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Decision making in treatment of radial head fractures: Delphi methodology. Surucu, S., et al. (2022) Level of Evidence : 5 Follow recommendation : 👍 👍 (2/4 Thumbs up) Type of study : Therapeutic Topic : Radial head fractures - Management This is a Delphi study which aimed at obtaining consensus from a panel of orthopaedic surgeons on the management of radial head fractures. Surgeons' were given a total of 96 clinical scenarios and asked to determine whether they would treat the patients surgically or conservatively. The results showed that there was a high level of agreement for 30 scenarios (32%). The characteristics of the clinical scenarios with high agreement are reported in the tables below. The results showed that if patients were over 80 years old, presented with no block to ROM after aspiration/injection (to exclude pain as a factor limiting ROM), no crepitation with ROM, and no tenderness on DRUJ/interosseous membrane (dorsal forearm) they were suggested to undergo conservative treatment regardless of radial head involvement on imaging. In contrast, those patients presenting with a gap/displacement ≥ 2mm, ≥ 30% radial head involvement with a block to a range of motion, regardless of tenderness over DRUJ or interosseous membrane (dorsal forearm) or crepitation, should be managed surgically. 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, in people over 80 yrs old without an elbow ROM limitation, conservative management is the most common approach following a radial head fracture. In contrast, surgical management is preferred in those younger patients presenting with or without ROM limitations in association with crepitus or fracture displacement/large fracture of the radial head. If left untreated these injuries may lead to severe range of movement limitations, pain, and they are likely to lead to post-traumatic elbow osteoarthritis . The type of fractures more likely to undergo surgery are the ones caused by complex elbow dislocations , which are not only associated with fractures but also significant ligament injury. URL : https://doi.org/10.1016/j.jse.2022.10.002 Abstract Background: The treatment of partial, displaced radial head fractures is determined not only by the type of fracture, but also by patient characteristics such as age, occupation, hand dominance, mechanism of injury, and concomitant injuries and comorbidities. The goal of this study was to employ the Delphi method to achieve consensus on the management of patients with radial head fractures, utilizing the experience of the ASES elbow fracture-dislocation multicenter study group and Mayo Elbow Club surgeons. Methods: The initial survey was sent to participants, which included consent to participate in the study and questions about their experience, knowledge, and interest in participating in the Delphi method.We used both open-ended and category-based questions. The second questionnaire generated 76 variables, and individual questions with mean Likert ratings of < 2.0 or > 4.0 were deemed significant and merged to form multifactorial clinical scenarios relating to both nonoperative and operative management, respectively. Results: Of surgeons who responded to the questionnaire; 64% were from the United States, while the remainder were from overseas practices. Years in practice on average were 12.4 years (range, 1-40). Seven of the 76 factors met the criteria of a mean Likert score of <2.0 or >4.0. These factors were; age, block to the range of motion (ROM) after aspiration/injection, crepitation with ROM, tenderness over the distal radioulnar joint (DRUJ) and/or interosseous membrane (dorsal forearm), gap and/or displacement >2mm on imaging, complete loss of contact of the head with rest of radius on imaging, fracture head involvement 30% on imaging. 22 (46%) of the 96 clinical scenarios gained >90% consensus in favor of surgical treatment, whereas 8 (17%) reached >90% consensus in favor of non-operative treatment. Conclusion: Obtaining expert consensus on the treatment of radial head fractures remains challenging. Certain factors such as gap/displacement ≥ 2mm without complete loss of contact, ≥ 30% head involvement with a block to a range of motion regardless of tenderness over DRUJ or interosseous membrane (dorsal forearm) or crepitation when the patient was <80 years of age led to a recommendation of operative treatment in 100% of the surveyed surgeons. Patients greater than 80 years of age with no block to ROM after aspiration/injection, no crepitation with ROM, and no tenderness on DRUJ/interosseous membrane (dorsal forearm) were recommended for non-operative treatment regardless of the size of the radial head involvement on imaging. 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

