Search Results

Atraumatic, progressive, and painful elbow contracture from a ganglion cyst. Goyal, N., T. J. Luchetti, A. T. Blank and M. S. Cohen (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic This is the answer for last week Sherlock Handy. The patient was a 37 years old male presenting with worsening of left elbow stiffness and pain in the last 9 months. Subjective and objective examination revealed no neurovascular impairments. They had no previous history of surgery or trauma to the elbow. Active range of movement (AROM) in elbow extension and flexion was 30° to 110° respectively. X-rays were normal. An MRI (see below) was obtained and it identified a ganglion cyst in the volar aspect of the elbow (deep to the brachialis muscle). Surgery was perfomed to remove the ganglion and perform a volar capsular release. The surgical release was followed by early rehabilitation. At nine months post surgery, the patient had no pain or AROM limitations. 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, ganglion cysts limiting elbow AROM are a rare presentation. If a client with progressive atraumatic elbow AROM limitation presented to our clinic, a set of x-rays and US imaging would be warranted. A referral to a surgeon may be advisable as further investigations to exclude benign or malignant pathologies such as synovial sarcomas may be required. If you are interested in recent evidence about how to deal with post-traumatic elbow stiffness, have a look at this synopsis . URL: https://doi.org/10.1016/j.jhsa.2020.06.005 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Ganglion cysts are benign soft tissue tumors that often occur adjacent to joints or tendons. We report a case of an elbow joint ganglion cyst in a patient who presented with a painful, progressive elbow contracture. The patient was successfully treated with resection of the subbrachialis ganglion cyst combined with an anterior capsular release and an ulnar nerve decompression to recover elbow motion. This case highlights the value of advanced imaging in patients presenting with an atraumatic, painful, and progressive elbow contracture.

Mobile technology and cumulative trauma symptomology among millennials. Short, N., Blair, M., Crowell, C., Loewenstein, A., Lynch, A., Nakum, R., & Warner, A. (2019) Level of Evidence : 2c Follow recommendation : 👍 👍 Type of study : Symptoms prevalence study Topic : Mobile technology use - symptoms prevalence in healthy people This cross sectional study assessed the difference in mobile technology use between people with and without symptoms on objective examination (physical tests) of the upper limb. Healthy, pain-free participants (n = 42) were included. The average age was 24 years old. Mobile technology use was quantified by the self-reported time spent on mobile devices each day. The objective examination involved a series of orthopaedic tests for the upper limb. These included the hyperabduction test, elbow flexion test, Maudsley's test, Finkelstein's test, and Lever's test. If participants reported symptoms in any test, they were classified as "pathological". If participants did not report symptoms in any test they were classified as "controls". The results showed that there was no statistically significant difference in time spent on mobile technology between the "control" and "pathological" group. Of the total sample, 55% (n = 23) of participants were positive on at least one orthopaedic test. 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, there is no correlation between mobile technology use and presence of sub-clinical conditions of the hand and upper limb. The results from this study suggest that orthopedic tests may be positive in asymptomatic people. This study is a nice addition to a previous synopsis on texting and neck pain . Open Access URL : https://journals.sagepub.com/doi/abs/10.1177/1758998319871075 Abstract Introduction Technology use among the millennial population is increasing and related postural compromise may lead to cumulative trauma disorder symptomology. The aim of this study was to explore trends of hand-held mobile technology use and upper extremity cumulative trauma disorder symptomology among a sample of millennials. Methods A convenience sample of graduate students (n = 42) was used for the study. Demographic and technology use information was obtained through self-report using the smartphone screen time tracking feature. Cumulative trauma disorder symptomology was assessed through administration of various orthopedic special tests. Results On average, participants spent 2 h and 23 min per day using hand-held mobile devices. Out of 42 participants, 54.8% tested positive for at least one orthopedic special test. The symptomatic group spent 2 h and 29 min using hand-held mobile devices, while the asymptomatic group spent 2 h and 4 min. The most common positive orthopedic special tests were Finkelstein’s test (n = 19; 36%), hyperabduction (Wright’s) test (n = 13; 25%), and the elbow flexion test (n = 10; 18.9%), indicating symptoms associated with De Quervain’s tenosynovitis, thoracic outlet syndrome, and cubital tunnel syndrome, respectively. Discussion Results were consistent with prior research on time spent using hand-held mobile technology and cumulative trauma disorder among millennials. Additionally, a difference in mean time spent using mobile technology between the asymptomatic and symptomatic groups was found, suggesting a relationship which warrants further research.

