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Inappropriate preoperative gabapentinoid use among patients with carpal tunnel syndrome. Billig, J. I., Sears, E. D., Gunaseelan, V., Santosa, K. B., Iwashyna, T. J., Englesbe, M. J., . . . Waljee, J. F. (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Gabapentin - Carpal tunnel syndrome This is a prospective study assessing the risks associated with the use of gabapentinoids (i.e. gabapentin and pregabalin) before a carpal tunnel syndrome (CTS) decompression surgery. A total of 56,593 participants were included. Participants were followed up at 3 and 6 months after surgery. More than 50% of participants were over 50 years old. The risk was assessed by quantifying the number of patients who continued utilising gabapentinoids or started utilising opioids after CTS surgery. The results showed that participants who utilised gabapentinoids prior to CTS surgery were 19 times ( relative risk ) more likely to continue utilising gabapentinoids after surgery. In addition, patients taking gabapentinoids pre-surgery were 2.3 times more likelly ( relative risk ) to start using opiods after CTS surgery. The findings did not change when people with persistent pain conditions (e.g. arthritis) in addition to CTS were excluded from the analyses. Clinical Take Home Message : Hand therapists should advise against the use of gabapentinoids for the treatment of CTS. Gabapentinoids have not shown to be more effective than placebo for CTS ( Hui et al., 2010 ) and they may double the probability of clients starting to use opioids after CTS surgery. Hand therapists should encourage the implementation of evidence-based non surgical interventions (e.g. e ducation and splinting , manual therapy ) instead of gabapentinoids use. If non surgical interventions fail, referral to a hand specialist for potential surgery is indicated. URL : https://www.jhandsurg.org/article/S0363-5023(20)30213-6/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.

Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. Surgical exploration for diagnostic and potential treatment purposes was undertaken. The procedure revealed the presence of a Linburg-Comstock syndrome. This is a tendinous connection between flexor pollicius longus (FPL) and flexor digitorum profondus (FDP) (of the index finger in this case) which is present in 30% of people. A tenosynovectomy was completed to allow for independent tendon gliding of the FPL and FDP. At three months follow up symptoms had markedly improved and at one year follow up, symptoms had completely resolved. Clinical take home message : Hand therapists may consider Lindburg-Comstock syndrome when the ipj of the thumb is unable to flex without dipj flexion of the index finger. This syndrome may be painful and surgical release can provide symptoms resolution. If you enjoyed this type of synopsis, put a like on it! URL : https://www.jhandsurg.org/article/S0363-5023(20)30189-1/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract With the intricate anatomy of the hand and upper extremity, there are many possible etiologies of pain. In addition, one must be alert to conditions typically affecting other areas of the body presenting in the hand and upper extremity. To add to the complexity of diagnosis, one must also be aware of potential secondary gains. With this in mind, a thorough history, physical examination, and broad differential can help avoid mislabeling patients with uncommon ailments. In this article, we present 4 cases of unusual causes of hand and upper extremity pain.

