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Effectiveness of proximal interphalangeal joint–blocking orthosis vs metacarpophalangeal joint–blocking orthosis in trigger digit management: A randomized clinical trial Teo, S., Ng, D., & Wong, Y. Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Trigger finger conservative treatment - mcpj vs pipj splint This is a randomised clinical trial comparing the effectiveness of two splinting regimes for A1-pulley trigger finger (TF). A metacarpophalangeal joint (mcpj) block was compared to an oval 8 positioned at the proximal interphalangeal joint. Effectiveness of splinting regime was assessed through Green's classification (grade 1 to 4) for TF severity, pain (NRS), and function (QuickDASH). Participants with isolated TF of the thumb were excluded. The treatment lasted 8 weeks and participants were asked to wear the splint 24/7. A total of 42 participants were randomised to the mcpj block (n = 18) and oval 8 (n = 24) group. The results need to be considered in the context of several limitations. No information was provided on allocation concealment. Outcome assessors were not blinded to the intervention. No intention to treat (ITT) analysis was reported, making the two groups potentially heterogeneous. Multiple t-tests were used for pain and function instead of using two-way ANOVAs, which would have reduced the chance of type I errors (possibility of identifying statistically significant difference only due to the increased number of tests performed). The results showed no difference between groups on TF severity following treatment (Green's classification system). However, there was a statistically significant difference between groups for pain, with the oval 8 group only showing clinically significant improvements from baseline. There was no difference between groups in functional improvements. A final important note is related to the compliance with splint wearing. Compliance was statistically significantly higher in the oval 8 group (13hrs/day) compared to the mcpj block group (10hrs/day). Clinical Take Home Message : Conservative splinting options for TF appear to be useful in reducing pain. The pipj splint appears to provide better results compared to a mcpj block. Hand therapists should not expect clinically significant changes in triggering grade or function (QuickDASH) when using splints for TF. Compliance with treatment appears to be a potentially important factor and patients should be invited to wear the splint 24/7. URL : https://www.jhandtherapy.org/article/S0894-1130(17)30284-3/pdf

Development and validation of a prognostic, risk-adjusted scoring system for operative upper-extremity infections Sharma, K., Mull, A., Friedman, J., Pan, D., Poppler, L., Fox, I., Levin, L., & Moore, A. M. Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Post-surgical infections - prognostic factors This retrospective study assessed the ability of several risk factors to predict persistent post-surgical infections. The total number of participants was 602. Of these, 301 patients were utilised to assess the individual and combined effect of risk factors. The prediction ability of these risk factors was then validated on another group of 301 patients. The results showed that diabetes, smoking, and animal bites could predict a persistent infection. The presence of any of these factors in isolation increased the likelihood of persistent infections by 15%. The risk increased to 20% when a combination of two were present, and to 45% when all three risk factors were reported by patients. Clinical Take Home Message : Hand therapists may be alerted to a heightened risk of infection if patients report history of diabetes, smoking, or animal bites. Patients with these characteristics should be monitored for the onset of new symptoms and promptly referred if an infection is suspected. URL : https://www.jhandsurg.org/article/S0363-5023(19)31422-4/fulltext

Short-term clinical outcome of orthosis alone vs combination of orthosis, nerve, and tendon gliding exercises and ultrasound therapy for treatment of carpal tunnel syndrome Sim, S., Gunasagaran, J., Goh, K., & Ahmad, T. Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Carpal Tunnel Syndrome (CTS) conservative treatment - orthosis vs orthosis plus nerve and tendon gliding exercises. This randomised trial assessed the effectiveness of a custom made wrist splint and wrist exercises on pain and function (Boston Carpal Tunnel Questionnaire) in participants with Carpal Tunnel Syndrome (CTS). Participants had to present with symptoms of carpal CTS. The diagnosis was confirmed through physical examination and nerve conduction studies. Participants were randomly allocated to wear a custom wrist splint only (n = 27) or to wear a custom wrist splint and perform nerve and tendon gliding exercises (n = 29). The trial lasted 8 weeks, with patients required to wear the splint 23 hours per day. The tendon and nerve gliding exercises were performed 10 times per day. The results need to be considered in the context of a few limitations. Allocation concealment was not mentioned in the randomisation process, and independent t-tests were utilised for dependent observations, which is a direct assumption violation for this analysis. The results showed that after 8 weeks of treatment both groups (splint only vs splint plus exercises) presented with statistically significant improvements in pain and function (but only the functional outcomes improved to a clinically meaningful level). There were no differences between groups on pain and function, suggesting that the addition of tendon and nerve gliding exercises to a splinting regime provided no added benefit. Clinical Take Home Message : The addition of nerve and tendon gliding exercises does not appear to add any benefit to the splinting regime. Clinicians might consider utilising these exercises in patients at higher risk of developing stiffness. URL : https://www.jhandtherapy.org/article/S0894-1130(17)30221-1/fulltext

