Search Results

The effect of diabetes on functional outcomes among individuals with distal radial fractures Alsubheen, S., MacDermid, J., Walton, D., & Grewal, R. Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Distal radial fracture - diabetes and functional recovery This retrospective study assessed the effect of diabetes on functional recovery following a distal radial fracture. Functional recovery was measured through the Patient-Rated Wrist Evaluation (PRWE) questionnaire, and the presence of diabetes was self-reported by participants. A total of 479 participants were recruited at baseline and they were assessed at one week, three months, and one year after fracture. Participants were treated with splinting (10%), plaster cast (64%), and surgery (26%). The results showed that 10% (n = 48) of the participants reported diabetes (no information was provided on number of participants with Type 1 or Type 2 diabetes). Participants' functional improvements in the diabetes group were slower and smaller compared to the participants without diabetes, at both three months and one year. The results of this study need to be taken with caution. The statistical analysis did not take into consideration confounding factors such as additional comorbidities or fracture treatment modality. It is possible that factors other than diabetes may contribute to disparity between the two groups considered. Clinical Take Home Message: Hand therapists may consider following up diabetic patients with distal radial fractures over longer periods of time (possibly up to one year) compared to patients without this comorbidity. A greater attention towards optimisation of rehabilitation may be useful in this subgroup of patients. URL: https://www.jhandtherapy.org/article/S0894-1130(17)30201-6/fulltext

Development and validation of a prognostic, risk-adjusted scoring system for operative upper-extremity infections Sharma, K., Mull, A., Friedman, J., Pan, D., Poppler, L., Fox, I., Levin, L., & Moore, A. M. Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Post-surgical infections - prognostic factors This retrospective study assessed the ability of several risk factors to predict persistent post-surgical infections. The total number of participants was 602. Of these, 301 patients were utilised to assess the individual and combined effect of risk factors. The prediction ability of these risk factors was then validated on another group of 301 patients. The results showed that diabetes, smoking, and animal bites could predict a persistent infection. The presence of any of these factors in isolation increased the likelihood of persistent infections by 15%. The risk increased to 20% when a combination of two were present, and to 45% when all three risk factors were reported by patients. Clinical Take Home Message: Hand therapists may be alerted to a heightened risk of infection if patients report history of diabetes, smoking, or animal bites. Patients with these characteristics should be monitored for the onset of new symptoms and promptly referred if an infection is suspected. URL: https://www.jhandsurg.org/article/S0363-5023(19)31422-4/fulltext

Personal, biomechanical, psychosocial, and organizational risk factors for carpal tunnel syndrome: A structural equation modeling approach Roquelaure, Y., Garlantezec, R., Evanoff, B., Descatha, A., Fassier, J., & Bodin, J. Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Aetiologic Topic: Carpal tunnel syndrome - Demographic, biomechanical, psychological, and work pace factors This prospective study assessed the effect of age, gender, BMI, work-related biomechanical exposure, work-related psychological distress, and machine- vs customer-paced jobs on carpal tunnel syndrome (CTS) development. The study included a large sample (n = 1367) of participants involved in several different occupations. Work-related biomechanical exposure was defined as repetitive or sustained wrist movements for prolonged periods of time, exposure to vibration hand tools, activities involving pinching, and work requiring physical exertion. Work-related psychological distress factors included the inability to make autonomous decisions. Working pace was either set by machine production (machine-paced) or dependent on customer demands (customer-paced). All of the participants were healthy at baseline. At follow up (average 5 years), 3.7% of sample (n =51) participants presented with symptomatic CTS (pain/paraesthesia in the 2nd and 3rd digit) and of these, 2.3% of sample (n = 32) presented with signs of CTS (positive on either wrist flexion and compression, carpal compression, Phalen, or Tinel test). The results showed that older age and female gender were risk factors for CTS in this cohort. Biomechanical exposure was the main risk factor leading to CTS. Work-related psychological distress (inability to make autonomous decisions) indirectly increased the risk of CTS by increasing biomechanical exposure. Both biomechanical exposure and psychological distress (inability to make autonomous decisions) were increased when involved in machine-paced jobs. Customer-paced jobs appeared to reduce biomechanical exposure and reduce psychological distress, which reduced the risk of CTS. No direct link was found between psychological distress and CTS development. BMI was not associated with an increased risk of developing CTS. Clinical Take Home Message: Biomechanical exposure appears to be a key risk factor in the development of CTS. Hand therapists might liaise with the workplace supervisor to find strategies to limit extreme wrist position, repetitive motions, use of vibration hand tools, pinching activities, and physical exertion in patients presenting with CTS, or to prevent the development of this condition. Increasing the number of breaks or reducing the work load may be effective strategies. Hand therapists should be aware that workers in a machine-paced job are at higher risk of developing CTS. URL: https://journals.lww.com/pain/Fulltext/2020/04000/Personal,_biomechanical,_psychosocial,_and.11.aspx

