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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 55 years old presenting with right side pain on the lateral antecubital area of elbow/forearm and elbow flexion weakness, which developed over the course of 7 months. They reported cramps in the anterior portion of their arm. Pain was reproduced with elbow flexion in forearm pronation, or in full elbow extension. There was atrophy of the brachialis but biceps function was retained (see picture). Neurological examination identified no central nervous system pathology. Age related changes where identified on cervical MRI. What was it?

Effects of a progressive resistance exercise program in patients with hand osteoarthritis: A randomized, controlled trial with a blinded assessor. Nery, M., et al. (2021) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Resistance training - application in hand OA This is a randomised controlled trial assessing the effectiveness of resistance training exercises for hand OA. A total of sixty participants were included in this study. Participants were included if they presented with the American College of Rheumatology classification criteria, and if their pain was between 3 and 8 points out of 10 on a Numerical Rating Scale at the interphalangeal joints of the hand. Resistance training exercises were compared to control groups undergoing no exercise. Efficacy of intervention was assessed through improvements in pain, function (i.e., AUSCAN), grip and pinch strength. Participants in the training and control group received one educational session on hand OA at baseline. Participants in the control group received no additional interventions. In contrast, participants in the training group also performed resistance exercises for gross grip and intrinsic muscles of the hand, twice a week for twelve weeks. Exercises were performed in groups of up to 5 participants. During each training session, participants performed three sets of 10 repetitions for each exercise in both hands. Unfortunately, the training intensity is unknown as participants were working against elastic resistance. The results showed that there was no statistically significant difference between the exercise and control group on pain, grip or pinch strength. These variables were unchanged from baseline in both groups. Function appeared to improve to a statistically significant level in the resistance training group, however the clinical relevance is unclear because of the scoring method utilised. 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 improve pain or hand strength in clients with interphalangeal OA. At the same time resistance training does not appear to worsen symptoms compared to no exercise in people with symptomatic hand OA. Resistance exercises may improve hand function, however, the extent of these improvements is unclear. These results are consistent with a systematic review and meta analysis covered in a previous synopsis. Considering these results, a multimodal approach to the treatment of hand OA may be more effective to reduce pain (see previous synopsis on the topic). It is also important to remember that clients' expectations on the type of treatment provided will affect treatment results. The good news is that since resistance training does not worsen hand pain, we may be even more inclined to suggest our clients with symptomatic hand OA to follow the World Health Organisation guidelines for physical activity. Thus, people with symptomatic hand OA are at greater risk of cardiovascular disease and physical activity may extend their life span and health span. URL: https://doi.org/10.1177/02692155211030622 Available through EBSCO Health Databases for PNZ members. Abstract Objective To assess the effectiveness of a progressive resistance strength program on pain, function and strength in hand osteoarthritis patients. Design Randomized controlled trial.Settings:Outpatients, University Hospital.Subjects:Sixty hand osteoarthritis patients were randomly allocated to exercise group (n?=?30) or control group (n?=?30).Intervention:The exercise group performed a progressive resistance strength program for hand muscles over 12?weeks. Both groups had a single education session. Main measures The primary outcome was pain intensity (numeric pain scale). The secondary outcomes were the AUSCAN Hand Osteoarthritis Index, Cochin Hand Functional Scale for function and grip and pinch strength. A blinded evaluator performed the evaluations at baseline, 6 and 12 weeks. Results The mean age were 68.9 (8.8) and 64.7 (8.9) for control and exercise groups, respectively. No significant differences between-group was observed for pain after 12 weeks (mean difference between groups was 1.30 (0.02 to 2.62) for dominant hand and 1.33 (0.01 to 2.65) for non-dominant hand at T12, with P=0.085 and 0.295, respectively). Regarding secondary outcomes, statistically significant differences between groups were found in exercise group: AUSCAN index total score (P=0.005), pain (P=0.006), function (P=0.047), and Cochin scale (P=0.042) with the following mean difference between groups: 9.9 (4.07 to 15.73), 3.26 (1.06 to 5.46), 5.03 (1.20 to 8.86), and 6.27 (0.18 to 12.36), respectively. Conclusion No difference was observed for pain (numerical pain scale) after the progressive resistance exercise program performed, however in exercise group, an improvement was observed on secondary outcomes such as pain during activities and function for patients with hand osteoarthritis.

