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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?

Upper-extremity venous thromboembolism following operative treatment of distal radius fractures: An uncommon but dangerous complication. Calotta, N. A., J. T. Shores and D. Coon (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Distal radius fracture – Upper limb thromboembolism This is a retrospective study assessing the prevalence of venous thromboembolism and its risk factors in a group of patients undergoing open reduction and internal fixation (ORIF) for distal radius fracture. A total of 24,494 participants were included in the study. Potential participants were excluded if they presented with a preexisting thrombophilic condition (e.g. thrombophilia). Participants' average age ranged between 18 to 91. Thromboembolism was identified up to 60 days after surgery. The statistical analyses took into account demographic information to reduce the contribution of confounding factors to the overall results. The results showed that 0.3% (n = 79) of participants developed thromboembolism. The risk factors were heart failure (greatest risk), the use of estrogen, and a score greater than 3 on the Charlson Comorbidity Index (CCI), which includes age and other comorbidities (e.g. diabetes) for its calculation. 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 risk of thromboembolism in the general population post distal radius ORIF is very low. Thus, this will occur in 3 out of a 1,000 clients. However, if the client is above 70 (this will automatically give a CCI score of 3), if they are female (more likely to take estrogen), and if they present with cardiovascular disease (heart failure in particular), they are at greater risk of developing a thromboembolism within 60 days of distal radius ORIF. It is therefore important to keep this differential diagnosis in mind in this subgroup of clients. If you are interested in other potential complications following distal radius fracture have a look at these synopses on the effect of smoking on the risk of infection or other complications. If your clients are smoking, you may ask them if they would like some help to quit smoking. URL: https://doi.org/10.1016/j.jhsa.2021.03.011 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE. Methods: We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery. Results: The study included 24,494 patients. The mean age was 50.7 years (range, 18–91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE. Conclusions: Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE.

Return to work following distal triceps repair. Agarwalla, A., Gowd, A. K., Jan, K., Liu, J. N., Garcia, G. H., Naami, E., . . . Verma, N. N. (2020) Level of Evidence: 4 Follow recommendation: 👍 Type of study: Prognostic Topic: Distal triceps repair - Return to work This is a retrospective study assessing return to work following a distal triceps repair surgery. Distal triceps ruptures have an incident of 1% in the general population. A repair is usually undertaken when the tear is greater than 50% of the tendon. A total of 81 participants with distal triceps repair were included. Patients' average age was 46 (SD: 11 years ) years old. Return to work outcomes timeframes (in months) were recorded according to work intensity. Work intensity was defined based on the maximum lifting involved. Work intensity was classified as sedentary (max 5kg), light (max 10kg), moderate (max 25kg), and heavy (max 50kg). Pain was assessed through the visual analogue scale (VAS), and function through the quickDASH. All patients followed the same post surgical instructions. These included a limitation to 20deg of elbow flexion (hinge brace) for the fist two weeks followed by a progression to 90deg by weeks six. At six weeks there were no restrictions in active range of movement. At eight weeks clients could start performing isometric triceps resisted exercises. The results showed that all clients in sedentary and light occupations returned to work within one month and three months respectively. Most (80%) of the patients in moderate and heavy occupations returned to work within six months and nine months respectively. The average return to work time reported across all work intensities was 2 months. Clinical Take Home Message: Based on what we know today, we may provide clients with an estimated return to work timeframe of 1 to 9 months, following distal triceps repair, depending on their work intensity. A simple way to remember it is associating the weight they need to lift with the number of weeks. For example if their maximum lifting required is 5 kg, then we expect 5 weeks, 10 kg requires 10 weeks, 25kg requires 25 weeks, and more than that will require up to one year. The average return to work for people undergoing distal triceps repair (2 months) appears to be shorter than the time required for distal biceps repair (3-4 months). This may be due to the fact that biceps is heavily involved in lifting activities compared to triceps. Unlike distal biceps repair, no major surgical complication were reported URL: https://www.jshoulderelbow.org/article/S1058-2746(19)30836-5/pdf You can ask the authors for the full through ResearchGate. Available through EBSCO Health Databases if you have access (PNZ) Abstract Purpose: Evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR). Methods: Consecutive patients undergoing DTR from 2009-2017 at our institution were retrospectively reviewed at a minimum of one year postoperatively. Patients completed a standardized and validated work questionnaire, a visual analog scale for pain (VAS-Pain), Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder, and Hand Score (quick-DASH) and a satisfaction survey. Results: Out of 113 eligible patients who had a DTR, eighty-one patients (71.7%) were contacted. Of which, 74 patients (91.4%) were employed within three years prior to surgery (mean age: 46.0 ± 10.7 years; mean follow-up: 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. 