Sticking to the facts: A systematic review of the effects of therapeutic tape in lateral epicondylalgia George, C., Heales, L., Stanton, R., Wintour, S., & Kean, C. Level of Evidence: 3a Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia – Effect of taping. This is a systematic review assessing the effect of strapping on pain and grip strength in patients with lateral epicondylalgia. The effect of rigid tape, kinesiotape, and placebo tape was assessed. Eight papers were included for a total of 183 participants with lateral epicondylalgia. The results showed that the placebo tape provided 3-22% symptomatic relief. The experimental taping was generally more effective than placebo taping and led to a 20-52% reduction in symptoms 30 minutes after its application. After 1 to 2 weeks of repetitive taping application, symptoms reduced by 17-61%. There were mixed findings for pain-free grip strength improvements. Clinical Take Home Message: Hand therapists may use rigid tape or kinesiotape to reduce symptoms in patients with lateral epicondylalgia. Taping appears to reduce symptoms immediately and in the short term. Hand therapists should not expect improvements in pain-free grip strength. URL: https://www.sciencedirect.com/science/article/pii/S1466853X1930032X?via%3Dihub

Value of physical tests in diagnosing cervical radiculopathy: A systematic review Thoomes, E., van Geest, S., van der Windt, D., Falla, D., Verhagen, A., Koes, B., Thoomes-de Graaf, M., Kuijper, B., Scholten-Peeters, W., & Vleggeert-Lankamp, C. Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Diagnostic Topic: Cervical radiculopathy – Physical tests This is a systematic review assessing the usefulness of physical tests in making a diagnosis of cervical radiculopathy in patients with a disk herniation or osteoarthritic changes. Five papers, which compared physical test results against MRI/CT scans or surgical findings were included. The variables of interest were the sensitivity and specificity of physical tests. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. Spurling’s test and cervical distraction test showed high specificity and low sensitivity. Upper limb neurodynamic tests showed high sensitivity and low specificity. The arm squeeze test showed high sensitivity and high specificity. The arm squeeze test is performed by compressing the anterior and posterior mid portion of the patient’s arm. The test is considered positive if compression of the arm is 3/10 points more painful than squeezing the patient’s shoulder joint. The cervical distraction test showed high specificity and low sensitivity. The cervical distraction test is considered positive when manual cervical traction relieves symptoms in the upper limb. Clinical Take Home Message: Based on what we know today, hand therapists may use a combination upper limb neurodynamic test, and arm squeeze test to rule out a radiculopathy. If neurodynamic tests do not elicit pain and the arm squeeze test is negative, the presence of a radiculopathy is less likely. A diagnosis of cervical radiculopathy can be made if the arm squeeze test and Spurling’s test are positive, and if the cervical distraction test relieves pain. URL: https://www.thespinejournalonline.com/article/S1529-9430(17)30918-X/fulltext

Observed patterns of cervical radiculopathy: how often do they differ from a standard, “Netter diagram” distribution? McAnany, S., Rhee, J., Baird, E., Shi, W., Konopka, J., Neustein, T., & Arceo, R. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Symptoms prevalence study Topic: Cervical radiculopathy – Dermatomal patterns This is a retrospective study assessing the agreement between radiculopathy symptoms reported by patients and standard textbook patterns of radiculopathy. Patients were selected if they presented with a single level cervical radiculopathy (identified through MRI/CT scan), if they had been unresponsive to conservative treatment, and if they had a 75% improvement of symptoms at 6 months after anterior cervical discectomy and fusion (ACDF) surgery. The results showed that ipsilateral neck pain was present in 80% of patients before surgery. Shoulder pain on the side of the radiculopathy was present in 60% of the cases before surgery. Any spinal level from C3-C4 to C7-T1 could present with symptoms beyond the shoulder before surgery. The pain/numbness patterns described by the patients significantly deviated from the patterns described in textbooks and only 54% of patients presented with a standard pain/numbness pattern. 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, radiculopathies may present with a dermatomal pattern as described in textbooks in 54% of the cases. The presence or lack of symptoms beyond the neck/shoulder is not useful in identifying the level of cervical compression. URL: https://doi.org/10.1016/j.spinee.2018.08.002 Abstract BACKGROUND CONTEXT Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a “Netter diagram.” To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF. PURPOSE The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns. STUDY DESIGN/SETTING A retrospective study. PATIENT SAMPLE Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included. OUTCOME MEASURES Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams. METHODS We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern. RESULTS Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p<.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern. CONCLUSIONS Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III level of evidence. 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