Risk of infection in thumb carpometacarpal surgery after corticosteroid injection. Qin, M. M., C. D. Qin, D. J. Johnson and D. M. Kalainov (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: 1st cmcj OA injections - Are they worth it? This is a retrospective study assessing post-surgical complications in clients who underwent cortisone injection (3 months prior to surgery) vs those who did not (for a least 6 months prior to surgery), before surgery for symptomatic 1st cmcj OA. Different surgical procedures were provided across the sample (e.g. suspension arthroplasty). A total of 3,733 participants, took part in this study. Of these, 3,047 (82%) did not receive a cortisone injection in the 1st cmcj for at least 6 months prior to surgery, and 686 (18%) received at least one 1st cmcj cortisone injection three months prior to surgery. The outcome assessed was the number of infections at the surgical site or the presence of additional surgery for wound complications within 90 days from surgery. The results showed that there was no difference between groups in terms of number of wound complications within 90 days from surgery. However, the number of participants that required surgery for those complications was statistically significant higher in the group who received a 1st cmcj cortisone injection within 3 months prior to surgery (n = 15; 2.2% of sample), compared to those who did not receive one in the 6 month prior (n = 32; 1.1% of the sample). We need to keep in mind that this is a retrospective study and the association between recent cortisone injections and surgery for wound complications may be mediated by a third variable which was not measured. This is therefore a limitation of the study. 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, cortisone injections for 1st cmcj OA provided 3 months prior to surgery may increase the probability of requiring a second surgery for wound complications. In particular, it appears that 1 person in 50 will require a second surgery surgery for wound complication if they received a cortisone injections in the 3 months prior surgery. In contrast, it appears that 1 person in 100 will require a second surgery surgery for wound complication if they did not have a cortisone injections for at least 6 months prior to surgery. The findings from this study are consistent with previous research in 1st cmcj OA and research showing an increase risk of post surgical infections in other joint (e.g. hip). Considering that the effectiveness of cortisone injections for 1st cmcj OA is not superior to placebo, their use may be questionable. Our clients should be provided with this information and the risks vs benefits of having an injection just prior to surgery may be discussed. This may provide them with a chance to make an informed decision about the most suitable therapeutic option for their needs. URL: https://doi.org/10.1016/j.jhsa.2021.04.010 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection into the thumb carpometacarpal (CMC) joint for the treatment of arthritis within the 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection in comparison with patients who did not receive an injection within 6 months or who received an injection between 3 and 6 months before surgery. Methods We identified 5,046 patients in the Humana claims database who underwent surgery for CMC joint arthritis. The patients were stratified into 3 groups: (1) no thumb injection within 6 months of CMC joint surgery, (2) thumb injection between 3 and 6 months before CMC joint surgery, and (3) thumb injection within 3 months before CMC joint surgery. The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Multivariable logistic regression was performed to assess the associations between the timing of injection and wound complication/infection and repeat surgery for wound complication/infection. Results The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups. However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had a 2.2 times greater likelihood of repeat surgery for a wound complication/infection compared with patients who did not have an injection within 6 months before surgery. Conclusions Patients who receive an intra-articular corticosteroid injection within the 3 months before surgery for CMC joint arthritis may be at increased risk of repeat surgery to treat a wound complication/infection in the 90-day postoperative period.

