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Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Incidence : Rare Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was an 18 years old male who had been experiencing pain and swelling in the back of the wrist in the last 2 years. Objectively, there was a 3x3 cm non-pulsatile mass in the back of the wrist. Extension range of movement had a deficit of 20 degrees. X-ray was impeccable, however, computer tomography and MRI scans revealed an ill-defined soft tissue mass between scaphoid, trapezoid, and capitate (see picture below). What is it?

Concurrent validity of a low-cost and time-efficient clinical sensory test battery to evaluate somatosensory dysfunction. Zhu, G. C., Böttger, K., Slater, H., Cook, C., Farrell, S. F., Hailey, L., . . . Schmid, A. B. (2019) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Sensory testing - Bed side tests This is a validation study of bedside tests for clients presenting with musculoskeletal conditions including carpal tunnel syndrome (CTS). The results of a series of bedside tests, which included temperature detection (heat, cold), mechanical detection (e.g. monofilament testing), pressure pain thresholds, and others were compared to quantitative sensory testing, which is the current gold standard to assess the function of the sensory system. The most valid tests for loss of sensation were the warm/cold detection and the cotton wool touch detection. The most valid tests for sensory gain (hyperalgesia) were pressure pain thresholds on the thenar eminence with a pencil eraser or the clinicians' thumb. All the tests were compared to the contralateral limb or a non affected are of the hand to determine whether there was a loss of sensation or hyperalgesia. Clinical Take Home Message : Based on what we know today, a few bedside tests can be implemented in addition to our monofilament and manual muscle tests for carpal tunnel syndrome. These tests include cold/warm sensation assessment, which can be done through cold/warm coins, and pain pressure threshold based on compression of the thenar eminence through a clinician's thumb. These tests need to be compared to the healthy contralateral limb (if asymptomatic) to identify whether we have a loss or gain in sensation. In addition, we can perform pinprick testing, which is on indicator of small nerve fibre integrity . By monitoring our patients through these tests, we may be able to identify improvements following our intervention , which may go unnoticed if assessed through monofilament or manual muscle testing only. Open Access URL : https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1456 Abstract Background This study describes a low‐cost and time‐efficient clinical sensory test (CST) battery and evaluates its concurrent validity as a screening tool to detect somatosensory dysfunction as determined using quantitative sensory testing (QST). Method Three patient cohorts with carpal tunnel syndrome (CTS, n = 76), non‐specific neck and arm pain (NSNAP, n = 40) and lumbar radicular pain/radiculopathy (LR, n = 26) were included. The CST consisted of 13 tests, each corresponding to a QST parameter and evaluating a broad spectrum of sensory functions using thermal (coins, ice cube, hot test tube) and mechanical (cotton wool, von Frey hairs, tuning fork, toothpicks, thumb and eraser pressure) detection and pain thresholds testing both loss and gain of function. Agreement rate, statistical significance and strength of correlation (phi coefficient) between CST and QST parameters were calculated. Results Several CST parameters (cold, warm and mechanical detection thresholds as well as cold and pressure pain thresholds) were significantly correlated with QST, with a majority demonstrating >60% agreement rates and moderate to relatively strong correlations. However, agreement varied among cohorts. Gain of function parameters showed stronger agreement in the CTS and LR cohorts, whereas loss of function parameters had better agreement in the NSNAP cohort. Other CST parameters (16 mN von Frey tests, vibration detection, heat and mechanical pain thresholds, wind‐up ratio) did not significantly correlate with QST. Conclusion Some of the tests in the CST could help detect somatosensory dysfunction as determined with QST. Parts of the CST could therefore be used as a low‐cost screening tool in a clinical setting. Significance Quantitative sensory testing, albeit considered the gold standard to evaluate somatosensory dysfunction, requires expensive equipment, specialized examiner training and substantial time commitment which challenges its use in a clinical setting. Our study describes a CST as a low‐cost and time‐efficient alternative. Some of the CST tools (cold, warm, mechanical detection thresholds; pressure pain thresholds) significantly correlated with the respective QST parameters, suggesting that they may be useful in a clinical setting to detect sensory dysfunction.

Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review Heales, L., McClintock, S., Maynard, S., Lems, C., Rose, J., Hill, C., Kean, C., & Obst, S. (2020) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Forearm and wrist orthoses This is a systematic review and meta-analysis assessing the short term effectiveness of wrist and forearm orthoses vs a control group on pain-free grip strength in people with lateral epicondylalgia. Seven studies were included for a total of 267 participants. Forearm orthoses included straps placed 2-5cm distally to the lateral epicondyle, or elbow sleves. Wrist orthoses were rigid splints supporting the wrist in extension. The control group wore either no orthoses, or a placebo orthoses. Pain-free grip strength was defined as the greates grip strength that participants could develop without pain. The assessment was completed immediately before and after the application of the orthoses. The results showed pain-free grip strength improved to a statistically significant level in participants wearing a forearm orthoses (mean difference: 2.5 kg; 95%CI: 0.5 to 4.5). No improvements in pain-free grip strength were noticed with wrist orthoses. These results suggest that the forearm orthosis improved pain-free grip, although the results may not be clinically meaningful. The quality of evidence supporting these results was low (GRADE) suggesting that the true effect may be substantially different from what has been presented. Clinical Take Home Message : Hand therapists may expect an immediate improvement in pain-free grip strength (between 0.5 and 4.5 kg) following the application of a forearm orthosis in patients with lateral epicondylalgia. This orthosis may be utilised as an adjunct to education and progressive upper limb strengthening in lateral epicondylalgia. URL : https://www.sciencedirect.com/science/article/abs/pii/S2468781219301419

Strain reduction of the extensor carpi radialis brevis tendon proximal origin following the application of a forearm support band. Takasaki, H., Aoki, M., Oshiro, S., Izumi, T., Hidaka, E., Fujii, M., & Tatsumi, H. (2008) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Forearm based orthosis This is an experimental study assessing extensor carpi radialis brevis (ECRB) tendon strain with or without a forearm based orthosis (strap) in cadavers. Eight cadavers' arms were prepared for this study. A strain gauge was positioned at the ECRB origin at the lateral epicondyle to measure tendon strain. The ECRB strain was measured under three different conditions, which included the sole application of a forearm based orthosis (∼ 5cm distal to lateral epicondyle) with a tension of 2 kg, a tensional load of 2.2 kg applied to the distal ECRB tendon, or with the combination of 2.2 kg tendon load and the forearm based orthosis. The study needs to be considered in the context of a few limitations. The experiment was performed in cadavers and in vivo studies may show different results. The load applied to ECRB (2.2 kg) equates to 10% of the maximum ECRB load. The results showed that the sole application of the forearm based orthosis did not cause any strain on the ECRB tendon. When ECRB was loaded with 2.2 kg, the tendon strain was 2.4%, indicating that the tendon was elongated 2.4% of its original lenght. When ECRB was loaded with 2.2 kg while the forearm based orthosis was applied, the tendon strain was 0.85%, indicating that the tendon was elonagated 0.85% of its original lenght (stretched on tendon was reduced by more than 50%). Clinical Take Home Message : Hand therapists may consider utilising a forearm based orthosis for patients with lateral epicondylalgia. This intervention appears to reduce the strain on ECRB proximal tendon through a mechanical effect. The effectiveness of this forearm based strap in reducing strain may be limited to light activities and not heavier manual tasks. URL : https://www.jospt.org/doi/abs/10.2519/jospt.2008.2672

