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A scoping review of the use of exercise-based upper extremity injury prevention programs for industrial workers. Boyette, J. and J. Bell (2021) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic/Preventative Topic: Injury prevention - Industrial workers This is a systematic review and meta-analysis on the effect of upper limb injury prevention programs for industrial workers. Fourteen studies, of which 10 were RCTs were included in the systematic review, for a total of 2682 participants. Participants included were from an industrial population and the outcomes analysed varied significantly across the studies included. The overall strength of evidence was not assessed and a meta-analysis was not completed. Despite exercise programs varying quite significantly, the most common exercise frequency was three times per week. Exercises included stretching and strengthening programs. Overall the results suggest that exercise in any form appears to be beneficial from a pain, function, and return to work point of view. It is not possible to comment on the clinical relevance of these 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, exercise in any form (stretching/strengthening) appears to be useful in preventing and/or reducing symptoms and improving function in people with upper limb conditions working in industrial settings. Currently, it is not possible to comment on which exercises are most effective. Overall, I would suggest for clients to follow the World Health Organisation guidelines for physical activity, which are likely to induce physical as well as mental health benefits. In addition to exercise, our clients may benefit from the adjunct of pain neurophysiology education, which seems to boost the effect of exercise. Remember that pain neurophysiology education alone does not appear to be enough to reduce pain and it needs to be combined with exercises to have a clinically relevant effect. If you are interested in additional information on the effectiveness of pain education on persistent pain, have a look at this synopsis. You may also want to rethink the use of some terms such as "overuse injury", which probably needs updating. URL: https://doi.org/10.1016/j.jht.2021.04.020 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study is a scoping review. Introduction Exercise-based upper extremity injury prevention programs are used by employers to reduce the cost of work-related injuries in the industrial work setting. Purpose of the Study The purpose of the study was to identify, report, and evaluate all published literature that describes exercise-based upper extremity injury prevention programs used with an industrial workforce. Methods A systematic search of Medline, ProQuest, Pubmed, and Worldcat databases was performed. Data extracted included the type of outcome tool used, the outcome that was measured, the components of the exercise program, and the effectiveness toward reducing injury. Results 14 studies were included in the final analysis and summary. 12 articles included strengthening (85%) 10 included stretching (71%), 2 included health coaching (14%), and 2 included work simulation (14%). The most prevalent treatment approach was combined stretching and strengthening which accounted for 5 of the 14 studies, or 36%. The intervention period ranged from 4 weeks to 1 year and the program frequency ranged from before every work shift to weekly performance. There were 22 different outcome measures with health condition reported in 12 of 14 studies (86%) and function reported in 7 of 14 studies (50%). Discussion and Conclusions Although many of the studies showed positive benefits to the exercise program, there is a wide variance in the current literature regarding the implementation, supervision, and exercise components of an upper extremity injury prevention program in an industrial work setting. Because there is no commonly-accepted exercise program, a conclusion regarding effectiveness cannot be generalized outside of the environment, supervision requirements, frequency, and duration in which the research was performed. There is a need for improved reporting techniques and a preferred program to be replicated across multiple work settings in order to allow generalizability of findings.