A proximal interphalangeal joint custom-made orthosis in trigger finger: Functional outcome. Pataradool, K. and C. Lertmahandpueti (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Trigger finger conservative treatment - pipj splint This is a non experimental, before-after study assessing the effectiveness of a proximal interphalangeal joint (pipj) splinting regime for A1-pulley trigger finger (TF). Participants were included if they presented with a Green's grade 1 to 2 (I - intermittent, II - actively correctable, III - passively correctable, IV fixed flexion deformity). Participants were provided with a splint to block pipj flexion for six weeks. Participants were excluded if they presented with trigger thumb or if they received prior treatment for trigger finger. Effectiveness of splinting regime was assessed through Green's classification grade 1 to 4 for trigger severity, pain (VAS), and function (QuickDASH). Compliance with splinting was also recorded. A total of 30 participants were included in the prent study. The results showed that the grading of trigger finger reduced by one point, after six weeks of treatment. In addition, pain (3.4 points out of 10) and function (29 points out of 100) reduced to a statistically and clinically significant level after six weeks. There was also a correlation between compliance an improvements in function, with greater compliance being associated with lower disability at the end of the trial (see scatter plot). The results from this study, need to be considered in light of a few limitations. In particular, there was no control group to account for natural history or other non specific effect of treatment. 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, splinting of the pipj joint may lead to significant improvements in pain, function, and triggering grade in trigger finger. In addition, it appears that greater compliance with splinting is associated with larger improvements on QuickDASH, suggesting that this may be a relevant factor in treatment's success. It is important to keep in mind that greater grades off triggering are associated with greater likelihood of developing fixed pipj flexion contractures. Clients with higher triggering grade may therefore require closer supervision. If clients are encouraged to wear splint full time, it may be important to perform passive AROM, to avoid developing pipj stiffness. It is also important to remember that comorbidities such as diabetes have been shown to lead to worst outcomes compared following trigger finger surgery. If you'd like to read more about splinting for trigger finger, please refer to this synopsis, which compared mcpj to pipj splinting. URL: https://doi.org/10.1177/17589983211018717 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Trigger finger is a common and functionally limiting disorder. Finger immobilization using an orthotic device is one of the conservative treatment options for treating this condition. The most common orthosis previously described for trigger finger is metacarpophalangeal joint immobilization. There are limited studies describing the effectiveness of proximal interphalangeal joint orthosis for treatment of trigger finger. Methods This study was a single group pretest-posttest design. Adult patients with single digit idiopathic trigger finger were recruited and asked to wear a full-time orthoses for 6?weeks. The pre- and post-outcome measures included Quick-DASH score, the Stages of Stenosing Tenosynovitis (SST), the Visual Analogue Scale (VAS) for pain, the number of triggering events in ten active fists, and participant satisfaction with symptom improvement. Orthotic devices were made with thermoplastic material fabricated with adjustable Velcro tape at dorsal side. All participants were given written handouts on this disease, orthotic care and gliding exercises. Paired t-tests were used to determine changes in outcome measures before and after wearing the orthosis. Results There were 30 participants included in this study. Evaluation after the use of PIP joint orthosis at 6?weeks revealed that there were statistically significant improvements in Quick-DASH score from enrolment (mean difference ?29.0 (95%CI ?34.5 to ?23.4); p?<?0.001), SST (mean difference ?1.4 (95%CI ?1.8 to ?1.0); p?<?0.001) and VAS (mean difference ?3.4 (95%CI ?4.3 to ?2.5); p?<?0.001). There were no serious adverse events and patient satisfaction with the treatment was high. Conclusions Despite our small study size, the use of proximal interphalangeal joint orthosis for 6?weeks resulted in statistically significant improvements in function, pain and triggering, and also high rates of acceptance in patients with isolated idiopathic trigger finger.

Relative motion flexion splinting for the rehabilitation of flexor tendon repairs: A systematic review. Newington, L., R. Ross and J. W. Howell (2021) Level of Evidence: 3a Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Relative motion flexion splint - Flexor tendon repairs This is a systematic review reporting on the usefulness of relative motion flexion (RMF) splints following flexor tendon repair. Three non experimental studies were included in the systematic review, for a total of 19 participants and four cadavers. All the studies included were assessed through the Joanna Briggs Institute (JBI) critical appraisal tool for case series criteria. RMF splints for the mcpj (affected finger was placed in greater flexion compared to the unaffected) were trialled in combination with wrist splints fro tendon flexors zone I, II, and III. Use of the affected hand for light tasks was suggested for the first three weeks post surgery. After three weeks participants could lift light weights with both hands and return to jogging. Movement and lifting restriction were removed after 8-10 weeks from surgery. Across all studies there was a 5% rupture rate. Clinical Take Home Message: Based on what we know today, RMF splints in combination with wrist