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Prognostic factors specific to work-related musculoskeletal disorders: An overview of recent systematic reviews. Tousignant-Laflamme, Y., et al. (2023) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Prognostic Topic: Modifiable factors - Personalise recovery This is a systematic review summarising the evidence on modifiable prognostic factors associated with recovery following work-related musculoskeletal injuries. A total of 20 studies were included. The best evidence suggested that modifiable factors include receiving rehabilitation, negative expectations for return to work, higher levels of pain catastrophising, participation of stakeholders in return to work, odd working positions, heavy loads at work, high body weight, and high pain intensity. Other factors shown in the figure below showed a correlation with recovery, however, they were supported by lower quality evidence. 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, focusing on the identification of modifiable prognostic factors may help personalise and improve rehabilitation in people with work-related musculoskeletal injuries. These factors may include barrier removal to participation in rehabilitation (e.g. reduction of fees), improve patients confidence in their ability to return to work, include the employers in return to work program, reduce pain catastrophising, provide ergonomic advice, and reduce pain intensity levels. By doing so, hand therapists can personalise treatment and improve patients' recovery. The results of this review are in line with previous evidence for recovery trajectories in musculoskeletal conditions. To read even more on factors affecting recovery in our upper limb patients, have a look at the database. URL: https://doi.org/10.1016/j.msksp.2023.102825 Abstract Purpose: Work-related injuries affect a considerable number of people each year and represent a significant burden for society. To reduce this burden, optimizing rehabilitation care by integrating prognostic factors (PF) into the clinical decision-making process is a promising way to improve clinical outcomes. The aim of this study was to identify PF specific to work-related musculoskeletal disorders. Methods: We performed an overview of systematic reviews reporting on PF that had the following outcomes of interest: Return to work, pain, disability, functional status, or poor outcomes. Each extracted PF was categorized according to its level of evidence (grade A or B) and whether it was modifiable or not. The risk of bias of each study was assessed with the ROBIS tool. Results: We retrieved 757 citations from 3 databases. After removing 307 duplicates, 450 records were screened, and 20 studies were retained. We extracted a total of 20 PF with a Grade A recommendation, where 7 were deemed modifiable, 11 non-modifiable and 2 were index test. For example, return to work expectations, previous sick leave, delay in referral and pain intensity were found to be predictors of return-to-work outcomes. We also identified 17 PF with a Grade B recommendation, where 11 were deemed modifiable. For example, poor general health, negative recovery expectations, coping and fear-avoidance beliefs, pain severity, and particularly physical work were found to predict return to work outcomes. Conclusion: We found numerous modifiable PFs that can help clinicians personalize their treatment plan beyond diagnostic-related information for work-related musculoskeletal disorders. 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

Recurrent and persistent carpal tunnel syndrome: Predicting clinical outcome of revision surgery. Sun, P. O., et al. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Prognostic Topic: Carpal tunnel revision - who responds? This is a prospective study assessing the clinical outcome of revision surgery for carpal tunnel syndrome (CTS). A total of 114 participants who had a previous carpal tunnel release, who still presented with symptoms were included. The results showed that revision surgery significantly improved symptoms and function in the majority of patients. However, a longer total duration of symptoms, a higher Boston Carpal Tunnel Questionnaire (BCTQ) total score at intake, and diagnosis of complex regional pain syndrome (CRPS) along with CTS were associated with worse outcomes at 6 months post-operatively. The statistical analyses only explained 30% of the variance in outcome and other variables are likely to play a role in patients' recovery. 