66 patients (89.2%) patients were able to return to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9% by 0.3 ± 0.5 months, 1.8 ± 1.9 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months postoperatively. Fifteen (75%) workers compensation (WC) patients returned to work by 6.5 ± 4.3 months postoperatively, while 100% of non-WC patients returned to work by 1.1 ± 1.6 months (p<0.001). Seventy-one patients (95.9%) were at least somewhat satisfied with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would still have the operation again if presented the opportunity. A single patient (1.4%) required revision distal triceps repair. Conclusions: Approximately 93% of patients that undergo DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher intensity occupations had an equivalent rate of RTW, but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

Mental and social health are inseparable from physical health. Ring, D. (2021) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Psychosocial factors – Upper limb diagnosis and treatment This is an editorial from the Journal of Bone and Joint Surgery on the contribution of psychosocial factors on musculoskeletal conditions. The article highlights the impact of mental and social health factors on the diagnosis and treatment of our clients. In particular, the author reminds us that depression, catastrophising, and negative emotions can increase pain to a disproportionate level in relation to the physical injury. In addition, ethnicity as well as financial aspects of our clients may affect the care that they receive. For example, if people are in a financially precarious position, rest or surgery, may not be a viable option as these require taking time off work. We should therefore pay attention to their social situations as this can be an important factor in treatment decision. In a similar way, ethnicity, sex or other factors may lead to inequitable distribution of resources. 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: Information from this article may make us reflect on how we approach assessment and treatment of our clients. It is important to consider the financial and Whānau (family) needs of our clients and adapt the treatment to their situation. At times, an evidence based treatment is not pragmatical, as it impedes them from working or taking care of other people. Other solutions may therefore be required to accommodate their situation, whilst still providing them with the most effective treatment. Mental health aspect have also previously suggested to mediate recovery from musculoskeletal conditions as well as as the number of visits required for treatment of upper limb conditions. Mental health factors should be kept in mind and a referral to the suitable professional may be performed if possible. Other interventions, which may help with mental health status include physical activity, and yoga, and meditation, although this last one may present with undesirable side effects. Open Access URL: http://dx.doi.org/10.2106/JBJS.21.00121 No Abstract available

De quervain tenosynovitis: An evaluation of the epidemiology and utility of multiple injections using a national database. Hassan, K., A. Sohn, L. Shi, M. Lee and J. M. Wolf (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Treatment Topic: De Quervain - Conservative treatment This is a retrospective study on the failure rate of cortisone injections for De Quervain syndrome. A total of 17,820 participants were retrospectively identified through an insurance database. Participants were included if the insurance code indicated the presence of De Quervain. No further information was provided about participants. Failure of injection was defined as the need for a second injection or surgical intervention. The results showed that in 72% of participants, the first injection was successful. The second and third injection was successful in 66% and 60% of participants. 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 first cortisone injection for De Quervain syndrome appears to be effective in 70% of people. Despite a reduction in effectiveness with additional injections (60-66% effectiveness), these can still provide pain relief in a large group of clients. Future studies comparing cortisone injection to saline for De Quervain syndrome are required to clarify whether they are more effective than placebo. As a matter of fact, in people with thumb OA or tennis elbow, this is not the case. In addition, clients undergoing cortisone injections close to the time of surgery for thumb OA appear to be at greater risk of post surgical complications. It is unclear whether this increased risk is due to the active principle (cortisone) or the injection itself. URL: https://doi.org/10.1016/j.jhsa.2021.04.018 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: We hypothesized that repeat injections are associated with a decreased rate of success and that the success rate of injections correlates with patient comorbidities. Methods: Using a commercially available insurance database, patients diagnosed with De Quervain tenosynovitis were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes and stratified by therapeutic interventions, including therapy, injections, and surgery, as well as comorbidities. Injection failure was defined as a