Entrapment neuropathies: A contemporary approach to pathophysiology, clinical assessment, and management. Schmid, A. B., Fundaun, J., & Tampin, B. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Symptoms prevalence, Aetiologic, Diagnostic, Therapeutic Topic : Entrapment neuropaties - Presentation and diagnostics This is an updated narrative review on clinical presentation, aetiology, and diagnostic tests for peripheral neuropathies (e.g. carpal tunnel syndrome - CTS). In terms of aetiology, genetic predisposition appears to be one of the strongest risk factors for entrapment neuropathies. It is unknown whether these genetic changes cause entrapment neuropathies due to anatomical alterations of the tunnels or connective tissue impairments within the nerve. The pathophysiology of compression neuropathy includes oedema, ischemia, and fibrosis of tissues within the nerve and outside of the nerve, which are believed to limit neural gliding. Moderate to severe entrapment neuropathies also present with axonal degeneration and/or demyelination, which causes nerve conduction blocks or slowing down of information transmission. These changes may lead to random electric shock symptoms or symptoms provoked by Tinel's testing. These axonal impairments often involve small fibre (detecting hot/cold and pinprick) during the initial stages of the entrapment neuropathy and large fibre (affecting light touch and muscle contraction) when the neuropathy becomes more severe. Interestingly, neuroinflamation has been suggested to increase the sensitivity of the affected nerve, often causing symptoms beyond the peripheral innervation territory of the compressed nerve. Changes within the central nervous system have also been identified in people with entrapment neuropathies. However, it is still unclear whether changes within the central nervous system can lead to on-going symptoms in absence of peripheral nerve entrapment. From an objective assessment point of view, in addition to motor and monofilament testing (Aβ - large fibre), pin prick testing (Aδ and C - small fibre) should be completed. A loss of function (painless weakness, larger monofilament required, or inability to feel pain on pin prick testing) could be used to confirm a neuropathy. Nerve conduction studies and US imaging may be useful in excluding differential diagnoses. Clinical Take Home Message : Hand therapists should be aware that entrapment neuropathies often present with unconventional peripheral nerve patterns. The distribution of symptoms outside of peripheral nerve patterns or dermatomal patterns does not excluded the presence of an entrapment neuropathy. Pin prick testing should be included in the objective assessment, and US imaging may be useful in assessing nerve edema and exclude other conditions. The same authors have published another article, which has been covered in a previous synopsis . Open Access URL : https://journals.lww.com/painrpts/Fulltext/2020/08000/Entrapment_neuropathies__a_contemporary_approach.4.aspx Abstract Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study This paper presents with four case studies. I covered one case in a previous synopsis and the following is another interesting case. Have a think about it. If you like, you can leave a comment indicating what the diagnosis may be and how you would treat it. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. What is it and how would you treat it? URL : https://www.jhandsurg.org/article/S0363-5023(20)30189-1/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.

Acute scaphoid fractures: guidelines for diagnosis and treatment. Clementson, M., Björkman, A., & Thomsen, N. O. B. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Scaphoid fractures - when to refer This is a narrative review on diagnosis and treatment of schapoid fractures. Scaphoid fractures represent 60% of the carpal fractures and 10% of all hand fractures. Most often, the scaphoid fracture is located at the waist (70%) with a smaller percentage affecting the distal pole (25%), or the proximal proximal pole (5%). A few clinical diagnostic tests are available and they include tenderness on palpation at the snuff box or scaphoid tubercle, and pain on axial compression of the thumb. Each of these three tests is very sensitive (100%), meaning that if no pain is elicited, it is very unlikely that the client presents with a scaphoid fracture. However, only the combination of three positive tests has a reasonable specificity (74%), meaning that if all three tests reproduce pain there is a higher probability of scaphoid fracture. X-rays are useful but are not very sensitive (70% sensitivity - not always useful in excluding a fracture). If an x-ray is negative and there is clinical suspicious of a scaphoid fracture, the wrist should be immobilised and x-ray repeated at 2 weeks. If a scaphoid fracture is identified on x-ray, the treatment depends on the fracture location and stability of the fracture. Distal pole fractures (25% of scaphoid fractures) are the most likely to heal with conservative treatment and require between 4 (tubercle fracture) and 6 weeks (distal pole, not tubercle) of immobilisation. Surgical treatment of scaphoid distal pole fracture should be considered if the fracture is displaced. Scaphoid waist fractures can be treated conservativaly with immobilisation for 6 to 10 weeks if they are not displaced. Longer immobilisation periods are suggested if the fracture is comminuted, the client is a smoker, or if there is limited compliance. Displaced fractures of the waist of the scaphoid require surgical treatment. Proximal pole scaphoid fractures require surgical treatment more often than conservative treatment. This is irrespective of fracture displacement. A short arm cast should be utilised for conservative treatment as there is no benefit in utilising a cast which includes the whole thumb. Clinical Take Home Message : Hand therapists may treat scaphoid distal pole or waist fractures conservatively if there is no displacement. This can be done with a short arm cast, which allows thumb movement. If fracture displacement is suspected, referral to a hand surgeon is warranted in all cases except for a scaphoid tubercle fracture. Scaphoid proximal pole fractures require surgical treatment without exception. Open Access URL : https://online.boneandjoint.org.uk/doi/epub/10.1302/2058-5241.5.190025