splint are not main stream treatment for flexor tendon repairs. Currently there is not enough high quality research to allow the implementation of this splinting regime according to an evidence based approach. The risk of implementing RMF splinting at this point is that it may lead to a higher number of tendon ruptures compared to more traditional splinting regimes. Thus, tendon ruptures have not been formally assessed in a larger randomised controlled trial. In contrast, there is evidence suggesting that RME splints can be utilised in clinical practice for extensors zone V and VI repairs. URL: https://doi.org/10.1177/17589983211017584 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Relative motion splinting has been used successfully in the treatment of extensor tendon repairs and has recently been applied in flexor tendon rehabilitation. The purpose of this systematic review was to identify articles reporting use of relative motion flexion (RMF) splinting following flexor tendon repair and to examine indications for use and clinical outcomes. Methods Seven medical databases, four trials registries and three grey literature sources were systematically searched and screened against pre-specified eligibility criteria. Screening, data extraction and quality appraisal were independently performed by two reviewers. Results A total of 12 studies were identified, of which three met the review eligibility criteria: one retrospective case series; one cadaveric proof of concept study; and one ongoing prospective case series. The type of splint (including metacarpophalangeal joint position and available movement), exercise programme, and zone of tendon injury varied between studies. Both case series presented acceptable range of movement and grip strength outcomes. The prospective series reported one tendon rupture and two tenolysis procedures; the retrospective series reported no tendon ruptures or secondary surgeries. Discussion We found limited evidence supporting the use of RMF splinting in the rehabilitation of zones I-III flexor tendon repairs. Further prospective research with larger patient cohorts is required to assess the clinical outcomes, patient reported outcomes and safety of RMF splinting in comparison to other regimes. Application of the relative motion principles to flexor tendon splinting varied across the included studies, and we suggest an operational definition of relative motion in this context.

Blood flow restriction training for the shoulder: A case for proximal benefit. Lambert, B., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Resistance training - Blood flow restriction training This is a randomised trial without blinding assessing the effectiveness of resistance training with or without blood flow restriction (BFR) training on upper limb lean mass and shoulder strength in healthy participants. Participants (N = 32) were young (26 years old) inactive subjects (less than once a week upper limb strength training). Participants were excluded if they had a history of upper limb pathology, clotting disorders, or obese. Upper limb lean mass (muscle mass) was measured through dual-energy x-ray absorptiometry (DEXA). Seated and prone shoulder strength in internal rotation and external rotation was measured. In addition, strength of shoulder forward flexion (in 90° of shoulder abduction), and forward flexion were measured. A microFET2 device was utilised for the strength measurements. Treatment allocation was randomised, however, assessors were not blinded. Participants were provided with either low intensity BFR training (n = 16) or low intensity training (n = 16). Participants trained twice a week for eight weeks in both groups. During each session participants performed shoulder external and internal rotation with a pulley in standing, shoulder external rotation in side lying with a dumbbell, and shoulder flexion in standing with a dumbbell. At each session, 3 sets of 30, 15, 15 repetitions and one final set of repetitions to fatigue were completed for each exercise. An interset rest of 30 seconds was provided. A two minutes rest was provided in between exercises. Participants started to exercise at an intensity of 20% of 1-repetition maximum identified at baseline. The training weight was increase by 0.5 kg each week if the participants could completed at least 15 repetitions during the last set of the exercise on two consecutive training sessions. While exercising, the BFR group wore a pressure cuff (11cm wide) inflated at 50% of arterial occlusion around their upper arm. The pressure cuff was worn on one upper limb only. The cuff was inflated during the intersets rest and deflated in between exercises. The results showed that the BFR group upper limb lean mass improved to a significant and possibly clinically relevant level (increase of 200g with blood flow restriction, equal to a 2-3 times increase from baseline). Shoulder strength was significantly higher in the blood flow restriction group for internal rotation only (one out of 6 measurements). Both resistance training interventions increased strength at the end of training. 