Outcomes and prognostic factors for nerve grafting following high radial nerve injury. Zhu, S., et al. (2023). Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 Thumbs up) Type of study : Prognostic Topic : Recovery post radial nerve graft - Prognostic factors This is a retrospective study assessing factors affecting the recovery outcomes following nerve graft for a high radial nerve injuries (distal to the motor branch of the triceps and proximal to the posterior interosseous nerve). A total of 33 patients with severe radial nerve lesions (inability to elicit motor action measured through EMG with nerve conduction studies) were included in the study. Participants were defined as recovered following grafting if they presented with the ability to extend their wrist/fingers at least against resistance. The patients were followed up for at least one year. The results showed that a radial nerve grafting within 6 months, a nerve length defect of less than 5 cm, and the use of three or more donor nerve cables (living nerve tissue used in the transplant) were associated with better recovery. The average time for ECRL and EDC reinnervation after surgery was 9 and 12 months respectively. The study found that the recovery of wrist and finger extension was good but that of thumb extension was poor. Tendon transfer approaches may be more effective in those people presenting with delayed repairs and larger than 5 cm nerve defects. 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, patients with radial nerve grafting of defects smaller than 5 cm, which occur within 6 months of injury, recover well at 9-12 months. A tendon transfer may be more appropriate if patients don't present with these characteristics. Read these other synopses if you are interested in peripheral nervous system lesions have a read of these other synopses on digits' sensory loss and ulnar entrapment at the Guyons' canal . URL : https://doi.org/10.1177/17531934221147651 Abstract In this study, we examined the prognostic factors affecting outcomes following nerve grafting in high radial nerve injuries. Thirty-three patients with radial nerve injuries at a level distal to the first branch to the triceps and proximal to the posterior interosseous nerve were retrospectively studied. After a follow-up of at least 1 year, 24 patients (73%) obtained M3+ wrist extension, 16 (48%) obtained M3+ finger extension and only ten (30%) obtained M3+ thumb extension. Univariate, multivariate and receiver operating characteristic analyses showed that a delay in the repair of less than 6 months, a defect length of less than 5 cm or when grafted with three or more donor nerve cables achieved better recovery. Number of cables used was related to muscle strength recovery but not time to reinnervation. Nerve grafting for high radial nerve injury achieved relatively good wrist extension but poor thumb extension and is affected by certain prognostic factors. 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

Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect. Hohenschurz-Schmidt, D., et al. (2022) Level of Evidence : 5 Follow recommendation : 👍 👍 (2/4 Thumbs up) Type of study : Therapeutic Topic : Placebo and nocebo – What are they? This masterclass discusses the negative repercussions associated with the use of fear avoiding language, discarding factors such as the inheritability or socioeconomic contributors to disability, and the higher importance given to biomechanics compared to other factors in rehabilitation settings. The authors explain that these behaviours have the potential to induce nocebo in our patients through learning and expectation mechanisms. From a neurophysiological point of view, these factors act through descending pain modulatory pathways. For example, telling patients that they will experience pain during a certain activity is likely to increase their chance of experiencing pain. Moreover, not recognising the importance of genetic factors in the predisposition to certain diseases, has the potential to reduce patients' self-esteem and self-efficacy. As clinicians, we should aim at modifying false beliefs, and reduce anxiety. Providing positive messages regarding the function and structure of the human body should be the priority. 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, we should provide our clients with positive messages and consider factors beyond biomechanics in the assessment and treatment of musculoskeletal conditions. It is important to understand what factors contribute to placebo and nocebo so we can boost the placebo effect during our treatments. Research also showed that pain response is modulated by observing the behavior of other people . If you cringe when your patients show you what they would like to do or have been doing, it is more likely that they will feel pain with that activity. If you are interested in testing your pain science, take this quiz which other hand therapists have completed in research settings . URL : https://doi.org/10.1016/j.msksp.2022.102677 Abstract Introduction: While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects. Purpose: In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects. Implications This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the ‘prism’ of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context. 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

