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Effect of habitual knuckle cracking on hand function. Castellanos, J. and D. Axelrod (1990) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Aetiologic Topic: Knuckle cracking - Hand OA This is a cross-sectional study assessing whether habitually cracking knuckles is associated with hand osteoarthritis. A total of 300 participants were included in the study. Of these, 74 reported habitually cracking their knuckles, whilst 226 reported not cracking their knuckles. Participants were included if they were over 45 years old. The assessment included observation of Heberden's and Bouchard's nodes. The results showed that participants who had been cracking their knuckles had been doing so for 18 to 60 years. There was no difference between people cracking or not their knuckles in terms of hand osteoarthritis. 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, cracking your knuckles does not appear to be lead to hand osteoarthritis. If you would like to know what factors currently appear to predict the risk of hand osteoarthritis, have a look at this study. You will also be able to access the prediction model which allows you to calculate your clients/your risk of developing hand OA at 12 years. Open Access URL: http://dx.doi.org/10.1136/ard.49.5.308 Abstract The relation of habitual knuckle cracking to osteoarthrosis with functional impairment of the hand has long been considered an old wives' tale without experimental support. The mechanical sequelae of knuckle cracking have been shown to produce the rapid release of energy in the form of sudden vibratory energy, much like the forces responsible for the destruction of hydraulic blades and ship propellers. To investigate the relation of habitual knuckle cracking to hand function 300 consecutive patients aged 45 years or above and without evidence of neuromuscular, inflammatory, or malignant disease were evaluated for the presence of habitual knuckle cracking and hand arthritis/dysfunction. The age and sex distribution of the patients (74 habitual knuckle crackers, 226 non-knuckle crackers) was similar. There was no increased preponderance of arthritis of the hand in either group; however, habitual knuckle crackers were more likely to have hand swelling and lower grip strength. Habitual knuckle cracking was associated with manual labour, biting of the nails, smoking, and drinking alcohol. It is concluded that habitual knuckle cracking results in functional hand impairment. 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

What are the prevalence of and factors independently associated with depression and anxiety among patients with posttraumatic elbow stiffness? A cross-sectional, multicenter study. Liu, W., et al. (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Prognostic Topic: Elbow stiffness - Mental health This is a cross-sectional study assessing the relationship between depression and anxiety and impairments associated with elbow stiffness. A total of 108 participants were included. Participants were included if they presented with post-traumatic elbow stiffness and if they had no symptoms of depression and anxiety prior to the injury. Potential participants were excluded if they presented with neurological conditions. General demographic information, clinical measures, and the presence of depression/anxiety (DASS21) were assessed on average 12 months post-injury. The results showed that 20-40% and 25-30% of participants presented with mild-moderate and moderate-severe depression/anxiety respectively. In addition, impairments of elbow flexion, and pain on elbow movement were both factors associated with the increased odds of presenting with depression and anxiety. 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, clients with post-traumatic elbow stiffness are likely to present with depression and anxiety if they present pain on elbow movement and limitations of elbow flexion. The prevalence of these symptoms is reasonably high even at one-year post-injury, and it is, therefore, useful to screen people for these conditions. Thus, the recovery profile of people with mental health issues is worst than people without these conditions. If you would like further information on the treatment of post-traumatic elbow stiffness, refer to this synopsis. URL: https://doi.org/10.1016/j.jse.2021.11.014 Abstract Background: Joint stiffness is a common complication after articular-related trauma in the elbow, resulting in significant limb disability, psychological stress, and a negative impact on daily life. No previous study has reported the impact of posttraumatic elbow stiffness (PTES) on psychological health. This study aims to (1) investigate the depression and anxiety levels and (2) identify factors independently associated with depression and anxiety symptoms in patients with PTES. Methods: A total of 108 patients with PTES presenting to four collaborative municipal hospitals were consecutively enrolled from September to December 2020. Socio-demographic and clinical characteristics were collected through questionnaires and medical records. The Depression Anxiety Stress Scale-21 (DASS21) was used to assess depression and anxiety status. Ordinal logistic regression