Chronic complex persistent elbow instability: A consecutive and prospective case series and review of recent literature. Giannicola, G., Sessa, P., Calella, P., Gumina, S., & Cinotti, G. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Chronic complex persistent elbow instability - Elbow stability and function after surgery This is a prospective case-series study assessing elbow stability and function following surgery for chronic complex persistent elbow instability (CCPEI). This condition is defined as an on-going (chronic) static (persistent) elbow subluxation/dislocation (instability), due to bony and soft tissue lesion (complex) following trauma. A total of 21 adult participants were included. Participants were included if they had previous surgical treatment for a traumatic elbow lesion. The most common elbow trauma (n = 13) was the terrible triad (elbow dislocation with radial head and coronoid fractures). A Monteggia-like lesion (ulnar fracture with additional soft tissue/bony lesions) was the second most common injury (n = 6). Participants also had to present with pre-surgical elbow instability identified through x-rays or CT scan. Success of surgery was assessed through fluoroscopy. In addition, function was assessed through the Mayo Elbow Performance Score, the modified American Shoulder and Elbow Surgeons assessment form, and the QuickDASH. The results showed that surgery improved stability and function to a statistically and clinically significant level in patients with CCPEI at 2.5 years follow-up. A 23% (n = 5) complication rate was reported and this required additional surgery in most cases. 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, chronic complex persistent elbow instability is the result of severe elbow dislocations associated with fractures. If conservative treatment is not appropriate or ineffective, clients may have to undergo surgery. It appears that the post-surgical recovery time is quite extensive and can take between 2 to 3 years. If clients develop stiffness that limits their daily activities, have a look at this other synopsis on treatment of post-traumatic elbow stiffness . URL : https://doi.org/10.1016/j.jse.2019.11.021 Available through EBSCO Health Databases for PNZ members. Abstract Background Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature. Methods We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13, Monteggia-like lesion in 6, humeral shear fracture-dislocation in 1, and radial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively. Results The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases. Conclusions CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis reported by the paper next week. The patient was a 37 years old male presenting with worsening of left elbow stiffness and pain in the last 9 months. Subjective and objective examination revealed no neurovascular impairments. They had no previous history of surgery or trauma to the elbow. Active range of movement in elbow extension and flexion was 30° to 110° respectively. X-rays (see below) were normal. What was it?

The active future for the Passive Therapist. Nicholls, D. A. (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Passive interventions - Are they underestimated? This is an article focusing on social and economic aspects influencing health care treatments. I have included this paper in HandyEvidence in an attempt to broaden the range of articles included, extending beyond quantitative research. The article revolves mainly around the concept of active and passive interventions that health care providers deliver. In the last few years, passive interventions have been considered as "low value interventions" compared to "high value interventions" such as exercise. The argument brought forward is that this discrimination is primarily driven by an economical argument without taking into consideration the clients' views. It is therefore suggested that people in the future will continue to seek passive care independently of this neoliberalism approach focusing mainly on the economic value of care. In support of this argument, history is been brought as evidence. Thus, people throughout times have always sought passive approaches at some point in their recovery, suggesting that this approach has a place along the course of rehabilitation. 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 classification of "high" vs "low" value interventions is driven by economical factors rather than client's reported views. This has made me think that I should dedicate more attention towards qualitative research that takes into account clients' views and can guide, in conjunction with quantitative research, better care for the people I treat. Going forward I am planning to include more qualitative research in the HandyEvidence synopses. URL : https://doi.org/10.2519/jospt.2021.10536 Available through EBSCO Health Databases for PNZ members. Abstract In this paper I argue that we may be at an inflection point for the physiotherapy profession. The current debate over "active" and "passive" therapies highlights once again how much physical therapy practices reflect shifting cultural and social attitudes. Calls for less passive management of musculoskeletal conditions, and more self-management reflect the neoliberal desire for autonomous, entrepreneurial, and endlessly resilient, self-sufficient subjects who will take the burden of responsibility for healthcare away from the state. Shifts in practice like this have important implications for therapists and clients alike, and practitioners should give careful thought to what is going on at a deeper societal level when they contemplate profound practice changes.

