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Perspectives on climate change: Can hand surgery go carbon neutral? Dickson, K., Cooper, K. and Gardiner, M. D. (2022). Level of Evidence: N/A Follow recommendation: N/A Type of study: N/A Topic: Carbon neutral - Hand Therapy We are all familiar with the detrimental effects of carbon emissions on the environment and population health. There is substantial evidence that increasing levels of greenhouse gases contribute to climate change and that greater levels of carbon emissions/pollutants contribute to a worsening of health conditions. A recent analysis has shown that the healthcare contributes to an increase in green-house effects largely due to staff commuting. When looking specifically at hand therapy/surgery, the prescription medical equipment (e.g. splinting), imaging, and referrals to other health professionals all contribute, albeit to a lower extent, to carbon emissions. It may be useful for individual businesses to quantify their carbon footprint and start by reducing our emissions where possible. 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, hand therapy contributes to a significant amount of carbon footprint, especially due to the commute of clinicians. If changing our commuting habits is not possible (e.g. remote clinic locations or limited public transport), we may still be able to reduce our carbon footprint by being more aware of what we consume (provide to clients). For example, splinting may be reserved only for those conditions that really require it (e.g. use splinting for thumb OA parsimoniously). As a matter of fact, the creation of splints/thermoplastic materials at a commercial level does have a carbon footprint. Reducing unnecessary referrals or surgeries may be helpful too. Considering that several interventions (e.g. surgery/PRP/cortisone injections for tennis elbow) are not more effective than a placebo, we could probably do without them. URL: https://doi.org/10.1177/17531934221096786 No Abstract 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

Posterolateral rotatory instability of the elbow: Part I. Mechanism of injury and the posterolateral rotatory drawer test. Camp, C. L., Smith, J. and O'Driscoll, S. W. (2017) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic Topic: Posterolateral rotatory instability – Drawer test This is an expert opinion on the mechanism of injury and objective testing for posterolateral rotatory instability (PLRI) of the elbow. PLRI is often caused by a fall onto an outstretched arm, leading to varus loading of the elbow associated with internal rotation of the humerus on a fixed forearm. The lateral collateral ligament (LCL) of the elbow is typically involved as it limits varus movement of the elbow and posterior displacement of the radial head in relation to the humerus. Subjectively, patients often present with a painful laxity (instability). Objectively, we could perform the posterolateral rotatory drawer test, which is performed with the patient in supine. Whilst stabilising the humerus and the forearm, an anteroposterior force is applied to the proximal aspect of the radius. As you can see in the video below, increase laxity in the affected side compared to the unaffected side, suggests a lesion of the LCL. Further tissue involvement (e.g., Medial collateral ligament) may be present depending on the trauma severity. Unfortunately, we do not currently have information about the sensitivity and specificity of this test. 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, posterolateral rotatory instability of the elbow often presents following a fall onto an outstretched hand. A posterolateral rotatory drawer test may be useful in making a diagnosis. Unfortunately, like many other orthopaedic tests for the elbow, we don't have information regarding the diagnostic accuracy of the posterolateral rotatory drawer test. Open Access URL: https://doi.org/10.1016/j.eats.2016.10.016 Abstract Posterolateral rotatory instability (PLRI) is the most commonly encountered pattern of elbow instability. It is the result of disruption of the lateral collateral ligament complex leading to a posterolateral rotatory subluxation of the ulna and radial head. A number of examination maneuvers have been described to assist in clinical identification of PLRI. Despite this, some inconsistency in the description of these techniques remains in the orthopaedic literature. This Technical Note details the mechanism of injury and patient presentation, and emphasizes the primacy of the posterolateral rotatory drawer test in the assessment of PLRI while providing video instruction on how it should be performed. 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