analysis was performed to identify factors independently associated with depression and anxiety symptoms. Results: The detection rates of mild-to-moderate depression and anxiety are 40.7% and 27.8%, and severe-to-extremely severe levels are 23.1% and 25.9%, respectively. Regression results show that factors independently associated with depression include elbow flexion (OR per 1° loss =1.021, 95% CI: 1.001-1.041, p=0.035), elbow pain on movement (OR per 1 point increase =1.236, 95% CI: 1.029-1.484, p=0.023), family relationship (OR less close / very close =10.059, 95% CI: 2.170-46.633, p=0.003) and self-care ability (OR unable / able =3.858, 95% CI: 1.244-11.961, p=0.019). Factors independently associated with anxiety are elbow flexion (OR per 1° loss =1.031, 95% CI: 1.009-1.052, p=0.005), elbow pain on movement (OR per 1 point increase =1.212, 95% CI: 1.003-1.465, p=0.047) and clinically significant heterotopic ossification (HO) around elbow (OR yes / no =2.344, 95% CI: 1.048-5.243, p=0.038). Conclusion: Patients with PTES exhibit significant depression and anxiety symptoms. Several Socio-demographic and clinical characteristics are independently associated with depression and anxiety levels. Identifying and addressing these factors may be of particular benefit during PTES management. Future research might address whether depression and anxiety affect the outcome after stiff elbow surgery. 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 value added of advanced imaging in the diagnosis and treatment of triangular fibrocartilage complex pathology. Cunningham, D. J., T. S. Pidgeon, E. B. Saltzman, R. C. Mather and D. S. Ruch (2021). Level of Evidence: 3b Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Diagnostic Topic: MRI findings ulnar wrist - cost analysis This is study assessed the benefit of adding expensive imaging (e.g. MRI) to history and physical assessment for the treatment of patients with ulnar sided pain. This study was created by modelling the cost vs benefit based on existing evidence. Patients were assumed to be younger than 55 years old, presenting with ulnar sided pain, having subacute to chronic pain, and normal x-rays (e.g. not presenting with positive ulnar variance). The benefits were assessed by predicting changes in QuickDASH under different assessment strategies. The results showed that expensive imaging in addition to history and physical assessment did not provide larger benefits compared to an assessment based on history and physical tests alone (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, history, physical assessment, and an x-ray are sufficient to treat people with ulnar sided wrist pain with subacute to acute symptoms. Referral to a hand surgeon is clearly important if symptoms do not resolve with conservative treatment, however, the addition of MRI imaging is unlikely to significantly change the therapeutic strategy and/or its effectiveness. Additional evidence in support of the limited utility of MRI for ulnar sided wrist pain has been shown in a previous study, where elite tennis players with and without ulnar sided wrist pain were assessed. If you would like hints on how to treat ulnar sided wrist pain, have a look at this synopsis. URL: https://doi.org/10.1016/j.jhsa.2021.06.027 Abstract Purpose Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. Methods A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand–adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed. Results All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand–adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand–adjusted life year), inclusion of MRA became the most favorable strategy. Conclusions Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics. 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

Persistent tennis elbow symptoms have little prognostic value: A systematic review and meta-analysis. Ikonen, J., et al. (2021) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 (4/4 thumbs up) Type of study: Prognostic Topic: Lateral epicondylalgia – Symptoms duration and recovery This is a systematic review and meta-analysis assessing the recovery trajectory of people with long term lateral epicondylalgia. Only randomised controlled trials (RCT) were included. All the studies were assessed through the Cochrane Risk of Bias criteria. The recovery trajectory was assessed for the control/placebo arm only. Recovery was defined as either "much improvement" or "total resolution of symptoms" at 1, 3, 6, or 12 months. The statistical analyses assessed whether LE symptoms recovery was affected by the duration of symptoms prior to inclusion in the study. The results showed that by 3 months, 50% of participants in the control/placebo arm had recovered, and by 12 months, 90% of them had recovered. The probability of recovery was independent of the duration of symptoms prior to inclusion in the trials. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the probability of recovery from tennis elbow does not reduce with longer symptoms duration. This is very encouraging as we can reassure our clients that there is a high probability (90%) of their symptoms to resolve at one year independently of how long they have been suffering from LE. This also suggests that we should avoid referring our clients for surgery just because they have been having pain for a long period of time. Thus, surgery for tennis elbow does not currently appear to be more effective than placebo. URL: https://doi.org/10.1097/corr.0000000000002058 Available through EBSCO Health Databases for PNZ members. Abstract Background: Tennis elbow is a common painful enthesopathy of the lateral elbow that limits upper limb function and frequently results in lost time at work. Surgeons often recommend surgery if symptoms persist despite nonsurgical management, but operations for tennis elbow are inconsistent in their efficacy, and what we know about those operations often derives from observational studies that assume the condition does not continue to improve over time. This assumption is largely untested, and it may not be true; meta-analyzing results from the control arms of tennis elbow studies can help us to evaluate this premise, but to our knowledge, this has not been done. Questions/purposes: The aims of this systematic review were to describe the course of (1) global improvement, (2) pain, and (3) disability in participants who received no active treatment (placebo or no treatment) in published randomized controlled trials (RCTs) on tennis elbow. We also assessed (4) whether the duration of symptoms or placebo effect is associated with differences in symptom trajectories. Methods: We searched MEDLINE, Embase, and CENTRAL from database inception to August 12, 2019, for trials including participants with tennis elbow and a placebo or a no-treatment arm and a minimum follow-up duration of 6 months. There were no language restrictions or exclusion criteria. We extracted global improvement, pain, and disability outcomes. We used the Cochrane Risk of Bias tool to assess the risk of bias of included trials. To estimate the typical course of tennis elbow without active treatment, we pooled global improvement (the proportion of participants who reported feeling much better or completely recovered), mean pain, and mean disability using baseline, 1-month, 3-month, 6-month, and 12-month follow-up data. We transformed pain and disability data from the original papers so that at each timepoint the relevant outcome was expressed as change relative to baseline to account for different baseline values. We used meta-regression to assess whether the placebo effect or duration of symptoms before enrollment was associated with differences in symptom trajectories. We included 24 trials with 1085 participants who received no active treatment. Results: The number of patients who were not improved decreased exponentially over time. The half-life of global improvement was between 2.5 and 3 months (that is, every 2.5 to 3 months, 50% of the remaining symptomatic patients reported complete recovery or greatly improved symptoms). At 1 year, 89% (189 of 213; 95% CI 80% to 97%) of patients experienced global improvement. The mean pain and disability followed a similar pattern, halving every 3 to 4 months. Eighty-eight percent of pain (95% CI 70% to 100%) and 85% of disability (95% CI 60% to 100%) had resolved by 1 year. The mean duration of symptoms before trial enrollment was not associated with differences in symptom trajectories. The trajectories of the no-treatment and placebo arms were similar, indicating that the placebo effect of the studied active treatments likely is negligible. Conclusion: Based on the placebo or no-treatment control arms of randomized trials, about 90% of people with untreated tennis elbow achieve symptom resolution at 1 year. The probability of resolution appears to remain constant throughout the first year of follow-up and does not depend on previous symptom duration, undermining the rationale that surgery is appropriate if symptoms persist beyond a certain point of time. We recommend that clinicians inform people who are frustrated with persisting symptoms that this is not a cause for apprehension, given that spontaneous improvement is about as likely during the subsequent few months as it was early after the symptoms first appeared. Because of the high likelihood of spontaneous recovery, any active intervention needs to be justified by high levels of early efficacy and little or no risk to outperform watchful waiting. Level of Evidence Level I, therapeutic study. 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

Dynamic stabilization home exercise program for treatment of thumb carpometacarpal osteoarthritis: A prospective randomized control trial. McVeigh, K. H., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Therapeutic Topic: Thumb osteoarthritis - stabilisation exercises This is a multi-centre randomised controlled study assessing the effect of standard care vs standard care plus thumb stabilisation exercises in participants with thumb osteoarthritis (OA). Participants (N = 64) underwent both a radiological and clinical assessment and were then recruited if they presented with signs and symptoms of thumb OA. Function was measured through the QuickDASH and pain intensity was measured through the Numerical Rating Pain scale (NRS). Other variables such as grip and three different pinch strengths were included in the statistical analyses. The standard