PEER systematic review of randomized controlled trials: Management of chronic neuropathic pain in primary care. Falk, J., et al. (2021) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Neuropathic pain - Pharmacological interventions This is a systematic review and meta-analysis assessing the effectiveness of different types of medications for neuropathic pain. A total of 67 RCTs were included in the present review, for a total of 15,984 participants. Most of the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. All the pharmacological interventions were compared to placebo. Efficacy of intervention was defined as a clinically significant reduction in pain of at least 30% compared to the placebo group. The number needed to treat (NNT) to obtain one desired outcome (clinically significant reduction in the experimental group compared to placebo) was reported. The results showed that there is moderate quality of evidence suggesting that gabapentin or pregabalin would provide a significantly greater number of treatment responders (46%) compared to placebo (30%). The number of patients needed to treat to have one responder is 7. 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, gabapentin or pregabalin have a role in the pain treatment of neuropathic pain presentations. These medications perform better than placebo, however, we would need to treat 7 clients to observe one more responder (reduction in pain of 30%) compared to a placebo. We may refer our clients presenting with neuropathic pain back to their GP to verify whether they may benefit from a course of gabapentin or pregabalin. This should not apply to carpal tunnel conditions, where these medications have shown to have a detrimental effect on post-surgical outcomes . For carpal tunnel syndrome, conservative treatments (e.g. splinting / neurodynamic exercises or cortisone injections ) may be relevant therapeutic options prior to surgery. Additionally, in clients with chemotherapy induced neuropathic pain, we could advise them to perform any kind of mild to moderate exercise as aerobic exercise appears to have a neuroprotective effect . This synopsis may also be relevant for burns clients as there is a significant probability that they may develop neuropathic pain . Finally, it is important to remember that our clients with psychological distress are more likely to present with a slower recovery and a multidisciplinary approach (if available) may improve their outcomes. Open Access URL : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115961/ Available through EBSCO Health Databases for PNZ members. Abstract OBJECTIVE: To determine the proportion of patients with neuropathic pain who achieve a clinically meaningful improvement in their pain with the use of different pharmacologic and nonpharmacologic treatments. DATA SOURCES: MEDLINE, EMBASE, the Cochrane Library, and a gray literature search. STUDY SELECTION: Randomized controlled trials that reported a responder analysis of adults with neuropathic pain-specifically diabetic neuropathy, postherpetic neuralgia, or trigeminal neuralgia-treated with any of the following 8 treatments: exercise, acupuncture, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), topical rubefacients, opioids, anticonvulsant medications, and topical lidocaine. SYNTHESIS: A total of 67 randomized controlled trials were included. There was moderate certainty of evidence that anticonvulsant medications (risk ratio of 1.54; 95% CI 1.45 to 1.63; number needed to treat [NNT] of 7) and SNRIs (risk ratio of 1.45; 95% CI 1.33 to 1.59; NNT = 7) might provide a clinically meaningful benefit to patients with neuropathic pain. There was low certainty of evidence for a clinically meaningful benefit for rubefacients (ie, capsaicin; NNT = 7) and opioids (NNT = 8), and very low certainty of evidence for TCAs. Very low-quality evidence demonstrated that acupuncture was ineffective. All drug classes, except TCAs, had a greater likelihood of deriving a clinically meaningful benefit than having withdrawals due to adverse events (number needed to harm between 12 and 15). No trials met the inclusion criteria for exercise or lidocaine, nor were any trials identified for trigeminal neuralgia. CONCLUSION: There is moderate certainty of evidence that anticonvulsant medications and SNRIs provide a clinically meaningful reduction in pain in those with neuropathic pain, with lower certainty of evidence for rubefacients and opioids, and very low certainty of evidence for TCAs. Owing to low-quality evidence for many interventions, future high-quality trials that report responder analyses will be important to strengthen understanding of the relative benefits and harms of treatments in patients with neuropathic pain.