General anxiety is associated with problematic initial recovery after carpal tunnel release. Ryan, C., Miner, H., Ramachandran, S., Ring, D. and Fatehi, A. (2022). Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Therapeutic Topic: Carpal tunnel release recovery - The role of anxiety This is a retrospective study assessing the association between pre-operative mental health and a problematic initial recovery following carpal tunnel release. Problematic recovery was defined as unchanged post-operative pain, persistent or new nerve symptoms, stiffness, wound issues, or kinesiophobia. A total of 156 patients were included, out of which 38 were classified as having a problematic initial recovery. The results showed that greater levels of preoperative anxiety were associated with a greater likelihood of a problematic initial recovery following carpal tunnel release. 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, greater preoperative anxiety is associated with a greater chance of a problematic initial recovery following carpal tunnel release. These findings are in line with other upper limb research showing that we have the opportunity to improve recovery in those people with anxiety/depression/or pain catastrophising prior to or following surgery for upper limb conditions. URL: https://doi.org/10.1097/CORR.0000000000002115 Abstract BACKGROUND: Carpal tunnel release can stop the progression of idiopathic median neuropathy at the wrist (carpal tunnel syndrome). Intermittent symptoms tend to resolve after surgery, but loss of sensibility can be permanent. Both pathophysiology (severe neuropathy) and mental health (symptoms of despair or worry) contribute to problematic recovery after carpal tunnel release, but their relative associations are unclear. QUESTION/PURPOSE: Is problematic initial recovery after carpal tunnel release associated with psychologic distress rather than with disease severity? METHODS: We retrospectively studied 156 patients who underwent in-office carpal tunnel release between November 2017 and February 2020, and we recorded their symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD]) and depression (Patient Health Questionnaire), signs of severe median neuropathy (loss of sensibility, thenar muscle atrophy, and palmar abduction weakness), and problematic recovery. The initial recovery (first 2 weeks) was categorized as problematic if the patient was upset about persistent numbness, experienced unsettling postoperative pain, developed hand stiffness, or experienced wound issues-all of which are routinely recorded in the medical record by the treating surgeon along with signs of severe median neuropathy. Twenty-four percent (38 of 156) of patients had a problematic initial recovery characterized by distress regarding persistent numbness (16% [25 of 156]), unsettling pain (8% [12 of 156]), hand stiffness (5% [8 of 156]), or wound issues (1% [2 of 156]); 6% (9 of 156) of patients had more than one issue. Associations between problematic initial recovery and age, gender, symptoms of anxiety and depression, disease severity, specific exam findings, and insurance were evaluated using t-tests, Mann-Whitney tests, and chi-square tests, with the plan to perform logistic regression if at least two variables had an association with p < 0.10. RESULTS: The only factor associated with problematic initial recovery was greater symptoms of anxiety (median GAD score 1.5 [interquartile range 0 to 7.8] for problematic initial recovery compared with a median score of 0 [IQR 0 to 2] for nonproblematic recovery; p = 0.04), so we did not perform a logistic regression. Physical examination findings consistent with severe median neuropathy were not associated with problematic initial recovery. CONCLUSION: The finding that problematic initial recovery after carpal tunnel release was related to symptoms of anxiety and not to the severity of median neuropathy highlights the need to study the ability of efforts to ameliorate anxiety symptoms before carpal tunnel release as an effective intervention to reduce unplanned visits and additional tests, therapy, and repeat surgery, while improving patient-reported outcomes and experience. 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

Terrible triad injuries are no longer terrible! Functional outcomes of terrible triad injuries: A scoping review. Stambulic, T., Desai, V., Bicknell, R. and Daneshvar, P. (2022) Level of Evidence: 3a Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Terrible triad – Recovery This is a review assessing the recovery of terrible triad injuries. A total of 43 studies were included in the review. Functional outcomes (e.g. QuickDASH), complication rates, and range of movement were recorded at follow-up (average 2-3 years post-surgery). More than 2,000 participants were included across all the studies. The result showed that patients surgically treated for a terrible triad presented with low disability at 2-3 years post-surgery. The re-operation rate for complications was around 8%. In addition, patients recovered a functional range of movement of the elbow. 