Hand therapists' knowledge and practice-related beliefs about pain science: A survey study. Stern, B. Z. and T. H. Howe (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Hand Therapists – Pain science knowledge This is a cross-sectional survey study to assess Hand Therapists understanding of acute and persistent pain. The reason why this is important is that both acute and persistent pain clients would benefit from an understanding of pain that is beyond the traditional biomedical approach. A total of 366 (11% of the total contacted) American Hand Therapists tool part in the study. These participants completed a survey, which included the Revised Neurophysiology of Pain Questionnaire (R-NPQ). Participants reported seeing clients with persistent pain of the elbow, wrist, and/or hand routinely/often, which makes pain neurophysiology understanding relevant. The results showed that the scores on the R-NPQ ranged from 5/12 to 12/12, with greater scores representing greater knowledge. The mean R-NPQ score was 9/12. Have a go at testing your pain neurophysiology understanding by taking the same questionnaire as these participants did! Don't worry if you scored low, I have linked a few resources in the clinical take home message, which you may find useful. 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, pain science knowledge is important for hand therapists when treating clients with acute and persistent pain. Thus, it has been shown that pain neuroscience education in combination with exercise has a clinically relevant effect in clients with musculoskeletal pain. As a matter of fact, the words that we use can increase or decrease our clients' pain. Suggesting clients that doing certain activities will increase their pain is likely to augment their pain response through a conditioning mechanism. It is also important to reduce fear of movement in our clients as this is associated with upper limb disability. It would be good to follow expected healing time-frames for hand conditions rather than clients' reported pain. Pain is often mediated by other factors and is not a good indicator of healing in several uncomplicated hand fractures and scaphoid fractures. Finally, being empathetic and smiling has also been shown to reduce pain in our clients. URL: https://doi.org/10.1016/j.jht.2020.07.007 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract INTRODUCTION: Identifying hand therapists' knowledge and beliefs about pain can illuminate familiarity with modern pain science within hand therapy. PURPOSE OF THE STUDY: The primary aim was to identify hand therapists' knowledge of pain neurophysiology. Secondary purposes were to explore demographic variation in knowledge, describe practice-related beliefs about pain science, and explore associations between knowledge and beliefs. STUDY DESIGN: Cross-sectional descriptive survey study. METHODS: An electronic survey, including the Revised Neurophysiology of Pain Questionnaire (R-NPQ) and Likert-type questions about practice-related beliefs, was distributed to American Society of Hand Therapists members. RESULTS: Data from 305 survey responses were analyzed. R-NPQ accuracy ranged from 42% to 100%, with a mean of 75% (9/12 ± 1.5). Certified hand therapists scored, on average, 0.8 points lower than their noncertified peers. Participants with a doctoral degree scored 0.7 or 0.6 points higher, respectively, than those with a bachelor's or master's degree. Objective knowledge of pain neurophysiology was positively associated with perceived knowledge of pain science (ρ = .31, P < .001). Associations between R-NPQ and perceived importance of knowing pain science; confidence in pain-related evaluation, treatment, and education; and frequency of incorporating pain science principles into practice were small but statistically significant (ρ = .12-.25, P = <.001-.04). CONCLUSIONS: Although hand therapists recognized the importance of knowing pain science, they had objective and subjective limitations in that knowledge. Specific errors in their R-NPQ responses suggest misconceptions related to the modern differentiation between nociception and pain. Blurring of these constructs may relate to participants' self-reported practice emphasis on acute versus chronic conditions. Future studies should explore knowledge, attitudes, and beliefs about pain beyond R-NPQ scores to understand variation in practice and training needs. 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

Recovery of grip strength and hand dexterity after distal radius fracture: A two-year prospective cohort study. Bobos, P., G. Nazari, E. A. Lalone, R. Grewal and J. C. MacDermid (2017) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Distal radius fractures - Strength and dexterity deficits This is a prospective cohort study assessing the level of grip strength and dexterity impairments at short and long term after distal radius fracture. A total of 154 participants with a distal radius fracture were included. In total, 73% of these participants had undergone surgery. In addition, 80% of the whole sample were female and the average age was 54 years old. Grip strength and hand dexterity were measured at 3, 6, 12, and 24 months. Grip strength was assessed through a hand held dynamometer whilst hand dexterity was assessed through the NK dexterity board. The results showed that at 3 and 6 months grip strength was clinically significantly lower than the contralateral side (more than 6.5 kg deficit). These impairments no longer reached a clinically significant level at 12 or 24 months. Hand dexterity was impaired only at 3 months with normalisation at 6, 12, and 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, grip strength deficits are no longer clinically relevant at 12 months post distal radius fracture. In addition, hand dexterity seems to improve to a large extent after the 3 months mark without relevant impairments by the 6 months