patient receiving a repeat injection or subsequent surgical management. Success was defined as no further therapies identified after an intervention. Results: From 2007 to 2017, 33,420 patients with a primary diagnosis of De Quervain tenosynovitis were identified. Women represented 77.5% (25,908) of the total and were 2.6 times more likely to be diagnosed than men. Black patients were more likely to be diagnosed than White patients. Black and White women were found to have the highest incidence (relative risk 3.4 and 2.3, respectively, compared with White men). Age was also significantly correlated with an increased risk of diagnosis of the condition, with a peak incidence at the age of 40–59 years (relative risk, 10.6). Diabetes, rheumatoid arthritis, lupus, and hypothyroidism were associated with an increased risk of diagnosis. Overall, 53.3% of the patients were treated with injections, 11.6% underwent surgery, and 5.2% underwent therapy. Treatment with a single injection was successful in 71.9% of the patients, with 19.7% receiving a repeat injection and 8.4% treated with surgery. The overall success rate of subsequent injections was 66.3% for the second injection and 60.5% for the third. The initial injection had a higher rate of success in diabetics than in nondiabetics; however, the difference (2%) was not clinically relevant. Conclusions: Although the success rate for the treatment of De Quervains tenosynovitis decreases with multiple injections, repeat injections have a high rate of success and are a viable clinical option.

Clinical assessment of hand oedema: A systematic review. Miller, L. K., C. Jerosch-Herold and L. Shepstone (2017) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Diagnostic Topic: Hand swelling - How to reliably measure it This is a systematic review assessing the reliability and validity of different forms of hand swelling measurement. Reliability could be defined as the ability of a tool (e.g. figure-of-eight) to repeatedly measure a specific variable (e.g. hand swelling) without significant error. Validity could be defined as the ability of a tool to measure a specific variable (e.g. hand swelling) rather than other variables (e.g. range of movement). Usually validity of a tool is compared against an existing "gold standard", known to measure that specific variable. Six RCTs were included for a total of 243 participants. Each study was assessed through the Consensus-based Standards for the selection of health Measurement Instruments checklist (COSMIN). No overall quality of evidence assessment was provided. Three different assessment methods, which included visual inspection, perometer, and figure-of-eight, were compared against volumetry ("gold standard" for hand swelling). These measures were taken from participants with hand swelling presenting with several different conditions including cerebrovascular accidents, hand burns/surgery/trauma. The results showed that the figure-of-eight measurement presented with good inter-rater (repeated measurements from the same person) and intra-rater (measurements from different people) reliability. Limited information was provided in terms of validity, except for the fact that both figure-of-eight and the volumeter could measure changes in swelling reasonably well. Visual inspection did not appear to be valid against the volumeter. The perometer was reliable but did not appear to be valid against the volumeter. Clinical Take Home Message: Based on what we know today, figure-of-eight appears to be reliable when the same or different clinicians measure the same hand. In addition, it appears to be valid when compared to other clinical tools available, although we need more research assessing its validity. Visual assessment of hand swelling is a gross measure of swelling and does not appear to be particularly useful to track swelling changes. URL: https://doi.org/10.1177/1758998317724405 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Assessment of oedema after trauma or surgery is important to determine whether treatment is effective and to detect change over time. Volumetry is referred to as the "gold standard" method of measuring volume. However, this has practical limitations and other methods are available. The aim of this systematic review was to evaluate the psychometric properties of alternative methods used to assess hand oedema. Methods: A search of electronic bibliographic databases was undertaken for any studies published in English reporting the psychometric evaluation of a method for measuring hand oedema, in an adult population with hand swelling from surgery, trauma or stroke. The Consensus?based Standards for the Selection of health Measurement Instruments (COSMIN) checklist was used to evaluate the methodological quality. Results: Six studies met the inclusion criteria. Three methods were identified assessing hand oedema: perometry, visual inspection and the figure-of-eight tape measure, all were compared to volumetry. Four different psychometric properties were assessed. Studies scored fair or poor on COSMIN criteria. There is low-quality evidence supporting the use of the figure-of-eight tape measure to assess hand volume. The perometer systematically overestimated volume and visual estimation had poor sensitivity and specificity. Discussion: The figure-of-eight tape measure is the best alternative to volumetry for hand oedema. Benefits include reduced cost and time while having comparable reliability to the "gold standard". Further research is needed to compare methods in patients with greater variability of conditions and with isolated digit oedema. Visual estimation of hand oedema is not recommended.