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, low intensity exercise with or without blood flow restriction can lead to improvement in strength of the upper limb in inactive subjects. Blood flow restriction training appears to lead to higher levels of lean mass, however, there seems to be no difference between the two exercise interventions in terms of strength. This synopsis is a nice addition to a previous synopsis on blood flow restriction training to improve grip strength and upper limb strength. If you are interested in how blood flow restriction training has been implemented in a feasibility study for hand osteoarthritis, have a look at my PhD thesis below (page 135). Open Access URL: Full text here Abstract Background Although blood flow restriction (BFR) is becoming increasingly popular in physical therapy and athletic training settings, little is known about the effects of BFR combined with low-intensity exercise (LIX) on muscles proximal to the site of occlusion. Hypothesis/Purpose Determine whether LIX combined with BFR applied distally to the shoulder on the brachial region of the arm (BFR-LIX) promotes greater increases in shoulder lean mass, rotator cuff strength, endurance, and acute increases in shoulder muscle activation compared with LIX alone. We hypothesized that BFR-LIX would elicit greater increases in rotator cuff strength, endurance, and muscle mass. We also hypothesized that the application of BFR would increase EMG amplitude in the shoulder muscles during acute exercise. Study Design Controlled laboratory study. Methods 32 healthy adults were randomized into 2 groups (BFR group, 13 men, 3 women; No-BFR group, 10 men, 6 women) who performed 8 weeks of shoulder LIX (2 times per week; 4 sets [30/15/15/fatigue]; 20% maximum) using common rotator cuff exercises (cable external rotation [ER], cable internal rotation [IR], dumbbell scaption, and side-lying dumbbell ER). The BFR group also trained with an automated tourniquet placed at the proximal arm (50% occlusion). Regional lean mass (dual-energy x-ray absorptiometry), isometric strength, and muscular endurance (repetitions to fatigue [RTF]; 20% maximum; with and without 50% occlusion) were measured before and after training. Electromyographic amplitude (EMGa) was recorded from target shoulder muscles during endurance testing. A mixed-model analysis of covariance (covaried on baseline measures) was used to detect within-group and between-group differences in primary outcome measures (α = .05). Results The BFR group had greater increases in lean mass in the arm (mean ± 95% CI: BFR, 175 ± 54 g; No BFR, –17 ± 77 g; P < .01) and shoulder (mean ± 95% CI: BFR, 278 ± 90 g; No BFR, 96 ± 61 g; P < .01), isometric IR strength (mean ± 95% CI: BFR, 2.9 ± 1.3 kg; No BFR, 0.1 ± 1.3 kg; P < .01), single-set RTF volume (repetitions × resistance) for IR (~1.7- to 2.1-fold higher; P < .01), and weekly training volume (weeks 4, 6-8, ~5%-22%; P < .05). Acute occlusion (independent of group or timepoint) yielded increases in EMGa during RTF (~10%-20%; P < .05). Conclusion Combined BFR-LIX may yield greater increases in shoulder and arm lean mass, strength, and muscular endurance compared with fatiguing LIX alone during rotator cuff exercises. These findings may be due, in part, to a greater activation of shoulder muscles while using BFR.Clinical Relevance:The present study demonstrates that BFR-LIX may be a suitable candidate for augmenting preventive training or rehabilitation outcomes for the shoulder.

Benefits and harms of exercise therapy in people with multimorbidity: A systematic review and meta-analysis of randomised controlled trials.

The “ulnar fovea sign” for defining ulnar wrist pain: An analysis of sensitivity and specificity. Tay, S. C., K. Tomita and R. A. Berger (2007) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Fovea sign - Sensitivity and specificity This is a prospective study on the specificity and sensitivity of of the "fovea sign" for disruption of the ulnotriquetral ligament, or foveal disruption of the distal radio-ulnar joint (DRUJ) ligaments. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. A total of 272 participants were included, with 55% of them presenting with ulnar sided pain. The "fovea sign" test was completed in all participants by pressing on the soft tissue between ulnar styloid and fexor carpi ulnaris tendon (see picture). A test was defined as positive if it reproduced the client's pain. Arthroscopy was completed in all participants. The results showed that the "fovea sign" test was 95% sensitive and 87% specific in making in diagnosing ulnotriquetral or foveal disruption. 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 "fovea sign" is useful in screening for, or making a diagnosis of, ulnotriquetral ligament/foveal disruption. Despite it being a useful diagnostic test, it can lead (like all tests) to false positive caused by other pathologies such as scapholunate ligament disruption (see table below from the same paper). This may be specially true for acute wrist injuries. Read these other synopsis to sharpen your diagnostics skills for wrist ligament injuries or fractures. URL: https://doi.org/10.1016/j.jhsa.2007.01.022 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose Eliciting tenderness in the region of the ulnar fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based on anecdotal observations, a hypothesis was developed stating that ulnar fovea tenderness (positive “ulnar fovea sign”) is sensitive and specific in detecting two ulnar-sided wrist conditions: foveal disruption of the distal radioulnar ligaments and ulnotriquetral (UT) ligament injuries. Methods The clinical records of 272 consecutive patients with wrist arthroscopy performed by the senior author from 1998 through to 2005 were reviewed. Relevant clinical and surgical data were abstracted. The ulnar fovea sign test is executed by pressing the examiner’s thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive ulnar fovea sign is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side. Results There were a total of 90 foveal disruptions and 68 UT ligament injuries diagnosed during wrist arthroscopy. The ulnar fovea sign was positive in 156 patients. The sensitivity of the fovea sign in detecting foveal disruptions and/or UT ligament injuries was 95.2%. Its specificity was 86.5%. Conclusions The hypothesis stating that the ulnar fovea sign is a useful clinical maneuver to detect foveal disruptions and UT ligament tears is supported. The conditions represent 2 common sources of ulnar-sided wrist pain. The differentiation between the 2 conditions may be made clinically, where UT ligament tears are typically associated with a stable distal radioulnar joint and foveal disruptions are typically associated with an unstable distal radioulnar joint.