Prospective cohort study to investigate factors associated with continued immobilization of a nondisplaced scaphoid waist fracture. Bulstra, A. E. J., et al. (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Scaphoid fractures - Length of immobilisation predictors This is a prospective study assessing the correlation between imaging/psychological well being/physical examination findings and duration of immobilisation following a non displaced scaphoid fracture. A total of 46 participants were included. Potential participants were excluded if they presented more than 3 weeks post injury, if they had an undisplaced saphoid waist fracture (assessed trough CT scan when in doubt), or had a previous history of scaphoid fracture. All participants were immobilised for 6 weeks in a below elbow thumb spica cast, after which a surgeon's follow up was completed to decide whether they required a further immobilisation period. Clients psychological well being was assessed through the PROMIS CATs for physical function, depression, and pain interference (score it yourself or use it for your clients - Try the PROMIS CAT Demo>> ). The results of this questionnaire were unavailable to the surgeon at the follow up appointment. In addition, all participants underwent x-ray imaging to assess fracture healing. The results showed that participants presenting with greater depression and what surgeon's identified as a lack of healing on x-ray was associated with prolonged immobilisation. Interestingly, healing vs non-healing on x-ray was associated with immobilisation time rather than time from injury. In addition, as mentioned in the article, x-ray evaluation is unreliable in identifying fracture healing, despite it being commonly utilised for stopping or prolonging immobilisation. There are a couple of limitations to this study. First, this study did not objectively assess fracture's union because there is currently no gold standard that can measure this outcome. Second, the sample size was possibly too small for the type of statistics utilised (Multivariate logistic regression). Clinical Take Home Message : Based on what we know today, non displaced scaphoid waist fracture immobilisation period may depend on psychological comorbidities (e.g. depression) which may unconsciously affect surgeon's decision to prolong casting. In addition, lack of healing on x-rays, which has been suggested as an unreliable marker, is another factor contributing to prolonged immobilisation. This article is a nice reminder that factors other than objective findings may drive our willingness to continue immobilising a fracture. Previous research has also shown that tenderness on palpation may not be a reliable indicator of fracture healing , and it may be better to follow traditional fracture healing times as a guide. If you are interested in having a read through what physical test are currently suggested for occult scaphoid fractures I have previously created a synopsis on the topic. URL : https://doi.org/10.1016/j.jhsa.2021.03.027 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: The decision to continue immobilization of a nondisplaced scaphoid waist fracture is often based on radiographic appearance (despite evidence that radiographs are unreliable and inaccurate for diagnosing scaphoid union 6–12 weeks after fracture) and fracture tenderness (even though it is influenced by cognitive biases on pain). This may result in unhelpful additional immobilization. We studied nondisplaced scaphoid waist fractures to determine the factors associated with (1) the surgeon’s decision to continue cast or splint immobilization at the first visit when cast removal was being considered; (2) greater pain on examination; and (3) the surgeon’s concern about radiographic consolidation. Methods: We prospectively included 46 patients with a nondisplaced scaphoid waist fracture treated nonoperatively. At the first visit when cast removal was considered – after an average of 6 weeks of immobilization – patients rated pain during 4 examination maneuvers. The treating surgeon assessed union on radiographs and decided whether to continue or discontinue immobilization. Patients completed measures of the following: (1) the degree to which pain limits activities (Patient-Reported Outcome