care group was provided with a splint and advice on joint protection. The stabilisation exercise group was provided with three exercises shown below (adductor stretching, pinching maintaining an "O" sign, first dorsal interosseus strengthening). These exercises were performed multiple times during the day. The results showed that both groups presented with clinically relevant improvements in pain intensity and close to clinically relevant improvements in the QuickDASH at both six weeks and six months. No statistical or clinically relevant differences were identified between 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, our clients with thumb OA do not benefit from additional stabilisation exercises if we provide them with a multimodal set of interventions already. What seems to be particularly important for people to respond to treatment is their expectations. Thus, in a previous study, positive treatment expectations were associated with better conservative treatment results in people with thumb OA. URL: https://www.sciencedirect.com/science/article/pii/S0894113021000831 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Randomized control trial. Introduction Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common cause of hand pain and disability. Standard conservative therapy (SCT) for thumb CMC OA includes an orthosis and instruction in joint protection, adaptive equipment, and pain relieving modalities. The dynamic stability home exercise (HE) program is complementary conservative therapy designed to strengthen the stabilizing muscles of the thumb CMC. Purpose of the Study: To investigate whether the addition of HE to SCT (SCT+HE) was more effective at reducing pain and disability in thumb CMC OA compared to SCT alone. Methods The study compared 2 groups: SCT and SCT+HE. The SCT group received SCT with in-home pain management instructions, joint protection strategies with adaptive equipment, and a hand-based thumb-spica orthosis. The SCT+HE group received HE program instructions for adductor stretching and opponens and first dorsal interosseous strengthening in addition to SCT. Our primary outcome measure was the numerical rating scale (NRS) with secondary outcome measures of QuickDASH (shortened Disabilities of the Arm, Shoulder and Hand questionnaire), range of motion, grip strength, and pinch strength. Outcome measurements were assessed at first visit, 6 weeks, and 6 months. Results: There was no statistical difference between the 2 groups for NRS and QuickDASH at 6 weeks (P = .28 and P = .36, respectively) or 6 months (P = .52 and P = .97, respectively). However, there was a statistically significant decrease in NRS and QuickDASH scores at 6 weeks and 6 months within both groups. Conclusions: Both SCT and SCT+HE are effective at reducing pain and disability in OA of the thumb CMC joint. Neither therapy program was superior to the other at improving NRS or QuickDASH scores at 6-week or 6-month follow-up. 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

Arthroscopic surgery versus open surgery in lateral epicondylitis in active work population: A comparative study. López-Alameda, S., et al. (2021) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Therapeutic Topic: Lateral epicondylalgia - Arthroscopy vs open surgery This is a retrospective study comparing arthroscopy vs open surgery for lateral epicondylalgia. A total of 47 participants were included. Of these, 27 had undergone arthroscopic surgery and 20 open surgery. Participants underwent surgery if they had been unresponsive to three months of conservative treatment. The average time between the onset of pain and surgery in both groups was six months. The QuickDASH was utilised to assess changes in function after surgery. The results showed that there was a clinically significant improvement in both surgical groups, however, there were no differences between the two surgical 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, there is no difference between arthroscopic and open surgery for tennis elbow. Considering that surgery for tennis elbow does not appear to be more effective than placebo and that 90% of people do well at one year, independently of how long they have been having symptoms for, surgery for tennis elbow should probably be left as a last resort. URL: https://doi.org/10.1016/j.jse.2021.11.017 Available through EBSCO Health Databases for PNZ members. Abstract Background: Lateral Epicondylitis is common in workers who perform repetitive movements of the entire upper limb. Approximately 85% to 90% respond satisfactorily to conservative treatment, but in resistant patients, surgical treatment is considered. Classic open surgery is successful between 70% and 97%, similar to more modern techniques such as arthroscopy. We tried to demonstrate the superiority of the Wolf technique in clinical results. The goals of this study were to compare the functional and pain outcomes of arthroscopic surgery with open surgery using fasciotomy as the wolf technique in the treatment of lateral epicondylitis. Methods: This was a retrospective study of 47 working-age patients with resistant lateral epicondylitis: 27 underwent surgery arthroscopically, and 20 underwent open surgery. Pre- and postsurgical