Patient expectations about a clinical diagnostic test may influence the clinician's test interpretation. Coppieters, M. W., B. Rehn and M. L. Plinsinga (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Client's expectations - Physical tests This is an experiment assessing the effect of client's expectations on pain intensity and area during physical tests. A total of 15 healthy participants were included in the present study. All participants were injected with a hypersaline solution in the thenar muscle of the tested hand to cause a pain response. All participants subsequently underwent median nerve neurodynamic test (see Figure 1 below), during which changes in pain intensity and area were recorded. Prior to the injection and testing, all participants received general information regarding the nature of the neurodynamic test (gradual increase in nerve stretch). However, participants randomised to the "nerve pain group" (n = 7) were told that their pain was caused by irritation of nerve receptors (n = 7; "nerve pain group") whilst the participants randomised to the "muscle pain group" (n = 8) were told that the injection would cause muscle pain. The results showed that the "nerve pain group" presented a statistically and clinically relevant increase in pain intensity (1.6 points out of 10) and pain area (80% increase in painful area) from the least stretched (-2) to the most stretched position (+2) during the median nerve neurodynamic test. In contrast, no change in pain intensity or area was noted in the "muscle pain group" (see Figure 2 below). Figure 1 Figure 2 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, expectations of increased pain during physical tests can increase the pain intensity and painful area in our clients. Even if we don't tell them that the test will cause them pain, if they have an understanding of the physical test, their pain response can be influenced. This may be one of the reason why fracture tenderness on palpation is an unreliable indicator or fractures' healing. This study also highlights the importance of the words and behaviors we implement with our clients as they can increase or decrease their pain. We can conclude that expectations not only play role in the treatment but also in the assessment of our clients. URL: https://doi.org/10.1016/j.msksp.2021.102387 Available through EBSCO Health Databases for PNZ members. Abstract Background: With medical information widely available, patients often have preconceived ideas regarding diagnostic procedures and management strategies. Objectives: To investigate whether expectations, such as beliefs about the source of symptoms and knowledge about diagnostic tests, influence pain perception during a clinical diagnostic test. Design: Cross-sectional study. Methods: Pain was induced by intramuscular hypertonic saline infusion in the thenar muscles. In line with sample size calculations, fifteen participants were included. All participants received identical background information regarding basic median nerve biomechanics and basic concepts of differential diagnosis via mechanical loading of painful structures. Based on different explanations about the origin of their induced pain, half of the participants believed (correctly) they had ‘muscle pain’ and half believed (incorrectly) they had ‘nerve pain’. Pain intensity and size of the painful area were evaluated in five different positions of the median nerve neurodynamic test (ULNT1 MEDIAN). Data were analysed with two-way analyses of variance. Results /findings: Changes in pain in the ULNT1 MEDIAN positions were different between the ‘muscle pain’ and ‘nerve pain’ group (p < 0.001). In line with their expectations, the ‘muscle pain’ group demonstrated no changes in pain throughout the test (p > 0.38). In contrast, pain intensity (p ≤ 0.003) and size of the painful area (p ≤ 0.03) increased and decreased in the ‘nerve pain’ group consistent with their expectations and the level of mechanical nerve loading. Conclusion: Pain perception during a clinical diagnostic test may be substantially influenced by pain anticipation. Moreover, pain was more aligned with beliefs and expectations than with the actual pathobiological process.