Measure Interactive System [PROMIS] Pain Interference Computer Adaptive Test [CAT], Pain Self-Efficacy Questionnaire-2); (2) symptoms of depression (PROMIS Depression CAT); and (3) upper extremity function (PROMIS Upper Extremity Function CAT). We used multivariable regression analysis to investigate the factors associated with each outcome. Results: Perceived inadequate radiographic healing and greater symptoms of depression were independently associated with continued immobilization. Pain during the examination was not associated with continued immobilization. Patient age was associated with pain on examination. Shorter immobilization duration was the only factor associated with the surgeon’s perception of inadequate radiographic consolidation. Conclusions: Inadequate radiographic healing and greater symptoms of depression are associated with a surgeon’s decision to continue cast or splint immobilization of a nondisplaced scaphoid waist fracture. Clinical relevance: Overreliance on radiographs and inadequate accounting for psychological distress may hinder the adoption of shorter immobilization times for nondisplaced waist fractures.

Significant significance? Bothe, T. L. and A. Patzak (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Research implementation Through the HandyEvidence survey, I have discovered that Hand Therapists are interested in tips on how to critique research article. This synopsis is the first of a series (if you find them useful - leave a comment if so) providing tips on how to interpret what research you read. In particular, this synopsis aims at helping you to understand and making sense of what "statistical significant", "p < 0.05", or "p < 0.001" really mean. Below are a few points: 1) "Statistical significance" simply means that there is a low chance that the results reported are due to chance. This is great to know because ideally we want to provide treatments that consistently, or at least most of the time, provide useful outcomes. Keep reading for more important info below. 2) "p < 0.05", or "p < 0.001" simply means that there is less than 5% or 0.1% probability that the results are due to chance. The p value will often get smaller with larger sample sizes, however, it does not mean that the lower the p value the more clinically relevant the findings are. 3) This is probably the most important point of all. If a paper states that the results are "statistical significant", or that the "p < 0.05", or "p < 0.001", this does not tell us how relevant the findings are. In other words, it does not clarify whether the results are clinically relevant. We could have for example a study showing a "statistical significant (p < 0.05)" reduction in pain with an experimental treatment compared to a control. However, the absolute difference between the experimental and control groups could be 0.5 points out of 10 on the Numerical Rating Scale (NRS). In other words, you have a low probability of this finding to be due to chance (less than 5% chance), but the extent of pain relief is small (0.5 out of 10 on NRS). This is a perfect example of a "statistically significant" but not "clinically relevant" finding. I hope this synopsis provides with some useful tips in interpreting research findings. If you found it useful or if you have other topics on research interpretation that you would like me to cover, post a comment. 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 : Evidence guided practice is not easy to implement and at times can cause frustration. Statistical significance may be one of those jargon terms that adds to the confusion and that can potentially lead to misinterpretation of research. All you need to remember is that if something is "statistical significant", "p < 0.05", or "p < 0.001" there is a low probability of the results being due to chance. You then need to take a additional step and ask yourself whether this difference is "clinically relevant". Often you can find this information in tables where the results for each group are reported. If the difference between groups is not "clinically relevant" (e.g. 2 points out of 10 for pain) you can then make an educated guess on whether you should change your practice based on these findings. If you liked this synopsis you may also like other topics such as the implementation of research to clinical practice and how to make evidence guided decisions when limited evidence is available . URL : https://doi.org/10.1111/apha.13665 Available through EBSCO Health Databases for PNZ members. No Abstract available