A 4-year study of the use of the short metacarpal cast in the management of metacarpal shaft fractures. Street, J., L. Nessa, A. Logan and R. W. Trickett (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Metacarpal shaft fracture - conservative vs surgical This is a retrospective study assessing the outcomes of metacarpal shaft fractures treated with a hand based cast. A total of 117 participants were included in the present study. Participants were included if they presented with acceptable alignment on x-ray (less than 10° of dorsal apex angulation), or if closed reduction was successful (for more information on the fracture type and outcomes see comments below). All participants were casted with a hand based plaster of paris (see picture). The outcomes recorded included the number of participants requiring surgery due to loos of fracture reduction, and the average deformity at final radiographic assessment. The results showed that participants were casted for 3-4 weeks. At one week 50% of participants required a new cast due to swelling reduction and loosening. A total of 15 participants presented with complications, which required surgery. On average the deformity on final radiograph was 5-6° of dorsal apex angulation. 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, metacarpal shaft fractures may be treated with a hand based orthosis only. This is an important article as it provides some evidence that the immobilisation does not need to involve the wrist like it has bee previously suggested. For additional information on 5th metacarpal fractures conservative management, refer to this review and this randomised controlled trial. URL: https://doi.org/10.1177/17531934211024579 Available through EBSCO Health Databases for PNZ members. Abstract We report on our experience of using a short, moulded metacarpal cast over a 4-year period in the non-surgical management of metacarpal shaft fractures. Between 6 April 2015 and 6 April 2019, 117 patients were treated using this method. The majority were male, and the mean age was 24.6 years. The most common mechanism of injury was a punch injury (73 patients, 62%). Fifteen patients (13%) were treated for multiple metacarpal fractures. Immediately after cast removal, 68% had a full range of finger movement and 68% were pain free. Few required formal hand therapy. Fifteen patients experienced minor complications, primarily soft tissue irritation from the cast and non-limiting extensor lag. The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction.