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, revision surgery for carpal tunnel syndrome (CTS) is an effective treatment for patients with recurrent and persistent symptoms. However, in patients with lower scores on the Boston Carpal Tunnel Questionnaire, longer duration of symptoms, and diagnosis of CRPS the likelihood of improvement with revision surgery is reduced. These results appear to support additional evidence on prognostic factors for responders to carpal tunnel release. URL: https://doi.org/10.3171/2018.11.JNS182598 Abstract OBJECTIVE: The aim of this study was to evaluate the self-reported outcome of revision surgery in patients with recurrent and persistent carpal tunnel syndrome (CTS) and to identify predictors of clinical outcome of revision surgery. METHODS: A total of 114 hands in 112 patients were surgically treated for recurrent and persistent CTS in one of 10 specialized hand clinics. As part of routine care, patients were asked to complete online questionnaires regarding demographic data, comorbidities, and clinical severity measures. The Boston Carpal Tunnel Questionnaire (BCTQ) was administered at intake and at 6 months postoperatively to evaluate clinical outcome. The BCTQ comprises the subscales Symptom Severity Scale (SSS) and Functional Status Scale (FSS), and the individual scores were also assessed. Using multivariable regression models, the authors identified factors predictive of the outcome as measured by the BCTQ FSS, SSS, and total score at 6 months. RESULTS: Revision surgery significantly improved symptoms and function. Longer total duration of symptoms, a higher BCTQ total score at intake, and diagnosis of complex regional pain syndrome (CRPS) along with CTS were associated with worse outcome after revision surgery at 6 months postoperatively. The multivariable prediction models could explain 33%, 23%, and 30% of the variance in outcome as measured by the FSS, SSS, and BCTQ total scores, respectively, at 6 months. Although patients with higher BCTQ scores at intake have worse outcomes, they generally have the most improvement in symptoms and function. CONCLUSIONS: This study identified total duration of symptoms, BCTQ total score at intake, and diagnosis of CRPS along with CTS as predictors of clinical outcome and confirmed that revision surgery significantly improves self-reported symptoms and function in patients with recurrent and persistent CTS. Patients with more severe CTS symptoms have greater improvement in symptoms at 6 months postoperatively than patients with less severe CTS, but 80% of patients still had residual symptoms 6 months postoperatively. These results can be used to inform both patient and surgeon to manage expectations on improvement of symptoms. 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

Scapholunate instability: Diagnosis and management - Anatomy, kinematics, and clinical assessment - Part I. Wessel, L. E. and Wolfe, S. W. (2023) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Diagnostic, Therapeutic Topic: Scapholunate injury - Diagnosis and treatment This review provides an update on the anatomy of the scapholunate ligament and its stabilizing ligaments, such as the dorsal capsuloligamentous scapholunate septum, the deep scapholunate ligament, and the dorsal intercarpal ligament. Scapholunate instability is a term used to describe wrist dysfunction resulting from disruption of the scapholunate interosseous ligament. It is important to remember that the severity of scapholunate injuries sits on a spectrum rather than being a categorical presentation (yes/no instability). High-resolution MRI is the imaging modality of choice if available. If not available, clenched fist pencil view and Watson's test appear to be useful in making a diagnosis. 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, scapholunate instability is a complex condition that requires a thorough understanding of ligament anatomy and pathoanatomy, as well as normal and injured carpal kinematics. It is important to be aware of the imaging available (e.g. clenched fist pencil view, US imaging), which allows us to make a diagnosis of the condition. Once the diagnosis is made, early (within 6 weeks from injury) or delayed (within 12 weeks from injury) surgery provides similar outcomes. In terms of post-surgical rehabilitation, early mobilisation (after 2 weeks from surgery) or delayed mobilisation (5-6 post-surgery), provides similar outcomes. URL: https://doi.org/10.1016/j.jhsa.2023.05.013 Abstract Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes. 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

Anatomic relationship of hand intrinsic tendons at the metacarpal head as it relates to the diagnosis of saddle syndrome: A cadaveric study. Campbell, B. R., et al. (2023) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic This cadaveric study explored the anatomy of the deep transverse metacarpal ligament (TML) and the intrinsic muscle of the hand in an attempt to clarify diagnosis and treatment of saddle deformity. This condition is caused by adhesions between the lumbrical and interosseous tendons plus/minus TML. Measurements between the TML and the joined tendon of lumbricals and interossei was assessed in both the neutral and intrinsic plus positions. Results showed that the distance between the tendons and TML decreased towards the ulnar digits and when assuming an intrinsic plus compared to neutral position. It was concluded that if inflamed/injured, the joining between lumbrical and interossei may cause impingement when getting into the intrinsic plus position or when stretching the intrinsic muscles of the hand. Corticosteroid injections, physical therapy, and in the most complex cases surgical release are successful (87%) in providing good to excellent outcomes. 