Efficacy of surgical interventions for trapeziometacarpal (thumb base) osteoarthritis: A systematic review. Hamasaki, T., et al. (2021) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Surgical intervention - Thumb OA This is a systematic review assessing the effectiveness of several surgical interventions for first carpometacarpal joint (cmcj) osteoarthritis (OA). Systematic reviews (SR), randomised controlled trials (RCT), and non-randomised controlled trials (nRCT) were included in the present review. A total of 59 studies were included, of which one was a SR, 18 were RCTs, and 40 were nRCT. All the studies were formally assessed for their research quality. Different critiquing tools were utilised according to the type of study analyses (SR, RCT, nRCT). The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. The results showed that there are 11 different surgical approaches for first cmcj OA. All the studies compared one surgical approach to another surgical approach. No studies compared a surgical intervention to a sham procedure. Overall it appeared that a "simpler" intervention such as trapeziectomy provided better outcomes (e.g. lower complications) compared to other more complex interventions (e.g. suspension arthroplasty). The result of this review were however supported by low quality evidence. Clinical Take Home Message: Based on what we know today, several surgical interventions are available for symptomatic first cmcj OA. Trapeziectomy may provide better results compared to other surgical interventions. Despite these surgical interventions been commonly performed for clients with first cmcj OA, they have never been compared to sham surgery. This trend is changing and a systematic review assessing orthopedic surgical procedures vs sham surgery in other joints has already been published. Their results suggested that both real and sham surgery improved pain and function to the same extent. Open access URL: https://doi.org/10.1016/j.jhsg.2021.02.003 Abstract Purpose: This systematic review (SR) aimed to identify the surgical interventions available for trapeziometacarpal osteoarthritis and document their efficacy on pain, physical function, psychological well-being, quality of life, treatment satisfaction, and/or adverse events. Methods: This PROSPERO-registered SR’s protocol was developed based on the Cochrane intervention review methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Among 9049 potential studies identified, 1 SR, 18 randomized controlled trials, and 40 nonrandomized controlled trials were included. We identified 11 categories of surgical techniques: first metacarpal osteotomy, first metacarpal and trapezium partial resection, arthrodesis, trapeziectomy (T), T+ligament reconstruction (LR), T+tendon interposition (TI), T+ligament reconstruction and tendon interposition (LRTI), hematoma distraction arthroplasty (HDA), chondrocostal graft interposition, autologous fat injection, and manufactured implant use. These findings supported by low-quality evidence revealed moderately or largely superior effects of the following interventions: (1) trapeziectomy over T+LRTI using ½ flexor carpi radialis (FCR) and metacarpal tunnel (MT) or using abductor pollicis longus (APL) and FCR for adverse events; (2) trapeziectomy over T+TI using palmaris longus (PL) for pain; (3) T+LR with ½FCR-MT over T+LRTI with ½FCR-MT for physical function; (4) trapeziectomy by anterior approach over that by posterior approach for treatment satisfaction and adverse events; (5) T+LRTI using ½FCR-MT over T+TI with PL for pain; and (6) T+HDA over T+LR using APL-MT-FCR for pain, physical function, and adverse events. GraftJacket (Wright Medical Group, Memphis, TN), Swanson (Wright Medical Group, Letchworth Garden City, UK), and Permacol (Tissue Science Laboratories, Aldershot, UK) implants and hardware (plate/screw) would cause more complications than an autograft. The effect estimates of other surgical procedures were supported by evidence of very low quality. Conclusions: This SR provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis. Some interventions showed a moderate-to-large superior effect on the studied outcome(s) compared with others. However, these findings must be interpreted with caution because of low-quality evidence. To provide stronger evidence, more randomized controlled trials and methodological uniformization are needed.

