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Management of nondissociative instability of the wrist. Zelenski, N, & Shin, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Carpal instability non dissociative - Diagnosis and treatment This is a narrative review on presentation, diagnosis, and treatment of non dissociative carpal instability (CIND), which is reported as a rare condition. This pathology is defined as a loss of synchronous movement of the carpal rows associated with pathology of extrinsic ligaments of the wrist with intact intrinsic ligaments. In contrast, a carpal instability dissociative disorder (e.g. DISI, VISI) is characterised by an intrinsic ligament pathology of the wrist. Patients with CIND often report absence of trauma, achiness following activity, and relief by rest. Objectively, generalised ligament laxity has been reported in 70% of people with symptomatic CIND. The midcarpal shift test and axial load radioulnar deviation test are often performed. These tests should only be considered positive if there is an obvious hypermobility and patients report wrist pain. X-rays can identify volar intercalated segment instability (VISI) and/or subluxation of the carpus in relation to the radius. The authors suggest that pain is the only indication for treatment of CIND. Non operative treatment includes proprioceptive and resistance training, short time splinting, and taping as required. Surgical and conservative treatment outcomes are similar, making the non-operative option the first line treatment for these patients. If conservative treatment fails, surgical intervention with ligament reconstruction or arthrodesis may be performed. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, non dissociative carpal instability is a rarely encountered pathology. A history of atraumatic wrist pain, the objective presence of laxity (pain associated with hypermobility), a positive midcarpal shift test and axial load radioulnar deviation test may direct the hand therapist towards a diagnosis of CIND. First line treatment involves proprioceptive and strength training, escalated to surgical management if conservative treatment fails. URL: https://doi.org/10.1016/j.jhsa.2019.10.030 Abstract Nondissociative carpal instability is instability of an entire carpal row and can lead to vague ulnar-sided wrist pain as well as a clunking wrist. The etiology of this process is most often generalized ligamentous laxity; however, it can infrequently occur as a result of trauma or malalignment of the radiocarpal joint. Whereas treatment remains controversial, the literature supports nonsurgical management and includes patient education, dynamic placement of orthoses, proprioceptive therapy, and extensor carpi ulnaris strengthening. If extensive nonsurgical therapy fails, surgical intervention includes soft tissue and bony procedures, all with high complication and failure rates and limited long-term outcome data. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

The association between symptoms of depression and office visits in patients with nontraumatic upper-extremity illness. Crijns, T., Bernstein, D., Teunis, T., Gonzalez, R., Wilbur, D., Ring, D., & Hammert, W. Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Symptoms prevalence study Topic: Trigger finger, carpal tunnel syndrome, benign lumps, hand osteoarthritis, and de Quervain tendinopathy association with depression - Mental health and number of outpatient visits This retrospective study assessed the association between the number of visits to an outpatient hand surgeons' clinic and levels of pain and depression. The patients presented with several different conditions including trigger finger (30%), carpal tunnel syndrome (27%), benign lumps (20%), hand osteoarthritis (13%), and de Quervain tendinopathy (9%). The results showed that people with greater depressive symptoms or pain attended the clinic for an additional 2 appointments compared to the rest of the sample. Unfortunately, due to the study design, we cannot comment on whether higher levels of depression/pain lead to greater disease severity and therefore higher number of visit or vice versa. Clinical Take Home Message: Hand therapists could support patients with depression by providing information about free help lines. In addition, a referral to the GP or psychologist could be useful to initiate treatment for this condition. It is also possible that improvements in hand condition will lead to reduction in symptoms of depression. Further research will need to clarify this last point. URL: https://www.jhandsurg.org/article/S0363-5023(18)30704-4/abstract

Synovial hemangioma of the wrist with cystic invasion of trapezoid and capitate bones Zhao, X., Qi, C., Chen, J., Li, H., Zhang, Y., & Yu, T. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Synovial Haemangioma - Diagnosis and treatment This is the answer for the case study from last week. The patient was an 18 year old male who had been experiencing pain and swelling in the back of the wrist in the last 2 years. Objectively, there was a 3x3 cm non-pulsatile mass in the back of the wrist. Extension range of movement had a deficit of 20 degrees. X-ray was impeccable, however, computer tomography and MRI scans revealed an ill-defined soft tissue mass between scaphoid, trapezoid, and capitate. Following surgery, it was possible to make a diagnosis of wrist synovial haemangioma. Synovial haemangiomas are rare benign tumours which usually affect children or young adults. Only 300 cases have been reported in the literature, most of which occurred in the knee. Symptoms vary and intermittent pain may be present or absent. 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: Hand therapists should refer young children or teenagers for x-rays and ultrasound when there is evidence of an irregularly shaped, soft mass which appears to or is reported to have grown over time. The likelihood of identifying a synovial haemangioma is extremely rare, however, this work up would help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, haematomas associated with haemophilia, infections or other rare forms of cancer. URL: https://www.jhandsurg.org/article/S0363-5023(18)30316-2/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Synovial hemangiomas (SHs) are rare lesions of the joints or tendon sheaths that are difficult to diagnose. We present the case of an 18-year-old man with an SH in the wrist joint. Physical examination revealed a slightly tender, ill-defined, nonpulsatile soft mass, 3 cm × 3 cm in size on the dorsal aspect of the left wrist. Computed tomography showed an irregular, ill-defined, soft tissue mass in the expanded joint space, which was formed by the scaphoid, trapezoid, and capitate bones. Magnetic resonance imaging showed the typical features of SH and also revealed cavitary erosion of the scaphoid, trapezoid, and capitate bones. An open arthrotomy was performed via a dorsal approach, and the mass was excised. The histological examination findings were consistent with the diagnosis of SH.

Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture Dewan, N., MacDermid, J., MacIntyre, N., & Grewal, R. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Preventative Topic: Fracture prevention - Prevention of further falls/fractures after distal radius fracture. This survey study assessed clinicians' knowledge on prevention of subsequent falls/osteoporotic fractures in patients over 45 years old who presented to the clinic after a distal radius fracture. The results showed that there is a lack of attention towards assessment, treatment, and prevention in these patients with only 30% of therapists assessing either balance, lower limb strength, levels of physical activity, or fear of falling. These findings are despite compelling evidence that fall prevention treatments reduce the risks of falls by 50% in older adults. Outcomes measures such as the Chair Stand Test, the Timed up and Go test, the Rapid Assessment of Physical Activity scale, and Fracture Risk Assessment Tool (FRAX) can be used as simple screening tools. Several treatments including Tai Chi, progressive strength training, and aerobic exercises can be promoted to improve bone health. Clinical Take Home Message: Hand therapists should assess risk of falls in people over 45 years old who present to the clinic with a distal radius fracture. A quick assessment tool, which only requires demographic data and minimal history taking, is the FRAX. This is a freely available validated online tool which can predict risk of falls within the next 10 years. If interested, hand therapists can use the Chair Stand Test and the Timed up and Go test, which both take 1-4 minutes to complete. Once screened, patients could be provided with educational resources (e.g. NIH, NOF, IOF) or referred to other health practitioners for fall prevention programs and medical treatment for osteoporosis (e.g. Physiotherapists, community exercise classes, GPs). URL: https://www.jhandtherapy.org/article/S0894-1130(17)30270-3/fulltext

Anatomical relationship of palmar carpal bone landmarks used in locating the lunate and capitate during palpation: A cadaveric investigation Davis, A., Wilhelm, M., Pendergrass, T., Sechrist, D., Brismée, J., Sizer, P., & Gilbert, K. (2019) Level of Evidence: N/A Follow recommendation: N/A Type of study: Anatomical Topic: Carpal bone landmarks - Cadaveric study This anatomical study performed on 25 cadavers, on average 75 years old, identified four reliable ways of locating the capitate on the palmar aspect of the wrist and one reliable way of determining the position of the lunate on the dorsal aspect of the wrist (all 100% correct). The capitate was located by identifying the midpoint of the line between the scaphoid tubercle/trapezium tubercle and pisiform/hook of hamate. Alternatively, the crossing point between these lines could be used. Lunate was located correctly when the midpoint between the radial and ulnar styloid line was found on the dorsal aspect of the wrist. Clinical Take Home Message: Hand therapists can use the well-defined landmarks of the trapezium and scaphoid tubercle, pisiform, and hook of hamate to identify the position of the capitate palmarly. This may be useful in identifying capitate fractures, which occur in 1.3% of all carpal fractures, and capitate stress fractures occasionally identified in gymnasts. The correct identification of lunate's position may help differentiating between symptomatic presentation of lunotriquetral, scapholunate instability, or Kienböck's Disease. URL: https://www.jhandtherapy.org/article/S0894-1130(17)30323-X/fulltext

The relationship of mental health status to functional outcome and satisfaction after carpal tunnel release Maempel, J., Jenkins, P., & McEachan, J. Level of Evidence: 4 Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Carpal tunnel syndrome (CT) and mental health - Outcomes before and after surgical intervention This is a prospective cohort study assessing the relationship between mental health and outcomes following surgery for CT. The results are to be considered in the context of a few limitations. Of the entire cohort, only 52% of the participants returned the Short Form-12 (SF-12), used to assess mental health. In addition, SF-12 scores were only collected at one-year post surgery, which defeats the point of a prospective cohort study. The results show a correlation between mental health status and patient reported satisfaction at one year after surgery. There was also a statistically, but not clinically significant difference in QuickDASH scores of patients presenting with mental health problems compared to healthy patients at one year follow up. This correlation might be due to worse mental health state leading to lower function or vice versa. It is also possible that a third unknown variable, not measured in the present study, mediated this association. Clinical Take Home Message: Hand therapists should keep in mind that functional recovery of patients undergoing surgery for CT may be worse if they present with poorer mental health. A multidisciplinary approach to treatment and rehabilitation may be effective in improving functional outcomes. URL: https://journals.sagepub.com/doi/full/10.1177/1753193419866400