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, saddle deformity is an underrecognized and underreported pathology following traumatic events of the hand. Symptoms can be reproduced during either stretching of the intrinsic muscles of the hand or during active intrinsic plus movement. The results of the study highlight the importance of getting the hand moving as soon as possible following trauma. In addition, it highlights that immobilising the hand in POSI may contribute to the development of saddle deformity as in this position the tendon joining the intrinsic and lumbrical muscles is in close proximity to the deep transverse carpal ligament. If you would like to see a clinical example of saddle deformity, have a look at this case study. URL: https://doi.org/10.1016/j.jhsa.2023.06.005 Abstract Purpose: The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity—posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation. Methods: Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or “true tendon,” were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as “pseudotendon.” Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion. Results: The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits. Conclusions: There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas. Clinical relevance: These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML in vivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice. 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

Predicting the need for collateral ligament repair in transolecranon fractures of the elbow: A traffic light model. Stringfellow, T. D., Matheron, G., Subramanian, P. and Domos, P. (2023) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Diagnostic Topic: Transolecranon fractures x-ray – LCL rupture This retrospective study assessed the need for lateral collateral ligament (LCL) repair in transolecranon fractures of the elbow. A total of 19 consecutive participants with transolecranon fracture dislocations were included. The indirect measure utilised to determine the need for LCL repair was the distance between the centre of the radial head and the center of the capitellum obtained on lateral x-rays. Results showed that when the radial head was displaced more than 1 cm, there was a high likelihood of LCL rupture and the need for repair. A traffic light model was developed to triage the likelihood of needing a collateral ligament reconstruction. Further work is needed to validate this model and assess its value in clinical practice. 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, transolecranon fractures of the elbow can be difficult to classify and manage. If the distance between the centre of the radial head and capitellum is more than 1 cm, an LCL repair is likely required. Keep in mind that this threshold has not been validated in a different population other than the sample studied. Assessment of LCL injury in less severe elbow injuries may be performed through the postero-lateral rotatory drawer test of the elbow, which appears to have high sensitivity and specificity. URL: https://doi.org/10.1016/j.jse.2023.06.006 Abstract Background: Biomechanical studies have shown translation of the proximal radius relative to the capitellum in the sagittal plane can predict integrity of the collateral ligaments in a transolecranon fracture model; no studies have examined this in clinical practice. Methods & Materials: Nineteen consecutive transolecranon fracture dislocations were retrospectively reviewed. Data collection included: patient demographics, fracture classifications, surgical management and failure with instability. Distance between the center of the radial head and the center of the capitellum was measured on initial radiographs by two independent raters on three separate occasions. Statistical analysis was used to compare the median displacement between patients who required collateral ligament repair for stability and those who did not. Results: Sixteen cases with a mean age of 57 years (32-85) were analyzed with an inter-rater Pearson coefficient of 0.89 for displacement measurement. Median displacement where collateral ligament repair was needed and performed was 17.13mm (IQR=10.43-23.88) compared with 4.63mm (IQR=2.68-6.58) where collateral ligament repair was not performed and not required; p=0.002. In 4 cases, ligament repair was not performed initially but deemed necessary based on clinical outcome, postoperative and intra-operative images. Of these, the median displacement was 15.59mm (IQR=10.09-21.20) and 2 of these required revision fixation. Discussion: Where displacement on initial radiographs exceeded 10mm, LUCL repair was required in all cases (red group). If less than 5mm, ligament repair was not required in any case (green group). Between 5-10mm, following fracture fixation, the elbow must be screened carefully to assess for any instability and a low threshold set for LUCL repair to prevent posterolateral rotatory instability (amber group). Using these findings, we propose a traffic light model to predict the need for collateral ligament repair in transolecranon fractures and dislocation. 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