Atraumatic, progressive, and painful elbow contracture from a ganglion cyst. Goyal, N., T. J. Luchetti, A. T. Blank and M. S. Cohen (2021) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic This is the answer for last week Sherlock Handy. The patient was a 37 years old male presenting with worsening of left elbow stiffness and pain in the last 9 months. Subjective and objective examination revealed no neurovascular impairments. They had no previous history of surgery or trauma to the elbow. Active range of movement (AROM) in elbow extension and flexion was 30° to 110° respectively. X-rays were normal. An MRI (see below) was obtained and it identified a ganglion cyst in the volar aspect of the elbow (deep to the brachialis muscle). Surgery was perfomed to remove the ganglion and perform a volar capsular release. The surgical release was followed by early rehabilitation. At nine months post surgery, the patient had no pain or AROM limitations. 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, ganglion cysts limiting elbow AROM are a rare presentation. If a client with progressive atraumatic elbow AROM limitation presented to our clinic, a set of x-rays and US imaging would be warranted. A referral to a surgeon may be advisable as further investigations to exclude benign or malignant pathologies such as synovial sarcomas may be required. If you are interested in recent evidence about how to deal with post-traumatic elbow stiffness, have a look at this synopsis. URL: https://doi.org/10.1016/j.jhsa.2020.06.005 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Ganglion cysts are benign soft tissue tumors that often occur adjacent to joints or tendons. We report a case of an elbow joint ganglion cyst in a patient who presented with a painful, progressive elbow contracture. The patient was successfully treated with resection of the subbrachialis ganglion cyst combined with an anterior capsular release and an ulnar nerve decompression to recover elbow motion. This case highlights the value of advanced imaging in patients presenting with an atraumatic, painful, and progressive elbow contracture.

Chronic complex persistent elbow instability: A consecutive and prospective case series and review of recent literature. Giannicola, G., Sessa, P., Calella, P., Gumina, S., & Cinotti, G. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Chronic complex persistent elbow instability - Elbow stability and function after surgery This is a prospective case-series study assessing elbow stability and function following surgery for chronic complex persistent elbow instability (CCPEI). This condition is defined as an on-going (chronic) static (persistent) elbow subluxation/dislocation (instability), due to bony and soft tissue lesion (complex) following trauma. A total of 21 adult participants were included. Participants were included if they had previous surgical treatment for a traumatic elbow lesion. The most common elbow trauma (n = 13) was the terrible triad (elbow dislocation with radial head and coronoid fractures). A Monteggia-like lesion (ulnar fracture with additional soft tissue/bony lesions) was the second most common injury (n = 6). Participants also had to present with pre-surgical elbow instability identified through x-rays or CT scan. Success of surgery was assessed through fluoroscopy. In addition, function was assessed through the Mayo Elbow Performance Score, the modified American Shoulder and Elbow Surgeons assessment form, and the QuickDASH. The results showed that surgery improved stability and function to a statistically and clinically significant level in patients with CCPEI at 2.5 years follow-up. A 23% (n = 5) complication rate was reported and this required additional surgery in most cases. 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, chronic complex persistent elbow instability is the result of severe elbow dislocations associated with fractures. If conservative treatment is not appropriate or ineffective, clients may have to undergo surgery. It appears that the post-surgical recovery time is quite extensive and can take between 2 to 3 years. If clients develop stiffness that limits their daily activities, have a look at this other synopsis on treatment of post-traumatic elbow stiffness. URL: https://doi.org/10.1016/j.jse.2019.11.021 Available through EBSCO Health Databases for PNZ members. Abstract Background Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature. Methods We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13, Monteggia-like lesion in 6, humeral shear fracture-dislocation in 1, and radial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively. Results The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases. Conclusions CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.