Idiopathic avascular necrosis of trapezoid in adolescence: 3-year follow-up Hong, S., Roh, Y., Gong, H., & Baek, G. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Trapezoid avascular necrosis – Idiopatic This is the answer for last week Sherlock Handy. The patient was a 13 years old male who had been experiencing pain at the base of the second metacarpal for the past 3 months. They had no history of trauma or signs of symptoms of infection. Objectively, they presented with pain on wrist range of movement assessment, but no objective signs of carpal or carpalmetacarpal instability. Grip and pinch strength were reduce by 30% and 40% respectively. X-ray investigations revealed sclerotic changes of the trapezoid, blood tests excluded the presence of an infection or rheumatic condition, and MRI investigations confirmed the presence of an AVN of the trapezoid (see picture). A non-surgical approach was initiated. The affected hand and wrist were immobilised for 6 weeks with a short-arm cast, followed by 4 weeks of a removable splint. NSAIDs were provided for pain control. Symptoms persisted at 6 months, where MRI investigations revealed a signal improvement in the trapezoid. At 12 months, pain had reduced with a complete symptoms resolution at 36 months. Clinical improvements were associated with signal improvements on MRI. 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, avascular necrosis of the trapezoid may be considered as a rare differential diagnosis in patients who report pain at the base of the second metacarpal with an insidious onset. Differential diagnoses include infections and rheumatic conditions. Hand therapist may utilise x-ray and ultrasound to gather information to help in the differential diagnosis. If you are interested in avascular necrosis of other bones in the hand, look at this synopsis. URL: https://doi.org/10.1016/j.jhsa.2018.12.002 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Avascular necrosis (AVN) is relatively uncommon in the carpal bones, although it most frequently involves the lunate and scaphoid. The trapezoid has abundant vascular channels from a rich network of dorsal and palmar vessels, and only a few cases of AVN have been reported in adults who sustained a traumatic insult. We present a rare case of idiopathic AVN of the trapezoid in an adolescent presenting with refractory pain at the second metacarpal base. Over a period of 36 months, follow-up symptom evaluations and serial magnetic resonance images showed prominent gradual improvement, consistent with spontaneous resolution.

The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri Zunke, P., Auffarth, A., Hitzl, W., & Moursy, M. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Thoracic spine manual therapy This is a randomised placebo controlled trial assessing the acute effect of one session of thoracic mobilisations on pain-free grip strength and sympathetic nervous system activation in participants with lateral epicondilalgia (LE). Participants (N = 30) were diagnosed with LE if they presented with pain on either gripping, resisted contraction of the wrist extensors, or pain at the lateral epicondyle during palpation. If the clinical picture suggested the presence of any other pathology (e.g. cervical radiculopathy, posterolateral instability of the elbow), participants were excluded. Participants' pain-free grip strength was assessed immediately before and after the intervention on the pathological and on the healthy side. Sympathetic nervous system activation was measured through finger skin conductance and skin temperature tests. Greater skin conductance (due to sweating) and lower skin temperature (due to vasoconstriction) suggest a greater activation of the sympathetic nervous system. Adverse events were recorded. Participants were randomised to either a thoracic mobilisation or sham ultrasound. For the experimental group (n = 15), a grade III thoracic mobilisation of T5 was delivered for 2 minutes and was directed in a postero-anterior direction with the participant in prone. The placebo group (n= 15) received 2 minutes of sham ultrasound at the T5 level in prone. The results showed that the thoracic mobilisation group improved in pain-free grip strength on the affected side by 25% (95%CI: 10%-40% - 4.4 kg improvement). This improvement was statistically significant and borderline clinically relevant (an absolute improvement of 5 kg in grip strength and 20% improvement from baseline in grip strength would be defined clinically significant). In the placebo group, no statistically significant improvement in pain-free grip strength of the affected side was detected. There were no differences between the two groups in grip strength. Sympathetic nervous system activity was statistically significantly greater after the thoracic mobilisation compared to the placebo intervention. No adverse events were reported. 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, thoracic mobilisations in patients with lateral epicondilalgia may provide acute pain-free grip strength improvements. However, there were quite a few limitations in this study and there is limited previous evidence to support these findings. It is possible that thoracic mobilisations, have, if any, a non-specific effect on pain through a neurophysiological effect. Currently, the mainstream interventions for tennis elbow has been suggested to be reduced loading in the acute phase (reactive tendinopathy phase) followed by gradual loading. Cortisone injections are advised against, PRP injections do not appear to be more effective than saline, and MWMs do not appear to be more effective than placebo. Open Access URL: https://doi.org/10.1186/s12891-020-3175-y Abstract Background: The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short-term effect on pain and sympathetic activity. Methods: Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy. Results: Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by - 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group. Conclusion: A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia. 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 13 years old male who had been experiencing pain at the base of the second metacarpal for the past 3 months. They had no history of trauma or signs of symptoms of infection. Objectively, they presented with pain on wrist range of movement assessment, but no objective signs of carpal or carpalmetacarpal instability. Grip and pinch strength were reduce by 30% and 40% respectively. X-ray investigations revealed sclerotic changes of the trapezoid, blood tests excluded the presence of an infection or rheumatic condition, and MRI investigations showed changes at the trapezoid (see picture). What is it?