Social determinants of health and physical activity are related to pain intensity and mental health in patients with carpal tunnel syndrome. Núñez-Cortés, R., et al. (2023) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Symptoms prevalence Topic : Social risk factors - Carpal tunnel syndrome burden This is a cross-sectional study assessing the effect of social factors (e.g. employment) and physical activity on carpal tunnel syndrome (CTS) disease burden. A total of 86 participants on a waiting list for carpal tunnel release (severe CTS) were included in the study. The social risk factors assessed were employment status and educational level. Physical activity was assessed as high in those people following the World Health Organisation (WHO) guidelines (at least 150 minutes/week of moderate exercise or 75 minutes of vigorous-intensity exercise) and low in those who did not meet the criteria. Carpal tunnel syndrome burden was assessed based on pain, anxiety/depression, and pain catastrophising. The results showed that meeting the WHO guidelines for physical activity was associated with lower levels of pain and depression. Being employed and having a higher educational level were associated with lower anxiety and pain catastrophising respectively. 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, social risk factors and lower physical activity levels are associated with the greater disease burden in carpal tunnel syndrome. Based on these results we should encourage our clients with carpal tunnel syndrome to follow the WHO guidelines for physical activity , which may reduce pain as well as the likelihood of developing or severity depression. In addition, those people who are unemployed and have a lower educational level may require more support from us in terms of the number of sessions that we provide, reduction in attendance barriers (e.g. removal of copayments), referral to free physical activity classes (e.g. green prescription ), and additional efforts on our side to reduce pain catastrophising . If left to their own devise, we know that patients with social risk factors tend to have worse outcomes when affected by conditions such as arthritis and flexor tendon repairs . URL : https://doi.org/10.1016/j.msksp.2023.102723 Abstract Background: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy of the upper limb and a frequent cause of disability. Objective To analyze the association between social determinants of health (SDH) and physical activity with pain intensity and mental health in patients with CTS. Design: A cross-sectional study was conducted in patients with CTS awaiting surgery in two public hospitals in Chile. Methods: The SDH collected included: employment status, educational level and monetary income. The level of physical activity was defined according to compliance with WHO recommendations. Outcome measures included: Pain intensity (Visual Analog Scale), Symptoms of anxiety and depression (Hospital Anxiety and Depression Scale), and catastrophic thinking (Pain Catastrophizing Scale). The adjusted regression coefficient (β) for the association between SDH and physical activity with each outcome was obtained using multivariable linear regression models controlling for age, sex, body mass index and symptom duration. Results: Eighty-six participants were included (mean age 50.9 ± 10 years, 94% women). A high level of physical activity was associated with a 12.41 mm decrease in pain intensity (β = −12.41, 95%CI: 23.87 to −0.95) and a 3.29 point decrease in depressive symptoms (β = −3.29, 95%CI: 5.52 to −1.06). In addition, being employed was associated with a 2.30 point decrease in anxiety symptoms (β = −2.30; 95%CI: 4.41 to −0.19) and a high educational level was associated with a 7.71 point decrease in catastrophizing (β = −7.71; 95%CI: 14.06 to −1.36). Conclusion: Multidisciplinary care teams should be aware of the association between SDH and physical activity with physical and mental health. 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

Neglected posterior dislocation of elbow: A review. Pal, C. P., Mittal, V., Dinkar, K. S., Kapoor, R. and Gupta, M. (2021) Level of Evidence : 5 Follow recommendation : 👍 👍 (2/4 Thumbs up) Type of study : Therapeutic Topic : Posterior elbow dislocation - Treatment This is an expert opinion on the assessment and treatment of posterior elbow dislocations that go untreated for 3 weeks or more. A discussion on symptoms, diagnosis, and treatment for this condition is presented. Patients with non-reduced posterior elbow dislocation are usually able to move the elbow through some range, however, this is significantly limited and likely associated with elbow deformity. Range of movement limitations are due to the lack of reduction with or without heterotopic ossification/fracture displacement as well as numbness/tingling/P&N in the ulnar distribution due to ulnar nerve entrapment at the cubital tunnel. Diagnosis requires imaging and in severe cases CT scans. Treatment of neglected posterior dislocations is challenging due to the potential presence of ligament insufficiencies alongside fracture displacement or nerve injuries. Open reduction is almost always required and soft tissue debridement is often required (e.g. triceps tendon). The aim of surgery is to regain a painless, stable elbow with a functional range of movements. Unfortunately, due to the injury complexity, full range of movement is rarely regained in adults. 