A Simple Physical Exam Maneuver to Distinguish Trigger Digit, Dupuytren's Nodule, and Flexor Sheath Ganglion.

Trigger digit, Dupuytren's disease, and ganglion cysts are 3 common disorders treated by hand surgeons. Despite the varying nature of their pathology, these 3 entities can all present as a mass at the flexor crease in the distal palm. The regional similarity of these presentations can make diagnosis more difficult. In this paper, we describe a simple clinical exam method that can assist in distinguishing between trigger digit, Dupuytren's disease, and flexor sheath ganglion cysts.

Direct and indirect utilities of patients with mild to moderate versus severe carpal tunnel syndrome.

Health utility is a quantitative global measure of patients' health status. This retrospective cohort study aimed to compare health utilities of patients with mild to moderate versus severe carpal tunnel syndrome and determine inter-instrumental agreement. Health utilities of 29 patients with varying severity of carpal tunnel syndrome were measured indirectly by Short-Form Sixth Dimension and EuroQol 5D questionnaire and directly by Chained Standard Gamble and a visual analogue scale. Health utility was 0.69 for Short-Form Sixth Dimension, 0.78 for EuroQol 5D Questionnaire, 0.98 for Chained Standard Gamble, and 0.76 for the visual analogue scale. There was a significant inter-instrumental agreement between three of the instruments, but not the Chained Standard Gamble. The difference in health utilities between patients with mild or moderate versus severe carpal tunnel syndrome was significant only for the EuroQol 5D questionnaire. We conclude based on our results that there are no clear indications on how health utilities can be integrated into decision analysis models and economic evaluation regarding carpal tunnel syndrome of various severities.Level of evidence: IV.

The Epidemiology of Scapholunate Advanced Collapse.

Background: Scapholunate advanced collapse (SLAC) is the most common pattern of wrist arthritis. Sparse data exist regarding the SLAC wrist pattern of arthritis. This study aimed to document the epidemiology of advanced SLAC in terms of patients' sociodemographics and possible association with trauma. Methods: Sixty-one patients with severe SLAC wrist were included. Baseline sociodemographic characteristics were reviewed. To evaluate the relationship to injury, this group of cases was compared with a control group of 61 patients with first carpometacarpal osteoarthritis (CMC OA). The following data were collected for both groups: age, gender, history of traumatic injury, history of manual labor, duration of symptoms, and dominant hand involvement. Pearson chi-square tests for categorical variables and independent samples t test for continuous variables were performed to determine differences between groups. Results: Patients with SLAC wrist were more likely to be male (80.3% vs 31.1%; p<0.001), have a history of a traumatic injury (69.5% vs 25.9%, P < .001), have longer symptom duration (10.3 ± 13.3 vs 3.5 ± 2.5 years, P = .001), be involved in a manual labor job (49.0% vs 20.0%, P = .002), and be younger (53.1 ± 10.4 vs 58.3 ± 9.8; P = .006) compared with patients with CMC OA. There was no difference in dominant hand involvement (49.2% vs 53.3%; P = .571) between the groups. Conclusions: This study identified the characteristics of patients with advanced SLAC wrist. Compared with a control cohort of CMC OA, patients with SLAC wrist were more likely to be male, have a history of a traumatic injury, and be younger.

Stable rates of operative treatment of distal radius fractures in Ontario, Canada: a population-based retrospective cohort study (2004­2013)

Background: Rates of surgical management of distal radius fractures are increasing internationally despite the higher cost and limited outcome evidence to support this shift. This study examines the epidemiology of distal radius fractures and asks if the same shift has occurred in Ontario, Canada (population 13.9 million). Methods: This population-based, retrospective cohort study examined distal radius fractures in people aged 18 years and older over a 10-year period (2004­2013). The incidence analyses were based on the first occurrence of a fracture within a 2-year time period. The number of fractures, age-adjusted incidence rates and frequency of fracture treatment type by year were assessed. We used a Poisson regression with robust standard errors to determine if there was a statistically significant change in the frequency of fracture treatment type over time. Results: There were 25 355 distal radius fractures among Ontarians 18 years of age and older in 2013. Between 2004 and 2013, the age-adjusted incidence rate for people 35 years of age and older was stable, between 2.32 and 2.70 per 1000 population. Rates of cast immobilization remained stable between 82% and 84%. Of those patients treated surgically, the rate of open reduction and internal fixation rose from 7% in 2004 to 13% in 2013 at the expense of other types of surgical management. Conclusion: In Ontario, rates of cast immobilization are stable and there has been a movement toward open reduction and internal fixation among patients treated surgically.