The effect of diabetes on functional outcomes among individuals with distal radial fractures Alsubheen, S., MacDermid, J., Walton, D., & Grewal, R. Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Prognostic Topic : Distal radial fracture - diabetes and functional recovery This retrospective study assessed the effect of diabetes on functional recovery following a distal radial fracture. Functional recovery was measured through the Patient-Rated Wrist Evaluation (PRWE) questionnaire, and the presence of diabetes was self-reported by participants. A total of 479 participants were recruited at baseline and they were assessed at one week, three months, and one year after fracture. Participants were treated with splinting (10%), plaster cast (64%), and surgery (26%). The results showed that 10% (n = 48) of the participants reported diabetes (no information was provided on number of participants with Type 1 or Type 2 diabetes). Participants' functional improvements in the diabetes group were slower and smaller compared to the participants without diabetes, at both three months and one year. The results of this study need to be taken with caution. The statistical analysis did not take into consideration confounding factors such as additional comorbidities or fracture treatment modality. It is possible that factors other than diabetes may contribute to disparity between the two groups considered. Clinical Take Home Message : Hand therapists may consider following up diabetic patients with distal radial fractures over longer periods of time (possibly up to one year) compared to patients without this comorbidity. A greater attention towards optimisation of rehabilitation may be useful in this subgroup of patients. URL : https://www.jhandtherapy.org/article/S0894-1130(17)30201-6/fulltext

Sticking to the facts: A systematic review of the effects of therapeutic tape in lateral epicondylalgia George, C., Heales, L., Stanton, R., Wintour, S., & Kean, C. Level of Evidence : 3a Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia – Effect of taping. This is a systematic review assessing the effect of strapping on pain and grip strength in patients with lateral epicondylalgia. The effect of rigid tape, kinesiotape, and placebo tape was assessed. Eight papers were included for a total of 183 participants with lateral epicondylalgia. The results showed that the placebo tape provided 3-22% symptomatic relief. The experimental taping was generally more effective than placebo taping and led to a 20-52% reduction in symptoms 30 minutes after its application. After 1 to 2 weeks of repetitive taping application, symptoms reduced by 17-61%. There were mixed findings for pain-free grip strength improvements. Clinical Take Home Message : Hand therapists may use rigid tape or kinesiotape to reduce symptoms in patients with lateral epicondylalgia. Taping appears to reduce symptoms immediately and in the short term. Hand therapists should not expect improvements in pain-free grip strength. URL : https://www.sciencedirect.com/science/article/pii/S1466853X1930032X?via%3Dihub

Distal biceps tendon repair and reconstruction Srinivasan, R., Pederson, W., & Morrey, B. Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Biceps tendon rupture - Incidence, surgery and rehabilitation. This narrative review reported on biceps tendon rupture demographics, diagnostic methods, conservative, surgical, and rehabilitative plans. Ninety percent of biceps tendon lesions occur in middle aged males with smoking and large BMI being significant risk factors. The Hook test is 95% sensitive (useful for screening) and 85% specific (useful for confirmation of diagnosis). MRI is the investigation of choice. Conservative management is appropriate for individuals with low functional demands, elbow OA, and significant medical comorbidities. Conservative management often leads to a forearm supination and elbow flexion strength deficits of 40% and 30% respectively. With operative management data suggests that there is limited flexion strength deficit, however, a 10-20% deficit in supination strength is likely to remain. In case of surgical management, the greatest risk for repair failure within the first two weeks. Post-surgical rehabilitation for low tension repairs requires a posterior elbow orthosis at 80° of elbow flexion and forearm neutral position worn 24/7 for 2/52. When the repair is performed under greater tension (repair after 4/52 from injury), the elbow orthosis is transformed into a hinge splint at 2 weeks with a block at 40° of flexion. Every week, the extension restriction is reduced by 10° until reaching 0° of extension at 6/52. After two weeks, the patient is allowed to lift a maximum of 2kg until week 6-10 according to the type of surgery and quality of tissues repair. Following this period, light resistance training can be initiated with a full return to heavy duties by 3-6 months. Complications can include paraesthesia of the radial aspect of the forearm due to a lateral antebrachial cutaneous nerve lesion or wrist/fingers/thumb extension and thumb abduction weakness due to involvement of the posterior interosseus nerve. Clinical Take Home Message : Hand therapists should use the hook test as a screening and diagnostic tool when suspecting biceps tendon rupture. Conservative treatment is an option, however, considering the complications associated with delays in surgical interventions beyond 4/52, it is advisable to refer patients with this condition to a hand surgeon. Post-surgical rehabilitation includes 2/52 full time elbow splinting, followed by range of movement exercises and introduction of light resistance exercises at 6-10/52 according to surgical procedure and quality of tissues repaired. Hand therapists should watch out for motor and sensory deficits following surgery as they are potential adverse events. URL : https://www.jhandsurg.org/article/S0363-5023(19)31469-8/fulltext