Current methods, outcomes and challenges for the treatment of hand fractures. Boeckstyns, M. E. H. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Hand fractures - Surgical vs conservative treatment This is a narrative review on treatment of metacarpal, carpometacarpal, and phalangeal fractures. Most metcarpal fractures can be treated conservatively with good outcomes. Surgey is required if dorsal angulation is greater than 20-40° is present or if there is an open or unstable fracture. Carpometacarpal fractures can be managed conservatively when no dislocation is present. Phalangeal shaft fractures can be treated conservatively with splinting if there is no rotational deformity (scissoring). If rotation deformity is identified, this requires surgical correction. Phalangeal base fractures can be managed conservatively with close monitoring of rotational malunion (scissoring). Salter-Harris type 2, commonly seen in kids, can be managed conservatively. Intrarticular pipj fractures are the most challenging fractures to treat and there is an ongoing debate on what is the most appropriate line of treatment. Intrarticular pipj fractures often involve either the volar or dorsal aspect of the distal phalanx. For volar fractures, surgical treatment is required if a "V" sign is identified on the dorsal apsect of the pipj on a lateral view. Dorsal fractures usually requires surgical intervention. Bony Mallet is often treated conservatively and a recent study has suggested that even with bony fragments greater than 1/3 of the articular surface, conservative treatment is feasible. During conservative treatment, it is advisable to perform radiographic controls the to assess the development of distal phalanx subluxation. Thumb bony avulsion of ucl of mcpj associated with Stener lesion (interposition of adductor pollicis) usually requires surgical intervention. This condition can be identified on x-ray if a bony fragment is present. Bennett's fracture is a fracture of the proximal metacarpal of the thumb, which extends into the cmcj of the thumb. No research has shown better outcomes with either conservative or surgical management in Bennett's fracture. Clinical Take Home Message : Hand therapists should be able to treat most hand fractures conservatively. A few exceptions include open and/or unstable fractures, metacarpal fractures with severe angulation, metacarpal or phalangeal fractures associated with scissoring of fingers, pipj intrarticular fractures, bony mallet with subluxation, and Stener's lesions of the thumb. When in doubt a second opinion from a hand surgeon is always indicated. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420928820

Splinting versus extension-block pinning of bony mallet finger: A randomized clinical trial. Thillemann, J. K., Thillemann, T. M., Kristensen, P. K., Foldager-Jensen, A. D., & Munk, B. (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Bony mallet - Conservative vs surgical treatment This is a randomised single-blind controlled trial assessing the effectiveness of surgery vs splinting in participants bony mallet greater than 1/3 of the articular surface. Participants (N=28) were diagnosed with bony mallet through lateral radiographs. Participants were excluded if the bony mallet fragment was less than 1/3 of the dipj articular surface or if the dipj presented with volar subluxation. Participants with bony mallet of the thumb were excluded. Effectiveness of treatment was assessed by extension lag of the dipj and subluxation of the distal phalanx. Extension lag was assessed at baseline and at 6 months. Subluxation of the distal phalanx was assessed before treatment, immediately after surgery or immobilisation, at 6 weeks, and 6 months. After inclusion in the study, participants were randomised to surgical treatment through extension block pinning (n=14) or splinting (n=14). The extension block pinning group was treated with two k-wire to avoid extensor tendon traction on the bony fragment and distal phalanx subluxation. K-wire were removed after 6 weeks. The splinting group was immobilised in dipj extension with an aluminium splint fixed in place with tape. This had to be worn 24/7 for 6 weeks with regular changes of padding and tape. Care was taken to avoid loss of dipj extension during tape changes, although the process was not supervised. In both groups, the pipj of the affected finger was free to move. Correct position of the distal phalanx was assessed for both groups after immobilisation with a lateral x-ray and revealed good alignment in all participants. Rehabilitation was initiated for both groups after 6 weeks and it included active dipj extension/flexion and a static night splint. This was progressed to loaded dipj extension/flexion and night splint at 8 weeks. At 12 weeks, patients resumed their normal activities without limitations. The results showed that there was no difference in dipj lag at 6 months between the two groups (splint: 12 ° , range: 8-16; surgery: 10, range: 4-16). Three participants in the splinting group vs no participants in the surgical group presented with distal phalanx subluxation at six months. This difference was not statistically signifcant (I performed a Fisher t-test), although it is possible that the study was underpowered to detect differences. Clinical Take Home Message : Hand therapists may expect similar treatment outcomes when bony mallet greater than 1/3 of the articular surface (without subluxation) are treated conservatively or surgically. However, follow up x-rays during conservative treatment may be required to exclude distal phalanx subluxation. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420917567