Comparison of total elbow arthroplasty complications between various surgical indications at 90-day and 1-year follow-up in 1600 elbows. Romero, B., et al. (2023) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Prognostic Topic: Total elbow arthroplasty - Complications This retrospective study assessed complications following total elbow arthroplasty (TEA) for rheumatoid arthritis (RA), elbow osteoarthritis (OA), and fracture (FX) in 1,600 elbows. The results showed that there were no significant differences in systemic complications and surgical complications between the three groups at 90 days post-operatively. However, at 1 year post-operatively, patients who had a TEA for an elbow fracture were more likely to have elbow stiffness (compared to TEA for elbow OA) and RA patients were more likely to have wound disruption and deep infection. For a full list of complications post-TEA, have a look at the table 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, TEA is an effective solution with moderate complication rates for patients with elbow fractures, osteoarthritis, and rheumatoid arthritis. However, patients undergoing TEA following an elbow fracture are more likely to have elbow stiffness (compared to TEA for elbow OA) due to heterotopic ossification at one-year post-surgery. Have a look at what other causes may lead to elbow stiffness. This is an important issue as greater elbow stiffness is associated with greater levels of depression. URL: https://doi.org/10.1016/j.jse.2023.02.008 Abstract Background: Total elbow arthroplasty (TEA) was traditionally a mainstay of treatment for patients with severe inflammatory arthritis. Recently, the indications for TEA have expanded, and TEA has grown into a versatile procedure that can be used to treat several pathologies of the elbow. The objective of this study was to compare complication rates between TEAs performed for rheumatoid arthritis (RA), fracture (FX), or osteoarthritis (degenerative joint disease [DJD]). Methods: A retrospective analysis of the MUExtr data set of the PearlDiver national database was performed. International Classification of Diseases, Tenth Revision codes were used to identify patients who underwent TEA from 2010-2020 and to separate them into RA, FX, and DJD cohorts. Demographic characteristics, comorbidities, and hospital data were identified and compared using analysis of variance. Systemic complications at 90 days and surgical complications at both 90 days and 1 year were compared using multivariable logistic regression. Surgical complications included wound dehiscence, hematoma, deep infection, periprosthetic FX, stiffness, instability, triceps injury, nerve injury, and need for revision. Results: We identified 1600 patients (DJD, 38.9%; FX, 48.8%; and RA, 12.3%). The majority of patients in all 3 cohorts were female patients, with the RA group having a significantly higher percentage of female patients than the FX and DJD groups (87.3% vs. 81.4% and 76.9%, respectively; P = .003). No significant differences in systemic complications and surgical complications were noted between all 3 groups at 90 days postoperatively. After controlling for patient factors, FX patients were more likely to have elbow stiffness (odds ratio, 1.53; P = .006) and less likely to have a triceps injury (odds ratio, 0.26; P < .001) at 1 year than were RA or DJD patients. Conclusion: The indications for TEA have expanded over the past 10 years, with nearly half of all cases being performed for FX. At 1 year postoperatively, TEAs performed for FX have a significantly lower rate of triceps injury and higher rate of elbow stiffness than TEAs performed for other indications. This finding is important to consider when preoperatively planning, as well as when discussing expected outcomes with patients prior to surgery, especially with the expanded incidence of TEA for FX being performed over the past decade. 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

Comparison of intralesional corticosteroid injection with and without thumb Spica cast for de-Quervain tenosynovitis. Shahzad, K., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: De Quervain tenosynovitis - Injection plus splinting? This non-experimental (no randomisation) controlled trial, assessed the effect of corticosteroid injection followed by splinting vs no splinting for De Quervain tenosynovitis. A total of 82 participants were included. Age ranged between 18 and 70 years. Participants were either provided with a cortisone injection and a forearm-based splint (limiting ulnar deviation) or a cortisone injection alone. The results showed that there were no differences between people who wore or did not wear the wrist splint. A limitation of this study was the lack of randomisation of subjects to the treatment group. 