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, surgical treatment of a "Terrible triad" injury leads to reasonable outcomes in terms of function and range of movement at 2-3 years post-surgery. The re-operation rate for complications is around 8%. Hence, we could call rename this condition the "Manageable triad", which may reduce catastrophic thinking in our clients. Considering the extensive recovery time as well as the lack of complete recovery, it is important to set clients' expectations. In addition, it is likely that clients affected by this condition will develop depression, which could further impair their perceived function. URL: https://doi.org/10.1016/j.xrrt.2022.01.002 Abstract Background: The terrible triad injury (TTI) of the elbow is a combination of a posterolateral dislocation of the elbow joint combined with fractures of the radial head and coronoid process most often caused by a fall on an outstretched hand. The injury pattern was named for its poor outcomes and high complication rates following surgical repair, but increased understanding of elbow anatomy and biomechanics has led to the development of standardized surgical protocols in an attempt to improve outcomes. Most existing literature on terrible triad injuries is from small retrospective cohort studies and surgical techniques to improve outcomes. Therefore, the purpose of this scoping review is to provide an overview of the functional outcomes, prognosis, and complications following current surgical treatment of TTIs. Methods: A scoping review was performed to evaluate the literature. In total, 617 studies were identified and screened by 2 reviewers, with 43 studies included for qualitative analysis. These 43 studies underwent data extraction for functional outcomes using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand score (DASH) and were stratified accordingly. Secondary outcome measures assessed in the study were a range of motion (ROM) and complication rate. Results: The average MEPS was 90 (excellent) from a total of 37 studies with 1609 patients, and the average DASH score was 16 from 16 studies with 441 patients. Another 6 studies with a total of 127 patients reported a mean Q-DASH score of 13. A total of 39 studies consisting of 1637 patients had a mean forearm rotation of 135 degrees, and 36 studies consisting of 1606 patients had a mean flexion-extension arc of 113 degrees. Among the studies, there was a 30% complication rate with a need for revision surgery in 7.8% of cases. The most common complications were radiographic evidence of heterotopic ossification (11%) and ulnar nerve neuropathy (2.6%). Discussion/Conclusions: This study shows that current surgical treatment for terrible triad injuries has resulted in improved outcomes. Based on primary outcome measures using MEPS and DASH scores, almost all of the studies have highlighted good or excellent functional outcomes. This highlighted the marked improvement in outcome scores since the term was coined, suggesting that terrible triad injuries may no longer be so terrible. 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

Late displacement after lateral condylar fractures of the humerus. Aibara, N., Takagi, T. and Seki, A. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Prognostic Topic: Lateral condyle fracture of the humerus – Predict displacement This is a retrospective study assessing whether it is possible to predict lateral condyle fracture of the humerus displacement in conservatively treated children/teenagers. Lateral condyle fractures of the humerus account for 10-20% of humeral fractures in children. If they are undisplaced, they can be treated conservatively with immobilisation, however, about 15% of them require delayed surgery due to late displacement. The association between age, sex, elbow immobilisation position, initial displacement, fat pad sign, elbow flexion angle, forearm position (neutral/pronation) and the presence of displacement (>= 1 mm on AP or lateral x-ray) was assessed. A total of 62 participants between 1 and 16 years old (average: 5 yrs old) with undisplaced lateral condyle fractures of the humerus at baseline were included in the study. They were all initially treated conservatively. The results showed that 45% of participants presented with fracture displacement (>= 1 mm on AP or lateral x-ray) at 7 days. The results also showed that there was no association between any of the variables considered and the development of a displaced fracture at 7 days. 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 are currently unable to predict who will develop a displaced lateral condyle fracture of the humerus one week after injury. It is therefore best to repeat a lateral, AP, and internal oblique view seven days post-injury to determine whether surgery is required. After 7 days, the likelihood of fracture displacement appears to plateau. In terms of immobilisation position, there is no evidence that the degree of elbow flexion/extension or forearm supination/pronation will prevent fracture displacement. If you are interested in children/teenagers' elbow conditions, you may also want to read about osteochondritis dissecans. URL: https://doi.org/10.1016/j.jse.2022.06.003 Abstract Background: Nondisplaced or slightly displaced lateral condyle fractures may subsequently displace if treated with cast immobilization alone, and displacement indicates surgery. In this context, placing the forehand in pronation is sometimes recommended, and the prediction of the late displacement based on the presence of the fat pad sign is useful. However, few studies have quantitatively shown the relationships between forearm position during immobilization and late displacement and between the presence of the fat pad sign and late displacement. We investigated the factors that may affect the late