The value of magnetic resonance imaging and ultrasound in diagnosing displaced rupture of the thumb ulnar collateral ligament. Hamborg-Petersen, E., Torfing, T., & Viberg, B. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Thumb UCL – Ultrasound and MRI diagnostic This is a non-peer reviewed prospective study assessing the usefulness of MRI and Ultrasound (US) in identifying thumb UCL (mcpj) ruptures. A total of 49 participants were included in the study. Only participants with a ruptured UCL identified clinically and with fluoroscopic diagnsosis were included. UCL rupture was confirmed if there was a greater than 35° of mcpj medial gapping on stress test (in 0° to 30° of mcpj flexion) or if there was more than 10° difference between sides. Potential participants were excluded if trauma had occured longer than 6 weeks before assessment. The variables of interest were the sensitivity of MRI and US. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition (good for screening purposes). Diagnostic accuracy of MRI and US was based on the intraoperative findings (gold standard). The results showed that median time from injury to MRI and US was 6 and 9 days respectively (range 1-20). Median time from injury to surgery was 9 days (range 1-33). The sensitivity of MRI was 65% and 73% for UCL rupture and Stener lesion respectively. The sensitivity of US was 65% and 36% for UCL rupture and Stener lesion respectively. Clinical Take Home Message : Hand therapists may not refer patients for US scans to screen for an UCL rupture or a Stener lesion. The sensitivity of this test is too low and does not appear to be useful in excluding these pathologies when the scans are negative. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420932496

Are you translating research into clinical practice? What to think about when it does not seem to be working. Murphy, M. C., W. Gibson, G. L. Moseley and E. K. Rio (2021). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Research implementation This article presents a potential few reasons of why evidence based practice does not always work in clinical practice: 1) Participants included in a study may be different from the ones that you are seeing. Furthermore, the diagnostic criteria for participants inclusion may be different from the ones that you use. 2) Are your clients presenting with comorbidities that were utilised as exclusion criteria in research? If this is the case, the effectiveness of treatment in clinical practice may not be as significant. 3) Is there any placebo effect that has not been controlled for in research or in clinical practice? Consider potential confounding variables that could contribute to the findings - Take home message - "believe nothing, question everything, trust nobody" 4) Case series are not answering questions. They provide a story about clients' presentation, treatment, and outcomes. Causality cannot be ascertained. Same goes for clinical experience. 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. I still think that we should try to implement research while keeping an eye on the characteristics of the research sample (participants may be different from the clients we see in clinical practice). It is good practice to keep questioning what we read and hear, not out of disrespect, but to get closer to what actually works. I reviewed another article that you may find useful to take decisions when there is a lack of research available. URL : http://bjsm.bmj.com/content/early/2021/01/11/bjsports-2020-102369.abstract Available through EBSCO Health Databases for PNZ members. Abstract The value of clinical research can be lost in translation and implementation. One often overlooked issue is whether clinicians can determine if their patient is similar to research participants and, ipso facto, whether the clinician treating that patient will have the same effects as what was reported in a research study. We present five questions and clinical tips for clinicians.

Acute bilateral compartment syndrome of the forearms. Wrafter, P., O. Kelly and M. O’Shaughnessy (2020). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Incidence : Rare Topic : What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. A diagnosis of bilateral forearm compartment syndrome was made, possibly secondary to rhabdomyolysis. Rhabdomyolysis is a pathology leading to muscle break down. This condition is often caused by unaccustomed overexertion, dehydration and myotoxic medications (medications toxic to muscle), which include statins and angiotensin inhibitors. The patient was treated with bilateral forearm fasciotomy, which relieved pressure and lead to a good overall recovery. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Compartment syndrome may be considered as a differential diagnosis in clients who report: taking statins or angiotensin inhibitors, recently having overexerted themselves, being dehydrated, or consuming alcohol. Objectively they would present with swollen painful muscles, which cause extreme pain when stretched. If acute compartment syndrome is suspected, clients should immediately be referred to ED. URL : https://www.jhandsurg.org/article/S0363-5023(18)31003-7/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract A 43-year-old woman presented to our emergency department with severe bilateral forearm pain. On examination, both forearms were tense and swollen and the patient had excruciating pain, made much worse on passive extension of the fingers. The pain did not resolve with analgesia. The symptoms and clinical examination were highly suspicious for compartment syndrome. However, there was no history of trauma, strenuous physical activity, or any other obvious factor that might have precipitated the onset of a compartment syndrome. The serum creatinine kinase at presentation was greater than 37,000. The patient, however, did have a history of hypertension and was taking losartan, an angiotensinogen II antagonist that has been associated with rhabdomyolysis. The patient was brought to surgery for emergency fasciotomies and made an excellent recovery after surgery. The etiology of this patient’s bilateral compartment syndrome is uncertain but may be a manifestation of drug-induced rhabdomyolysis.

