Search Results

328 items found

  • What is the differential diagnosis for this finger haematoma?

    Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) 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 48 years old right-handed woman. They reported recurrent (years) haematomas and pain on the volar aspect of all fingers (except thumbs) with sparring of the fingertip (see picture). These haematomas occurred every few weeks and were not always associated with trauma/handling of heavy objects. Objectively, they did not present with temperature changes in the fingers. They reported that the symptoms and bruising usually resolved within a few days. Overall they were healthy, and they were not taking blood-thinning medications. What is it?

  • Does Vitamin C reduce the risk of developing CRPS following distal radius fracture?

    Effect of perioperative vitamin C on the incidence of Complex Regional Pain Syndrome: A systematic review and meta-analysis. Seth, I., et al. (2021) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 (4/4 thumbs up) Type of study: Therapeutic/Preventative Topic: Radius fracture - vitamin C to reduce the incidence This is a systematic review and meta-analysis assessing the effectiveness of vitamin C vs placebo in preventing complex regional pain syndrome type I (CRPS-I; absence of nerve lesions) post distal radius fracture and ankle/foot surgery. A total of 7 RCTs and 1 quasi-experimental (no randomisation) study were included in the review. Of these studies, six were completed in people with a distal radius fracture. The total number of participants was 1,427 evenly distributed between vitamin C and placebo treatment. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has been suggested by the Cochrane group for systematic reviews. Vitamin C in 500mg or 1g dose was provided daily for 40-50 days post-injury/surgical intervention to the experimental group. The presence of CRPS was assessed from 3 to 12 months. The results showed that there is moderate to high-quality evidence suggesting that 500mg/1g of daily vitamin C significantly reduced (odds ratio: 0.37) the risk of developing CRPS-I compared to placebo. Both dosages (500mg and 1g) were effective in reducing the risk. The risk of complications was equal between placebo and vitamin C. 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, 500mg or 1g of vitamin C taken daily for 40-50 days post distal radius fracture can significantly reduce the risk of developing CRPS-I. It may be feasible to reach these dosages through diet, however, considering for example that one medium-size orange contains around 70mg of vitamin C, you would need to eat quite a few of them to reach therapeutic levels. It may be best to refer our clients to a pharmacist to make sure that these dosages of vitamin C are safe for them, and advise on the best vitamin C supplement. URL: https://doi.org/10.1053/j.jfas.2021.11.008 Abstract Complex regional pain syndrome type 1 (CRPS-I) is a complex complication that occurs after limb extremity surgeries. Controversy exists regarding the effectiveness of vitamin C in reducing that condition. Therefore, we conducted this systematic review and meta-analysis to assess the role of vitamin C on CRPS-I and functional outcomes after distal radius, wrist, foot, and ankle surgeries. We searched Medline (via PubMed), Embase, the Cochrane Library, Clinicaltrial.gov, and Google Scholar for relevant studies comparing perioperative vitamin C versus placebo after distal radius, wrist, foot, and ankle surgeries from infinity to May 2021. Continuous data such as functional outcomes and pain scores were pooled as mean differences, while dichotomous variables such as the incidence of complex regional pain syndrome and complications were pooled as odds ratios, with 95% confidence interval, using R software (meta package, version 4.9-0) for Windows. Eight studies were included. The timeframe for vitamin C administration in each study ranged from 42 to 50 days postinjury and/or surgical fixation. The effect size showed that vitamin C was associated with a decreased rate of CRPS-1 than placebo (odds ratio 0.33, 95% confidence interval [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (odds ratio 1.90, 95% confidence interval [0.99, 3.65]), functional outcomes (mean difference 6.37, 95% confidence interval [-1.40, 14.15]), and pain scores (mean difference -0.14, 95% confidence interval [-1.07, 0.79]). Overall, vitamin C was associated with a decreased rate of CRPS-I than placebo, while no significant difference was found regarding complications, functional outcomes, and pain scores. These results hold true when stratifying fracture type (distal radius, ankle, and foot surgeries) and vitamin C dose (500 mg or 1 g). 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

  • Closed ring avulsion, what does it look like?