displacement and the features of the consequences during the late displacement. Methods: Between October 2003 and July 2020, we observed 62 patients (45 boys and 17 girls). We evaluated the correlation between the factors age, gender, the initial displacement, the presence of a fat pad sign, the flexion angle of the elbow, the forearm position (pronation or neutral), and the late displacement on day 7 after the injury, which means the difference between the displacement on day 0 and that on day 7 in the 62 cases with the minimal displacement. Moreover, of all 62 cases observed, we further investigated those 52 cases that had been treated conservatively for 3 weeks for any resultant effects. We used the Friedman test to evaluate the difference in the late displacement on each day. We acknowledged the P value < .05 as significant. Results: There was no significant correlation between each factor (age, sex, initial displacement, presence of the fat pad sign, flexion angle of the elbow, or forearm position) and displacement on day 7, whereas there was significant progressive displacement until day 7. Conclusion: The present study concluded that late displacement would happen until the 7 postoperative dates, regardless of the splint angle, the fat pad sign, the age, or the gender. Therefore, it is important to follow any case, even with mild-displaced lateral condylar humeral fractures, until day 7 because the late displacement might occur. 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

Evaluation of a convolutional neural network to identify scaphoid fractures on radiographs. Li, T., et al. (2022). Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic: Machine learning – Scaphoid fractures detection on x-ray This is a retrospective study assessing whether machine learning algorithms are able to detect scaphoid fractures on baseline x-rays with acceptable diagnostic accuracy. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. The machine learning model was trained on 930 x-ray images and tested on 100 baseline images. Three surgeons with 3, 13, and 14 years of experience assessed the same 100 x-rays and reached an agreement on each x-ray regarding the presence or not of a scaphoid fracture. The results showed that the surgeons had sensitivity and specificity of 76% and 96% respectively. The machine learning algorithm had similar results with a sensitivity and specificity of 82% and 94%. 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, machine learning is as good at identifying scaphoid fractures on x-ray as experienced surgeons. In the future, it is likely that these algorithms will be implemented in radiology software to aid scaphoid fracture detection. We are experiencing a surge of research showing the usefulness of machine learning for the prediction of treatment responders and the assessment of patients with upper limb conditions. URL: https://doi.org/10.1177/1753193422112709 Abstract This study aimed to develop and evaluate a convolutional neural network for identifying scaphoid fractures on radiographs. A dataset of 1918 wrist radiographs (600 patients) was taken from an orthopaedic referral centre between 2010 to 2020. A YOLOv3 and a MobileNetV3 convolutional neural network were trained for scaphoid detection and fracture classification, respectively. The diagnostic performance of the convolutional neural network was compared with the majority decision of four hand surgeons. The convolutional neural network achieved a sensitivity of 82% and specificity of 94%, with an area under the receiver operating characteristic of 92%, whereas the surgeons achieved a sensitivity of 76% and specificity of 96%. The comparison indicated that the convolutional neural network’s performance was similar to the majority vote of surgeons. It further revealed that convolutional neural network could be used in identifying scaphoid fractures on radiographs reliably, and has potential to achieve the expert-level performance. 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

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit? Crijns, T., Al Salman, A., Bashour, L., Ring, D. and Teunis, T. (2022) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic Topic: Clinicians' stress - Clients' psychosocial health This is a survey assessing the surgeons' levels of stress associated with simulated patients' presentations. A total of 111 surgeons took part in the study. Surgeons' were asked to rate their level of stress when consulting different types of patients. Simulated patients were described as presenting with different characteristics. Simulated patients presented with or without disproportionate levels of pain, a high number of prior consultations with other surgeons, as well as "googling" their condition and being convinced that they knew what to do for their condition prior to the appointment. The results showed that surgeons experience greater levels of futility, inadequacy, and frustration when patients presented with the characteristics described above. 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, clinicians experience greater levels of stress when interacting with clients presenting with unhelpful pain beliefs/disproportionate levels of pain or clients with a long list of office visits/second opinions. Being aware of this link may help us provide better care for our clients as well as provide them with a different perspective on pain. URL: https://doi.org/10.1016/j.pecinn.2022.100043 Abstract Objective: To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit. Methods: A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales. Results: Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration. Conclusion: Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration. Innovation: Training for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness. 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