Contexte: Le taux de prise en charge chirurgicale des fractures du radius distal augmente partout dans le monde, malgré le coût supérieur de l'intervention et le manque de données probantes sur les issues. Cette étude se penche sur l'épidémiologie des fractures du radius distal et cherche à savoir si cette augmentation se reflète en Ontario, au Canada (population : 13,9 millions). Méthodes: Cette étude de cohorte rétrospective basée sur la population examinait les fractures du radius distal chez les personnes âgées de 18 ans et plus sur une période de 10 ans (de 2004 à 2013). Les analyses de l'incidence étaient fondées sur la première occurrence de fracture en 2 ans. Le nombre de fractures, le taux d'incidence ajusté en fonction de l'âge et la fréquence annuelle des types de traitement des fractures ont été évalués. Nous avons utilisé une régression de Poisson avec des erreurs types robustes pour déterminer s'il y avait des changements statistiquement significatifs dans la fréquence des types de traitement des fractures au fil du temps. Résultats: Il y a eu 25 355 fractures du radius distal chez les Ontariens de 18 ans et plus en 2013. Entre 2004 et 2013, le taux d'incidence ajusté en fonction de l'âge pour les personnes de 35 ans et plus était stable, entre 2,32 et 2,70 pour 1000 personnes. Le taux d'immobilisation plâtrée est demeuré stable entre 82 % et 84 %. Chez les patients traités par chirurgie, le taux de réduction chirurgicale et de fixation interne est passé de 7 % en 2004 à 13 % en 2013, au détriment des autres types de prise en charge chirurgicale. Conclusion: En Ontario, le taux d'immobilisation plâtrée est demeuré stable et il y a eu une augmentation de la réduction chirurgicale et de la fixation interne chez les patients traités par chirurgie.

Factor Structure of the Disabilities of the Arm, Shoulder and Hand Questionnaire in Upper Extremity Nerve Injury.

BACKGROUND: This study evaluated the validity of the factor structure of the Disabilities of the Arm, Shoulder and Hand questionnaire to assess upper extremity disability in patients with upper extremity nerve injury. METHODS: Data were used from previous cross-sectional studies of patients with upper extremity nerve injuries. Research ethics approval was obtained for secondary data analyses. Descriptive and factor analyses were performed. RESULTS: Patients (n = 242; 170 men and 72 women) with upper extremity nerve injury included distal nerve (n = 131), brachial plexus (n = 88), and single proximal shoulder nerve (n = 23). The mean Disabilities of the Arm, Shoulder and Hand questionnaire score was 47.3 ± 22. For the questionnaire, a three-factor structure had the highest variance and no overlap between factors. The factors related to (1) light effort tasks, (2) greater effort tasks, and (3) work/social activity limitations and pain. Brachial plexus injuries had significantly higher overall questionnaire scores compared to distal and single proximal nerve injuries. The light effort factor scores were significantly lower in single proximal nerve injuries compared with brachial plexus and distal nerve injuries. Nondominant compared to dominant hand involvement revealed no difference in overall questionnaire scores but significantly higher dominant hand scores in the light effort factor (p = 0.001). CONCLUSIONS: In patients with nerve injury, the factor analysis of the Disabilities of the Arm, Shoulder and Hand questionnaire indicated a multifactor construct. These domains should be considered when using the questionnaire and may be helpful to assess disability related to specific tasks in different nerve injuries and with dominant hand involvement.

