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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 13 years old male who had been experiencing pain at the base of the second metacarpal for the past 3 months. They had no history of trauma or signs of symptoms of infection. Objectively, they presented with pain on wrist range of movement assessment, but no objective signs of carpal or carpalmetacarpal instability. Grip and pinch strength were reduce by 30% and 40% respectively. X-ray investigations revealed sclerotic changes of the trapezoid, blood tests excluded the presence of an infection or rheumatic condition, and MRI investigations showed changes at the trapezoid (see picture). What is it?

Upper-extremity venous thromboembolism following operative treatment of distal radius fractures: An uncommon but dangerous complication. Calotta, N. A., J. T. Shores and D. Coon (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Distal radius fracture – Upper limb thromboembolism This is a retrospective study assessing the prevalence of venous thromboembolism and its risk factors in a group of patients undergoing open reduction and internal fixation (ORIF) for distal radius fracture. A total of 24,494 participants were included in the study. Potential participants were excluded if they presented with a preexisting thrombophilic condition (e.g. thrombophilia). Participants' average age ranged between 18 to 91. Thromboembolism was identified up to 60 days after surgery. The statistical analyses took into account demographic information to reduce the contribution of confounding factors to the overall results. The results showed that 0.3% (n = 79) of participants developed thromboembolism. The risk factors were heart failure (greatest risk), the use of estrogen, and a score greater than 3 on the Charlson Comorbidity Index (CCI) , which includes age and other comorbidities (e.g. diabetes) for its calculation. 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 risk of thromboembolism in the general population post distal radius ORIF is very low. Thus, this will occur in 3 out of a 1,000 clients. However, if the client is above 70 (this will automatically give a CCI score of 3), if they are female (more likely to take estrogen), and if they present with cardiovascular disease (heart failure in particular), they are at greater risk of developing a thromboembolism within 60 days of distal radius ORIF. It is therefore important to keep this differential diagnosis in mind in this subgroup of clients. If you are interested in other potential complications following distal radius fracture have a look at these synopses on the effect of smoking on the risk of infection or other complications . If your clients are smoking, you may ask them if they would like some help to quit smoking . URL : https://doi.org/10.1016/j.jhsa.2021.03.011 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE. Methods: We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery. Results: The study included 24,494 patients. The mean age was 50.7 years (range, 18–91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE. Conclusions: Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE.

De quervain tenosynovitis: An evaluation of the epidemiology and utility of multiple injections using a national database. Hassan, K., A. Sohn, L. Shi, M. Lee and J. M. Wolf (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Treatment Topic : De Quervain - Conservative treatment This is a retrospective study on the failure rate of cortisone injections for De Quervain syndrome. A total of 17,820 participants were retrospectively identified through an insurance database. Participants were included if the insurance code indicated the presence of De Quervain. No further information was provided about participants. Failure of injection was defined as the need for a second injection or surgical intervention. The results showed that in 72% of participants, the first injection was successful. The second and third injection was successful in 66% and 60% of participants. 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 first cortisone injection for De Quervain syndrome appears to be effective in 70% of people. Despite a reduction in effectiveness with additional injections (60-66% effectiveness), these can still provide pain relief in a large group of clients. Future studies comparing cortisone injection to saline for De Quervain syndrome are required to clarify whether they are more effective than placebo. As a matter of fact, in people with thumb OA or tennis elbow , this is not the case. In addition, clients undergoing cortisone injections close to the time of surgery for thumb OA appear to be at greater risk of post surgical complications. It is unclear whether this increased risk is due to the active principle (cortisone) or the injection itself. URL : https://doi.org/10.1016/j.jhsa.2021.04.018 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: We hypothesized that repeat injections are associated with a decreased rate of success and that the success rate of injections correlates with patient comorbidities. Methods: Using a commercially available insurance database, patients diagnosed with De Quervain tenosynovitis were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes and stratified by therapeutic interventions, including therapy, injections, and surgery, as well as comorbidities. Injection failure was defined as a patient receiving a repeat injection or subsequent surgical management. Success was defined as no further therapies identified after an intervention. Results: From 2007 to 2017, 33,420 patients with a primary diagnosis of De Quervain tenosynovitis were identified. Women represented 77.5% (25,908) of the total and were 2.6 times more likely to be diagnosed than men. Black patients were more likely to be diagnosed than White patients. Black and White women were found to have the highest incidence (relative risk 3.4 and 2.3, respectively, compared with White men). Age was also significantly correlated with an increased risk of diagnosis of the condition, with a peak incidence at the age of 40–59 years (relative risk, 10.6). Diabetes, rheumatoid arthritis, lupus, and hypothyroidism were associated with an increased risk of diagnosis. Overall, 53.3% of the patients were treated with injections, 11.6% underwent surgery, and 5.2% underwent therapy. Treatment with a single injection was successful in 71.9% of the patients, with 19.7% receiving a repeat injection and 8.4% treated with surgery. The overall success rate of subsequent injections was 66.3% for the second injection and 60.5% for the third. The initial injection had a higher rate of success in diabetics than in nondiabetics; however, the difference (2%) was not clinically relevant. Conclusions: Although the success rate for the treatment of De Quervains tenosynovitis decreases with multiple injections, repeat injections have a high rate of success and are a viable clinical option.