Preseason shoulder range of motion screening and in-season risk of shoulder and elbow injuries in overhead athletes: Systematic review and meta-analysis. Pozzi, F., et al. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 (4/4 Thumbs up) Type of study: Prognostic Topic: Elbow injury - Risk factors This is a systematic review and meta-analysis assessing the usefulness of shoulder range of movement screening to predict upper limb injury in overhead athletes. The systematic review included prospective studies only. Shoulder flexion, shoulder internal/external rotation at 90° of shoulder abduction, and shoulder horizontal adduction were assessed. Injury was defined as any shoulder- or elbow-related complaint incurred in the season. A total of 7 studies were included in the meta-analysis. Overhead sports included baseball (n = 2471), handball (n = 535), softball (n = 103), swimming (n = 74), volleyball (n = 66), and tennis (n = 65). The results showed that shoulder external rotation on the throwing arm was a useful screening tool for professional baseball pitchers. Those players who did not present with an external rotation of the throwing arm of at least 5° greater than the contralateral, were twice as likely to injure their pitching shoulder or elbow. Limited evidence was available for the other overhead sports. This may be due to the small number of studies investigating athletes involved in other sports. 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 may test shoulder external rotation in professional baseball pitchers to assess their risk of developing an elbow or shoulder injury. Interventions aimed at modifying these impairments may be useful in reducing their risk of elbow and shoulder injury. For example, eccentric resistance training of internal rotators towards the end of shoulder external rotation may be a useful exercise. Thus, resistance training has been shown to not only improve strength but also the flexibility of the exercising muscles. Structural limitations may be suspected if this exercise regime does not lead to flexibility changes. Open Access URL: http://dx.doi.org/10.1136/bjsports-2019-100698 Abstract Objective: To characterise whether preseason screening of shoulder range of motion (ROM) is associated with the risk of shoulder and elbow injuries in overhead athletes. Design: Systematic review and meta-analysis. Data sources: Six electronic databases up to 22 September 2018. Eligibility criteria: Inclusion criteria were (1) overhead athletes from Olympic or college sports, (2) preseason measures of shoulder ROM, (3) tracked in-season injuries at the shoulder and elbow, and (4) prospective cohort design. Exclusion criteria were (1) included contact injuries, (2) lower extremity, spine and hand injuries, and (3) full report not published in English. Results: Fifteen studies were identified, and they included 3314 overhead athletes (baseball (74.6%), softball (3.1%), handball (16.1%), tennis (2.0%), volleyball (2.0%) and swimming (2.2%)). Female athletes are unrepresented (12% of the overall sample). Study quality ranged from 11 to 18 points on a modified Downs and Black checklist (maximum score 21, better quality). In one study, swimmers with low (&lt;93°) or high (&gt;100°) shoulder external rotation were at higher risk of injuries. Using data pooled from three studies of professional baseball pitchers, we showed in the meta-analysis that shoulder external rotation insufficiency (throwing arm &lt;5° greater than the non-throwing arm) was associated with injury (odds ratio=1.90, 95% confidence interval 1.24 to 2.92, p&lt;0.01). Conclusion: Preseason screening of shoulder external rotation ROM may identify professional baseball pitchers and swimmers at risk of injury. Shoulder ROM screening may not be effective to identify handball, softball, volleyball and tennis players at risk of injuries. The results of this systematic review and meta-analysis should be interpreted with caution due to the limited number of studies and their high degree of heterogeneity. 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