VAS and function were assessed using DASH, MEPS and BMRS scales, as well as the return to their previous work and the surgical time. Results: The reduction in VAS showed no statistically significant differences between the groups (5.26 in arthroscopy versus 5.75 in fasciotomy, p = 0.5), QuickDash (19 versus 19.4 with p = 0.9), MEPS (82 versus 81.5 with p = 0.8) or BMRS (81.9 versus 82.6 with p = 0.9). The differences in terms of time off were also not statistically significant. The days of work leave in the arthroscopy group corresponded on average 83.78 days, and in the Wolff group, it corresponded to 89.95 days. The mean surgical time in the arthroscopic intervention group was 44.2 minutes and in the fasciotomy group was 27.5 minutes, showing statistically significant results (p <0.001). Conclusions: Arthroscopic surgery and open surgery in lateral epicondylitis techniques provide similar functional results and pain reduction. 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

Distal intersection syndrome combined with partial attritional changes of the extensor carpi radialis brevis in tennis players. Sunagawa, T., D. Dohi and R. Shinomiya (2021) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic/Therapeutic This is the answer to last week's Sherlock Handy. The patient was a 23 years old right-handed recreational tennis player with right dorsal radial wrist pain. The pain was aggravated during double backhand shots during tennis. There was pain and swelling just distal and radial to Lister's tubercle. MRI findings are reported below. A cortisone injection was provided at the painful site and a wrist splinting was worn for two months. After this period of conservative treatment, they were still symptomatic. Surgery was therefore performed for diagnostic and therapeutic purposes. The surgical intervention identified a distal intersection syndrome between extensor pollicius longus (EPL), extensor carpi radialis brevis (ECRB) and longus (ECRL), associated with fraying of extensor carpi radialis brevis at the intersection with EPL. Synevectomy, extensor retinaculum release, and trimming of EPL fraying was completed. The patient's wrist was immobilised for 3 months followed by graded rehab. Three months post surgery the patient was able to return to tennis without pain after 3 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, distal intersection syndrome (2nd and 3rd compartment) is a rarer condition compared to proximal intersection syndrome (abductor pollicius longus vs ECRB/ECRL). The distal intersection syndrome is characterised by pain distal and radial to the Lister's tubercle, where EPL intersects both ECRB and ECRL. If you are interested in reading about additional clinical cases reporting radial wrist pain, have a look at this synovial hemangioma, trapezium osteosarcoma, and Linburg-Comstock syndrome. Open Access URL: https://doi.org/10.1016/j.jhsg.2021.04.005 Abstract The purpose of this study is to report the cases of 2 tennis players with distal intersection syndrome, a rare pathological condition, combined with partial attritional changes of the extensor carpi radialis brevis tendon. Both individuals were able to return to their original level of performance after surgical intervention consisting of synovectomy within the distal intersection and release of the distal part of the extensor retinaculum. Physicians should familiarize themselves with distal intersection syndrome, which can cause dorsoradial wrist pain in tennis players. If pain is prolonged, tendon attrition may occur, and surgical treatment may be indicated. 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

Cross-sectional area of the median nerve as a prognostic indicator in carpal tunnel syndrome treated with local steroid injection. Yeom, J. W., J.-H. Cho, S. J. Kim and H. I. Lee (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 thumb up) Type of study: Prognostic Topic: Carpal tunnel response to cortisone injection - morphological predictor This is a retrospective study assessing the prognostic relevance of median nerve morphological changes (cross sectional area - CSA) in people with carpal tunnel syndrome (CTS) treated with cortisone injections. Participants were included (N = 40) if they presented symptoms such as paraesthesia in median nerve distribution of the hand, atrophy of thenar muscles, positive Phalen's and Tinel's test, and if a conservative treatment trial (e.g. splinting) had failed. All participants underwent CSA ultrasound assessment of the median nerve before injection (see figure). This identified 16 participants with an increase in CSA of the median nerve proximal to the carpal tunnel (more severe compression) and 21 without such findings. The injection was performed under ultrasound guidance in all participants. The Boston Carpal Tunnel Questionnaire was utilised to assess the treatment outcomes at baseline and six months after injection. The results showed that CSA area of the median nerve was not a predictor of injection outcome. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, median nerve cross-sectional area alone is not a predictor of cortisone injection treatment success in people with carpal tunnel syndrome. Cortisone injections for clients with carpal tunnel syndrome appear to be a useful conservative treatment intervention and they appear to be superior to night splinting for our clients (≥ 40 years old) with moderate/severe carpal tunnel syndrome. URL: https://doi.org/10.1016/j.jhsa.2021.09.022 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Local steroid injection is an effective treatment modality for carpal tunnel syndrome. This study aimed to investigate the success rate of ultrasonography-guided local steroid injection and determine the prognostic value of the cross-sectional area (CSA) of the median nerve for steroid injection. Methods: We retrospectively evaluated 40 patients with carpal tunnel syndrome whose median nerve CSA was >15 mm2 (large-CSA group; n = 16) or ≤15 mm2 (small-CSA group; n = 24). The CSA was measured using ultrasonography, and all the patients were treated with ultrasonography-guided corticosteroid injection. Demographic characteristics, symptoms, initial QuickDASH score, Boston Carpal Tunnel Questionnaires, and results of the nerve conduction study were assessed at baseline. Treatment success was defined in this study as the absence of symptom recurrence within the entire follow-up period. Results: The treatment success rate was 45% (n = 18) after an average follow-up of 16 months. Overall, 11 patients (28%) underwent carpal tunnel release on an average of 11 months after steroid injection. The large-CSA group showed a significantly worse grade of electrodiagnostic testing at baseline than did the small-CSA group; however, there was no significant difference in final Boston Carpal Tunnel Questionnaires symptom score (1.7 vs 1.8, respectively) and the rate of continued treatment success at the last follow-up (42% vs 50%, respectively). The proportions of patients who required carpal tunnel decompression were 29% and 25% in the small-CSA and large-CSA groups, respectively. Conclusions: Local steroid injection for carpal tunnel syndrome has an overall success rate of 45% after a mean follow-up of 16 months. Preinjection CSA was not associated with whether the steroid injection was considered successful. This indicates that increased median nerve CSA does not preclude the possibility of symptomatic relief after a local steroid injection. 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

Six weeks of resistance training (plus advice) vs advice only in hand osteoarthritis: A single-blind, randomised, controlled feasibility trial. Magni, N., P. McNair and D. Rice (2021) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Therapeutic Topic: Resistance training - application in hand OA This is a pilot randomised controlled trial assessing the feasibility of resistance training exercises for hand OA. A total of fifty-nine participants were included in this study. Participants were included if they presented with the American College of Rheumatology classification criteria, if their pain was at least 3 out of 10 on a Numerical Rating Scale, and if they had pain every day for at least three consecutive months in the year of inclusion. Participants were randomised into either high-intensity resistance training (HIT) plus advice (n = 20), blood-flow restriction training (BFR) plus advice (n = 19), or an advice only group (n = 20). Feasibility measures included exercise-induced pain (post exercise pain - pre exercise pain), pain exacerbations (increases in pain that lasted beyond 24 hrs after exercise). Efficacy of intervention was assessed through the OMERACT-OARSI criteria (a combination of pain, function, and disease burden outcome), pain (NRS), function (i.e., FIHOA), grip and pinch strength. All participants received advice as per Arthritis New Zealand pamphlet on osteoarthritis. In addition, participants in the resistance exercise groups trained three times per week for six weeks one on one with a physiotherapist. Participants in the advice only group received no additional intervention. Exercises were performed starting at 30% and 60% of maximum voluntary contraction for the BFR and HIT groups respectively. Participants were started on two sets for each exercise (gripping, pinching, and thumb-abduction). The exercises progressed both in terms of intensity (40% and 70% for BFR and HIT respectively) and number of sets (up to 4 sets). The results showed that exercise-induced pain remained unchanged despite doubling of exercise volume (sets x repetitions), see figure below. In addition, the number of pain exacerbations was low in both resistance training interventions. The number of responders was 79%, 60%, and 35% in the BFR, HIT, and advice only groups respectively. Pain improved to a clinically relevant level with resistance training interventions but not with advice only. There were no clinically relevant changes in function, grip, or pinch strength. 