mark. If you are interested in knowing how minimal clinically relevant differences are calculated, head over to this previous synopsis. A synopsis on clinically relevant changes in grip strength will come out in the following weeks. Remember that it may be important to follow clients with a distal radius fracture for longer if they present with diabetes, as this appears to be associated with a slower functional recovery compared to clients without this condition. Also remember that in older female clients with a distal radius fracture, a bone mass density scan is advised as this may reduce the risk of additional fractures. URL: https://doi.org/10.1177/1758998317731436 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Clinicians often evaluate deficits after an injury by comparing the injured and uninjured side. It is important to understand what deficits occur in hand function after distal radius fracture, how they change over time and their clinical relevance. The purpose of this study was to evaluate the differences in grip strength and hand dexterity between the injured and uninjured hands of patients two years following distal radius fracture. Methods Patients with distal radius fracture were recruited in a specialized hand clinic. Grip strength and hand dexterity were examined bilaterally with a Jamar hand-held dynamometer and with the NK dexterity device at 3, 6, 12 and 24 months post-injury respectively. Generalized linear modeling was performed, with age and sex as covariates to assess changes over time, and between sides. Results Patients (n?=?154) exhibited mean differences of grip strength between injured and uninjured side at 3 months (12.09 kg) and 6 months (7.47 kg) follow-up. The associated deficit standardized response means (SRM) were 1.30 and 0.73, respectively. At 2-years follow-up the mean deficit on the injured side was 2.30 kg with SRM=0.22. One hundred and eleven patients who completed dexterity testing demonstrated small to trivial side to side differences across all time points. Conclusions There were clinically important differences in grip strength between the injured and uninjured hands in patients with a distal radius fracture at 3 and 6 months? follow-up. However, at 12 and 24 months, grip strength differences were small and of uncertain clinical importance. Trivial to small differences in hand dexterity can be expected between the injured and uninjured hand by 2 years after distal radius fracture.

Increasing incidence of hand and distal upper extremity injuries associated with electric scooter use. LaGreca, M., C. J. Didzbalis, N. C. Oleck, J. S. Weisberger and H. S. Ayyala (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Preventative Topic: Electric scooters - Injury incidence This is a retrospective study on the number of injuries associated with electronic scooters/skateboards from 2010 to 2019. A total of 26,000 injuries were estimated to have occurred due to electronic scooter/skateboard, when the American National Electronic Injury Surveillance System (NEISS) was reviewed (see graph). The number of injuries had increased 240% during this nine years period. The most common injury was fracture (55%) of the upper limb. 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, it appears that the number of electric scooters/skateboards injuries has been increasing in the last 10 years. This appears to be reasonable considering the increased use of these devices. There was however no comparison to the number of injuries from non electric scooters/skateboards. This would have been relevant as it is possible that whilst the number of electric scooters injuries went up (due to greater use), the number of non electric scooters/skateboards injuries may have gone down, potentially leaving the total number of injuries unchanged. URL: https://doi.org/10.1016/j.jhsa.2021.05.021 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose Electric scooters (e-scooters) have seen an increase in popularity in cities across the United States as a form of recreation and transportation. The advent of ride-sharing applications allows anyone with a smartphone to easily access these devices, without any investment or experience required. In this study, the authors analyze scooter-related injuries of the hand and upper extremity. Methods The National Electronic Injury Surveillance System (NEISS) was queried to look for injuries related to the use of e-scooters between 2010 and 2019. Data collected included demographic information, the location of the injury, the injury diagnosis, and disposition. National estimates (emergency room visits in the United States) were calculated using the weight variable included in the NEISS database. Miscoded reports were excluded. As a corollary, Google Trends data were utilized to establish a correlation between e-scooter-related injuries and the relative number of e-scooter hits on the Google search engine. Results From 2010 to 2019, there were 730 e-scooter-related injuries reported to the NEISS database. This corresponds to an estimated 26,412 injuries nationally during this time period. The incidence of scooter-related injuries increased by over 230% (2,130 national injuries in 2010; 7,213 national injuries in 2019; relative difference 5,083). Injuries most commonly occurred in patients aged 10 to 18 years (30.3%). The most frequent site of injury was the wrist (41.9%). The most common injury diagnosis was fracture (55.3%). Additionally, there was a correlation between the number of Google Trends e-scooter hits and the number of injuries during this time period. Conclusions The incidence of e-scooter-related upper extremity injuries increased dramatically in the United States between 2010 and 2019. Clinical relevance As novel e-scooter-sharing apps become increasingly popular, it is imperative that users are educated about the risk of injury and that use of proper protective equipment is encouraged.