Evaluating the impact of gabapentinoids on sleep health in patients with chronic neuropathic pain: a systematic review and meta-analysis Kapustin, D., Bhatia, A., McParland, A., Trivedi, A., Davidson, A., Brull, R., & Singh, M. Level of Evidence: 1a Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Neuropathic pain - Pharmacological treatment This is a systematic review and meta-analysis on the effect of gabapentinoids (gabapentin and pregabalin) and placebo on sleep disturbance in patients with diabetic and postherpetic neuropatic pain. The results showed that sleep disturbances associated with pain and patient global impression of change (patient's satisfaction) improved significantly when high doses (higher than 300mg/day of pregabalin or 1800mg/day of gabapentin) of medications were provided for 6 weeks or longer. In contrast, low doses of gabapentinoids were only effective when treatment lasted for more than 6 weeks. Pain improved to a statistically significant, however, all the improvements did not reach the clinically important difference currently suggested for neuropathic pain. Patients in the gapapentinoids group had 2 to 6 times greater probability of being satisfied compared to the placebo group. Clinical Take Home Message: Hand therapists often assess and treat patients with neuropathic pain (e.g. carpal or cubital tunnel syndrome) who may be taking gabapentinoids. Hand therapist can remind patients that this treatment may take 6 weeks or longer to provide benefits and that drowsiness is a common side effect. They could also explain that improvements in pain and sleep may be modest with more than double probability of finding benefits compared to somebody taking a placebo pill. URL: https://journals.lww.com/pain/Abstract/2020/03000/Evaluating_the_impact_of_gabapentinoids_on_sleep.4.aspx

Avascular necrosis of the carpal bones other than Kienböck disease Afshar, A., & Tabrizi, A. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Avascular necrosis of carpal bones- Diagnosis and treatment This is a narrative review of carpal bones avascular necrosis (AVN) diagnosis and treatment. Due to their vascular anatomy, the scaphoid and capitate are the two most common bones presenting with AVN after the lunate. All the other carpal bones can present AVN but it is much less likely. Clinically, patients may present with wrist pain and a history of trauma. Objectively, there may be swelling, range of movement limitations, and grip strength deficits. X-rays are usually negative initially and further MRI imaging is required to make a diagnosis and exclude fractures, infections, and malignancies. Treatment for the initial stage includes NSAIDs, immobilisation, and corticosteroid injections. Bone grafts or surgical interventions with fusion or arthroplasty may be required if conservative treatment fails. Clinical Take Home Message: Avascular necrosis of the lunate (Kienböck's disease) is a rare condition and AVN of other carpal bones is even rarer. However, it is not unheard of and all the carpal bones can develop AVN with the scaphoid and capitate being the most prevalent after the lunate. Due to the possibility of scaphoid fractures resulting in AVN of the proximal pole or scaphoid non-uniuon advance collapse (SNAC), patients should be monitored closely during their recovery. Chronic pain following fractures of the hook of the hamate may alert the hand therapists to AVN of the hook which needs to be assessed through MRI. URL: https://www.jhandsurg.org/article/S0363-5023(18)31168-7/fulltext

Comparison of the effect of nocturnal use of commercial versus custom-made wrist orthoses, in addition to gliding exercises, in the function and symptoms of carpal tunnel syndrome: A pilot randomized trial Figueiredo, D., Ciol, M., da Conceição dos Santos, M., de Araújo Silva, L., Bidin Brooks, J., Santos Diniz, R., & Tucci, H. Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Carpal Tunnel Syndrome (CTS) conservative treatment - custom vs commercial orthosis. This is a pilot randomised controlled trial (n = 24) assessing the effectiveness of night use of a custom vs commercial splint in combination with tendon and median nerve gliding exercises in people with Carpal Tunnel Syndrome (CTS). The assessment was performed at baseline and after 45 days of therapy. The results showed that pain reduced to a statistically significant level in both groups with an improvement of 0.5/10 and 1.5/10 points in the commercial and custom splint group respectively. The reduction in pain was not clinically significant for either group, however, there was a trend for greater improvement in the custom-made splint. Functional improvement reached a clinically significant improvement in the custom-made splint with a 20% chance of this finding just being due to chance. Pulp to pulp and tripod pinch improved for both groups between 3% and 13% without a significant difference between groups. The authors also assessed extensor carpi radialis and flexor carpi ulnaris activation through EMG and found no difference before and after the intervention or between groups. Clinical Take Home Message: Hand therapists may decide to use a night splint to improve symptoms in people with CTS. There appears to be no difference between a custom made and a commercially available splint. Some functional and strength improvements may be evident after 6 weeks splinting, however, they may not reach a clinically significant level. URL: https://www.mskscienceandpractice.com/article/S2468-7812(19)30357-1/fulltext

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.