    Closed ring avulsion injury with isolated arterial insufficiency. Bouz, A., Y. Liu, K. T. Yamaguchi and J. B. Friedrich (2021) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Preventative Topic: Closed ring avulsion - Presentation This is a case report of 68 years old male with a close ring avulsion injury. The patient was working on his boat at the time of the accident. They slipped and ended up hanging off their wedding ring for a few seconds before being able to disengage the ring from a hook. They immediately went to the emergency department where they presented without fractures/major cutaneous lesions. However, there was a haematoma, paleness (see figure 1), numbness and objective evidence of reduced temperature in the left ring finger. There was full active range of movement in the finger. The patient was immediately referred for further specialist assessment. Pencil doppler revealed the presence of a pulse at the base of the finger but a total absence of it beyond the proximal interphalangeal joint. In the meanwhile, symptoms had improved but the haematoma had extended to the distal phalanx (see figure 2). Surgical exploration revealed a complete transection of the ulnar digital artery and a thrombus in the radial digital artery. Both radial and digital nerves were intact. The ulnar and radial digital artery lesions were surgically resolved and over the course of three months of rehabilitation, the patient regained full active range of movement of the finger. 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, ring avulsion injuries could occur without cutaneous involvement. Despite lack of cutaneous involvement, this injury may be associated with damage to the neurovascular bundle. To reduce the risk of ring avulsion injuries, the use of silicon rings may be advisable. Thus, these rings have a breaking point of around 1/10 of metal rings. URL: https://doi.org/10.1016/j.jhsg.2021.07.004 Abstract Ring avulsion injuries are an uncommon, often catastrophic, pattern of digit injuries that result from sudden traction onto a ring-bearing digit. The reconstructive treatment of these injuries can be complex because of the characteristic involvement of nerves, muscles, vasculature, and bone. There is paucity of literature describing isolated arterial injuries in the absence of overlying soft tissue and underlying bone involvement. We present an unusual case of a closed ring avulsion injury, wherein a patient initially presented to his local urgent care center with a cool and pale digit without wounds or fractures, and abnormal pulse oximetry readings prompted his transfer to a tertiary care center for further evaluation. Surgical exploration demonstrated isolated disruption of both digital arteries and the preservation of both digital nerves. The digit was successfully revascularized with venous autografting and stripping of arterial thrombi. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • Physical activity: Another reason for us to prescribe it to our clients!

    Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: A study in 48 440 adult patients. Sallis, R., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs) Type of study: Preventative Topic: Physical activity and COVID-19 - Risk reduction This is a retrospective study assessing the correlation between pre-infection physical activity and severity of COVID-19 infection. A total of 103,337 participants were included. The severity of COVID-19 infection was measured by rate of hospitalisation, admission to ICU, and deaths associated with it. The results showed that of the total sample, 8.6% were hospitalised, 2.4% had to be admitted to ICU, and 1.6% died. Patients who were consistently inactive (did not meet the physical activity guidelines) were a greater odds of been hospitalised, being admitted to ICU, and dying compared to patients who consistently met the physical activity guidelines. These findings were retained even with analyses that adjusted for several confounding variables (e.g. age) - see forest plot below. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, physical activity appears to reduce the risk of COVID-19 severity. This is important to remember because many of our clients undergo periods of reduced activity due to their upper limb injuries. If possible, we should therefore find alternative exercising strategies that maintain them active whilst avoiding loading of healing tissues. Ideally we would suggest them to follow the physical activity guideline that were discussed in a previous synopsis (See picture below for further information). Following the WHO physical activity guidelines will not only improve prognosis for COVID-19 infection, but also improve wound healing, bone mass density, and mental health status, which is a factor influencing our clients recovery. Open Access URL: http://bjsm.bmj.com/content/early/2021/04/07/bjsports-2021-104080.abstract Abstract Objectives: To compare hospitalisation rates, intensive care unit (ICU) admissions and mortality for patients with COVID-19 who were consistently inactive, doing some activity or consistently meeting physical activity guidelines. Methods: We identified 48 440 adult patients with a COVID-19 diagnosis from 1 January 2020 to 21 October 2020, with at least three exercise vital sign measurements from 19 March 2018 to 18 March 2020. We linked each patient’s self-reported physical activity category (consistently inactive=0–10 min/week, some activity=11–149 min/week, consistently meeting guidelines=150+ min/week) to the risk of hospitalisation, ICU admission and death after COVID-19 diagnosis. We conducted multivariable logistic regression controlling for demographics and known risk factors to assess whether inactivity was associated with COVID-19 outcomes. Results: Patients with COVID-19 who were consistently inactive had a greater risk of hospitalisation (OR 2.26; 95% CI 1.81 to 2.83), admission to the ICU (OR 1.73; 95% CI 1.18 to 2.55) and death (OR 2.49; 95% CI 1.33 to 4.67) due to COVID-19 than patients who were consistently meeting physical activity guidelines. Patients who were consistently inactive also had a greater risk of hospitalisation (OR 1.20; 95% CI 1.10 to 1.32), admission to the ICU (OR 1.10; 95% CI 0.93 to 1.29) and death (OR 1.32; 95% CI 1.09 to 1.60) due to COVID-19 than patients who were doing some physical activity. Conclusions: Consistently meeting physical activity guidelines was strongly associated with a reduced risk for severe COVID-19 outcomes among infected adults. We recommend efforts to promote physical activity be prioritised by public health agencies and incorporated into routine medical care. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