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, elbow dislocations require assessment and treatment to avoid important sequelae in both children and adults. If left untreated they are associated with severe range of movement limitations, pain, and they are likely to lead to post-traumatic elbow osteoarthritis . If you are interested in reading more about elbow dislocations have a look at these synopses on the " drop sign ", differentiating between simple and complex elbow dislocations , what is the best treatment for simple dislocations , and how to test for postero-lateral rotatory instability . URL : https://doi.org/10.1016/j.jcot.2021.04.016 Abstract Untreated traumatic posterior dislocation of the elbow joint, 3 weeks or older, is defined as “neglected posterior dislocation of the elbow”. Around 90% of these are of posterolateral type. These are much more common in the developing and underdeveloped countries. Patients presents with a deformed, stiff and painful elbow with difficulty to perform activities of daily living. The clinical picture looks quite similar to malunited supracondylar fracture of the elbow. Diagnosis is usually confirmed radiographically. CT and MRI scan give additional information and are recommended before embarking on surgery. Treatment is quite challenging due to the significant soft tissue contractures, ligamentous insufficiencies and fibrosis, with possible associated nerve injuries, myositis ossificans, non-compliant patients and the need for long-term postoperative physiotherapy. Goal of surgical treatment is to achieve a painless, stable and mobile elbow with a congruent joint space. We have reviewed the literature and present our view on the prognosis and recommended surgical technique to treat this condition. 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

Inflammatory arthritis and the elbow surgeon. Dott, C., Chin, K. and Compson, J. (2021) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic Topic : Elbow inflammatory arthritis – Differential diagnosis This is an expert opinion on the differential diagnosis of inflammatory arthropathies of the elbow. The most common inflammatory arthropathy of the elbow is rheumatoid arthritis (RA). Other less frequent inflammatory arthropathies include psoriatic arthritis, gout, and lupus. Rheumatoid arthritis rarely affects the elbow alone (5%) and more frequently presents as a polyarthropathy (20-65% of cases). It often presents with bilateral symptomatology. With the advent of disease-modifying antirheumatic drugs (DMARDs) the number of patients affected by severe RA has reduced. Psoriatic arthritis tends to present bilaterally and it is present in 25% of people with psoriasis. Another inflammatory arthropathy is gout, and, although rare, it can present as a severely acute elbow mono-arthropathy. An acute elbow gout flare commonly presents at the olecranon bursa. Lupus rarely affects the elbow but it may present as a less severe and reversible arthropathy. All the acute presentations of elbow pain, especially if associated with redness and swelling need to be investigated and septic arthritis needs to be excluded. 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, rheumatoid arthritis is the most common inflammatory arthritis affecting the elbow. Less common inflammatory arthropathies of the elbow include psoriatic arthritis, gout, and lupus. Acute, non-traumatic, severe elbow pain presentations must be investigated and septic arthritis should be excluded. If the acute non-traumatic presentation is not septic arthritis and it's unilateral, it is likely to be an acute flare of gout. In contrast, if the symptoms are bilaterally and associated with skin lesions, it is more likely to be psoriatic arthritis. These inflammatory arthropathies also affect the periarticular soft tissue and may be mimickers of elbow tendinopathies. It's important to remember that these inflammatory elbow arthropathies are different from elbow osteoarthritis and should therefore be managed accordingly. URL : https://doi.org/10.1016/j.jcot.2021.101492 Abstract The treatment of inflammatory arthritis with disease modifying drugs and biological agents had reduced the number of patients needing surgical treatment. Surgical treatment of patients with inflammatory arthritis is challenging not only due to the factors such as bone stock and status of soft tissue but also due to the comorbidities associated with inflammatory arthritis. Multidisciplinary approach to these patients is recommended to deal with the complex poly-articular involvement and systemic physiological impairment especially when planning surgery. This review will cover the key articular and peri-articular pathologies that can affect the elbow in inflammatory arthritis and discuss the treatment strategies available to the orthopaedic surgeon in their management. From surgical point of view, the rheumatoid elbow can be classified into 4 types: 1) classic soft tissue type with increased joint laxity, malalignment and instability; 2) osteoarthritic type with stiffness, hypertrophic joints (hypertrophic) and preserved alignment; 3) nodular type with subcutaneous nodules and enthesopathies but preserved jointly; 4) mutilans with bone and joint destruction. Surgical managements of the articular problem in each of the subtypes are discussed in this review. On the other hand, the seronegative arthritis such as psoarisis, gout and lupus seems to affect the peri-articular tissue of the elbow more than the joint itself and the disease specific management of the peri-articular soft tissue problems, such as enthesopathies and inflammatory nodules, are also outlined. 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