MRI does not effectively diagnose ulnar-sided wrist pain in elite tennis players. Reid, M., et al. (2020). Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : MRI findings ulnar wrist - Elite tennis players This is a cross sectional study assessing the association between changes on MRI and the presence of ulnar wrist pain in elite tennis players. Elite tennis players with (n = 14) and without (n = 14) symptoms in the non-dominant ulnar wrist were compared to healthy non-tennis players controls (n = 12). Participants were on average 20 years old. Wrist MRI were completed for all participants. The only information that we have regarding the symptomatic participants is that they reported non-dominant ulnar pain on at least 7 or more days in the last year. The results showed that the average number of abnormalities was 3.6 (95% CI: 2.8 to 4.8) in symptomatic vs 2.6 (95% CI: 1.9 to 3.7) non symptomatic tennis players. Healthy non symptomatic tennis players presented with and average 2.5 (95%CI: 1.7 to 3.6) abnormalities. There was no significant difference between the number of abnormalities between groups. Secondary analyses revealed that participants with ulnar sided wrist pain were more likely to present with bony or articular abnormalities. Clinical Take Home Message : Based on what we know today, there is no significant correlation between the total amount of abnormalities reported on MRI and wrist pain in the painful non-dominant wrist of elite tennis players. Interestingly, a similar number of changes was reported by healthy non-tennis player control. This suggests that we should be careful in suggesting a correlation between imaging findings and pain. However, it is possible that bony and articular changes contribute, at least in part, to the pain reported by elite tennis players. We should keep in mind that factors other than MRI abnormalities may contribute to pain. These may include changes in training load and volume , poor sleep , and possibly psychological factors such as kinesiophobia . URL : https://doi.org/10.1016/j.jsams.2020.01.001 Available through EBSCO Health Databases for PNZ members. Abstract Objectives: Ulnar-sided injuries of the non-dominant wrist are common in elite tennis players using a double-handed backhand technique. This study investigated the radiological changes of the non-dominant wrist in elite symptomatic and asymptomatic players using this technique as well as healthy controls. We compared clinical findings to radiological abnormalities. Design: Cross-sectional design with blinded radiological assessment, and contemporaneous clinical assessment of symptomatic players. Methods: Magnetic resonance images (MRI) of wrists related to non-dominant ulnar-sided pain, were taken in 14 symptomatic tennis players, 14 asymptomatic tennis players, and 12 healthy controls which were then independently reviewed for abnormalities by blinded radiologists. Total abnormalities and global between-group differences in the triangular fibrocartilage complex (TFC), ulnar collateral ligament (UCL), extensor carpi ulnaris (ECU) and supporting structures, osseous-articular lesions and ganglia were assessed. These were then compared to clinical examinations of the symptomatic players to assess agreement. Results: Symptomatic players reported a mean 3.64 abnormalities, being exactly 1 abnormality greater than asymptomatic players (2.64) and controls (2.50), suggesting similar asymptomatic lesions in all three groups. Players with pain reported significantly more osseous-articular lesions, ECU tendon and dorsal radio-ulnar ligament abnormalities, while changes to the UCL may reflect an isolated problem in specific wrists. There were no between-group differences in the presence of ganglia, most TFC structures nor ECU subsheath tear and subluxation. Conclusions: Clinicians should carefully consider radiological changes alongside their clinical diagnosis of non-dominant wrist pain in tennis players due to possible tennis-related changes and/or asymptomatic findings.