Short functional dynamic orthosis for proximal interphalangeal joint extension deficit. Crest design Cantero-Téllez, R. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Proximal interphalangeal joint (pipj) extension lag treatment - Dynamic orthosis. This practice forum presented step by step instructions on how to create a dynamic splint for pipj extensor lag. It is advised to wear the splint 6 hours daily in combination to a static night splint for 6/52. The orthosis is reported to be a useful alternative in settings where off the shelf products are not available. A piece of 1.6 to 2mm thermoplastic, orficast, and elastic bands are required. A small cylinder for the proximal phalanx is created and connected to the distal cylinder which includes the proximal and distal phalanx. The pipj is therefore left free to move. The two cylinders are connected on radial and ulnar side by two orficast stripes to warrant stability of the splint. Two hooks are positioned on the dorsal proximal cylinder and at the dorsal distal cylinder at dipj level. An elastic band is attached to the two hooks to assist with pipj extension and allow pipj flexion. Clinical Take Home Message: Hand therapists should make sure that the extension lag at the pipj is not due to a central slip before deciding to apply this splint. If no central splip is suspected, the clinician may consider this new design as an alternative to existing splints. If available, however, an off the shelf LMB finger extension splint would probably achieve the same result. In a low resource setting, a relative motion flexion splint may be a suitable alternative to this new design. URL: https://www.jhandtherapy.org/article/S0894-1130(18)30148-0/fulltext

Distal biceps tendon repair and reconstruction Srinivasan, R., Pederson, W., & Morrey, B. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Biceps tendon rupture - Incidence, surgery and rehabilitation. This narrative review reported on biceps tendon rupture demographics, diagnostic methods, conservative, surgical, and rehabilitative plans. Ninety percent of biceps tendon lesions occur in middle aged males with smoking and large BMI being significant risk factors. The Hook test is 95% sensitive (useful for screening) and 85% specific (useful for confirmation of diagnosis). MRI is the investigation of choice. Conservative management is appropriate for individuals with low functional demands, elbow OA, and significant medical comorbidities. Conservative management often leads to a forearm supination and elbow flexion strength deficits of 40% and 30% respectively. With operative management data suggests that there is limited flexion strength deficit, however, a 10-20% deficit in supination strength is likely to remain. In case of surgical management, the greatest risk for repair failure within the first two weeks. Post-surgical rehabilitation for low tension repairs requires a posterior elbow orthosis at 80° of elbow flexion and forearm neutral position worn 24/7 for 2/52. When the repair is performed under greater tension (repair after 4/52 from injury), the elbow orthosis is transformed into a hinge splint at 2 weeks with a block at 40° of flexion. Every week, the extension restriction is reduced by 10° until reaching 0° of extension at 6/52. After two weeks, the patient is allowed to lift a maximum of 2kg until week 6-10 according to the type of surgery and quality of tissues repair. Following this period, light resistance training can be initiated with a full return to heavy duties by 3-6 months. Complications can include paraesthesia of the radial aspect of the forearm due to a lateral antebrachial cutaneous nerve lesion or wrist/fingers/thumb extension and thumb abduction weakness due to involvement of the posterior interosseus nerve. Clinical Take Home Message: Hand therapists should use the hook test as a screening and diagnostic tool when suspecting biceps tendon rupture. Conservative treatment is an option, however, considering the complications associated with delays in surgical interventions beyond 4/52, it is advisable to refer patients with this condition to a hand surgeon. Post-surgical rehabilitation includes 2/52 full time elbow splinting, followed by range of movement exercises and introduction of light resistance exercises at 6-10/52 according to surgical procedure and quality of tissues repaired. Hand therapists should watch out for motor and sensory deficits following surgery as they are potential adverse events. URL: https://www.jhandsurg.org/article/S0363-5023(19)31469-8/fulltext

Associations between insurance type and the presentation of cubital tunnel syndrome Cheng, C., & Rodner, C. Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Symptoms prevalence study Topic: Cubital tunnel syndrome (CuTS) progression - Disease stage in privately vs publicly insured patients in USA. This retrospective study analysed Cubital tunnel syndrome (CuTS) stages and time to first surgeon’s visit in American patients who were either privately or publicly insured. The results showed the odds of publicly insured patient to have intrinsic hand muscles weakness, atrophy, mild to severe disturbances on moving two-point discrimination, and nerve conduction impairments, were 4.4 times larger than patients who were privately insured. In addition, the wait time in the publicly insured patients was twice (7yrs) as long as the one for privately insured patients (3.5yrs). It can be speculated that greater disease severity in the publicly insured group were due to longer time with the condition, lower socio-economic status and health literacy, and inability to take leave from work. Further studies need to verify whether any causality between these factors and disease severity exists. Clinical Take Home Message: Based on what we know today, patients with longer standing CuTS may present with worse signs and symptoms. To avoid long term consequences, a prompt referral to a hand surgeon may be useful when conservative treatment for CuTS fails. In the United States, therapists should be aware that publicly insured patients may present with a worse clinical condition compared to privately insured patients. URL: https://www.jhandsurg.org/article/S0363-5023(18)31402-3/fulltext 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