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The long term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Hamzeh, H., Madi, M., Alghwiri, A. A., & Hawamdeh, Z. (2020) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Carpal tunnel conservative intervention - Neurodynamic vs general exercise This is a randomised controlled trial assessing the effectiveness of neurodynamic exercise vs general exercises on function, pain, range of movement (ROM), and grip strength in people with carpal tunnel syndrome (CTS). All the participants included (n = 41) were diagnosed with CTS through subjective reports of paraesthesia in the median nerve distribution at the hand, a positive Phalen's test, and impairments on nerve conduction studies. Potential participants were excluded if they presented with a history of neck pain radiating to the upper limb and/or previous hand trauma. Participants were randomised to a neurodynamic exercise group (n = 26), or to a general exercise group (n = 25). Both groups received four individual supervised sessions of one hour each. The neurodynamic group underwent neurodynamic exercises and they were progressed to the next level of exercise when the symptoms were no longer elicited by previous week neurodynamic testing. They also completed neurodynamic exercises at home. The general exercise group received tendon gliding exercises, active range of movement, stretching, and strengthening exercises. Both groups were asked to perform the exercises twice daily. Treatment effectiveness was assessed through the Boston Carpal Tunnel Syndrome Questionnaire (Primary outcome), QuickDASH, numerical pain rating scale (NRS), wrist ROM, and grip strength (All secondary outcomes). Participants were assessed at baseline, one month, and six months. Both groups improved to a statistically and clinically significant level for most outcomes. Considering the multiple statistical tests undertaken, 25% of the results are due to chance. Nevertheless, neurodynamic testing appeared to provide statistically and clinically relevant greater improvements in pain and function (QuickDASH) at 1 month compared to the general exercise group. Thus, the difference between the two groups was close to 2 (95%CI: -3.45 to -0.41) points out of 10, and 13 (95%CI: -24.5 to -0.7) points out of 100 for the NRS and QuickDASH respectively. No adverse events were reported. The confidence intervals for both outcomes were quite wide, suggesting that the effect of the intervention was not consistent. Clinical Take Home Message: Hand therapists may use either neurodynamic or general exercises to improve the clinical presentation of people with CTS. Neurodynamic exercises may be more effective in improving pain and function compared to general exercises in the short term. Hand therapists should be aware that the improvements reported with neurodynamic exercises are substantially variable and range from large, beyond clinically relevant improvements, to the same improvement as with general exercises. URL: https://www.sciencedirect.com/science/article/abs/pii/S0894113020301447 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Carpal tunnel syndrome (CTS) is a common disorder that limits function and quality of life. Little evidence is available on the long-term effect of neurodynamics and exercise therapy. Purpose of the Study: This study aimed to examine the long-term effect of neurodynamic techniques vs exercise therapy in managing patients with CTS. Study Design: Parallel group randomized clinical trial. Methods: Of 57 patients screened, 51 were randomly assigned to either receiving four sessions of neurodynamics and exercise or home exercise therapy alone as a control. Blinded assessment was performed before treatment allocation, at treatment completion, and 6 months posttreatment. Outcome measures included Symptom Severity Scale (SSS), Functional Status Scale (FSS), Shortened version of the Disabilities of the Arm, Shoulder, and Hand (DASH), Numerical Pain Rating Scale, grip strength and range of motion. Results: Data from 41 individuals (52 hands) were analyzed. The neurodynamics group demonstrated significant improvement in all outcome measures at 1 and 6 months (P < .05). Mean difference in SSS was 1.4 (95% CI= 0.9-1.4) at 1 month and 1.6 (95% CI = 0.9-2.2) at 6 months. Mean difference in FSS was 0.9 (95% CI = 0.4-1.4) at 1 month and 1.4 (95% CI = 0.7-2.0) at 6 months. Significant between-group differences were found in pain score at 1 month (−1.93) and in FSS (−0.5) and Shortened version of DASH (−12.6) at 6 months (P < .05). No patient needed surgery 1 year after treatment. Conclusions: Although both treatments led to positive outcomes, neurodynamics therapy was superior in improving function and strength and in decreasing pain.