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, corticosteroid injection alone is sufficient to treat de Quervain syndrome. Splinting does not appear to provide a significant benefit following this procedure. These results appear to be consistent with previous evidence. If you are interested in knowing how many people improve with a single cortisone injection or subsequent injections, head over to this other synopsis. Alternatively, have a look at the full database on De Quervain syndrome. URL: https://doi.org/10.1016/j.jhsa.2013.10.013 Abstract Purpose: To compare the corticosteroid injection (CSI) with or without thumb spica cast (TSC) for de Quervain tendinitis. Methods: In this prospective trial, 67 eligible patients with de Quervain tenosynovitis were randomly assigned into CSI + TSC (33 cases) and CSI (34 cases) groups. All patients received 40 mg of methylprednisolone acetate with 1 cc lidocaine 2% in the first dorsal compartment at the area of maximal point tenderness. The primary outcome was the treatment success rate, and the secondary outcome was the scale and quality of the treatment method using Quick Disabilities of Arm, Shoulder and Hand and visual analog scale scores. Results: The groups had no differences in mean age, sex, and occupation. The visual analog scale and Quick Disabilities of the Arm, Shoulder and Hand scores were similar in both groups before the treatment. The treatment success rate was 93% in the CSI + TSC group and 69% in the CSI group. Although both methods improved the patients' conditions significantly in terms of relieving pain and functional ability, CSI + TSC had a significantly higher treatment success rate. Conclusions: The combined technique of corticosteroid injection and thumb spica casting was better than injection alone in the treatment of de Quervain tenosynovitis in terms of treatment success and functional outcomes. 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

A unique discovery of saddle syndrome after elbow fracture-dislocation. MacDonald, J., Ivy, C. C. and Renfree, K. (2020) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic This is the answer to last week's Sherlock Handy. The patient was a 38 years old right-handed man who had a fracture (coronoid process) dislocation of their right elbow, which was reduced and managed conservatively with early active range of movement. Concurrently to their elbow pain, they also presented with pain (NRS: 8/10) at the dorsal aspect of the hand in the webspace between the index and middle finger. There was objective swelling around the affected mcp joints. There was tenderness on palpation at the second, third, and fourth webspace. There was no pain in active finger adduction/abduction, however, the test shown in the image below reproduced their pain. Hand x-rays showed no fracture. The patient was diagnosed with saddle syndrome, which is caused by scar tissue between the deep transverse metacarpal ligament and the tendons of intrinsic hand muscles (e.g. interossei and lumbricals). Symptoms resolved over the course of 4 weeks with bi-weekly hand therapy sessions. The exercises prescribed included tendon gliding and intrinsic plus stretches. 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, saddle syndrome is caused by scar tissue between the deep transverse metacarpal ligament and tendons of the instrinsic hand muscles. Pain location and pain reproduction on mcpjs abduction whilst in an intrinsic minus position may help making the diagnosis. Targeted stretching and tendon gliding in the early stages post-injury, may be helpful for treatment. It is likely that these interventions are most effective in the early stage post-injury when we are more likely to be able to affect the connective tissue. URL: https://doi.org/10.3928/24761222-20191125-04 Abstract Objective: Saddle syndrome occurs when adhesions form between the dorsal or palmar interosseous and lumbrical tendons on the volar side of the hand. This phenomenon was first described by Dr. Watson in 1974 in 12 cases in which surgical release was performed. Therapists and other providers may not identify the diagnosis and may mistake it for generalized hand stiffness. Therefore, this condition may be more prevalent than previously believed. This case report describes a situation in which the hand therapist identified the root cause of the client's stiff, painful hand within the first 2 weeks after injury and facilitated complete restoration of function to a score of zero on the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measure. Methods: Outcome measures in this single case included range of motion, pain scale score, QuickDASH score, visual analog scale of function score, and client report. Therapy included targeted stretching and soft tissue mobilization techniques. Results: Pain decreased from 80% to 0% on a visual analog scale, range of motion increased from 4-cm lag/50% of full fist to full fist, analog scale of disability score decreased from from 80% to 0%, circumference around the metacarpophalangeal joints decreased from 21.5 cm to 20 cm, and functional loss decreased from seven functional deficits to zero functional deficits. Conclusion: The hand therapist plays an important role in identifying saddle syndrome and intervening appropriately to prevent long-term pain, stiffness, and dysfunction. Additional research is needed to identify the frequency of saddle syndrome and the prospective effectiveness of therapy targeted at gliding of the lumbricals and inter-ossei. 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