Volar tilt of the lunate after open reduction internal fixation of a distal radius fracture. Bakker, D., et al. (2021) Level of Evidence: 4 Follow recommendation: 👍 Type of study: Aetiology/Diagnostic Topic: Distal radius fracture - is this a VISI? This is a case series assessing the alignment of the lunate post distal radius fracture. A total of five participants were included in the present study. What the x-rays showed was that after a distal radius fracture some people present with a volar tilt of the lunate on lateral x-ray views. This alignment suggested the presence of a volar intercalated segmental instability (VISI) due to a lunotriquetral (LT) injury (See picture). However, on further investigations, a similar alignment was identified on the contralateral side of one of the participants. In the other cases, arthroscopy was completed to "repair" the LT ligament, but no lesion was identified. 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, after a distal radius fracture, we may note a volar alignment of the lunate, which may or may not be associated with a LT ligament injury. Personally, from now on, I will refer clients for bilateral x-rays when I suspect a LT ligament injury. We are already doing this when we suspect a scapholunate (SL) injury by referring clients for a "clenched fist pencil view". If you want to sharpen your diagnostic skills, look at this previous synopsis on VISI and DISI or this other one on extrinsic wrist ligament injuries. Finally, if you were confused by the imaging shown above, do not despair, even the surgeons that wrote this article were unclear of why some people present with it! URL: https://doi.org/10.1016/j.jhsa.2020.06.016 Available through EBSCO Health Databases for PNZ members. Abstract The pathophysiology of carpal adaptations after fracture of the distal radius is incompletely understood. We report 5 patients who had normal carpal alignment on injury radiographs that developed marked volar angulation of the lunate during recovery from volar plate fixation of a fracture of the distal radius. There were no signs of alteration of the carpal ligaments. Two patients had similar volar tilt on the contralateral side. The cause and optimal treatment of carpal malalignment after restoration distal radial alignment are unclear.

Empirical treatment of uncomplicated septic olecranon bursitis without aspiration. Deal, J., Vaslow, A., Bickley, R., Verwiebe, E., & Ryan, P. (2020) Level of Evidence: 4 Follow recommendation: 👍 Type of study: Prognostic Topic: Conservative and invasive treatment for septic olecranon bursitis - Aspiration followed by antibiotics vs antibiotics only. This is a retrospective study assessing complications following treatment of septic olecranon bursitis with aspiration and antibiotics, or antibiotics alone. This study needs to be considered in light of a few limitations. The sample size was small (n = 30) and it is possible that larger studies could provide different results. In addition, due to the retrospective design of the study it is not possible to exclude the effect of an unknown variable on the results. The results showed that participants undergoing bursal aspiration (n = 11) had a much greater probability of undergoing bursectomy, compared to patients managed through antibiotics only (n = 19). Based on the number needed to treat to harm, out of 3 participants undergoing bursal aspiration, 2 would require a bursectomy due to unresolved complications. None of the participants managed through antibiotics only required a bursectomy. It is important to remember that the patients underwent a particular intervention based on the decision of a clinician, and were not randomised to a treatment. It is possible that those patients undergoing aspiration presented with a more severe clinical picture. A randomised controlled trial would likely clarify the causality, if any, between bursal aspiration and further complications. 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 undergoing aspiration due to septic olecranon bursitis are more likely to require bursectomy, compared to those who are managed with antibiotics only. Additional risk factors for poor wound healing and risk of infection in our clients include smoking, mental stress, and diabetes. Knowing the presence of these risk factors in your clients will help predicting what is their likelihood of developing an infection. If you are suspecting an infection, a workup may be useful. URL: https://www.jhandsurg.org/article/S0363-5023(18)30819-0/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract PURPOSE Although aspiration of septic olecranon bursitis is recommended in the literature, no high-level evidence exists to support this practice. The purpose of this study was to retrospectively compare the results of traditional bursal aspiration (TBA) with empirical management without aspiration (EM). We hypothesized that EM of uncomplicated septic olecranon bursitis results in resolution, with fewer chronic draining sinuses and less progression to bursectomy. METHODS We performed a retrospective review of all cases of septic olecranon bursitis seen by the orthopedic surgery department at a single tertiary referral center over a 5-year period. Cases were manually reviewed to determine patient demographics, management, and treatment results. The primary outcome was success of nonsurgical management versus requirement for surgical bursectomy. RESULTS Thirty cases of uncomplicated septic olecranon bursitis were identified within the study period. Eleven patients were initially managed with TBA (performed by an emergency or primary care physician prior to orthopedic consultation), resulting in 11 positive cultures. Only 1 of these prompted a change of antibiotic management, and despite this information, 5 patients required a second course of antibiotics for incomplete resolution. Eight of the TBA cases went on to bursectomy. Nineteen patients underwent EM. Sixteen of these cases resolved with a single course of empirical antibiotics, and 3 (16%) cases required a second antibiotic course. One patient had a recurrence of symptoms 2 months after resolution with a single course of empirical antibiotics. This resolved with a second course of oral antibiotics. No patients who underwent EM went on to require bursectomy. The number needed to harm when aspiration was performed was 1.46. CONCLUSIONS We found EM of uncomplicated septic olecranon bursitis to be effective. Although 1 recurrence did occur in the EM group, no other complications occurred. Empirical management without aspiration may be considered in cases of uncomplicated septic olecranon bursitis.