Manual therapy versus surgery for carpal tunnel syndrome: 4-year follow-up from a randomized controlled trial. Fernández-de-las-Peñas, C., Arias-Buría, J. L., Cleland, J. A., Pareja, J. A., Plaza-Manzano, G., & Ortega-Santiago, R. (2020) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Carpal tunnel conservative intervention - Manual therapy and exercise This is a randomised controlled trial assessing the effectiveness of a manual therapy approach vs surgery on pain in people with carpal tunnel syndrome (CTS). All the participants included (n = 120) were females on a waiting list for CTS surgery. Diagnosis of CTS was made through clinical findings (e.g. pain/paraesthesia in median nerve distribution and positive findings on Phalen's/Tinel's signs) and confirmed by nerve conduction studies. Participants were excluded if they had diabetes or thyroid conditions (which are known to worsen treatment prognosis), depression, if they were pregnant, or if they had other musculoskeletal conditions. Participants were randomised to a manual therapy and exercise program group (n = 60), or carpal tunnel decompression surgery (n = 60). The manual therapy and exercise program was delivered over the course of three sessions (one per week), each lasting 30 minutes. These sessions involved soft tissue mobilisation of potential entrapment sites af the median nerve. These included the pronator teres, biceps brachii, pectoralis minor, and scalene muscles. Lateral glides of the cervical spine and tendon/nerve gliding exercises were also completed. If interested, participants were also provided with an information sheet on how to perform tendon and nerve gliding. Treatment effectiveness was assessed through pain intensity (current and worst pain in the last week) on a numerical rating scale. Participants were assessed at baseline, one year, and 4 years. The results showed no difference between manual therapy and surgery at one year, and at 4 years. During the 4 years follow up, 9 participants (15%) in the manual therapy group, and 8 participants (13%) in the surgical group underwent surgery or a second surgery respectively (no differences between groups). Clinical Take Home Message: A manual therapy approach (mobilisation and tendon/nerve glides) directed at the upper limb appears to be as effective as surgery in the treatment of clients with carpal tunnel syndrome at one and four years follow up. Considering the low cost of three sessions of manual therapy compared to surgery, hand therapists should offer this treatment to clients. The combination of manual therapy, nerve gliding exercises, night splinting, and education may provide even better results, and a this conservative management approach should be trialed before undergoing surgery. URL: https://www.jpain.org/article/S1526-5900(15)00816-0/fulltext Available through EBSCO Health Databases if you have access (PNZ)

The title will be provided next week. Imran, R., & Jose, R. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: Skin rash – proximal compression Have a think about it this case study. If you like, you can leave a comment indicating what the diagnosis may be. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the arm proximally for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. What is it? URL: Next week

Adverse events in meditation practices and meditation-based therapies: a systematic review. Farias, M., Maraldi, E., Wallenkampf, K. C., & Lucchetti, G. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Meditation - Adverse events This is a systematic review and meta-analysis assessing adverse events associated with meditation practice. Fifty-four experimental studies, 14 cross sectional studies, and 15 case studies were included for a total of 6,464 participants. Studies were included if mindfulness or trascendental mediation were utilised. No formal critique of the included studies was reported (limitation). The prevalence and type of adverse events were reported. The overall prevalence of adverse events was 8.3% (95%CI: 5% to 12%). When only experimental studies were included, the prevalence reduced to 4% (95%CI: 2% to 5%). The most common adverse events included a worsening of anxiety (33%) and depression (26%). Clinical Take Home Message: Due to the close relationship between psychological factors and upper limb recovery or post surgical satisfaction following CTS surgery, we may refer our clients for meditation classes. If we decide to do so, we should warn them that there may be side effects such as worsening of their anxiety or depression. This occurs on average in 1 person out of 25. An alternative that does not appear to present with as many adverse event is yoga. Yoga sessions including at least 50% of physical exercise (e.g. asanas) appear to provide benefits with little or no side effects. Open Access URL: https://onlinelibrary.wiley.com/doi/epdf/10.1111/acps.13225 Abstract Objective: Meditation techniques are widely used as therapy and wellbeing practices, but there are growing concerns about its potential for harm. The aim of the present study is to systematically revie w meditation adverse events (MAEs), investigating its major clinical categories and its prevalence. Method: We searched PubMed, PsycINFO, Scopus, Embase