Triceps brachii hypertrophy is substantially greater after elbow extension training performed in the overhead versus neutral arm position. Maeo, S., et al. (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Triceps extensions - Overhead vs neutral shoulder This is a within-subject quasi-experimental study assessing the amount of hypertrophy and exercise load required during two different triceps exercises. In particular, overhead triceps extensions were compared to shoulder-neutral triceps extensions (see figure below). Participants performed one exercise in one limb and the other exercise in the contralateral limb. Which arm did which exercise was alternated when participants were recruited. A total of 21 healthy participants were included and they trained twice a week for 12 weeks performing 10 repetitions per set for five sets with two minutes interset rest. Exercise intensity started at 50% of 1 repetition maximum (1RM) during the first session followed by 60% and 70% in the second and third sessions. After that, 70% of 1RM was utilised. The results showed that in the overhead triceps extension position, 1RM at baseline was on average 34-39% lower compared to in neutral shoulder position. In addition, training in the overhead position lead to greater muscle hyperthropy (5-10%) compared to training in the neutral position. 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, the overhead triceps position requires a lower level of loading, compared to the neutral triceps extension, and provides greater levels of hypertrophy following 12 weeks of training. This appears to be true also if we account for the weight of the forearm ( 1.7% of body weight ), which adds to the external resistance in the overhead position. This is useful to know when treating triceps tendinopathies. Thus, lower tendon loads may be beneficial in the initial stages of resistance training. In terms of triceps tendon loading, have a look at this other synopsis to determine how you can progress the exercises for your patients . Open Access URL : https://doi.org/10.1080/17461391.2022.2100279 Abstract The biarticular triceps brachii long head (TBLong) is lengthened more in the overhead than neutral arm position. We compared triceps brachii hypertrophy after elbow extension training performed in the overhead vs. neutral arm position. Using a cable machine, 21 adults conducted elbow extensions (90−0°) with one arm in the overhead (Overhead-Arm) and the other arm in the neutral (Neutral-Arm) position at 70% one-repetition maximum (1RM), 10 reps/set, 5 sets/session, 2 sessions/week for 12 weeks. Training load was gradually increased (+5% 1RM/session) when the preceding session was completed without repetition failure. 1RM of the assigned condition and MRI-measured muscle volume of the TBLong, monoarticular lateral and medial heads (TBLat+Med), and whole triceps brachii (Whole-TB) were assessed pre- and post-training. Training load and 1RM increased in both arms similarly (+62−71% at post, P = 0.285), while their absolute values/weights were always lower in Overhead-Arm (-34−39%, P < 0.001). Changes in muscle volume in Overhead-Arm compared to Neutral-Arm were 1.5-fold greater for the TBLong (+28.5% vs. +19.6%, Cohen's d = 0.61, P < 0.001), 1.4-fold greater for the TBLat+Med (+14.6% vs. +10.5%, d = 0.39, P = 0.002), and 1.4-fold greater for the Whole-TB (+19.9% vs. +13.9%, d = 0.54, P < 0.001). In conclusion, triceps brachii hypertrophy was substantially greater after elbow extension training performed in the overhead versus neutral arm position, even with lower absolute loads used during the training. 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

Dislocations of the elbow – An instructional review. Reichert, I. L. H., Ganeshamoorthy, S., Aggarwal, S., Arya, A. and Sinha, J. (2021) Level of Evidence : 5 Follow recommendation : 👍 👍 (2/4 Thumbs up) Type of study : Therapeutic Topic : Elbow dislocation - Treatment This is an expert opinion on the assessment and conservative/surgical treatment of elbow dislocations. Following shoulder dislocations, elbow dislocations are the most common dislocations in adults. Simple dislocations are defined by the presence of no or small fractures and stability of the elbow post-reduction. Following simple elbow dislocations, It is possible to have ongoing instability due to ligament lesions and these require repair. The most common mechanism of trauma for elbow dislocation is a valgus hyperextension injury, which leads to posterior dislocation, which can cause damage to the lateral collateral ligament (LCL) +/- lateral ulnar collateral ligament (LUCL). Posterolateral instability can occur with partial or complete disruption of the LUCL. In more severe dislocations, damage to the LCL is followed by disruption of the anterior and posterior capsule followed by the medial collateral ligaments (anterior bundle) and in extreme cases the common flexor origin. Imaging pre- and post-reduction is required and the presence of the 'drop sign', which is identified by a gap between ulnar and humeral joint spaces, indicates ongoing instability, likely requiring surgical repair. Conservative treatment of simple elbow dislocations includes the provision of a posterior elbow split for two weeks followed by a progressive range of movement home exercise program. Weekly x-rays are required to identify displacement or re-positioning of fracture fragments. If surgical treatment is required, a posterior elbow splint can be provided for comfort, however, active assisted range of movement should be started within 24-48 hrs post-surgery. 