Advancing the management of upper extremity musculoskeletal conditions: Insights from the field of implementation science. Juckett, L. A., L. DeMott and H. V. Oliver (2021) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Research Implementation Topic: Making the jump from research to practice - Implementation This paper revolved around strategies to help clinicians implementing valuable research into clinical practice. The reason why this is important, is that it takes on average 17 years for research to be implemented in clinical practice. This means that concepts relevant to Hand Therapists published this year, may be applied in clinical practice in 2036. Why does this process take so long? Time is one factor. We are busy: looking, critiquing, and interpreting research is not something that we get paid for, although we are supposed to. Second, the papers we may want to read are often closed access and that makes it harder, if not impossible to read the full text. People may also feel that they lack confidence in applying new findings and this is likely to make them go back to what they were doing before reading the paper. The usefulness of different strategies to improve the uptake of research is called "implementation science". Currently, there are steps that have been suggested to help improving research uptake. These include: 1) Identification of barriers to evidence implementation by talking with Clinicians 2) Creation of a team of Clinicians and people interested in research to help reducing barriers and move forward. 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: I would like to take the first step identified above. I would like to hear from you rather than provide you with a clinical take home message: What are the barriers that you face when you try and implement evidence based practice? URL: https://doi.org/10.1016/j.jht.2021.04.004 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction The development of effective interventions in hand and upper extremity rehabilitation is critically important; yet even the most promising interventions may not successfully be implemented in practice. Occupational and physical therapists who provide specialized hand and upper extremity rehabilitation services (“hand therapists”) can face extensive, multi-level barriers when attempting to use research findings in real-world settings, widening the long-standing research-to-practice gap. Concepts from the field of implementation science can be leveraged to address this gap and expedite the application of research discoveries that can maximize treatment outcomes of the musculoskeletal upper extremity client. As the intersection of hand and upper extremity rehabilitation and implementation science draws growing attention, there is a great need for researchers and clinicians to infuse implementation science into the hand and upper extremity rehabilitation research and practice contexts. Purpose The purpose of this article is to define implementation science and synthesize several studies from the hand and upper extremity rehabilitation field that have examined the effect of implementation strategies (eg, chart audit and feedback techniques; implementation teams) on implementation outcomes (eg, acceptability, fidelity). We also present recommendations for how (1) hand and upper extremity rehabilitation researchers can design studies to examine both patient outcomes and implementation outcomes relative to interventions for the musculoskeletal upper extremity and (2) hand and upper extremity rehabilitation specialists and administrators can develop implementation teams to facilitate the use of evidence in practice. Conclusion Collaboration between researchers and clinicians has great potential to advance the entirety of the hand and upper extremity rehabilitation profession, especially when such collaborations are guided by the implementation science field.

