onset was either traumatic or gradual. The carpal seesaw test (see figure below) was utilised in combination with imaging to make the diagnosis. Surgery involved fusion of the affected carpometacarpal joints with bone graft, wires, or screws. Rehabilitation started soon after surgery to maintain range of movement. On average, radiographic union occured at 4 months. After union was observed onx-ray, grip strengthening was started as well as a gradual exposure to contact (e.g. water bags, pads). At 8 months, 80% of boxers returned to their pre-injury level. 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, most elite boxers undergoing cmcj (II to V) fusion for instability return to pre-injury levels at 8 months post-surgery. Early gentle active movements followed by strengthening once fusion is confirmed on radiograph, appear to be useful in achieving return to sport. Carpometacarpal joint instability is another upper limb pathology that we need to keep in mind when assessing patients involved in boxing. Other common conditions in boxers include boxer's knuckle and boxer's elbow. URL: https://doi.org/10.1016/j.jhsa.2022.07.021 Abstract Purpose: We describe a single-surgeon’s experience of managing hand carpometacarpal joint (CMCJ) instability in elite boxers, focusing on injury characteristics, surgical technique, and outcomes. Methods: This retrospective cohort included consecutive elite boxers undergoing surgery for hand CMCJ instability from 2009 to 2021. CMC joint instability is usually clear on clinical examination using a ‘seesaw’ test. All cases had a plain radiograph and in equivocal cases for instability advanced imaging such as MRI or ultrasound scan. CMCJs were accessed via longitudinal incisions between index/middle rays, and additionally ring/little. Often marked deficiency in the CMCJ ligamentous capsule was seen. The articular surfaces were decorticated to cancellous bone and autogenous bone graft impacted. The CMCJs were fixed in extension using various methods, latterly memory staples. Outcomes included radiographic fusion, return to boxing, and complications. Results: Forty hands had surgery in 38 boxers. In total, 101 CMCJs were fused, with an average of 2.5 joints per patient. Patients were mainly young (mean age 24.1 years), male (37/38) with the trailing hand more commonly affected (trailing hand 87.5%, leading hand 12.5%). The most frequently fused CMCJ was the index (97.5%, n = 39), then middle (95%, n = 38), ring (45%, n = 18), and little (15%, n = 6). There were 82% (31/38) of patients who returned to the same level of boxing at a median of 8 months from surgery (range 3–27 months). Three patients had revision surgery for non-union, a median of 10.3 months after initial surgery (range 9.4–133.1 months): 2 for index/middle and one for the little CMCJ. All 3 revisions fused and the patients returned to boxing at the same level, although the little CMCJ required a second bone graft and fixation. Conclusions: Patients can achieve full recovery after treatment of CMCJ instability, and most can return to boxing at the same level with little risk of complications. 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

Brief psychological screening for trapeziectomy: Identifying patients at high risk of a poor functional outcome. Larson, D., Nunney, I., Champion, R., Edwards, C. and Chojnowski, A. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Symptoms prevalence study Topic: Trapeziectomy - Psychological factors and recovery This is a prospective study assessing the association between psychological variables and recovery post-trapeziectomy. Participants (N = 83) with thumb OA underwent trapeziectomy and were assessed pre-surgery, 6, 16, and 52 weeks post-surgery. Psychological variables included the score on the STarT-Psych screening tool (See figure below - 0 to 5, 0 being no psychological factors, 5 being the highest amount of psychological factors). Participants were defined as presenting 'low-risk' if they scored 0-3/5 and 'high-risk' if they scored 4-5/5. Pain intensity (NRS) and QuickDASH were also assessed at these time points. The results showed that people at 'high-risk' presented with a slower recovery (NRS and QuickDASH) at all time points compared to the 'low-risk' group (see figure). 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 at 'high-risk' when screened through the STarT-Psych tool, present with slower recovery after trapeziectomy for thumb OA. This paper is in line with previous evidence showing that other psychological aspects (e.g. pain catastrophising, depression) contribute to the level of pain in people with hand OA or acute upper limb fractures. Recognising these aspects in our clients may help predict their recovery timeframes and provide them with better care. URL: https://doi.org/10.1177/17589983221120839 Abstract Introduction: This study investigates if the psychological subscale from the STarT Back Screening Tool (STarT Psych-sub) identifies patients at high risk of a poor functional outcome after a trapeziectomy based on modifiable psychological factors. Methods: A total of 83 patients completed the STarT Psych-sub, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), Patient Evaluation Measure (PEM) and a numeric pain rating scale (NPRS) before trapeziectomy. QuickDASH, PEM and NPRS were completed at 6 weeks, 16 weeks and 1 year after the trapeziectomy. Results: The STarT Psych-sub stratified 24 patients (29%) as 'high-risk' and 59 (71%) as 'not high-risk' of a poor outcome. The 'high-risk' group reported worse function and pain (QuickDASH = 72.7, PEM = 81.1, NPRS = 8.3) at baseline than the 'not high-risk' group (QuickDASH = 56.1, PEM = 66.4, NPRS = 7.2). This difference remained constant at all time points after the trapeziectomy with 1-year scores on the QuickDASH = 39.6; PEM = 47.1 and NPRS = 3.7 for the 'high-risk' group and QuickDASH = 24.3; PEM = 33.3 and NPRS = 1.9 for the 'not high-risk' group. Conclusions: Brief psychological screening shows that patients with psychological risk factors experience improved pain and function outcomes following trapeziectomy, however their outcomes are significantly worse than patients who do not have psychological risk 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