Quantification of hand function by power grip and pinch strength force measurements in ulnar nerve lesion simulated by ulnar nerve block. Wachter, N. J., Mentzel, M., Krischak, G. D., & Gülke, J. (2018) Level of Evidence : 4 Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Ulnar nerve impairment - Grip strength This is a study assessing hand strength before and after an ulnar nerve block at the Guyon's canal in the same participants (within-subject design). Twenty-five healthy participants were recruited for this study. Hand strength was assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tip to tip, tripod, and key pinch). The measurement were taken before and after the injection, without randomisation of condition (this is a limitation). The results showed that the greatest impairments were identified in the pinching tests (58-60% reduction) compared to grip testing (27% reduction in strength). Clinical Take Home Message : Hand therapists may utilise pinch strength as a measure of impairment/recovery for clients with entrapment neuropathies or lacerations of the ulnar nerve. The significant impairments in pinch strength following an ulnar nerve block are not surprising considering the innervation of the flexor pollicis brevis (deep portion), adductor pollicis and first dorsal interosseous by the ulnar nerve. In addition, the presence of a Riche-Cannieu anastomosis (ulnar to median nerve within the hand), which is present in 60% of subjects , may further explain the significant impairment caused by an ulnar nerve block at the Guyon's canal. URL : https://www.jhandtherapy.org/article/S0894-1130(16)30191-0/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members.

Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study This paper presents with four case studies. I found one particularly interesting. Have a think about it. If you like, you can leave a comment indicating what the diagnosis may be and how you would treat it. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 33 year old female with an insidious onset of pain at the base of the index finger for the last 3 months. Aggravating factors included playing tennis and increasing tennis frequency. In the last three months, they had been playing tennis more frequently. Objectively, there were no massess or skin changes. There was tenderness on palpation at the second metacarpal. There was no extensor digitorum subluxation at mcpj. Laboratory testing was negative for inflammatory conditions. X-rays revealed no bony abnormalities. MRI showed cortical thickening and bone edema of the second metacarpal shaft. What is it and how would you treat it? URL : https://www.jhandsurg.org/article/S0363-5023(20)30189-1/fulltext Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.

Evaluation of written and video education tools after mallet finger injury. Novak, C., Mak, L., & Chang, M. (2019) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Mallet splint resources - Video This is a prospective cohort study assessing the usefulness of written and video resources for clients with an acute mallet finger. Participants (N = 61) were diagnosed within four weeks from the injury and never presented with the condition before. They were all able to read and speak English. Participants were provided with a written pamphlet (not provided in the article) and video links to watch in their own time. The effectiveness of the written and video ( stack or through splint) resources was assessed through a 0 (not helpful) to 10 (extremely helpful) numerical rating scale. Outcomes were assessed after 2 weeks from treatment initiation. The results showed that most participants (n = 57) utilised written instruction compared to video instructions (n = 30). However, participants watching the video and reading the material found the video particularly helpful and more easy to understand compared to the written information. Clinical Take Home Message : Hand therapists may provide video resources on finger hygiene to clients presenting with a mallet finger injury. This may be particularly useful when clients cannot physically visit the clinic. In addition, alternatives to a custom made splint exist and may be available at the pharmacy. For instance, a finger cot splint can be easily bought at most pharmacies. URL : https://www.sciencedirect.com/science/article/abs/pii/S0894113018300413 Available through the Journal of Hand Therapy if you have direct access ( HTNZ ) Available through EBSCO Health Databases if you have access ( PNZ )