  • What clients with thumb OA are most likely going to respond to a multimodal treatment?

    Greater efficacy of a combination of conservative therapies for thumb base OA in individuals with lower radial subluxation – a pre-planned subgroup analysis of the COMBO trial. Deveza, L. A., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs) Type of study: Prognostic Topic: Thumb osteoarthritis - thumb base radial deviation and treatment response This is a subgroup analysis of a previously published randomised controlled trial. This subgroup analysis aimed at assessing whether base of thumb radial subluxation, Kellgren Lawrence grade (KL), presence of interphalangeal joint OA, and presence of erosive hand OA affected response to conservative treatment. The two treatment types have been previously reported in the trial and included education alone or a combination of multiple conservative treatments. There were a series of outcomes being collected to assess response to treatment with the primary being pain (visual analogue scale - VAS) and function (functional index of hand OA - FIHOA) measured at six weeks. The results showed a multimodal treatment was associated with better outcomes in people with lower levels of thumb base radial deviation. Despite this finding, the improvements were quite heterogeneous and may not be clinically relevant. No other factors appeared to mediate treatment response. 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, lower levels of thumb base subluxation may predict better treatment outcomes in people with thumb OA. Radiologic findings (e.g. erosive OA) do not appear to largely affect treatment. This appears to be supported by previous evidence showing that pain catastrophising (rather than x-ray findings) is associated with pain intensity in thumb OA. An additional factor that appears to mediate treatment response in thumb OA is treatment expectations. In particular, more positive treatment expectations are associated with better treatment outcomes. URL: https://doi.org/10.1016/j.joca.2021.07.010 Abstract Objective: To investigate heterogeneous effects of a combination of conservative therapies compared with an education comparator for thumb base (TB) osteoarthritis (OA) according to clinically relevant characteristics. Methods: Pre-planned subgroup analysis of the COMBO trial (n = 204) which compared a combination of education on self-management and ergonomic principles, a prefabricated neoprene splint, hand exercises, and diclofenac sodium gel, with education alone for radiographic and symptomatic TB OA. Primary outcomes were change in pain (visual analogue scale [VAS], 0–100 mm) and hand function (Functional Index for Hand Osteoarthritis questionnaire, 0–30) from baseline to week-6. Other outcomes were grip and tip-pinch strength and patient's global assessment (PGA) (VAS, 0–100 mm). Possible treatment effect modifiers were the presence of interphalangeal joint pain, erosive hand OA, radiographic thumb carpometacarpal joint subluxation (higher vs equal or lower than the sample mean), and baseline radiographic OA severity (Kellgren Lawrence grade). Linear regression models were fitted, adding interaction terms for each subgroup of interest. Results: The treatment effects of the combined intervention at 6 weeks were greater in participants with lower joint subluxation compared with those with greater subluxation (pain −11.6 [95%CI −22.2, −9.9] and 2.6 [−5.5, 10.7], respectively, difference between the subluxation groups 14.2 units (95% CI 2.3, 26.1), p-value 0.02; and PGA −14.0 [−22.4, −5.5] and 1.5 [−6.2, 9.3), respectively, difference between the subluxation groups 15.5 units (95% CI 4.2, 26.8), p-value 0.03). There was no statistically significant heterogeneity for the other subgroups. Conclusion: A combination of conservative therapies may provide greater benefits over 6 weeks in individuals with lower joint subluxation, although the clinical relevance is uncertain given the wide confidence intervals. Treatment strategies may need to be customized for those with greater joint subluxation. Trial registration number ACTRN 12616000353493. 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