Treatment of carpal tunnel syndrome with wrist splinting: study protocol for a randomized placebo-controlled trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is a common cause of pain, weakness, sensory loss, and activity limitations. Currently, the most common initial treatment is use of a rigid splint immobilizing the wrist, usually during night-time, for several weeks. Evidence regarding the efficacy and effect durability of wrist splinting is weak. The treatment is associated with costs and may cause discomfort and limit daily and work activities. No placebo-controlled trials have been performed. METHODS: This is a randomized controlled trial designed to assess the efficacy of a rigid wrist splint compared with soft wrist bandage (placebo) in patients with primary idiopathic CTS. The trial will be conducted at an orthopedic department. Patients, 25 to 65 years old, who seek primary health-care with symptoms of CTS will be screened, and potentially eligible patients will be referred to the study center. Patients who fulfill the trial's eligibility criteria will be invited to participate. A total of 112 patients who provide informed consent will be randomly assigned to treatment with either a rigid wrist splint or a soft bandage to be used initially for 6 weeks at night and, if possible, during the day. The splints and bandages will be fitted with a temperature-monitoring device to measure the total time during which they have actually been worn. The trial participants will complete a questionnaire that includes the 6-item CTS symptoms scale (CTS-6); the 11-item disabilities of the arm, shoulder, and hand (QuickDASH) scale; and the EuroQol 5-dimension (EQ-5D) health status and quality-of-life measure at baseline and at 6, 12, 24, and 52 weeks after treatment start. The participants will undergo physical examination and nerve conduction testing at baseline and at 52 weeks. The trial's primary outcomes are the change in the CTS-6 score from baseline to 12 weeks and the rate of carpal tunnel release surgery at 52 weeks. DISCUSSION: This is the first placebo-controlled randomized trial with electronic monitoring of actual splint use and will provide evidence regarding the efficacy of wrist splinting in patients with CTS. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN81836603 . Registered on May 5, 2018.

Decisional conflict in surgical patients: Should surgeons care?

Summary: Decisional conflict represents a state of uncertainty regarding an action one must take. It is a concept inherent to shared decision-making and can help promote high-quality and patient-centred decisions in surgical care, leading to better outcomes. Specific elements may cause more uncertainty or decisional conflict for patients: lack of knowledge about risks and benefits, poorly defined personal values about the importance of those risks and benefits, perception of a lack of support, unpredictable outcomes, or the impression that an inadequate decision has been made. Decisional conflict can be measured in the surgical setting using the 16-item validated patient-reported Decisional Conflict Scale (DCS). Better understanding of the reasons behind high decisional conflict can help surgeons support high-quality decisions and lead to more satisfactory outcomes and less decisional regret.

Universal Measures of Support Are Needed: A Cross-Sectional Study of Health Literacy in Patients with Dupuytren's Disease.

BACKGROUND: Health literacy represents the degree to which patients can understand and act on health information. The relevance of health literacy to health care delivery, outcomes, and overall surgical care is unambiguous. This study aimed (1) to determine the prevalence of limited health literacy in patients diagnosed with Dupuytren's contracture and (2) to identify independent predictors of limited health literacy. METHODS: This cross-sectional study included patients with Dupuytren's disease and with self-reported English fluency. The Newest Vital Sign, a rapid, validated, and reliable screening tool, was selected to measure health literacy. An exploratory multivariable logistic regression model was used to identify possible predictors of limited health literacy. RESULTS: A total of 185 patients met eligibility criteria and were included. From those, 82 (44 percent) were found to have limited health literacy, defined as a score of 3 or less on the Newest Vital Sign. The domain of prose literacy was most highly scored compared to numeracy and document literacy. Lower household income was associated with a 4.7-fold increase in the odds of having limited health literacy. Being an immigrant also increased the odds of having limited health literacy by a factor of 3.6. Sensitivity analyses and subgroup analyses (based on education, maternal language, and immigration status) corroborated these independent predictor findings. CONCLUSIONS: Limited health literacy is common among patients with Dupuytren's contracture. System level changes are necessary such as the access and integration to clinical care of universal measures of support to promote productive patient-surgeon interactions.

Health Literacy Among Surgical Patients: A Systematic Review and Meta-analysis.

Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients' health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7-39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5-39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.

Effect of Forearm Warming Compared to Hand Warming for Cold Intolerance Following Upper Extremity Trauma.