Conservative management of a suspected triangular fibrocartilage complex injury utilizing strength training exercises: A case report. Sergent, A., Shaw, T. and Richardson, M. (2023) Level of Evidence: 4 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Therapeutic Topic: TFCC - Resistance training This is a case report on the conservative management of a 36-year-old Brazilian Jiu-Jitsu athlete with a non-traumatic Triangular Fibrocartilage Complex (TFCC) presentation. Orthopedic tests such as the fovea sign, push-off test, and piano key test were used to diagnose the injury, and radiographic imaging was also performed to rule out fracture, dislocation, or positive ulnar variance. Their initial pain was 5/10. The patient was treated with a combination of progressive kettlebell swing/press, and Turkish Get Up to improve the strength and endurance of the upper limb muscle. After eight weeks of grip strength and resistance exercises, the patient reported no pain with all activities, including a full return to Brazilian Jiu-Jitsu. 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-traumatic TFCC presentations may be treated succesfully with progressive resistance training and no splinting. This provides us with potential alternative treatments for the management of TFCC conditions. Movement and exercise interventions could be used in certain cases instead of immobilisation approaches. One useful test to keep track of improvements in these patients is the push-off test, which has been previously described in the literature. URL: https://doi.org/10.1016/j.jbmt.2023.07.001 Abstract Objective: The purpose of this case report is to describe the conservative chiropractic management of a patient with a suspected triangular fibrocartilage complex (TFCC) injury. Clinical presentation: A 36-year-old Brazilian Jiu-Jitsu black belt athlete sought care for left-sided diffuse ulnar pain (numeric pain scale 5/10) with a notable bump over the ulna and weakness when grappling. A working diagnosis of suspected TFCC injury was made. Intervention and outcome: The patient was treated with forearm and grip strength exercises to rehabilitate the pain and strength loss. Following 6 visits and a home exercise program for 8 weeks, his numeric pain scale decreased to 0/10. Conclusion: In this case, it is evident that Triangular fibrocartilage complex injury was successfully treated conservatively without the need for surgical intervention or passive care modalities. 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

Radiologic severe osteoarthritis is related to worse clinical outcomes after arthroscopic osteocapsular arthroplasty in primary elbow osteoarthritis for a medium-term follow-up: A retrospective cohort study. So, S.-P., et al. (2023) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Prognostic Topic: Primary elbow osteoarthritis - What are the outcomes of surgery? This retrospective study looked at the clinical outcomes of 97 patients who underwent arthroscopic arthroplasty for primary elbow osteoarthritis (OA). The patients were divided into three groups according to Kwak's classification (I, II, and III). Patients were assessed at baseline, 3-12 months (mid-term), and at long-term follow-up (at least 3 yrs post-surgery). Results showed that the mean ROM and function improved significantly in all groups at the short- and medium-term follow-ups. The mean VAS pain score improved significantly in all groups at the short-term follow-up, but not at the medium-term follow-up. In addition, stage I had better post-surgical ROM and pain than stages II and III. Complications such as postoperative skin eruptions and ulnar nerve irritation occurred in some patients, however, all recovered after treatment. 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, greater elbow osteoarthritis is associated with a higher risk of complications post-surgery. It appears that surgery for early stages may provide better improvements in range of motion and pain compared to later stages. As a result, the benefits vs the risks of surgery may require more careful consideration in those severe cases of elbow OA. Thus, in these patients, the risks of postoperative complications (e.g. infection and ulnar nerve palsy) appears to be higher. These results are in line with previous research. If you are interested in calculating the preoperative likelihood of your patients regaining functional elbow range of movement post-surgery, click on the link below. URL: https://doi.org/10.1016/j.jse.2023.05.041 Abstract Purpose: This study aimed to compare the clinical outcomes after arthroscopic OCA in the medium-term follow-up according to the radiologic severity of primary elbow OA and assess serial changes in clinical outcomes in each group. Methods: Patients treated using arthroscopic OCA for primary elbow OA with a minimum 3 years of follow-up, from January 2010 to April 2019, were retrospectively assessed for range of motion (ROM), visual analog scale (VAS) pain score, and Mayo Elbow Performance Score (MEPS), preoperatively and at short- (postoperative 3 to 12 months) and medium-term (at least 3 years after surgery) follow-ups postoperatively. Preoperative computed tomography was performed to evaluate the radiologic severity of OA using the Kwak’s classification. Clinical outcomes were compared according to the radiologic severity of OA by their absolute values and the number of patients achieving patient acceptable