  • Brachial plexus injury: What are the best available tools to assess our clients?

    Evaluation of functional outcomes after brachial plexus injury. Quick, T. J. and H. Brown (2020) Level of Evidence: 4 Follow recommendation: 👍 (1/4 thumbs) Type of study: Diagnostic Topic: Assessment of brachial plexus injuries - Motor, sensory, and functional tests to assess brachial plexus injuries This narrative review focused on the available outcomes to assess motor, sensory, pain, and functional impairments in people with brachial plexus injuries. For motor outcomes, the use of dynamometers instead of traditional manual muscle testing has been advised. Thus, they appear to be more reliable and valid to assess muscle strength. Detection of stimuli can be assessed through monofilament testing, which appears to be a good outcome to measure change over time. In addition, the Shape Texture Identification (STI) for stereognosis and the locognosia test for touch localisation can both be used to assess further sensory impairments. Pain can be assessed through multiple outcomes and there is no specific measure for brachial plexus injuries. The visual analogue scale (VAS), the Numerical Rating Scale (NRS), and McGill Pain Questionnaire are only a few of several outcomes available. Finally, the DASH is commonly utilised in brachial plexus injuries, however, it has not been validated in this group of patients. The Brachial plexus Assessment Tool (BrAT) can be used as an alternative to the DASH, however, this is a new scale and requires further research supporting its use. 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, when assessing brachial plexus injuries, motor, sensory, and functional aspects need to be measured. Hand-held dynamometers can be purchased by hand therapists (roughly $1,600) and can provide more valid measurements than manual muscle testing. Monofilaments appear to be a good starting point to assess touch detection. Further assessment of sensibility can be performed through the test for touch localisation, which is free. The Shape Texture Identification test appears to be a great tool but it is not free (roughly $1,115). In regard to pain assessment, we are spoiled for choice. I would personally use both the NRS for pain intensity and the Douleur Neuropathique 4 (DN4), a quick questionnaire that includes three objective tests for the identification of neuropathic pain. URL: https://doi.org/10.1177%2F1753193419879645 Abstract Major nerve injuries such as those of the brachial plexus present a significant challenge for both rehabilitation and evaluation of outcome. With these often complex and multi-faceted injuries, correct selection of outcome measures is important. Healthy nerve function in humans heightens our interactions with the world, creating quality and enjoyment through our experiences of movement and touch. Therefore, assessments should be holistic and representative of all of these features. This article considers the assessment and evaluation of all of the features of nerve injury: sensorimotor, sensation (including that of pain), function and the psychosocial aspects. Current practice is described and combined with clinical experience and research findings to provide suggestions and recommendations for the selection of the most appropriate tools for use with this patient group. 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

  • When was tennis elbow described for the first time in the scientific literature?