PURPOSE: This study evaluated the effect of forearm or hand warming versus bare hand conditions to improve cold-induced symptoms and skin temperatures in hand trauma patients. METHODS: Adults with symptoms of cold intolerance at least 3 months following hand trauma and age-/sex-matched controls were included. Testing sessions (bare hand, hand warming, forearm warming) were completed in a climate laboratory with continuous temperature monitoring. Outcomes included physical findings (skin temperature) and self-report symptoms (thermal comfort, pain). RESULTS: Eighteen participants (9 hand trauma patients, 9 control subjects) underwent testing. More severe cold intolerance was associated with higher Disabilities of the Arm, Shoulder, and Hand scores. With bare hands, skin temperatures changed significantly from baseline to cold exposure and to rewarming. Hand trauma patients had the lowest skin temperatures with cold exposure in the injured digits (14.3°C ± 3.5°C) compared with the contralateral uninjured (16.9°C ± 4.1°C) digits. Compared with bare hands, wearing gloves significantly increased the minimum temperature during cold exposure and the maximum temperature after rewarming. Patients reported higher pain with cold exposure. All participants reported significantly more comfort with less coldness with forearm and hand warming. CONCLUSIONS: There was cold response variability in hand trauma patients and control subjects. Hand trauma patients had greater changes in skin temperature during cold exposure that improved with glove warming. Continuous temperature monitoring identified subtle physiological changes associated with cold-induced pain and with warming interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Case-Cohort Studies: Design and Applicability to Hand Surgery.

Observational studies are common research strategies in hand surgery. The case-cohort design offers an efficient and resource-friendly method for risk assessment and outcomes analysis. Case-cohorts remain underrepresented in upper extremity research despite several practical and economic advantages over case-control studies. This report outlines the purpose, utility, and structure of the case-cohort design and offers a sample research question to demonstrate its value to risk estimation for adverse surgical outcomes. The application of well-designed case-cohort studies is advocated in an effort to improve the quality and quantity of observational research evidence in hand and upper extremity surgery.

Using Decision Analysis to Understand the Indications for Unilateral Hand Transplantation.

Background: Upper extremity transplantation has been performed to improve quality of life, the benefit which must be traded off for the risk created by life-long immunosuppression. We believe the process of decision analysis is well suited to improve our understanding of these trade-offs. Method: We created a decision tree to include a branch point to illustrate the expected recovery of useful function in the transplant, using the best estimates for utility and probability that exist. Results: Our model revealed that when the probability of achieving a good result, graded as Chen level one or two is greater than 73%, transplantation is preferred over no transplantation. The decision is sensitive to the probability of major complications and the utility of a transplanted limb with minimal function. Conclusions: The results of this analysis show that under some circumstances given a high probability of satisfactory functional recovery, unilateral hand transplantation can be justified.

Prevalence of cold sensitivity in patients with hand pathology.

BACKGROUND: The purpose of this study was to evaluate the prevalence of cold sensitivity in patients with hand- and wrist-related diagnoses. METHODS: We included English-speaking adults who were more than 1 month following hand injury or onset of symptoms. Patients were asked if exposure to cold air or water provoked cold-related symptoms and to rank symptom severity (scale 0-10). Statistical analyses evaluated the relationships between the cold sensitivity and independent variables (age, gender, history of trauma, and time from injury/symptoms). RESULTS: There were 197 patients (mean age 49 ± 16 years): 98 trauma and 99 non-trauma cases. Cold-induced symptoms were reported by 34 %, with 10 % reporting severe symptoms. Exposure to cold air is the most common catalyst; mean severity score was 6.7 ± 2.2. Those with traumatic injuries compared to non-trauma diagnoses reported significantly more cold-induced symptoms (p = .04). Using backward linear regression, the significant predictors of cold symptom severity were trauma (p = .004) and time since onset (p = .003). Including only the trauma patients in the regression model, the significant predictor was time since injury (p = .005). CONCLUSIONS: Cold-induced symptoms are reported by more than 30 % of hand-related diagnoses, and exposure to cold air was the most commonly reported trigger. The significant predictors of cold-induced symptoms are traumatic injuries and longer time from injury. This study provides evidence of the common problem of cold sensitivity in patients with hand pathology. LEVEL OF EVIDENCE: Prognostic Level II.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions.