Comparison of the effect of nocturnal use of commercial versus custom-made wrist orthoses, in addition to gliding exercises, in the function and symptoms of carpal tunnel syndrome: A pilot randomized trial Figueiredo, D., Ciol, M., da Conceição dos Santos, M., de Araújo Silva, L., Bidin Brooks, J., Santos Diniz, R., & Tucci, H. Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Carpal Tunnel Syndrome (CTS) conservative treatment - custom vs commercial orthosis. This is a pilot randomised controlled trial ( n = 24) assessing the effectiveness of night use of a custom vs commercial splint in combination with tendon and median nerve gliding exercises in people with Carpal Tunnel Syndrome (CTS). The assessment was performed at baseline and after 45 days of therapy. The results showed that pain reduced to a statistically significant level in both groups with an improvement of 0.5/10 and 1.5/10 points in the commercial and custom splint group respectively. The reduction in pain was not clinically significant for either group, however, there was a trend for greater improvement in the custom-made splint. Functional improvement reached a clinically significant improvement in the custom-made splint with a 20% chance of this finding just being due to chance. Pulp to pulp and tripod pinch improved for both groups between 3% and 13% without a significant difference between groups. The authors also assessed extensor carpi radialis and flexor carpi ulnaris activation through EMG and found no difference before and after the intervention or between groups. Clinical Take Home Message : Hand therapists may decide to use a night splint to improve symptoms in people with CTS. There appears to be no difference between a custom made and a commercially available splint. Some functional and strength improvements may be evident after 6 weeks splinting, however, they may not reach a clinically significant level. URL: https://www.mskscienceandpractice.com/article/S2468-7812(19)30357-1/fulltext

Avascular necrosis of the carpal bones other than Kienböck disease Afshar, A., & Tabrizi, A. Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Incidence : Rare Topic : Avascular necrosis of carpal bones- Diagnosis and treatment This is a narrative review of carpal bones avascular necrosis (AVN) diagnosis and treatment. Due to their vascular anatomy, the scaphoid and capitate are the two most common bones presenting with AVN after the lunate. All the other carpal bones can present AVN but it is much less likely. Clinically, patients may present with wrist pain and a history of trauma. Objectively, there may be swelling, range of movement limitations, and grip strength deficits. X-rays are usually negative initially and further MRI imaging is required to make a diagnosis and exclude fractures, infections, and malignancies. Treatment for the initial stage includes NSAIDs, immobilisation, and corticosteroid injections. Bone grafts or surgical interventions with fusion or arthroplasty may be required if conservative treatment fails. Clinical Take Home Message : Avascular necrosis of the lunate (Kienböck's disease) is a rare condition and AVN of other carpal bones is even rarer. However, it is not unheard of and all the carpal bones can develop AVN with the scaphoid and capitate being the most prevalent after the lunate. Due to the possibility of scaphoid fractures resulting in AVN of the proximal pole or scaphoid non-uniuon advance collapse (SNAC), patients should be monitored closely during their recovery. Chronic pain following fractures of the hook of the hamate may alert the hand therapists to AVN of the hook which needs to be assessed through MRI. URL : https://www.jhandsurg.org/article/S0363-5023(18)31168-7/fulltext

Evaluating the impact of gabapentinoids on sleep health in patients with chronic neuropathic pain: a systematic review and meta-analysis Kapustin, D., Bhatia, A., McParland, A., Trivedi, A., Davidson, A., Brull, R., & Singh, M. Level of Evidence : 1a Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Neuropathic pain - Pharmacological treatment This is a systematic review and meta-analysis on the effect of gabapentinoids (gabapentin and pregabalin) and placebo on sleep disturbance in patients with diabetic and postherpetic neuropatic pain. The results showed that sleep disturbances associated with pain and patient global impression of change (patient's satisfaction) improved significantly when high doses (higher than 300mg/day of pregabalin or 1800mg/day of gabapentin) of medications were provided for 6 weeks or longer. In contrast, low doses of gabapentinoids were only effective when treatment lasted for more than 6 weeks. Pain improved to a statistically significant, however, all the improvements did not reach the clinically important difference currently suggested for neuropathic pain. Patients in the gapapentinoids group had 2 to 6 times greater probability of being satisfied compared to the placebo group. Clinical Take Home Message : Hand therapists often assess and treat patients with neuropathic pain (e.g. carpal or cubital tunnel syndrome) who may be taking gabapentinoids. Hand therapist can remind patients that this treatment may take 6 weeks or longer to provide benefits and that drowsiness is a common side effect. They could also explain that improvements in pain and sleep may be modest with more than double probability of finding benefits compared to somebody taking a placebo pill. URL : https://journals.lww.com/pain/Abstract/2020/03000/Evaluating_the_impact_of_gabapentinoids_on_sleep.4.aspx