    Translation of Runge's 1873 publication "On the etiology and treatment of writer's cramp": The first description of "tennis elbow". Stegink-Jansen, C. W., B. Jung and J. S. Somerson (2021) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic Topic: Lateral epicondylalgia – One of the first articles in scientific literature This paper (published in 2021), translated the original article which was published by Ferdinand Runge in 1873. This was one of the first scientific papers on tennis elbow, which was classified as part of the "writer's cramp" syndromes. In those days, tennis elbow was treated with cauterisation of the skin, galvanic currents, or absolute rest. The choice of treatment was dictated both by the patient's expectations and what Runge suspected to be the problem causing tennis elbow. In particular, Runge changed intervention if the patient lacked confidence in them. In addition, Runge utilised a combination of induction and deductive reasoning in generating the diagnosis and treating the client. Overall they reported being successful in most cases except a minority who would not get better. 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, tennis elbow has likely affected humans for a long time and one of the first published case studies dates back to 1873. Back then like today, it appears that tennis elbow resolves in most people within a short period of time (90% recovery within 12 months without any treatment). This suggests that independently of the treatment selected (if any) clients with tennis elbow are very likely to get better. Currently, the cheapest conservative treatment (e.g. counterforce brace followed by exercise) appears to be the most appropriate considering that more expensive interventions (e.g. surgery and PRP do not appear to be more effective than placebo). However, as indicated in this article by Runge, if clients do not have confidence in the intervention that we offer, it may be best to provide some other intervention. This hypothesis on the importance of expectations for therapeutic efficacy is supported by othet evidence. URL: https://doi.org/10.1002/ca.23830 Available through EBSCO Health Databases for PNZ members. Abstract This publication by Dr Ferdinand Runge is ubiquitously credited as first to describe the symptoms, pathology, and treatment of patients with lateral epicondylosis (tennis elbow). However, the main focus of his work was to provide insight into causes of writer's cramp and treatments for the condition, elegantly illustrated in four case reports. This work, recently cited as unavailable, is written in German. Given the high frequency of citations in the English literature, it was considered useful to translate it into English to widen access to a broader readership. The purpose of this project was briefly to introduce the life and clinical expertise of Dr. Ferdinand Runge and the content of his work, followed by a translation of the entire manuscript into English. The paper was translated by the three authors using a process of sequential consensus. All are proficient in German and English, with clinical expertise in both topics. A brief reflection is provided to place Dr Runge's observations, clinical reasoning, and contemporaneously available treatments in the context of current thinking about lateral epicondylalgia. Dr. Runge shares his expertise, carefully reporting pertinent examination findings for each case, sharing hypotheses about the etiology of writer's cramp, and using the effectiveness of his applied treatment as confirmation. He concludes that careful evaluation of the patient's activities that hindered writing prior to the onset of the writer's cramp is key to managing this ailment. The topics addressed in this classic work are still thought-provoking. 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

  • Does it matter what type of splint for thumb OA?

    User perspectives on orthoses for thumb carpometacarpal osteoarthritis. Grüschke, J., S., H. Reinders-Messelink, A. van der Vegt and C. van der Sluis (2019) Level of Evidence: N/A Follow recommendation: 👍 Type of study: Therapeutic Topic: Thumb carpo-metacarpal osteoarthritis (OA) and conservative treatment - Qualitative comparison of two thumb orthoses This qualitative study investigated patients' perspectives in relation to a Push-Ortho-Thumb-Brace (PB) and a Custom-Made orthosis (CM) for people with thumb carpo-metacarpal OA. The results showed that on average there was no difference between the two treatments and the pain-relieving effect was 3mm on a 0-100mm Visual Analogue Scale (VAS), similar to 0.3 change on a 0-10 Numerical Rating Scale (NRS). The change in pain was therefore not clinically meaningful, however, some participants reported benefitting from wearing the orthosis. Some reported better functional performance during heavy tasks, others were more comfortable wearing it while resting, and another subgroup used it to prevent further disease progression. While most of the participants considered OA an irreversible process, a subgroup believed in the potential for improvement. Some people reported the orthosis being a nuisance and stopped wearing it altogether. 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, some clients may benefit from thumb orthosis to provide comfort. The orthosis selection does not appear to be as important and patients' preferences should be accommodated. In clients who have trialled an orthosis and find it to be a nuisance, alternative treatments such as exercises should be offered. Hand therapists should have a conversation with those patients who believe that wearing the orthosis prevents OA progression, and explain that there is research suggesting that movement is useful for joint nutrition and health (test your own pain science understanding with this synopsis). Finally, a reminder that thumb OA orthoses providing biomechanical restrains do not appear to be more effective than placebo orthoses. URL: https://doi.org/10.1016/j.jht.2018.04.006 Abstract Study Design: Qualitative and interpretive description. IntroductionOrthoses are often the first-choice treatment for thumb carpometacarpal osteoarthritis (CMCOA). It is unknown to what extent the orthoses are used in the way intended by health professionals and why patients continue using the orthoses despite minimal pain reduction. Purpose of the Study: The purpose of this study is to investigate user perspectives and experiences with 2 types of CMCOA orthoses. Methods: Semistructured interviews were conducted with 16 individuals with CMCOA who used the Push-Ortho-Thumb-Brace-CMC (Nea International BV, Netherlands) and a custom-made orthosis. The data were analyzed using the phenomenological and the framework approach. Results: Four men and 12 women participated (mean age, 57 years; half of whom were employed). Five central phenomena were identified, explaining the essence of the relation between user and orthosis: the orthosis as stabilizer, tool, healer, preventer, and nuisance. Users mentioned better appearance and the ability to do a variety of activities as advantages of the Push-Ortho-Thumb-Brace-CMC and better support and the ability to do strenuous activities as advantages of the custom-made orthosis. The central phenomena were related to the users' understanding of the disease process and the working mechanism of the orthoses and affected the patterns of usage and orthosis preference. Discussion: It is recommended that the provider recognizes user perspectives and discusses the disease process of CMCOA along with the working mechanism of the orthosis to support therapy adherence. Conclusions: There is a wide variety in usage patterns of the CMCOA orthoses, which are influenced by different user perspectives. 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