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (swifft): A pragmatic, multicentre, open-label, randomised superiority trial. Dias, J. J., et al. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Scaphoid waist fractures - Surgery vs casting This is a randomised controlled trial assessing the outcomes of surgical fixation vs casting for non displaced waist scaphoid fractures . Only participants who presented with a bicortical fracture (through the waist of the scaphoid) with a step of 2 mm or less in any radiographic view were included. A total of 408 participants were included. Outcome measures included the patient-rated wrist evaluation (PRWE) at 0, 6,12, 26, and 52 weeks post randomisation. Secondary outcomes included adverse events associated with casting, surgery, or other medical issues. Casting was applied below the elbow and involved the thumb in some but not all participants. X-rays were repeated at 6-12 weeks and if non union was identified participants underwent surgery. The results showed that there was no statistically or clinically relevant difference in PRWE scores across all times (see graph). No differences were identified in rates of non-union. 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, non displaced scaphoid waist fracture of 2 mm or less can be managed with a below elbow cast (with or without thumb inclusion). The outcomes associated with casting immobilisation do not appear to be superior or inferior to screw fixation. Non union complications do not appear to be higher with conservative management compared to surgery. If you are interested in knowing what physical tests appear to be useful for identification of occult scaphoid fractures have a look at this synopsis. Also, remember that tenderness on palpation may not be a reliable indicator of fracture healing, and it may be better to follow traditional fracture healing times as a guide for weaning of casting/splint. Interestingly, it appears that the duration of immobilisation for scaphoid fractures not only depends on radiographic evidence of healing, which has been shown not to be a reliable indicator, but also on client's depressive symptoms. Once again, it may be best to judge immobilisation duration on timeframes from injury rather than subjective factors such as tenderness on palpation. Open Access URL: https://eprints.whiterose.ac.uk/161086/1/Final_SWIFFT_Manuscript_accepted_2020.04.16_3_.pdf Abstract Background Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. Methods This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1–2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. Findings Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2–14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference −2·1 [95% CI −5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). Interpretation Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite.

The minimal important change for the QuickDASH in patients with thumb carpometacarpal arthritis. Jørgensen, R. W. and M. R. K. Nyring (2021) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Minimal clinically important difference - QuickDASH Through HandyEvidence surveys, I have discovered that Hand Therapists are interested in tips on how to critique research article. This synopsis is the second of a series (if you find them useful - leave a comment) providing tips on how to interpret the research that you read. In particular, this synopsis revolves around the minimally clinically important difference concept. By minimal clinical important difference, we refer to the smallest change in a measure (e.g. QuickDASH) which can be considered as a real improvement in the clinical presentation of our clients. There are at least a couple of methods that can be used to estimate this value, and they are called "anchor-based" and "distribution-based" method. The anchor-based method calculates the minimal clinical important difference by determining the score of those participants who report benefiting from an intervention/treatment. The distribution-based methods instead does not take into account participants' opinion of improvement and simply calculates the minimal clinical important difference based on the error of the measure utilised. In the paper that I read this week, a group of surgeons calculated the minimal clinically important difference for the QuickDASH in a group of participants with thumb OA. In this paper, they assessed clients at baseline and 6 months after surgery for thumb OA (e.g. trapeziotomy). The results showed that the minimal clinically important difference calculated through an anchor-based method (utilising clients' feedback) was 18 points out of 100. When they calculated it through a distribution-based method, the minimal clinically important difference was 10 points out of 100. 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 minimal clinically important difference for the QuickDASH ranges between 10 to 18 points out of 100. Personally, I prefer the anchor-based method, hence I would suggest that a change of 18 points is clinically meaningful. This means that if one our clients scored 50/100 on the QuickDASH at the first assessment and 32/100 on discharge, we would have achieved a clinically meaningful improvement. Once again, it is possible that this change could be either due to our treatment, other people's treatment (e.g. GP medications), regression to the mean, variables that we have not considered (e.g. reduction in kinesiophobia), or natural history of the condition. If you liked this synopsis you may also like other topics such as the relevance of statistical significance or p<0.05, implementation of research to clinical practice, and how to make evidence guided decisions when limited evidence is available. URL: https://doi.org/10.1177/17531934211034749 