Clinical and cost effectiveness of arthritis gloves in rheumatoid arthritis (A-GLOVES): randomised controlled trial with economic analysis. Hammond, A., et al. (2021). Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Rheumatoid Arthritis - Gloves This is a randomised, multicentre, double-blind, placebo controlled trial assessing the effectiveness of compression gloves on pain in participants with rheumatoid arthritis (RA) affecting the hand. Participants (N = 206) were included if they were diagnosed with rheumatoid arthritis by a Rheumatology consultant and if they had difficulty sleeping due to hand pain or using their hands during the day. Importantly, participants were excluded if they had previously tried arthritis gloves. Pain was assessed through the numerical rating scale (NRS) at baseline and 12 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either wear arthritis gloves providing between 23 to 32 mmHg of compression (real gloves), or loose fitting gloves providing 15 to 25 mmHg of compression (placebo gloves). Participants were advised to wear the gloves for most of the day but less than 24 hours per day. Participants in both groups were also provided with joint protection advice and hand exercises. The results showed that participants in all groups used the gloves for an average of 5 hours during the day and 6 hours at night. Both groups had minor improvements in pain (1 point out of 10) at 12 weeks, which was not statistically or clinically different between groups. The arthritis gloves increased the cost of care by £129 without providing any significant benefit. 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, arthritis gloves do not provide any additional benefit than loose fitting gloves. Providing gloves is more pricey and the expense does not appear to be justified. Instead of providing gloves, it may be more useful to use those resources (money) for an additional session of hand therapy where we can provide them with exercise interventions which have been shown to be effective through the SARAH trial ( See previous synopsis with links to free online course ). Open access URL : https://doi.org/10.1186/s12891-020-03917-8 Abstract Arthritis (or compression) gloves are widely prescribed to people with rheumatoid arthritis and other forms of hand arthritis. They are prescribed for daytime wear to reduce hand pain and improve hand function, and/or night-time wear to reduce pain, improve sleep and reduce morning stiffness. However, evidence for their effectiveness is limited. The aims of this study were to investigate the clinical and cost effectiveness of arthritis gloves compared to placebo gloves on hand pain, stiffness and function in people with rheumatoid arthritis and persistent hand pain.

Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study. Ouegnin, A. and K. Valdes (2020). Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Aetiologic Topic : Symptomatic thumb osteoarthritis - Proprioception This is a multicentre case-control study assessing differences on proprioception (joint position test) in participants with thumb OA (cases) and healthy participants (controls). A total of 29 participants were included in the study. Thumb OA was diagnosed through clinical examination (e.g. positive grind test) and confirmed through x-ray in some participants but not all. Proprioception (joint position sense) was assessed through a hand held goniometer by asking participants to reproduce a specific thumb position (30 degrees of abduction) after moving the thumb through the full range of abduction. The difference between the target angle and the angle reproduced (error) was recorded. The results showed that participants with thumb OA presented with an average error of 10 degrees while the healthy participants presented with 1 degree error in joint repositioning. This finding was statistically and potentially clinically significant. There are however, a couple of limitations in this study. First, not all participants with thumb OA were matched to a healthy participant. In some cases, when thumb OA was unilateral, the controlateral thumb of the same participant was assessed. This leads to the second limitation, which is a statistical one. For the data analysis, an independent t-test was used, although this test can only be utilised when the two groups (thumb OA and controls) do not include the same 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, clients with thumb OA may present with proprioception deficit. It is possible that these impairments may contribute to functional deficits. Currently, there is no evidence supporting the use of specific proprioceptive training and other multidisciplinary approaches , supported by higher quality evidence, may be implemented first. URL : http://www.sciencedirect.com/science/article/pii/S0894113018302904 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study has a descriptive-comparative, cross-sectional design. Introduction Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA). Purpose of the Study This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test. Methods The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non–CMC OA group with the healthy control group. Results The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96. Conclusions Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Incidence : Rare Topic : What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. What is it? 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.