  • Proximal phalangeal # - Can you get it moving straight away?

    Non-surgical management of isolated proximal phalangeal fractures with immediate mobilization. Byrne, B., Jacques, A., & Gurfinkel, R. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Conservative treatment of proximal phalanx fracture - Splinting and immediate active movement. This single group prospective cohort study assessed the effectiveness of a splinting regime combined with an immediate range of movement exercise program in people with proximal phalanx fractures. Only patients with stable or stable after reduction fractures were included. In addition, angulation on sagittal and coronal plane had to be less than 25° and 10° respectively. Patients were provided with an edema glove and were immobilised in a custom-made hand splint which extended to the pipj and fixated the mcpj in full flexion. During the first week, patients were advised against removing the splint, however, they were encouraged to flex and extend the pipj and dipj hourly. Between week one and four, patients could remove the splint for hand hygiene only and were advised to continue exercising hourly. After four weeks, the splint was removed for light activities and at six weeks the splint was completely removed with progression to full activity as pain allowed. Discharge took place when pain had resolved and when full range of movement was achieved. The results showed that 2.5% of patients lost fracture reduction after one week and required surgical intervention. The median time to discharge was 6 weeks at which point pain had completely resolved and the average pipj flexion range of movement was 94° with 4° of hyperextension. 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 is possible to treat a proximal phalanx fracture conservatively with an intrinsic plus immobilisation splint and an early controlled active motion exercise program. This approach is applicable if there is less than 25° of sagittal angulation of the fracture and in absence of scissoring of digits. The patient should be monitored closely during the first week after injury as there is a possibility (2.5-9%) of losing fracture stability. Splint weaning should be based on expected healing timeframes as fracture tenderness on palpation does not appear to be a reliable indicator of bone healing. URL: https://doi.org/10.1177%2F1753193419881086 Available through EBSCO Health Databases for PNZ members. Abstract We performed a prospective, observational study using a non-surgical, conservative protocol with immediate mobilization for the treatment of 101 isolated stable or initially unstable proximal phalangeal fractures. The patients were evaluated at the time of discharge from therapy treatment, mean 7 weeks (range 3-15) after conservative treatment. These patients achieved a median proximal interphalangeal joint extension of -4° (IQR 0, -8), a mean total active motion of 253° (SD 20) and minimal pain. We conclude that a non-surgical, conservative protocol can be used for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25° in the sagittal plane or 10° in the coronal plane following closed reduction. Our data supports that a conservative protocol can be the good option for isolated stable or initially unstable proximal phalangeal fractures. 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

  • Does cracking your knuckles cause hand OA?

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