Predictive factors associated with proximal interphalangeal joint contracture in trigger finger. Sato, J., Ishii, Y., & Noguchi, H. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Prognostic Topic : Flexion deformity in trigger finger – How to predict it This is a non-peer reviewed prospective study assessing pipj flexion deformity predicting factors in trigger finger. A total of 126 participants affected by trigger finger were included in the study. Potential participants were excluded if the thumb was involved. The variables of interest were the digit involved, gender, age, body mass index (BMI), hand dominance, history of previous trigger finger in other digits, multiple digits involved, previous history of carpal tunnel syndrome (CTS) or De Quervain's syndrome, heavy manual labour, diabetes mellitus, trigger finger grade (I - intermittent, II - actively correctable, III - passively correctable), and duration of triggering. Participants were followed prospectively for a maximum of six years, however, there was no information on the follow up time range. The results showed that on average 30% of trigger digit presented with pipj contracture. In addition participants with a previous history of CTS or De Quervain's (n = 8/29; 28%) had 4.6 times greater odds of presenting with pipj deformity compared to participants without it (5/84; 6%). In addition, trigger finger grade was also found to be a predictor. Participants with a grade III trigger finger (14/22; 64%) had 5 to 8 times greater odds of presenting with pipj flexion deformity compared to participants with grade I (11/48; 19%) and II (12/33; 27%). Lenght of time with trigger finger was not identified as a predictive factor. Clinical Take Home Message : The risk of developing a pipj flexion deformity with grade I trigger finger is relatively low (1 in 5 people). If clients present with grade II or III they have a greater chance of developing pipj flexion deformity (grade II: 1 in 3 people; grade III: 2 in 3 people). Clients with grade III should therefore be referred for surgical management immediately. Clients with grade II may be monitored monitored over time and referred if the clinical presentation worsen. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420935768 Available through EBSCO Health Databases if you have access ( PNZ )

Counterforce bracing of lateral epicondylitis: A prospective, randomized, double-blinded, placebo-controlled clinical trial. Kroslak, M., Pirapakaran, K., & Murrell, G. A. (2019) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Counterforce brace - Real vs Placebo brace on pain and function This is a randomised double-blind placebo controlled trial assessing the effectiveness of counterforce brace on pain frequency and intensity in participants with lateral epicondylalgia (LE). Participants (N = 31) were diagnosed with LE if they presented point tenderness at the lateral epicondyle of the elbow and if they reported localised elbow pain with maximal grip strength testing. In addition, they had to present with a history of LE between 4 weeks and 6 months. Participants were excluded if they had sensory or motor changes distally to the elbow, if they had previous elbow surgery, or if they had a cortisone injection in the elbow within the past three months. Pain frequency and intensity during manual activities, during sleep, and at rest was assessed through a 5-points likert scale. Outcomes were assessed at 2, 6,12, and 26 weeks. Treatment allocation was randomised. No information on allocation concealment was provided. Participants and assessors were blinded to treatment allocation. The trial protocol was not registered a-priori. Participants were provided with a counterforce brace which was tightened around the proximal forearm (n = 17) or a strap withouth padding which was applied with a very low tension to the proximal forearm (sham) (n = 14). Both groups were provided with a resistance training program for the affected upper limb. The results showed that both groups reported lower pain frequency and intensity at 6 weeks and subsequent follow ups. Between groups differences were limited and a high number of statistical tests were performed. This increased the likelihood of a type II error (identification of statistically significant findings due to the high number of tests performed). It is not possible to comment on the clinical relevance of these findings because pain intensity was measured on a 5-points likert scale, which is rarely used in clllinical practice. Overall, the counterforce brace appeared to consistently provide greater improvements compared to the sham. Clinical Take Home Message : Hand therapists may provide a counterforce brace to clients affected by LE. This brace appears to reduce the frequency and intensity of pain to a greater extent compared to a placebo brace. URL : https://www.jshoulderelbow.org/article/S1058-2746(18)30733-X/fulltext Available through EBSCO Health Databases if you have access ( PNZ )

Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. Lucado, A. M., Dale, R. B., Vincent, J., & Day, J. M. (2019) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia – Manual therapy This is a systematic review and meta-analysis assessing the effectiveness of elbow Mobilisation With Movements (MWMs) on pain and pain-free grip strength in people with lateral epicondylalgia. Four randomised-controlled studies and one controlled study were included in the meta-analysis, for a total of 407 participants. All the studies were assessed through the PEDro scale (score 0 to 11 with greater scores indicating greater study quality). Efficacy of intervention was assessed through improvements in pain (VAS) and pain-free grip strength. The control groups included either no interventions or other interventions (e.g. ultrasound, exercise) without MWMs. Follow-up periods ranged from one months to one year. The study quality ranged between 5 to 10 and the average quality score was 7. There was a statistically significant but not clinical significant difference in favour of the MWMs group compared to the control group on pain (Mean difference: 0.43; 95%CI: 0.2 to 0.7) and pain-free grip strength (Mean difference: 0.31; 95%CI: 0.11 to 0.51). These differences equated to 0.43/10 point change on VAS and 0.31kg improvements in pain-free grip strength. Clinical Take Home Message : MWMs do not appear to be useful in improving pain or pain-free grip strength in lateral epicondylalgia in the short to long term (4 weeks to one year). These interventions may provide an immediate pain relief which is however quickly lost. Hand therapists may obtain better long term results by reducing extensor tendon loading in the acute phase and provide a graded resistance training program when pain irritability reduces. URL : https://www.jhandtherapy.org/article/S0894-1130(17)30289-2/pdf

Flexor digitorum profundus with or without flexor digitorum superficialis tendon repair in acute Zone 2B injuries. Sadek, A. F. (2020) Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Zone 2 flexor tendon repair - FDP and FDS vs FDP only repair This is a retrospective study assessing the outcomes of zone 2 flexor tendon repairs with or without FDS repair. A total of 53 patients underwent repair of FDP only (n=23), or FDP plus FDS (n=30). The surgical outcome was assessed through total active/passive range of movement in the operated digit/s and grip strength. Both outcomes were reported and analysed as a percentage of the controlateral healhy limb. Wide awake surgery with no tourniquet was used for 30 patients. The decision to repair or not FDS was based on FDP ease of gliding after the 6 strands repair. A2 pulley was resected or vented in all cases. Independently of repair completed, the postoperative care included a dorsal blocking wrist splint (50° mcpj flexion and ipj/dipj extension) and rubber band attached to the nail to provide passive finger flexion. During the first week, patients performed active finger flexion and extension exercises (as tolerated by pain) once a day for 5 minutes. Between week 2 and 4, patients performed passive finger extension/flexion exercises followed by pain free active extension and flexion twice a day for five minutes. In week 2 to 4 patients were also encouraged to perform dipj and pipj passive and active movements, flat fist and hook fist exercises. During this phase, patients were also asked to practice grasping, without lifting, objects of large diameter (e.g. water bottle) followed by a progression to small diameter objects. This was gradually progressed until in week 6 they were able to obtain a full fist. Between week 4 and 5 the wrist splint was discarded and the only protection left was an elastic band to provide passive flexion of the operated finger. Between week 5 and 6 full active range of movement exercises were promoted and participants were asked to exercise three times per day for 15 minutes. At the end of week 6, the elastic band was removed. At 12 weeks, participants initiated resisted exercises. Total active movement and grip strength were assessed with a goniometer and a hand held dynamometer respectively. The assessment time ranged between 12 and 84 months post surgery. The results showed that there was no statistically significant difference between groups in total active/passive range of movement. However, the average pipj flexion deformity was 20° in the FDP only repair group and 5° in the FDP plus FDS repair. Grip strength was statistically and clinically significant different between the two groups. The FDP and FDS repair group presented with 15% greater grip strength (Mean difference: 5kg) compared to the FDP repair only. There was one rerupture (FDP repair: 4%; FDP plus FDS repair: 3%) in each group. Involvement of multiple digits was associated with worse outcomes. Clinical Take Home Message : Hand therapists may expect similar outcomes after a zone 2 flexor tendon repair involving FPD and FDS, or FDP alone. However, it appears that repair of FPD alone leads to lower grip strength levels and greater pipj flexion deformities. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420932446