Physical examination of the elbow, what is the evidence? A systematic literature review. Zwerus, E. L., et al. (2018) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 (4/4 thumbs up) Type of study: Diagnostic Topic: Elbow conditions – Physical tests This is a systematic review assessing the diagnostic accuracy of physical tests for elbow conditions. A total of ten studies were included. The variables of interest were the sensitivity and specificity of physical tests. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. A large number of studies presented a high risk of bias. The results showed that tests for distal biceps tendon rupture were the most common in the literature. Only a few papers assessed the diagnostic validity of tests for other conditions. One of the largest issues with the published papers was the over-recruitment of people with the studied condition (e.g. PLRI), which makes it hard to generalise the sensitivity/specificity of these tests to clinical practice. Nevertheless, the study provided an extensive table presenting elbow conditions and relative tests (See 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 diagnostic accuracy of clinical tests for elbow conditions has not been investigated thoroughly. Sound anatomical knowledge combined with a thorough subjective examination is therefore necessary when trying to differentiate between common elbow conditions. In the future, we will have more details about the ability of common tests such as the hook test, distal biceps tendinopathy, tennis elbow, and ligament testing in identifying the pathologies that they aim to diagnose. URL: http://dx.doi.org/10.1136/bjsports-2016-096712 Abstract OBJECTIVE: Primary to provide an overview of diagnostic accuracy for clinical tests for common elbow (sport) injuries, secondary accompanied by reproducible instructions to perform these tests. DESIGN: A systematic literature review according to the PRISMA statement. DATA SOURCES: A comprehensive literature search was performed in MEDLINE via PubMed and EMBASE. ELIGIBILITY CRITERIA: We included studies reporting diagnostic accuracy and a description on the performance for elbow tests, targeting the following conditions: distal biceps rupture, triceps rupture, posteromedial impingement, medial collateral ligament (MCL) insufficiency, posterolateral rotatory instability (PLRI), lateral epicondylitis and medial epicondylitis. After identifying the articles, the methodological quality was assessed using the QUADAS-2 checklist. RESULTS: Our primary literature search yielded 1144 hits. After assessment 10 articles were included: six for distal biceps rupture, one for MCL insufficiency, two for PLRI and one for lateral epicondylitis. No articles were selected for triceps rupture, posteromedial impingement and medial epicondylitis. Quality assessment showed high or unclear risk of bias in nine studies. We described 24 test procedures of which 14 tests contained data on diagnostic accuracy. CONCLUSIONS: Numerous clinical tests for the elbow were described in literature, seldom accompanied with data on diagnostic accuracy. None of the described tests can provide adequate certainty to rule in or rule out a disease based on sufficient diagnostic accuracy. 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

Elbow biomechanics: Soft tissue stabilizers. Kaufmann, R. A. M. D., Wilps, T. B. S., Musahl, V. M. D. and Debski, R. E. P. (2020) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Anatomical Topic: Elbow ligaments - Biomechanics This is a narrative review on passive elbow structures contributing to valgus and varus joint stability. The authors report that valgus flexibility at the elbow is greatest at 30° of flexion and that the medial ulnar collateral ligament (MUCL) resists these valgus forces. The MUCL is divided into anterior and posterior bundles, with the anterior bundle being the main source of valgus stability. The MUCL (anterior bundle) tightens incrementally with elbow flexion, reaching the highest tension at 80° of elbow flexion. The lateral collateral ligaments of the elbow control varus forces and they include the lateral ulnar collateral ligament (LUCL) and the radial collateral ligament (RCL). The stabilisation role of these ligaments is debated, however, it is believed that both control varus forces and are important in the postero-lateral rotatory stability of the elbow. 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, valgus stress test of the elbow (30° of flexion) is restrained by the anterior bundle of the MUCL. Injury to the lateral collateral ligaments can be assessed through varus stress testing. Simple elbow dislocations may involve injury to a limited number of ligaments whilst complex dislocations are likely to injure multiple ligaments as well as the capsule. Have a look at these synopses for more info on the treatment and classification of elbow dislocations. URL: http://dx.doi.org/10.1016/j.jhsa.2019.10.034 Abstract The elbow positions the hand in a stable manner relative to the trunk while allowing flexion and extension as well as forearm rotation at varying shoulder positions. Its ability to perform this task without joint subluxation is accomplished through a combination of bony congruency, ligamentous restraint, and dynamic stabilization. Elbow stability is challenged repeatedly during everyday activities, particularly when the arm is abducted. Traumatic injuries that lead to an elbow dislocation or the microtrauma associated with pitching are frequent situations that destabilize the elbow. This article reviews the soft tissue stabilizers that contribute to elbow kinematics and stability. 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