and AMED up to October 2019. Eligible studies included origin al reports of meditation practices (excluding related physical practices such as Yoga postures) with adult samples across experimental, observational and case studies. We identified a total of 6742 citations, 83 of which met the inclusion criteria for MAEs with a total of 6703 participants who undertook meditation practice. Results: Of the 83 studies analysed, 55 (65%) included reports of at least one type of MAE. The total prevalence of adverse events was 8.3% (95% CI 0.05–0.12), though this varied considerably across types of studies – 3.7% (95% CI 0.02–0.05) for experimental and 33.2% (95% CI 0.25–0.41) for observational studies. The most common AEs were anxiety (33%, 18), depression (27%, 15) and cognitive anomalies (25%, 14); gastrointestinal problems and suicidal behaviours (both 11%, 6) were the least frequent. Conclusion: We found that the occurrence of AEs during or after meditation practices is not uncommon, and may occu r in individuals with no previous history of mental health problems. These results are relevant both for practitioners and clinicians, and con tribute to a balanced perspective of meditation as a practice that may lead to both positive and negative outcomes

A prospective randomized trial comparing the functional results of buddy taping versus closed reduction and cast immobilization in patients with fifth metacarpal neck fractures. Martínez-Catalán, N., Pajares, S., Llanos, L., Mahillo, I., & Calvo, E. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: 5th metacarpal neck fracture - buddy splinting This is a randomised controlled trial assessing the effectiveness of buddy taping vs close reduction and immobilisation in participants with 5th metacarpal neck fracture with less than 70° of volar angulation. Participants (N = 72) were included if they presented with a 5th metacarpal fracture within 72 hours to the emergency department. Participants were excluded if they presented with more than 70° of volar angulation, a comminuted fracture, previous 5th metacarpal fracture, rotational deformity, additional fractures, tendon injuries, or open fractures. Effectiveness of each intervention was assessed through the DASH (primary outcome) and pain (VAS), radiographs for fracture alignment, range of movement (degrees of mcpj movement), time for return to work, and grip strength (all secondary outcomes). The outcomes were measured at baseline, 3 and 9 weeks, and 12 months. Treatment allocation was randomised. The assessor was not blinded to treatment allocation. Participants were provided with either buddy taping of the ring finger and little finger (n = 36) or closed reduction and cast immobilisation (n = 38). The buddy taping group did not undergo a closed reduction and could mobilise wrist and fingers immediately. Buddy strapping was removed at three weeks and from nine weeks they could do heavier exercises. The immobilisation group underwent closed reduction followed by casting from the pipj to the forearm. The cast was removed at three weeks and followed a similar treatment progression to the buddy splinting group (You will not find the treatment details in the full text as they did not include them. I emailed the first author Natalia and they kindly provided with further information). The results showed that participants in the buddy splinting group had much greater function (twice the minimal clinical important difference), lower pain, similar volar angulation, and grip strength at 3 weeks compared to the close reduction and immobilisation group. In addition, the buddy splinting group returned to work 29 days earlier compared to the closed reduction and immobilisation group. Unfortunately, no information was provided in terms of what work they return to (sedentary vs manual). When asked, the first author confirmed that also manual laborers took part in the study without complications (Thanks Aaron for suggesting to get more information in this regard). Clinical Take Home Message: Hand therapists may choose to use buddy splinting for 5th metacarpal neck fracture presenting with no rotational deformity and less than 70° of volar angulation. However, hand therapists may utilise a hand based ulnar gutter splint to limit clients who are really eager to return to heavy manual tasks and reduce pain associated with potential knocking of the fracture site (Thanks Aaron White for the awesome discussion about this article!). URL: https://www.jhandsurg.org/article/S0363-5023(20)30280-X/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Although fifth metacarpal neck fractures are typically treated nonsurgically, most often with closed reduction and orthosis immobilization, cast immobilization may not improve outcomes compared with buddy taping without reduction. The aim of this study was to compare functional outcomes of buddy taping versus reduction and cast immobilization in patients with fifth metacarpal neck fractures. Methods: Adult patients with acute fifth metacarpal neck fractures with less than 70º volar angulation and without rotational deformity were randomly assigned to be treated either with buddy taping or a cast after closed reduction. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score at 9 weeks. Secondary outcomes included the DASH score at 3 weeks and 1 year, range of motion of the metacarpophalangeal joint, pain, grip strength, return to work, radiographic angulation, and complication rate. Results: We recruited 72 patients between August 2016 and January 2018. After 3 weeks, the DASH score was significantly lower for patients treated with buddy taping (19.7 ± 19.7) compared with cast immobilization (44.6 ± 15.0). At 9 weeks, clinical outcomes in the buddy taping group were better in terms of range of motion and DASH score, with a mean difference of 6.3 points, which did not exceed the minimally clinically important difference. There were more complications in the cast immobilization group. Fracture angulation after reduction was followed by a loss of reduction at 3 weeks’ follow-up and equivalent residual radiographic volar angulation was observed at 3 and 9 weeks after injury in both groups. Duration of time off from work was 28 days shorter with buddy taping compared with cast treatment. Conclusion: There is no benefit to reduction and orthosis immobilization of fifth metacarpal neck fractures with an initial angulation less than 70°. Use of buddy taping and early mobilization had good clinical results as well as significant improvement in time lost from work.

Association of daily step count and step intensity with mortality among us adults. Saint-Maurice, P. F., Troiano, R. P., Bassett, D. R., Jr., Graubard, B. I., Carlson, S. A., Shiroma, E. J., . . . Matthews, C. E. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: Daily steps - Mortality prediction This is a prospective cohort study assessing the effectiveness of step count and intensity on mortality. A total of 6,355 participants were included at baseline. Participants were followed up for 3 years. Participants were on average 57 years old. The step count and intensity was measured for one week only at baseline. The step count and intensity (walking speed) was measured through a device placed at the ankle. The results showed that participants completing 8,000 steps a day (7.5% of them died) were 50% less likely to die at any timepoint during the three year study compared to participants completing 4,000 steps per day (15% of them died). Greater step counts (12,000 steps/day - 5% of them died) reduced the likelihood of dying (at any point during the study) by 75% compared to the participants completing 4,000 steps per day. Stepping intensity (walking speed) did not predict mortality. The correlation reported in this study does not suggest causation and there may be other factors that explain this association. Clinical Take Home Message: Mortality appears to be higher in adults with lower number of daily step count. This synopsis is a nice addition to the one that was previously completed on grip strength and mortality. Due to the nature of the study considered, it is not possible to determine causality between the number of daily steps and mortality. However, hand therapists may prescribe clients with a walking regime with the aim of achieving the well known 10,000 seps per day. This may provide them with a longer lifespan (length of life) and healthspan (years of quality life - free from disease). URL: https://jamanetwork.com/journals/jama/article-abstract/2763292 Available through EBSCO Health Databases for PNZ members.

Inappropriate preoperative gabapentinoid use among patients with carpal tunnel syndrome. Billig, J. I., Sears, E. D., Gunaseelan, V., Santosa, K. B., Iwashyna, T. J., Englesbe, M. J., . . . Waljee, J. F. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Gabapentin - Carpal tunnel syndrome This is a prospective study assessing the risks associated with the use of gabapentinoids (i.e. gabapentin and pregabalin) before a carpal tunnel syndrome (CTS) decompression surgery. A total of 56,593 participants were included. Participants were followed up at 3 and 6 months after surgery. More than 50% of participants were over 50 years old. The risk was assessed by quantifying the number of patients who continued utilising gabapentinoids or started utilising opioids after CTS surgery. The results showed that participants who utilised gabapentinoids prior to CTS surgery were 19 times (relative risk) more likely to continue utilising gabapentinoids after surgery. In addition, patients taking gabapentinoids pre-surgery were 2.3 times more likelly (relative risk) to start using opiods after CTS surgery. The findings did not change when people with persistent pain conditions (e.g. arthritis) in addition to CTS were excluded from the analyses. Clinical Take Home Message: Hand therapists should advise against the use of gabapentinoids for the treatment of CTS. Gabapentinoids have not shown to be more effective than placebo for CTS (Hui et al., 2010) and they may double the probability of clients starting to use opioids after CTS surgery. Hand therapists should encourage the implementation of evidence-based non surgical interventions (e.g. education and splinting, manual therapy) instead of gabapentinoids use. If non surgical interventions fail, referral to a hand specialist for potential surgery is indicated. URL: https://www.jhandsurg.org/article/S0363-5023(20)30213-6/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.

Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. Surgical exploration for diagnostic and potential treatment purposes was undertaken. The procedure revealed the presence of a Linburg-Comstock syndrome. This is a tendinous connection between flexor pollicius longus (FPL) and flexor digitorum profondus (FDP) (of the index finger in this case) which is present in 30% of people. A tenosynovectomy was completed to allow for independent tendon gliding of the FPL and FDP. At three months follow up symptoms had markedly improved and at one year follow up, symptoms had completely resolved. Clinical take home message: Hand therapists may consider Lindburg-Comstock syndrome when the ipj of the thumb is unable to flex without dipj flexion of the index finger. This syndrome may be painful and surgical release can provide symptoms resolution. If you enjoyed this type of synopsis, put a like on it! URL: https://www.jhandsurg.org/article/S0363-5023(20)30189-1/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract With the intricate anatomy of the hand and upper extremity, there are many possible etiologies of pain. In addition, one must be alert to conditions typically affecting other areas of the body presenting in the hand and upper extremity. To add to the complexity of diagnosis, one must also be aware of potential secondary gains. With this in mind, a thorough history, physical examination, and broad differential can help avoid mislabeling patients with uncommon ailments. In this article, we present 4 cases of unusual causes of hand and upper extremity pain.

Entrapment neuropathies: A contemporary approach to pathophysiology, clinical assessment, and management. Schmid, A. B., Fundaun, J., & Tampin, B. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Symptoms prevalence, Aetiologic, Diagnostic, Therapeutic Topic: Entrapment neuropaties - Presentation and diagnostics This is an updated narrative review on clinical presentation, aetiology, and diagnostic tests for peripheral neuropathies (e.g. carpal tunnel syndrome - CTS). In terms of aetiology, genetic predisposition appears to be one of the strongest risk factors for entrapment neuropathies. It is unknown whether these genetic changes cause entrapment neuropathies due to anatomical alterations of the tunnels or connective tissue impairments within the nerve. The pathophysiology of compression neuropathy includes oedema, ischemia, and fibrosis of tissues within the nerve and outside of the nerve, which are believed to limit neural gliding. Moderate to severe entrapment neuropathies also present with axonal degeneration and/or demyelination, which causes nerve conduction blocks or slowing down of information transmission. These changes may lead to random electric shock symptoms or symptoms provoked by Tinel's testing. These axonal impairments often involve small fibre (detecting hot/cold and pinprick) during the initial stages of the entrapment neuropathy and large fibre (affecting light touch and muscle contraction) when the neuropathy becomes more severe. Interestingly, neuroinflamation has been suggested to increase the sensitivity of the affected nerve, often causing symptoms beyond the peripheral innervation territory of the compressed nerve. Changes within the central nervous system have also been identified in people with entrapment neuropathies. However, it is still unclear whether changes within the central nervous system can lead to on-going symptoms in absence of peripheral nerve entrapment. From an objective assessment point of view, in addition to motor and monofilament testing (Aβ - large fibre), pin prick testing (Aδ and C - small fibre) should be completed. A loss of function (painless weakness, larger monofilament required, or inability to feel pain on pin prick testing) could be used to confirm a neuropathy. Nerve conduction studies and US imaging may be useful in excluding differential diagnoses. Clinical Take Home Message: Hand therapists should be aware that entrapment neuropathies often present with unconventional peripheral nerve patterns. The distribution of symptoms outside of peripheral nerve patterns or dermatomal patterns does not excluded the presence of an entrapment neuropathy. Pin prick testing should be included in the objective assessment, and US imaging may be useful in assessing nerve edema and exclude other conditions. The same authors have published another article, which has been covered in a previous synopsis. Open Access URL: https://journals.lww.com/painrpts/Fulltext/2020/08000/Entrapment_neuropathies__a_contemporary_approach.4.aspx Abstract Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This paper presents with four case studies. I covered one case in a previous synopsis and the following is another interesting case. Have a think about it. If you like, you can leave a comment indicating what the diagnosis may be and how you would treat it. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. What is it and how would you treat it? URL: https://www.jhandsurg.org/article/S0363-5023(20)30189-1/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.