Available through EBSCO Health Databases for PNZ members. Abstract Evaluating the effect of treatment through change in patient-reported outcomes requires an understanding of the minimal important change. The aim of this study was to report the minimal important change for the Quick Disability of the Arm, Shoulder and Hand questionnaire (QuickDASH) in patients receiving surgical treatment for thumb carpometacarpal joint osteoarthritis. Three hundred and fifteen patients were seen before and 6 months following surgery. Two methods were used to calculate the minimal important change: a distribution-based method calculating the standard error of measurement and an anchor-based method based on the receiver operating characteristic curve. The minimal important change for QuickDASH was estimated to be 18.2 points using the anchor-based method. The area under the receiver operating curve was 0.82, indicating a satisfactory accuracy. The minimal important change was estimated to be 10.3 points using the distribution-based method. These values may be useful in future research on thumb carpometacarpal joint osteoarthritis. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Psychological factors are more strongly associated with pain than radiographic severity in non-invasively treated first carpometacarpal osteoarthritis. Hoogendam, L., et al. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Aetiology Topic: Thumb osteoarthritis - Pain and psychological factors This is a cross-sectional study assessing the association between psychological variables and pain in participants with thumb osteoarthritis (OA). Participants (N = 255) with thumb OA underwent a radiological assessment and were then recruited for the study. Psychological variables included pain catastrophising, anxiety, and depression. Pain intensity was measured through the pain section of the Michigan Hand Outcomes Questionnaire. Other variables such as radiological severity of thumb OA were included in the statistical analyses. The results showed that pain catastrophising was the most important predictor of pain intensity and it explained 29% of the pain variance. In contrast, radiological findings only explained 1% of pain variability (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, pain catastrophising is one of the strongest contributors to pain intensity in thumb OA. This study adds to the growing amount of evidence suggesting that mental health is an important factor to consider in our clients with hand and upper limb conditions. In particular, mental health issues have been shown to be associated with a greater number of hand clinic visits across a wide range of upper limb conditions as well as delay recovery in clients post carpal tunnel release. In addition, kinesiophobia has been shown to be associated with upper limb disability and we may be able to utilise a pain phenotype classification to predict recovery in our clients. Open access URL: https://doi.org/10.1080/09638288.2019.1685602 Abstract Background: The aim of this study was to investigate to what extent psychological factors are related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint. Methods: We included patients (n = 255) at the start of non-invasive treatment for osteoarthritis of the first carpometacarpal joint who completed the Michigan Hand Outcome Questionnaire. Psychological distress, pain catastrophizing behavior and illness perception was measured. X-rays were scored on presence of scaphotrapeziotrapezoid osteoarthritis. We used hierarchical linear regression analysis to determine to what extent pain levels could be explained by patient characteristics, X-ray scores, and psychological factors. Results: Patient characteristics and X-ray scores accounted for only 6% of the variation in pre-treatment pain levels. After adding the psychological factors to our model, 47% of the variance could be explained. Conclusions: Our results show that psychological factors are more strongly related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint than patient characteristics and X-ray scores, which implies the important role of these factors in the reporting of symptoms. More research is needed to determine whether psychological factors will also affect treatment outcomes for patients treated non-invasively for osteoarthritis of the first carpometacarpal joint. IMPLICATIONS FOR REHABILITATION: Pain is the most important complaint for patients with osteoarthritis of the first carpometacarpal joint. Psychological factors are strongly associated with pain levels prior to treatment. Pain catastrophizing behavior appears to be a promising target for complementary treatment in patients with osteoarthritis of the first carpometacarpal joint.

Clinical evaluation of a wrist sensorimotor rehabilitation program for triangular fibrocartilage complex injuries. Chen, Z. (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Triangular Fibrocartilage Complex (TFCC) rehabilitation - Four stages treatment over three months This case series reported the effectiveness of a four stage approach to the rehabilitation of TFCC injuries. Ten patients were included in the present study. The four stage approach has been previously described in this other synopsis. Effectiveness of treatment was assessed through pain during motion (0-10 Numerical Rating Scale - NRS), Pus Off Test, and hand function (Patient Rated Wrist Hand Evaluation - PRWHE). On average it took three months for participants to complete the four stages. The results showed that 100% of participants reported a clinically relevant improvement in pain (at least 2 points out of 10 on NRS). In addition, 70% of participants reported a clinically important change on the Pus Off Test (at least 4.4 kg improvement), and PRWHE (at