Accuracy of provocative tests for carpal tunnel syndrome. Zhang, D., C. M. Chruscielski, P. Blazar and B. E. Earp (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Carpal tunnel syndrome - Physical tests This is a prospective study on the specificity and sensitivity of four physical tests for carpal tunnel syndrome (CTS). If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. A total of 55 participants (85 symptomatic hands) were included in the present study. Nerve conduction studies were utilised as the gold standard to validate the diagnostic accuracy of the CTS tests. The four physical tests assessed were the Tinel's, Phalen's, Durkan's, and the combination of Phalen's and Durkan's test (see picture below). Out of the 55 participants, nine had no impairments on nerve conduction test of the median nerve at the carpal tunnel. The Phalen's and Dhurkan combination (shown in picture D below) was the most sensitive test (90% sensitivity) when utilised in isolation. This test could therefore be utilised for screening purposes, or in other words exclude the presence of CTS. The presence of four positive tests completed one after the other presented the highest specificity (80% specificity). 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 combination of the Phalen's and Durkan's test into one (see picture D above - Phdurkan test), is useful to exclude the diagnosis of CTS if negative. In contrast, if the Phdurkan test was positive we would probably want to complete the remaining three tests (Tinel, Phalen, Durkan) and find them all positive, to make a diagnosis of CTS with a good degree of confidence. In addition, we can complete the CTS-6 scoring criteria , which will provide us with useful information on the likelihood of our clients suffering from CTS. Open access URL : https://doi.org/10.1016/j.jhsg.2020.03.002 Abstract Purpose: Prior literature on the diagnostic accuracy of commonly used provocative tests for suspected carpal tunnel syndrome (CTS) is affected by research biases. The objectives of our study were to measure and compare the diagnostic accuracy of 4 commonly used provocative tests for CTS using electrodiagnostic study as the reference standard. Methods: We prospectively evaluated 85 hands in 55 patients with suspected CTS. Tinel sign, Phalen’s test, Durkan’s test, and Phdurkan test (a combination of wrist flexion and carpal compression) and subsequent electrodiagnostic testing were performed on all patients. Sensitivity and specificity were calculated using electrodiagnostic findings as the reference standard. McNemar test was used to compare differences in paired outcomes between provocative tests. Results: Tinel sign had a sensitivity of 0.47 and specificity of 0.56. Phalen’s test had a sensitivity of 0.50 and specificity of 0.33. Durkan’s test had a sensitivity of 0.71 and specificity of 0.22. Phdurkan test had a sensitivity of 0.84 and specificity of 0.11. Median time to a positive Phdurkan test result was 3 seconds. McNemar tests showed significant differences (P < .05) in the proportions of positive results among all CTS provocative tests except between Tinel sign and Phalen’s test. Conclusions: Commonly performed provocative tests for suspected CTS differ in sensitivity and specificity. As the examination maneuver becomes more provocative, the test becomes more sensitive and less specific for CTS.

Bizarre parosteal osteochondromatous proliferation (nora lesion) in pediatric phalanges. Martínez Álvarez, S., D. L. Azorín Cuadrillero and K. J. Little (2021). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic This is the answer for the case study from last week. The patient was a 12 years old boy who presented with a mass on the middle phalanx of the ring finger, which developed after finger trauma six months earlier. The mass was painless and developed on the volar/radial aspect of the finger. The x-rays identified a mass as shown below in the picture. At surgical removal, the mass appeared to be a combination of cartilage and bone. Biopsy reveled it to be consistent with a Nora lesion (named after Dr. Frederick E. Nora) which is a benign tumor. After excision, the patient experience no recurrence despite the high rate of relapse. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Hand therapists should refer young children or teenagers for x-rays and US when there is evidence of a mass which has grown over time. The likelihood of identifying a Nora lesion is rare, however, x-rays and US may help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, infections or other rare forms of cancer. URL : https://doi.org/10.1016/j.jhsa.2020.05.002 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Bizarre parosteal osteochondromatous proliferation, or Nora tumor, is an uncommon lesion affecting the tubular bones of the hands and feet. Normally arising from the cortical surface and periosteum of these bones, these lesions histologically consist of a hypercellular cartilaginous cap covering a bony stalk that is surrounded by ossified areas and spindle cell stroma. The differential diagnosis includes conditions involving the periosteum such as chondrosarcoma, parosteal osteosarcoma, osteochondroma, turret exostosis, and florid reactive periostitis. The only effective treatment is wide surgical excision; nevertheless, local recurrence rates are extremely high and may necessitate revision surgery. In the present study, we report 3 cases of Nora lesion located in the hand in pediatric patients. The diagnosis in these cases was challenging owing to their presenting symptoms and radiographic findings. The diagnosis was made based on characteristic findings noted on the radiographic images and was confirmed by histological examination following excision.