Clinical assessment of hand oedema: A systematic review. Miller, L. K., C. Jerosch-Herold and L. Shepstone (2017) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Diagnostic Topic : Hand swelling - How to reliably measure it This is a systematic review assessing the reliability and validity of different forms of hand swelling measurement. Reliability could be defined as the ability of a tool (e.g. figure-of-eight) to repeatedly measure a specific variable (e.g. hand swelling) without significant error. Validity could be defined as the ability of a tool to measure a specific variable (e.g. hand swelling) rather than other variables (e.g. range of movement). Usually validity of a tool is compared against an existing "gold standard", known to measure that specific variable. Six RCTs were included for a total of 243 participants. Each study was assessed through the Consensus-based Standards for the selection of health Measurement Instruments checklist (COSMIN) . No overall quality of evidence assessment was provided. Three different assessment methods, which included visual inspection, perometer , and figure-of-eight, were compared against volumetry ("gold standard" for hand swelling). These measures were taken from participants with hand swelling presenting with several different conditions including cerebrovascular accidents, hand burns/surgery/trauma. The results showed that the figure-of-eight measurement presented with good inter-rater (repeated measurements from the same person) and intra-rater (measurements from different people) reliability. Limited information was provided in terms of validity, except for the fact that both figure-of-eight and the volumeter could measure changes in swelling reasonably well. Visual inspection did not appear to be valid against the volumeter. The perometer was reliable but did not appear to be valid against the volumeter. Clinical Take Home Message : Based on what we know today, figure-of-eight appears to be reliable when the same or different clinicians measure the same hand. In addition, it appears to be valid when compared to other clinical tools available, although we need more research assessing its validity. Visual assessment of hand swelling is a gross measure of swelling and does not appear to be particularly useful to track swelling changes. URL : https://doi.org/10.1177/1758998317724405 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Assessment of oedema after trauma or surgery is important to determine whether treatment is effective and to detect change over time. Volumetry is referred to as the "gold standard" method of measuring volume. However, this has practical limitations and other methods are available. The aim of this systematic review was to evaluate the psychometric properties of alternative methods used to assess hand oedema. Methods: A search of electronic bibliographic databases was undertaken for any studies published in English reporting the psychometric evaluation of a method for measuring hand oedema, in an adult population with hand swelling from surgery, trauma or stroke. The Consensus?based Standards for the Selection of health Measurement Instruments (COSMIN) checklist was used to evaluate the methodological quality. Results: Six studies met the inclusion criteria. Three methods were identified assessing hand oedema: perometry, visual inspection and the figure-of-eight tape measure, all were compared to volumetry. Four different psychometric properties were assessed. Studies scored fair or poor on COSMIN criteria. There is low-quality evidence supporting the use of the figure-of-eight tape measure to assess hand volume. The perometer systematically overestimated volume and visual estimation had poor sensitivity and specificity. Discussion: The figure-of-eight tape measure is the best alternative to volumetry for hand oedema. Benefits include reduced cost and time while having comparable reliability to the "gold standard". Further research is needed to compare methods in patients with greater variability of conditions and with isolated digit oedema. Visual estimation of hand oedema is not recommended.