symptomatic state (PASS). Serial changes in the clinical outcomes of each subgroup were also assessed. Results: Of the 43 patients, 14, 18, and 11 were classified as stage I, II, and III groups, respectively; the mean follow-up duration was 71.3 ± 28.9 months and mean age was 56.5 ± 7.2 years. At the medium-term follow-up, stage I group had better ROM arc (I, 114°±14°; II, 100°±23°; and III, 97°±20°; P =.067) and VAS pain score (I, 0.9±1.3; II, 1.8±2.1; and III, 2.4±2.1; P =.168) than stage II and III groups without reaching statistical significance, while stage I group had significantly better MEPS (I, 93.2±7.5; II, 84.7±11.9; III, 78.6±15.2; P = .017) than stage III group. The percentage achieving PASS for ROM arc (P =.684) and VAS pain score (P =.398) were comparable between three groups, however, the percentage achieving PASS for MEPS was significantly higher in the stage I group than stage III group (I vs III, 100.0% vs 54.5%; P =.016). During serial assessment, all clinical outcomes tended to improve at the short-term follow-up. Compared to the short-term period, the ROM arc tended to decrease at the medium-term follow-up while VAS pain score and MEPS overall did not show significant changes. Conclusion: After arthroscopic OCA, stage I showed overall better ROM arc and pain than stage II and III at the medium-term follow-up, while stage I showed significantly better MEPS and higher percentage of patients achieving PASS for MEPS than stage III. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic Have a think about this case study. Leave a diagnostic comment if you like. The patient was a 38-years-old right-handed man who had a fracture (coronoid process) dislocation of their right elbow, which was reduced and managed conservatively with early active range of movement. Concurrently to their elbow pain, they also presented with pain (NRS: 8/10) at the dorsal aspect of the hand in the webspace between the index and middle finger. There was objective swelling around the affected mcp joints. There was tenderness on palpation at the second, third, and fourth webspace. There was no pain in active finger adduction/abduction, however, the test shown in the image below reproduced their pain. Hand x-rays showed no fracture. What is it?

Should we give patients what they want? Patient expectations and financial pressures need to be addressed to increase uptake of evidence-based practice. Lord Ferguson, S. (2023) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Therapeutic Topic: Evidence-based practice - How can we increase uptake This expert opinion examines the challenges faced by health care providers, including hand therapists, when trying to implement evidence-based practice (EBP) in private practice settings. It highlights the importance of managing patient expectations and financial pressures. The authors suggest that to aid the implementation of EBP, several efforts, which include knowledge translation, skills in behaviour change, interpersonal communication, motivational interviewing, coaching, customer relationship management, consumer segmentation, advertising, and selling, may be useful. We are currently at a very early stage on how to achieve EBP smoothly, but further research will help to clarify what are the key aspects that help both patients and private clinics in being successful. 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, implementing evidence-based practice is challenging. Even if clinicians were fully aware of the most effective assessment and treatment approaches, patient expectations, financial pressures, and referrer-provider relationships may hinder the integration of such knowledge. Improving our skills in communicating to patients what is the most useful approach, and learning how to "sell" it, may help reduce the burden on hand therapists who find themselves pressured between an internal drive to provide the best care and external factors that may not align with their intention. We also need to realise that patients' expectations drive a large portion of the treatment effect, hence, we may need to find a compromise between what "best practice" is and what the patients' beliefs require for a successful outcome. URL: https://doi.org/10.1016/j.msksp.2023.102831 Abstract Contextual factors such as patient expectations and financial pressures are overlooked challenges for Physiotherapists (PTs) and other rehabilitation professionals trying to implement evidence-based practice (EBP), particularly in private practice settings. In today's hypercompetitive pain management market, PTs may risk detrimental impacts to their reputation and livelihood if they do not give patients what they want, even if what they want does not align with clinical guidelines and research evidence. The aim of this professional practice paper is to shed light on these real-world challenges and encourage discussion among the PT community about strategies to increase uptake of EBP that involve multiple stakeholders such as PT training programs, professional organizations, researchers and clinic owners, which all have a role to play in supporting the translation of evidence into practice in our profession. 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