Nonsurgical treatment for symptomatic carpal tunnel syndrome: A randomized clinical trial comparing local corticosteroid injection versus night orthosis. de Moraes, V. Y., et al. (2021) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Carpal tunnel conservative intervention - Cortisone injections vs splinting This is a randomised clinical trial assessing the effectiveness of night splinting vs corticosteroid injections on night paraesthesia, pain, function, and complications in people with carpal tunnel syndrome (CTS). Participants were included (N = 95) if they were over 40 years old and presented with at least 4 of the following six criteria: night paraesthesia in median nerve distribution of the hand, paraesthesia in median nerve distribution of the hand, atrophy of thenar muscles, positive Phalen's and Tinel's test, reduction in two-point discrimination (>6 mm). In addition, participants had to present with moderate to severe nerve conduction impairments on sensory and motor testing. Participants could have unilateral or bilateral symptoms, however, only the most affected limb was treated for the duration of the study. Outcome assessors were blinded to treatment allocation. Participants were randomised to either night splinting (n = 45), or non US guided corticosteroid injection (n = 50). Treatment effectiveness was assessed through self-reported night paraesthesia, pain and function were measured through the Boston-Levine questionnaire (BLQ), and complications were defined as a worsening of numbness at the injection site or skin tissue atrophy. Participants were assessed at baseline, 1 week, 3 and 6 months after treatment initiation. The results showed that corticosteroid injections reduced night paraesthesia to a clinically greater level compared to night splinting (see picture below). The same results were found for pain and function measured through the Boston-Levine questionnaire (BLQ) where corticosteroid injections were superior to splinting. Night splinting improved pain and function (BLQ) to a clinically relevant level but not night paraesthesia. 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 injections appear to be superior to night splinting for our clients (≥ 40 years old) with moderate/severe carpal tunnel syndrome. This appears to be specially true for improvements in night paraesthesia. If clients decline a referral for a cortisone injections, splinting can still provide with some benefits (reduction in pain and disability) and other approaches such as manual therapy (mobilisation and tendon/nerve glides) directed at the upper limb appear to be as effective as surgery at one and four years follow up. 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://doi.org/10.1016/j.jhsa.2020.11.014 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: For carpal tunnel syndrome (CTS), local corticosteroid injection (corticosteroid), and/or wrist immobilization with night orthosis (orthosis) are commonly prescribed and are supported by strong evidence. The aim of this study was to compare orthosis versus corticosteroid for patients with CTS. Methods: A CTS diagnosis was made clinically and supported by electrodiagnostic study. Patients were randomly allocated to either orthosis or corticosteroid. Clinical assessments were performed before the intervention, within the first week of the intervention, and 1, 3, and 6 months after the intervention. Primary outcomes were improvement in nocturnal paresthesia and Boston-Levine questionnaire (BLQ) score. Secondary outcomes were pain assessed by visual analog scale and complications. Results: Of 100 patients enrolled in the study, 95 completed the planned follow-up (45 in the orthosis arm and 50 in the corticosteroid arm). Corticosteroid injections were superior to orthosis in remission of nocturnal paresthesia (remission rates at 1 month, 84.6% versus 43.83%; 3 months, 71.1% versus 40.4%; and 6 months, 80.3% versus 28.8%). The BLQ scores (functional and symptom subscales) were also more favorable for corticosteroid at 1, 3, and 6 months (minimal clinically important differences for Function > 0.5 and Symptom > 0.16). Pain scores were lower and favored the corticosteroid group. There were no complications in either group. Conclusions: Both options are effective in the short term. Corticosteroid is superior to orthosis for improving CTS-related nocturnal paresthesia, BLQ scores, and pain.