Acute scaphoid fractures: guidelines for diagnosis and treatment. Clementson, M., Björkman, A., & Thomsen, N. O. B. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Scaphoid fractures - when to refer This is a narrative review on diagnosis and treatment of schapoid fractures. Scaphoid fractures represent 60% of the carpal fractures and 10% of all hand fractures. Most often, the scaphoid fracture is located at the waist (70%) with a smaller percentage affecting the distal pole (25%), or the proximal proximal pole (5%). A few clinical diagnostic tests are available and they include tenderness on palpation at the snuff box or scaphoid tubercle, and pain on axial compression of the thumb. Each of these three tests is very sensitive (100%), meaning that if no pain is elicited, it is very unlikely that the client presents with a scaphoid fracture. However, only the combination of three positive tests has a reasonable specificity (74%), meaning that if all three tests reproduce pain there is a higher probability of scaphoid fracture. X-rays are useful but are not very sensitive (70% sensitivity - not always useful in excluding a fracture). If an x-ray is negative and there is clinical suspicious of a scaphoid fracture, the wrist should be immobilised and x-ray repeated at 2 weeks. If a scaphoid fracture is identified on x-ray, the treatment depends on the fracture location and stability of the fracture. Distal pole fractures (25% of scaphoid fractures) are the most likely to heal with conservative treatment and require between 4 (tubercle fracture) and 6 weeks (distal pole, not tubercle) of immobilisation. Surgical treatment of scaphoid distal pole fracture should be considered if the fracture is displaced. Scaphoid waist fractures can be treated conservativaly with immobilisation for 6 to 10 weeks if they are not displaced. Longer immobilisation periods are suggested if the fracture is comminuted, the client is a smoker, or if there is limited compliance. Displaced fractures of the waist of the scaphoid require surgical treatment. Proximal pole scaphoid fractures require surgical treatment more often than conservative treatment. This is irrespective of fracture displacement. A short arm cast should be utilised for conservative treatment as there is no benefit in utilising a cast which includes the whole thumb. Clinical Take Home Message: Hand therapists may treat scaphoid distal pole or waist fractures conservatively if there is no displacement. This can be done with a short arm cast, which allows thumb movement. If fracture displacement is suspected, referral to a hand surgeon is warranted in all cases except for a scaphoid tubercle fracture. Scaphoid proximal pole fractures require surgical treatment without exception. Open Access URL: https://online.boneandjoint.org.uk/doi/epub/10.1302/2058-5241.5.190025

Quantification of hand function by power grip and pinch strength force measurements in ulnar nerve lesion simulated by ulnar nerve block. Wachter, N. J., Mentzel, M., Krischak, G. D., & Gülke, J. (2018) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Ulnar nerve impairment - Grip strength This is a study assessing hand strength before and after an ulnar nerve block at the Guyon's canal in the same participants (within-subject design). Twenty-five healthy participants were recruited for this study. Hand strength was assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tip to tip, tripod, and key pinch). The measurement were taken before and after the injection, without randomisation of condition (this is a limitation). The results showed that the greatest impairments were identified in the pinching tests (58-60% reduction) compared to grip testing (27% reduction in strength). Clinical Take Home Message: Hand therapists may utilise pinch strength as a measure of impairment/recovery for clients with entrapment neuropathies or lacerations of the ulnar nerve. The significant impairments in pinch strength following an ulnar nerve block are not surprising considering the innervation of the flexor pollicis brevis (deep portion), adductor pollicis and first dorsal interosseous by the ulnar nerve. In addition, the presence of a Riche-Cannieu anastomosis (ulnar to median nerve within the hand), which is present in 60% of subjects, may further explain the significant impairment caused by an ulnar nerve block at the Guyon's canal. URL: https://www.jhandtherapy.org/article/S0894-1130(16)30191-0/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members.