Mental and social health are inseparable from physical health. Ring, D. (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Psychosocial factors – Upper limb diagnosis and treatment This is an editorial from the Journal of Bone and Joint Surgery on the contribution of psychosocial factors on musculoskeletal conditions. The article highlights the impact of mental and social health factors on the diagnosis and treatment of our clients. In particular, the author reminds us that depression, catastrophising, and negative emotions can increase pain to a disproportionate level in relation to the physical injury. In addition, ethnicity as well as financial aspects of our clients may affect the care that they receive. For example, if people are in a financially precarious position, rest or surgery, may not be a viable option as these require taking time off work. We should therefore pay attention to their social situations as this can be an important factor in treatment decision. In a similar way, ethnicity, sex or other factors may lead to inequitable distribution of resources. 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 : Information from this article may make us reflect on how we approach assessment and treatment of our clients. It is important to consider the financial and Whānau (family) needs of our clients and adapt the treatment to their situation. At times, an evidence based treatment is not pragmatical, as it impedes them from working or taking care of other people. Other solutions may therefore be required to accommodate their situation, whilst still providing them with the most effective treatment. Mental health aspect have also previously suggested to mediate recovery from musculoskeletal conditions as well as as the number of visits required for treatment of upper limb conditions . Mental health factors should be kept in mind and a referral to the suitable professional may be performed if possible. Other interventions, which may help with mental health status include physical activity , and yoga , and meditation, although this last one may present with undesirable side effects . Open Access URL : http://dx.doi.org/10.2106/JBJS.21.00121 No Abstract available

Efficacy of surgical interventions for trapeziometacarpal (thumb base) osteoarthritis: A systematic review. Hamasaki, T., et al. (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Surgical intervention - Thumb OA This is a systematic review assessing the effectiveness of several surgical interventions for first carpometacarpal joint (cmcj) osteoarthritis (OA). Systematic reviews (SR), randomised controlled trials (RCT), and non-randomised controlled trials (nRCT) were included in the present review. A total of 59 studies were included, of which one was a SR, 18 were RCTs, and 40 were nRCT. All the studies were formally assessed for their research quality. Different critiquing tools were utilised according to the type of study analyses (SR, RCT, nRCT). 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. The results showed that there are 11 different surgical approaches for first cmcj OA. All the studies compared one surgical approach to another surgical approach. No studies compared a surgical intervention to a sham procedure. Overall it appeared that a "simpler" intervention such as trapeziectomy provided better outcomes (e.g. lower complications) compared to other more complex interventions (e.g. suspension arthroplasty). The result of this review were however supported by low quality evidence. Clinical Take Home Message : Based on what we know today, several surgical interventions are available for symptomatic first cmcj OA. Trapeziectomy may provide better results compared to other surgical interventions. Despite these surgical interventions been commonly performed for clients with first cmcj OA, they have never been compared to sham surgery. This trend is changing and a systematic review assessing orthopedic surgical procedures vs sham surgery in other joints has already been published . Their results suggested that both real and sham surgery improved pain and function to the same extent. Open access URL : https://doi.org/10.1016/j.jhsg.2021.02.003 Abstract Purpose: This systematic review (SR) aimed to identify the surgical interventions available for trapeziometacarpal osteoarthritis and document their efficacy on pain, physical function, psychological well-being, quality of life, treatment satisfaction, and/or adverse events. Methods: This PROSPERO-registered SR’s protocol was developed based on the Cochrane intervention review methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Among 9049 potential studies identified, 1 SR, 18 randomized controlled trials, and 40 nonrandomized controlled trials were included. We identified 11 categories of surgical techniques: first metacarpal osteotomy, first metacarpal and trapezium partial resection, arthrodesis, trapeziectomy (T), T+ligament reconstruction (LR), T+tendon interposition (TI), T+ligament reconstruction and tendon interposition (LRTI), hematoma distraction arthroplasty (HDA), chondrocostal graft interposition, autologous fat injection, and manufactured implant use. These findings supported by low-quality evidence revealed moderately or largely superior effects of the following interventions: (1) trapeziectomy over T+LRTI using ½ flexor carpi radialis (FCR) and metacarpal tunnel (MT) or using abductor pollicis longus (APL) and FCR for adverse events; (2) trapeziectomy over T+TI using palmaris longus (PL) for pain; (3) T+LR with ½FCR-MT over T+LRTI with ½FCR-MT for physical function; (4) trapeziectomy by anterior approach over that by posterior approach for treatment satisfaction and adverse events; (5) T+LRTI using ½FCR-MT over T+TI with PL for pain; and (6) T+HDA over T+LR using APL-MT-FCR for pain, physical function, and adverse events. GraftJacket (Wright Medical Group, Memphis, TN), Swanson (Wright Medical Group, Letchworth Garden City, UK), and Permacol (Tissue Science Laboratories, Aldershot, UK) implants and hardware (plate/screw) would cause more complications than an autograft. The effect estimates of other surgical procedures were supported by evidence of very low quality. Conclusions: This SR provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis. Some interventions showed a moderate-to-large superior effect on the studied outcome(s) compared with others. However, these findings must be interpreted with caution because of low-quality evidence. To provide stronger evidence, more randomized controlled trials and methodological uniformization are needed.

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.