least 14 points change). One of the limitations of this study is that it did not present with a control group undergoing some other form of treatment or standard care. It is therefore possible that the improvements noted are due to the natural history of the condition rather than the four stage approach treatment. Clinical Take Home Message: Based on what we know today, a graded exercise program may be effective in people with symptomatic TFCC injuries. However, a randomised controlled trial will be required to determine whether the changes noted in this study are simply due to natural history or a specific component of this four stages approach. In addition, progressing exercises based on pain may be appropriate in some clients but not in others. Thus, there is evidence showing that a large proportion of pain intensity is mediated by psychological factors such as pain catastrophising. Considering also that other factors such as kinesiophobia mediate disability in people with upper limb musculoskeletal conditions, a more holistic approach including pain neurophysiology education in addition to exercise may provide better outcomes. URL: https://doi.org/10.1177/17589983211033313 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Triangular fibrocartilage complex (TFCC) injuries are associated with distal radioulnar joint (DRUJ) instability and impaired wrist proprioception. Sensorimotor training of extensor carpi ulnaris (ECU) and pronator quadratus (PQ) can enhance DRUJ stability. With limited evidence on effectiveness of TFCC sensorimotor rehabilitation, this study aimed to evaluate the effects and feasibility of a novel wrist sensorimotor rehabilitation program (WSRP) for TFCC injuries. Methods Patients diagnosed with TFCC injuries were recruited from May 2018 to January 2020 at an outpatient hand clinic in Singapore General Hospital. There are four stages in WSRP: (1) pain control, (2) muscle re-education and joint awareness, (3) neuromuscular rehabilitation, and (4) movement normalization and function. WSRP also incorporated dart throwing motion and proprioceptive neuromuscular facilitation. Outcome measures included grip strength measured with grip dynamometer, numerical pain rating scale, joint position sense (JPS) measurement, weight bearing measured with the "push-off" test, and wrist function reported on the Patient Rated Wrist Hand Evaluation. Results Ten patients completed the WSRP. Mean changes were compared with minimal clinically important differences (MCID) for outcomes. All patients achieved MCID on pain, 70% of patients achieved MCID on grip strength, weight bearing and wrist function. Paired t-tests and Cohen?s D for outcome measures were calculated. There were large effect sizes of 2.47, 1.35, and 2.81 for function, grip strength and pain respectively, and moderate effect sizes of 0.72 and 0.39 for axial loading and JPS respectively. Discussion WSRP presents a potential treatment approach in TFCC rehabilitation. There is a need for future prospective clinical trials with control groups.

Isolated entrapment of the brachialis branch of the musculocutaneous nerve: A case report. Ryhänen, J., E. Waris and S. Kujala (2021) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic This is the answer to last week Sherlock Handy. The client was 55 years old presenting with right side pain at the lateral antecubital area of the elbow/forearm. They reported developing elbow flexion weakness over the course of 7 months. Subjectively they also presented with cramps in the anterior portion of their arm. Pain was reproduced with resisted elbow flexion and forearm pronation, or full active elbow extension. There was atrophy of the brachialis, however, biceps function was retained (see picture). Neurological examination identified no central nervous system pathology. Age-related changes were identified on cervical MRI. Nerve conduction studies identified no sensory impairments or motor impairments at the level of the brachial plexus or main branch of the musculocutaneous nerve. However, a significant impairment at the level of the brachialis branch of the musculocutaneous nerve was identified. During surgical exploration, entrapment of the brachialis branch was identified at the level of the coracobrachialis fascia (nerve entrance - see picture), and this was released. Follow up at one year showed completed resolution of pain, however, atrophy had not resolved and weakness in elbow flexion was still present. 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, entrapment of the musculocutaneous branch to the brachialis muscle is a rare presentation. The differential diagnosis for this presentation included cervical entrapment radiculopathy, a peripheral entrapment neuropathy, a large brachialis tear, or central nervous system pathology. To screen for cervical radiculopathy (exclude it), we can utilise upper limb nerve tension tests and the arm squeeze test. To make a diagnosis of cervical radiculopathy, the presence of a positive Spurling's test, arm squeeze test, single-level myotomes weakness, and reduced reflexes may increase the likelihood of cervical radiculopathy. With a cervical entrapment radiculopathy, we would expect weakness of most muscles innervated by the cervical level affected. In contrast, a peripheral entrapment neuropathy (like in this case), is likely to affect only the muscles distal to the affected branch. Central nervous system pathology may be excluded in absence of signs of central nervous system involvement (e.g. multilevel weakness), however, a referral is warranted if we suspect the presence of a central nervous system pathology. URL: https://doi.org/10.1177/17531934211008795 Available through EBSCO Health Databases for PNZ members. 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