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, resistance training interventions do not appear to worsen pain and may actually improve symptoms in clients with hand OA. These findings are supported by another study, which showed no worsening of pain when people with interphalangeal hand OA who underwent resistance training for their hands. These results are also consistent with a systematic review and meta-analysis covered in a previous synopsis. Other activities that have been shown to be safe for clients' with hand OA include knitting. What these results suggest is that there are lots of options to keep our clients with hand OA active. In addition, if we provide treatments that our clients think will be helpful, there is a higher probability that they will report pain relief with it. URL: https://www.sciencedirect.com/science/article/pii/S2468781221001752 Available through EBSCO Health Databases for PNZ members. Abstract Background People with hand osteoarthritis (OA) may benefit from resistance training interventions. To date the feasibility of a such interventions for symptomatic hand OA, as per international guidelines, is unknown. Objective Determine the feasibility of a clinical trial comparing resistance training to an advice only control group in people with symptomatic hand OA. Design Single-blind, randomised, controlled feasibility study. Methods The American College of Rheumatology criteria for hand OA were utilised for inclusion. Participants were randomly allocated (1:1:1) to advice and blood flow restriction training (BFRT), advice and traditional high intensity training (HIT), or advice only (control). Participants receiving BFRT and HIT underwent supervised hand exercises three times a week for six weeks. Feasibility measures included recruitment rate, adherence, exercise induced pain, training acceptability, pain flares, and adverse events. Number of treatment responders, pain, grip strength, and hand function were also recorded. Results In total, 191 participants were screened, 59 (31%) were included. Retention rate was 89% for BFRT and 79% for HIT. Exercise did not worsen pain following training sessions, and training acceptability was equal between groups. Pain flares occurred in 1.6% (BFRT) and 4% (HIT) out of all the training sessions. There was one adverse event in the HIT group, with the participants withdrawing from the study due to pain. The number of treatment responders, and improvements in pain, were greater with BFRT and HIT. Grip and function did not improve. Conclusion A clinical trial comparing resistance training to advice for people with symptomatic hand OA is feasible. 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 for Kienböck disease familial clustering: A population-based cohort study. Kazmers, N. H., Yu, Z., Barker, T., Abraham, T., Romero, R., & Jurynec, M. J. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Kienböck disease - Genetic contributions This is a retrospective study assessing whether genetic factors and extrinsic risk factors contribute to the development of Kienböck's disease. A total of 394 patients diagnosed with Kienböck's disease were included. Extrinsic risk factors included a past history of diabetes, tobacco, glucocorticoid, and alcohol use. The results showed that a person with a first-degree relative (parent, sibling, or child) affected by Kienböck disease is more likely to have the condition with a relative risk (RR) of 11 (95% CI: 1.1 to 113). However, the wide confidence interval suggests that the risk magnitude is not accurate, and the result should be interpreted with caution. Extrinsic factors increased the likelihood of being diagnosed with Kienböck's disease by 2.2 times (diabetes), 2.5 times (tobacco use), 6 times (glucocorticoid use), and 2.1 (alcohol use) times. All these factors had a tighter confidence interval suggesting that the magnitude risk is more precise. 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, Kienböck disease is a rare condition, however, hand therapists should be suspicious of this pathology when a patient's first-degree relative has been diagnosed with it. These patients may have an 11 times greater probability of having the disease. Modifiable factors such as smoking and corticosteroid use, present with the highest risk of presenting with Kienböck disease. URL: https://www.jhandsurg.org/article/S0363-5023(19)31415-7/abstract Abstract PURPOSE Kienböck disease (KD) is rare and its etiology remains unknown. As a result, the ideal treatment is also in question. Our primary purpose was to test the hypothesis that KD would demonstrate familial clustering in a large statewide population with comprehensive genealogical records, possibly suggesting a genetic etiologic contribution. Our secondary purpose was to evaluate for associations between KD and known risk factors for avascular necrosis. METHODS Patients diagnosed with KD were identified by searching medical records from a comprehensive statewide database, the Utah Population Database. This database contains pedigrees dating back to the early 1800s, which are linked to 31 million medical records for 11 million patients from 1996 to the present. Affected individuals were then mapped to pedigrees to identify high-risk families with an increased incidence of KD relative to control pedigrees. The magnitude of familial risk of KD in related individuals was calculated using Cox regression models. Association of risk factors related to KD was analyzed using conditional logistic regression. RESULTS We identified 394 affected individuals linked to 194 unrelated high-risk pedigrees with increased incidence of KD. The relative risk of developing KD was significantly elevated in first-degree relatives. There was a significant correlation between alcohol, glucocorticoid, and tobacco use and a history of diabetes, and the diagnosis of KD. CONCLUSIONS Familial clustering of KD observed in the Utah Population Database cohort indicates a potential genetic contribution to the etiology of the disease. Identification of causal gene variants in these high-risk families may provide insight into the genes and pathways that contribute to the onset and progression of KD. CLINICAL RELEVANCE This study suggests that there is a potential genetic contribution to the etiology of KD and that the disease has a significant association with several 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