PURPOSE: To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument. METHODS: A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language. RESULTS: Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation. CONCLUSIONS: Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Characteristics of sleep disturbance in patients with carpal tunnel syndrome.

BACKGROUND: Sleep disturbance is common in carpal tunnel syndrome (CTS), and we hypothesize that it has an important impact on the quality of life of CTS patients. The characteristic of sleep problems associated with CTS has not been evaluated. METHODS: We performed a case-control study to measure the association between a variety of sleep disturbances and CTS. Sixty-two cases with clinically diagnosed CTS and a probable or classic hand diagram were compared to 138 primary care patients without CTS. In addition to demographic features, we collected the nature of sleep disturbance experienced by the patients from a categorical list and the nature, impact, and severity of sleep disturbance using the Insomnia Severity Index. RESULTS: Patients with CTS complained of significantly more severe problems with sleep than the control population and had multiple sleep complaints compared to the control group. Sixty-three of the 138 control patients indicated that they had one cause of sleeping disturbance with no control patient choosing more than one. In contrast, in CTS patients, 44 of 63 patients indicated they had two or more causes of sleep disturbance. The Insomnia Severity Index was significantly higher in CTS patients and the impact of sleep disturbance on quality of life was higher in the cases. CONCLUSION: Sleep disturbance in CTS patients is characterized by a broad array of physical symptoms that have a significant impact on quality of life.

Preferred sleep position on the side is associated with carpal tunnel syndrome.

BACKGROUND: Although carpal tunnel syndrome is the most common compressive neuropathy, there is no comprehensive theory of its etiology. Because of the prevalence of night symptoms, we are interested in the role of sleep position in the causation of carpal tunnel syndrome. METHODS: We performed a case-control study comparing the prevalence of preferred sleep position in 68 cases and 138 controls. Analysis was stratified by age and gender and controlled for body mass index. RESULTS: We found a strong and significant association between a preference for sleeping on the side and the presence of carpal tunnel syndrome in men and in women less than 60 years of age. Body mass index was associated with carpal tunnel syndrome in women but not men. CONCLUSIONS: Our findings of a strong association between the presence of carpal tunnel syndrome and preferred sleeping on the side suggest a comprehensive unifying theory of causation.

Evaluation of sleep position as a potential cause of carpal tunnel syndrome: preferred sleep position on the side is associated with age and gender.

PURPOSE: To test the hypothesis that an important step in a causative mechanism for carpal tunnel syndrome (CTS) is sleeping in a lateral position (sleeping on the side), we designed a cross-sectional survey to measure the association between sleep position, age, gender, and body mass index (BMI). METHODS AND FINDINGS: We surveyed 247 patients in a primary care setting. Fifty percent of men and 73% of women prefer to sleep on their side (p < .001; unadjusted odds ratio, 2.7). In addition, the proportion of women who prefer to sleep on their side increased with increasing age (p < .001). There was no association between BMI and sleeping in a lateral position. CONCLUSIONS: This study supports the hypothesis that sleeping on the side is an important step in a causal pathway for CTS.

Medical decision analysis: indications for tympanostomy tubes in RAOM by age at first episode.

OBJECTIVE: To compare utility estimates between tympanostomy tubes (TT) and short-courses of antibiotics in children with recurrent acute otitis media (RAOM) stratified by age at first episode. STUDY DESIGN AND SETTING: Formal decision analysis. RESULTS: The model recommended TT sooner in children with a history of a first episode of AOM occurring early in life. In children over 12 months old at onset, TT were recommended with seven episodes in 24 months, five episodes in 12 months, and three episodes in six months. In children under six months old at onset, TT were recommended with three episodes in 24 months and two episodes in a six-month or 12-month time span. CONCLUSIONS: Earlier TT may be indicated in children who developed a first episode of AOM at a very young age because of the higher risk of AOM recurrence. SIGNIFICANCE: This study is the first formal decision analysis to compare tympanostomy tubes and short-courses of antibiotics stratified by age at onset of the first AOM episode.