Early functional mobilization for non-operative treatment of simple elbow dislocations: A systematic review. Catapano, M., Pupic, N., Multani, I., Wasserstein, D. and Henry, P. (2022) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Simple elbow dislocation - Rehabilitation This is a systematic review assessing the best rehabilitation interventions for simple elbow dislocations. Simple elbow dislocations were characterised by stability through range after reduction associated or not with small fractures. A total of 15 studies were included in the review. Of these, three studies were randomised controlled studies. The two interventions most commonly utilised were either Plaster of Paris (PoP) for 21 days or early mobilisation with the intermittent use of an elbow splint. The studies adopting an early mobilisation approach performed forearm pronation/supination as well as elbow flexion/extension through a comfortable range. Most commonly, exercises were performed supine with the shoulder at 90° of flexion. In the early mobilisation group, a posterior elbow splint was utilised for three weeks and removed to perform exercises. The results showed that early mobilisation was associated with earlier return to work, reduced elbow stiffness, higher pain, and a lower likelihood of heterotopic ossification in the short term compared to 21 days of PoP cast. At one year, there was no difference between the early motion compared to PoP cast 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, simple elbow dislocations treated with early mobilisation appear to have better outcomes compared to PoP immobilisation for three weeks. There may be higher levels of pain in the short term but it appears that the benefit may outweigh this inconvenience. The treatment of complex elbow dislocations should follow surgeons' advice as these often need surgical management. URL: https://doi.org/10.1177/1758573220957631 Abstract Purpose: This systematic review aims to elucidate a non-operative rehabilitation program that optimizes recovery based on published approaches and outcomes. Methods: Searches of four databases from inception to 1 January 2020 were performed to identify clinical studies addressing the non-operative management of simple elbow dislocations. Results: Of 2435 studies that were eligible for title screen, 15 studies satisfied inclusion criteria. Three randomized control studies demonstrated that early mobilization expedited the return of range of motion, function and return to work or activities, however, resulted in increased pain within the six-week rehabilitation period compared to Plaster of Paris casting for 21 days. Patients returned to work sooner after early mobilization (10 vs. 18 days; p = 0.02) compared to Plaster of Paris casting. In all studies, early mobilization resulted in similar re-dislocation rates of 1.3% (3/237) versus 2.2% (12/549) in those with Plaster of Paris casting as well as lower incidence of heterotopic ossification (36% vs. 54%). No significant differences between rehabilitation protocols were determined; however, the large majority of recent papers utilized rehabilitation protocols. Conclusion: Early mobilization of simple elbow dislocations results in early return of Range-of-Motion, function and return to work with no increase in complication rates; however, increased pain during the rehabilitation period. 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

Elbow dislocations: A review ranging from soft tissue injuries to complex elbow fracture dislocations. Englert, C., Zellner, J., Koller, M., Nerlich, M. and Lenich, A. (2013) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Diagnostic Topic: Elbow dislocation - Classification This is an expert opinion on the diagnosis and treatment of elbow dislocations. What the authors suggest is to classify elbow dislocations as simple and complex. Simple elbow dislocations may be associated with small fractures and can be reduced without anaesthesia. These injuries are usually stable and a splint limiting extension/flexion is usually advisable for a short period of time. Complex dislocations often cannot be reduced without anaesthesia and are often associated with larger displaced fractures, which require surgical interventions. The common complications of elbow dislocations include chronic instability/stiffness, and heterotopic ossification. 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 may be classified as simple or complex according to the size/displacement of the fracture and the stability through range after reduction. Gross neurovascular function assessment and x-ray investigations are often required. If you are uncertain whether an x-ray is required, you can perform the elbow extension test. For the rehabilitation of simple dislocations, have a look at this other synopsis. URL: https://doi.org/10.1155/2013/951397 Abstract This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classifications of elbow dislocations. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. Special emphasis is put on injuries to the medial ulnar collateral ligament (MUCL) and on posttraumatic elbow stiffness. 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