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, the 'drop sign' on lateral elbow x-ray suggests the presence of significant ligament injury. These cases may require surgical repair. In all elbow dislocations, it is important to assess not only the stability post-reduction but also the presence of neurovascular lesions. If you are interested in elbow dislocations, you can read more about the ligaments providing biomechanical restrain to the elbow , how to test for postero-lateral rotatory instability , differentiating between simple and complex elbow dislocations , and what is the best treatment for simple dislocations . Remember, that the outcome of these injuries is dependent on achieving joint stability and initiating range of movement early. The sequelae of elbow stiffness are significant not only from a physical but also from a mental health perspective . URL : https://doi.org/10.1016/j.jcot.2021.101484 Abstract Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed. 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

Biceps disorder rehabilitation for the athlete: A continuum of moderate- to high-load exercises. Borms, D., I. Ackerman, P. Smets, G. Van den Berge and A. M. Cools (2017). Rehabilitation exercises for athletes with biceps disorders and slap lesions: A continuum of exercises with increasing loads on the biceps. Cools, A. M., et al. (2014) Level of Evidence : 2c Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Triceps tendon - Gradual loading These are two cross-sectional studies assessing the activation of triceps brachii during upper limb exercises. The aim was to identify which exercises should be included in the early/middle phase vs later phase rehabilitation of clients presenting with a triceps brachii pathology. A total of 62 healthy participants were included in these studies. Of these, 50% were females. Participants were excluded if they were performing resistance training of their upper limb for more than 5 hours a week and if they were competitive overhead athletes. Many different exercises were assessed. The weight utilised in the exercises was based on the participants' body weight. The percentage of triceps brachii activation was based on a maximum isometric voluntary contraction (MVC) of the triceps (EMG). In the exercises described, biceps activation ranged from a minimum of 15% of MVC to 50% of MVC. For your ease of use, I have created 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, the exercises described above can be utilised to gradually load triceps brachii during the early/middle and later phases of rehabilitation. These exercises may be appropriate for distal triceps brachii tendinopathies ( after an initial rest has been provided ), which could be detected through the overhead active resisted elbow extension . Progression beyond the exercises shown above may include overhead triceps extensions followed by shoulder-neutral triceps extensions . Borms et al. (2017) URL : https://doi.org/10.1177/0363546516674190 Cools, A. M., et al. (2014) URL : https://doi.org/10.1177/0363546514526692 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

Medical cannabis in hand surgery: A review of the current evidence. Yang, A., Townsend, C. B. and Ilyas, A. M. (2023) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Hand and upper limb pain - Medical cannabis This is a narrative review on the efficacy of medical cannabis for hand and upper limb persistent pain conditions/post-surgical analgesia. Cannabis's active ingredients include THC and cannabidiol. THC is the one with psychoactive effect. For the treatment of pain, cannabidiol has been utilised in several experiments. The used of medical cannabis might be appropriate for several different conditions, however, post-surgery its use appears problematic due to the interaction of THC/cannabidiol with anaesthesia and other drugs. Considering these side effects and the lack of studies reporting clinically relevant benefits, its use in acute post-operative settings is not advised. Some evidence has suggested that medical cannabis may be useful for neuropathic pain and may reduce opioid use, however, further research in the hand and upper limb will need to confirm these initial findings. 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, the use of medical cannabis following hand and upper limb surgery is advised against due to side effects caused by its interaction with anaesthesia. For persistent hand and upper limb pain, there is very little published evidence on the benefits of medical cannabis despite encouraging findings showing clinically relevant reductions in pain when topical cannabidiol (6.2 mg/ml) is applied in people with symptomatic thumb OA . URL : https://doi.org/10.1016/j.jhsa.2022.11.008 Abstract Acute and chronic pain management remains an ongoing challenge for hand surgeons. This has been compounded by the ongoing opioid epidemic in the United States. With the increasing legalization of medical and recreational cannabis throughout the United States and other countries, previous societal stigmas about this substance keep evolving, and recognition of medical cannabis as an opioid-sparing pain management alternative is growing. A review of the current literature demonstrates a strong interest from patients regarding the use of medical cannabis for pain control. Current evidence demonstrates its efficacy and safety for chronic musculoskeletal and neuropathic pain. However, definitive conclusions regarding the efficacy of cannabis for pain control in hand and upper extremity conditions require continued investigation. The purpose of this article is to provide a general review of the mechanism of medical cannabis and a scoping review of the current evidence for its efficacy, safety, and potential applicability in hand and upper extremity conditions. 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