Development and validation of a prediction model for incident hand osteoarthritis in the HUNT study. Johnsen, M. B., et al. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: Hand OA - Prognostic factors for incidence This is a prognostic study assessing the precision and validity of a statistical model to determine who will develop hand osteoarthritis (OA) in the future. A total of 35,835 participants were included in the present study. Of these, 17,153 were males and 18,682 were females. Participants were assessed over the course of 24 years. To be included, participants had to be free of hand osteoarthritis when assessed for the first time. Participants' age ranged between 35 and 70. Participants were diagnosed at follow up with hand OA if they presented with painful Heberden's or Buchard's nodes, or base of thumb OA. The prognostic model for males suggested that greater age, body mass index (BMI), education level, heavier work, and worse sleep quality all increased the chance of developing hand OA at 12 years. The prediction model for females suggested that greater age, BMI, heavier work, sedentary lifestyle, and poor general health increase the chance of developing hand OA. The prediction model was moderately precise for both males and females. However, it was more valid for males compared to females. 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, you can predict the likelihood of your clients developing hand OA at 12 years based on a few predicting factors. For males, it appears that greater BMI and worse sleep may increase the probability of developing hand OA. For females, higher BMI and inactivity increase the chance of developing hand OA. Based on these findings we may suggest our clients, both males and females, to follow the international guidelines for physical activity. In addition, if they are overweight or obese, we may refer them to a nutritionist in an attempt to reduce their BMI. For males, referral to a sleep specialist may also reduce the probability of developing hand OA. If you want to easily calculate the probability of your clients' developing hand OA, head over to this page. Open Access URL: https://doi.org/10.1016/j.joca.2020.04.005 Abstract Objective To develop and externally validate prediction models for incident hand osteoarthritis (OA) in a large population-based cohort of middle aged and older men and women. Design We included 17,153 men and 18,682 women from a population-based cohort, aged 35–70 years at baseline (1995–1997). Incident hand OA were obtained from diagnostic codes in the Norwegian National Patient Register (1995–2018). We studied whether a range of self-reported and clinically measured predictors could predict hand OA, using the Area Under the receiver-operating Curve (AUC) from logistic regression. External validation of an existing prediction model for male hand OA was tested on discrimination in a sample of men. Bootstrapping was used to avoid overfitting. Results The model for men showed modest discriminatory ability (AUC = 0.67, 95% CI 0.62–0.71). Adding a genetic risk score did not improve prediction. Similar discrimination was observed in the model for women (AUC = 0.62, 95% CI 0.59–0.64). Prediction was not improved by adding a genetic risk score or hormonal and reproductive factors. Applying external validation, similar results were observed among men in HUNT (The Nord-Trøndelag Health Study) as in the developmental sample (AUC = 0.62, 95% CI 0.57–0.65). Conclusion We developed prediction models for incident hand OA in men and women. For women, the model included body mass index (BMI), heavy physical work, high physical activity and perceived poor health. The model showed moderate discrimination. For men, we have shown that a prediction model including BMI, education and information on sleep can predict incident hand OA in several populations with moderate discriminative ability. 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: 👍 Type of study: Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis reported by the paper next week. The patient was a 23 years old right-handed recreational tennis player with right dorsal-radial wrist pain. The pain was aggravated during double backhand shots during tennis. There was pain and swelling just distal and radial to Lister's tubercle. MRI findings are reported below. A cortisone injection was provided at the painful site and a wrist splinting was worn for two months. After this period of conservative treatment, they were still symptomatic. What was it?