The association between symptoms of depression and office visits in patients with nontraumatic upper-extremity illness. Crijns, T., Bernstein, D., Teunis, T., Gonzalez, R., Wilbur, D., Ring, D., & Hammert, W. Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Symptoms prevalence study Topic : Trigger finger, carpal tunnel syndrome, benign lumps, hand osteoarthritis, and de Quervain tendinopathy association with depression - Mental health and number of outpatient visits This retrospective study assessed the association between the number of visits to an outpatient hand surgeons' clinic and levels of pain and depression. The patients presented with several different conditions including trigger finger (30%), carpal tunnel syndrome (27%), benign lumps (20%), hand osteoarthritis (13%), and de Quervain tendinopathy (9%). The results showed that people with greater depressive symptoms or pain attended the clinic for an additional 2 appointments compared to the rest of the sample. Unfortunately, due to the study design, we cannot comment on whether higher levels of depression/pain lead to greater disease severity and therefore higher number of visit or vice versa. Clinical Take Home Message : Hand therapists could support patients with depression by providing information about free help lines . In addition, a referral to the GP or psychologist could be useful to initiate treatment for this condition. It is also possible that improvements in hand condition will lead to reduction in symptoms of depression. Further research will need to clarify this last point. URL : https://www.jhandsurg.org/article/S0363-5023(18)30704-4/abstract

Synovial hemangioma of the wrist with cystic invasion of trapezoid and capitate bones Zhao, X., Qi, C., Chen, J., Li, H., Zhang, Y., & Yu, T. Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Incidence : Rare Topic : Synovial Haemangioma - Diagnosis and treatment This is the answer for the case study from last week. The patient was an 18 year 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. Following surgery, it was possible to make a diagnosis of wrist synovial haemangioma. Synovial haemangiomas are rare benign tumours which usually affect children or young adults. Only 300 cases have been reported in the literature, most of which occurred in the knee. Symptoms vary and intermittent pain may be present or absent. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Hand therapists should refer young children or teenagers for x-rays and ultrasound when there is evidence of an irregularly shaped, soft mass which appears to or is reported to have grown over time. The likelihood of identifying a synovial haemangioma is extremely rare, however, this work up would help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, haematomas associated with haemophilia, infections or other rare forms of cancer. URL : https://www.jhandsurg.org/article/S0363-5023(18)30316-2/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Synovial hemangiomas (SHs) are rare lesions of the joints or tendon sheaths that are difficult to diagnose. We present the case of an 18-year-old man with an SH in the wrist joint. Physical examination revealed a slightly tender, ill-defined, nonpulsatile soft mass, 3 cm × 3 cm in size on the dorsal aspect of the left wrist. Computed tomography showed an irregular, ill-defined, soft tissue mass in the expanded joint space, which was formed by the scaphoid, trapezoid, and capitate bones. Magnetic resonance imaging showed the typical features of SH and also revealed cavitary erosion of the scaphoid, trapezoid, and capitate bones. An open arthrotomy was performed via a dorsal approach, and the mass was excised. The histological examination findings were consistent with the diagnosis of SH.

The relationship of mental health status to functional outcome and satisfaction after carpal tunnel release Maempel, J., Jenkins, P., & McEachan, J. Level of Evidence : 4 Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Carpal tunnel syndrome (CT) and mental health - Outcomes before and after surgical intervention This is a prospective cohort study assessing the relationship between mental health and outcomes following surgery for CT. The results are to be considered in the context of a few limitations. Of the entire cohort, only 52% of the participants returned the Short Form-12 (SF-12), used to assess mental health. In addition, SF-12 scores were only collected at one-year post surgery, which defeats the point of a prospective cohort study. The results show a correlation between mental health status and patient reported satisfaction at one year after surgery. There was also a statistically, but not clinically significant difference in QuickDASH scores of patients presenting with mental health problems compared to healthy patients at one year follow up. This correlation might be due to worse mental health state leading to lower function or vice versa. It is also possible that a third unknown variable, not measured in the present study, mediated this association. Clinical Take Home Message : Hand therapists should keep in mind that functional recovery of patients undergoing surgery for CT may be worse if they present with poorer mental health. A multidisciplinary approach to treatment and rehabilitation may be effective in improving functional outcomes. URL : https://journals.sagepub.com/doi/full/10.1177/1753193419866400