Is it necessary to fix basal fractures of the ulnar styloid after anterior plate fixation of distal radius fractures? A randomized controlled trial. Afifi, A. and Mansour, A. (2022) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 (3/4 Thumbs up) Type of study : Therapeutic Topic : Distal radius fractures - Ulnar styloid fixation This randomised controlled study assessed whether ulnar styloid fracture fixation leads to better outcomes in distal radius fracture open reduction internal fixation (ORIF). A total of 86 participants undergoing distal radius fracture ORIF with an associated distal unlar styloid fracture were included. Potential participants were excluded if there was objective DRUJ laxity (ballottement test) identified intra-operatively (see figure below). In the control group, only the radius fracture was fixated whilst in the experimental group the radius and the ulnar styloid fractures were fixated (k-wire). To assess treatment outcomes, the QuickDASH was collected at 24 months. Post-operatively, participants were kept in a Plaster of Paris slab for 2 weeks during which elbow and hand motion was allowed. A hand therapist provided rehabilitation, which included active mobilisation of the elbow, forearm, hand, and finger joints. Resistance exercises were initiated when bony union was achieved. The results showed that there were no differences between the two groups at the 24 months follow-up. 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, in absence of DRUJ instability, fixating a distal radius ulnar styloid fracture does not lead to better outcomes during distal radius fracture open reduction internal fixation. This is one of the few randomised controlled trials in hand and upper limb surgery and the authors should be congratulated for carrying it out. If you are interested in more research concerning distal radius fractures, have a look at the full database where you can find synopses on mobilisation , the effect of catastrophising on stiffness, and complex regional pain syndrome . URL : https://doi.org/10.1177/17531934221140730 Abstract The purpose of this study was to investigate the necessity for surgical fixation of basal fractures of the ulnar styloid without distal radioulnar joint (DRUJ) instability, after stabilization of associated distal radial fractures using an anterior plate. This single-centre, prospective, randomized controlled trial, conducted between 2015 to 2021, included 43 patients in each study arm who were randomized to either fixation (Group A) or non-operative treatment (Group B) of the ulnar styloid. The mean follow-up period was 24 months (SD 5.2) in Group A and 23.9 months (SD 5.5) in Group B. At the final follow-up, patients were evaluated by the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the Modified Mayo Wrist Score (MMWS), the visual analogue scale (VAS) for pain, the grip strength, wrist range of motion. The DASH score was 6 (SD 2.6) in Group A and 6 (SD 2.4) in Group B; the MMWS was 87 (SD 5.6) in Group A and 87 (SD 5.6) in Group B; and the grip strength was 88% (SD 9.4) in Group A and 87% (SD 7.7) in Group B. In conclusion, fixation of basal ulnar styloid fractures is not mandatory if the DRUJ is stable after rigid fixation of the associated fracture of the distal radius. 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

Os centrale – a rare cause of wrist pain: A review. Nazifi, O., Griffiths, J. A. and Flores, D. M. A. (2023) 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 assessed radiographically for a suspected triquetrum fracture, which was confirmed with further investigations. However, during the radiographic assessment of the patient, an additional bone or fracture was identified between the scaphoid, trapezium, trapezoid, and capitate. Considering the presentation of ulnar wrist pain only, the authors concluded that this was an "os centrale" which is a vestigial bone of the wrist. In the literature, symptomatic "os centrale" cases have been reported and excision often revealed avascular necrosis of this bone. 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, "os centrale" is a rare vestigial bone that can in some instances cause pain due to avascular necrosis. Avascular necrosis has been reported in other carpal/wrist bones such as the trapezoid and the distal ulna . Differentiating between an os centrale and a fracture may be difficult if the client reports a history of trauma. URL : https://doi.org/10.1177/17531934221129761 No Abstract available 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