Validity of self-report measures of pain and disability for persons who have undergone arthroplasty for osteoarthritis of the carpometacarpal joint of the hand.

OBJECTIVE: To establish the validity of three self-report scales used to measure function following arthroplasty for osteoarthritis (OA) of the carpometacarpal joint. METHOD: Persons with OA of the carpometacarpal joint (n=122) were assessed on one occasion 9-117 months following tendon interposition arthroplasty. They completed three self-report measures of hand/upper limb disability: the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), the Patient-Rated Wrist Hand Evaluation (PRWHE), and the Disabilities of Arm, Shoulder and Hand (DASH). They also completed the Short Form 36 (SF-36) and performed tests of strength, range of motion (ROM), and dexterity. Factor analysis and correlations were used to determine the association among the scales and subscales considered to measure similar constructs (e.g., pain and physical disability). Correlations between the scales and measures of impairment were also conducted to examine construct validity of the disability measures. t-Tests evaluated the hypotheses that subjects with isolated hand OA would have lower scores than those with additional joint involvement. RESULTS: All three scales or their subscales loaded on one factor. Convergent validity of the disability measures was demonstrated by high correlations between similar subscales (r>0.75), and divergent validity by a lack of correlation between the measures and self-report hand appearance. As expected, correlations between disability and strength, dexterity, or a global measure of ROM were higher than with ROM of individual joints. The AUSCAN and the DASH were better able to discriminate those with localized hand OA from those with involvement of other joints. CONCLUSIONS: The AUSCAN, PRWHE, and DASH are valid assessments of pain and/or disability of hand OA, and provide information distinct from impairment measures.

Dimensionality and clinical importance of pain and disability in hand osteoarthritis: Development of the Australian/Canadian (AUSCAN) Osteoarthritis Hand Index.

OBJECTIVE: To develop a reliable, valid, and responsive self-administered questionnaire to probe pain, stiffness and physical disability in patients with osteoarthritis (OA) of the hand. DESIGN: In order to assess the dimensionality of the symptomatology of hand OA, a self-administered questionnaire was developed to probe various aspects of pain (10 items), stiffness (two items), and physical function (83 items). The question inventory was generated from eight existing health status measures and an interactive process involving four rheumatologists, two physiotherapists, and an orthopaedic surgeon. RESULTS: Face-to-face interviews were conducted with 50 OA hand patients; 39 females and 11 males with mean age 62.8 years and mean disease duration 9.4 years. Items retained were those which fulfilled specified selection criteria: prevalence > or =60% and mean importance score approximating or exceeding 2.0 Item exclusion criteria included low prevalence, gender-based, ambiguous, duplicates or similarities, alternatives, composite items, and items that were too restrictive. This process resulted in five pain, one stiffness and nine function items which have been proposed for incorporation in the AUSCAN Index. CONCLUSIONS: Using a traditional development strategy, we have constructed a self-administered multi-dimensional outcome measure for assessing hand OA. The next stage includes reliability, validity and responsiveness testing of the 15-item questionnaire.

Validity of pulp-to-palm distance as a measure of finger flexion.

This study investigated the validity of pulp-to-palm distance measures as clinical indicators of finger flexion capacity. Pulp-to-palm distance and goniometry of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints were measured by a single tester in 50 patients with abnormal digital flexion using a computerized hand assessment system. The correlation between pulp-to-palm distance measurements and total finger flexion measures obtained by goniometry, was moderate (r=-0.46 and -0.51). This indicates that the measures are not interchangeable. The relationship between an upper extremity disability score (DASH) and restricted motion was stronger for the goniometric measurements (r=0.45, P<0.01) than for the pulp-to-palm distance measurements (r<0.30, P>0.01). Both types of range of motion measurements were able to discriminate between minimal and substantial upper extremity disability. Further methodological evaluation is required to support the use of pulp-to-palm distance measures as an outcome indicator.

Assessment of complications of distal radius fractures and development of a complication checklist.

The purposes of this study were to determine the overall incidence of distal radius fracture (DRF) complications, determine the incidence and types of DRF complications in a consecutive cohort of 250 patients with DRFs, describe DRF complications reported by patients compared with those reported by physicians, and formulate a DRF complication checklist to improve recording of DRF complications. We found that the overall complication rates vary widely (6% to 80%). Physician-reported complication data were collected for 236 patients, and a physician-reported complication rate of 27% was determined. A patient-reported complication rate of 21% was found for 207 patients whose patient-reported data were collected. We also noted that patients and physicians assess DRF complications differently: patients are more focused on symptoms than diagnoses. A DRF complication checklist was developed to improve prospective data collection. The checklist includes a classification for all DRF complications and allows for assessment of severity of each complication.

Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation.

Twenty-two consecutive patients (23 wrists) underwent open reduction internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches. One of 5 experienced wrist surgeons performed these procedures within an average of 3 days of injury (range, 0-26 days) and intercarpal fixation was kept within the proximal carpal row. Motion was instituted an average of 10 weeks (range, 5-16 weeks) after injury. All patients were males. The average age at the time of injury was 32 years (range, 16-60 years). The average follow-up period was 37 months (range, 13-65 months). Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively, compared with the contralateral wrist. The scapholunate angle increased and the revised carpal height ratio decreased over time, which was statistically significant for both measurements. Three patients (3 wrists) required wrist arthrodesis and a fourth patient had an immediate scaphoid excision and 4-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched US population values; physical summary scores were significantly less. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Seventy-three percent of all patients had returned to full duties in their usual occupations and a total of 82% were employed.

Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture.

We evaluated the responsiveness of patient questionnaires and physical testing in the assessment of recovery after distal radius fracture. Patients (n = 59) were assessed at their baseline clinic visit and again 3 and 6 months after injury. At each visit patients completed a short form-36, Disability of the Arm, Shoulder, and Hand questionnaire, and patient-rated wrist evaluation (PRWE). At 3 and 6 months grip strength, range of motion, and dexterity were analyzed. Standardized response means (SRM) and effects sizes were calculated to indicate responsiveness. The PRWE was the most responsive. Both the PRWE (SRM = 2.27) and the Disability of the Arm, Shoulder, and Hand (SRM = 2.01) questionnaire were more responsive than the short form-36 (SRM = 0.92). The physical component summary score of the short form-36 was similar to that of the physical component subscales. Questionnaires were highly responsive during the 0- to 3-month time period when physical testing could not be performed. Of the physical tests, grip strength was most responsive, followed by range of motion. Responsive patient-rating scales and physical performance evaluations can assist with outcome evaluation of patients with distal radius fracture.

Intratester and intertester reliability of goniometric measurement of passive lateral shoulder rotation.

Measurement of lateral rotation range of motion (ROM) is frequently performed during shoulder evaluation. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurement of passive lateral rotation ROM of the shoulder. Two experienced PTs performed the testing in a randomized block design. They were blinded to all clinical information and to their goniometric readings. Passive lateral rotation ROM of the shoulder was assessed in 34 patients with a variety of shoulder pathologies. Patients were placed in the supine position with the arm abducted approximately 20 degrees to 30 degrees. A standard goniometer, placed along the joint axis by the therapist, was red by an independent assistant. Intraclass correlation coefficients (ICCs) and their associated 95% confidence intervals were calculated. Intratherapist ICCs (0.88 and 0.93) and intertherapist ICCs (0.85 and 0.80) were high. These findings suggest that reliable measures of passive lateral rotation ROM of the shoulder can be obtained from patients with shoulder pathology using standard goniometry and by placing the patient in a supine position.

Reliability of the NK dexterity board.

The NK computerized hand evaluation system includes a dexterity board that can be used to measure patients' ability to manipulate small, medium, and large objects. This study evaluated the test-retest reliability of the NK dexterity test. Thirty-seven healthy subjects aged 20 to 54 years completed two occasions of dexterity testing. Each occasion included bilateral dexterity tests consisting of two trials of each of three subtests. Intraoccasion intraclass correlation coefficients (ICCs) indicated fair to excellent reliability (ICC, 0.53-0.86). Interoccasion ICCs tended to be lower and ranged from 0.39 to 0.83, depending on the subtest. Reliability tended to be higher with the dominant hand than with the nondominant hand. Improvements in equipment design and alternative testing protocols may be needed to ensure consistently excellent reliability in dexterity scores with this test.

Patient rating of wrist pain and disability: a reliable and valid measurement tool.

OBJECTIVE: The goal of this study was to develop a reliable and valid tool for quantifying patient-rated wrist pain and disability. DESIGN: Survey, tool development, reliability, and validity study. SETTING: Upper extremity unit. PARTICIPANTS: One hundred members of the International Wrist Investigators were surveyed by mail to assist in development of the scale. Patients with distal radius (n = 64) or scaphoid (n = 35) fractures were enrolled in a reliability study, and 101 patients with distal radius fractures were enrolled in a validity study. INTERVENTION: Information from the expert survey, biomechanical literature, and patient interviews was used as a basis for item generation and definition of structural limitations for a scale that would be practical in the clinic. Patients with distal radius or scaphoid fractures completed the Patient-Rated Wrist Evaluation (PRWE) on two occasions to determine test-retest reliability. Patients with distal radius fractures (n = 101) completed the PRWE and the SF-36 and were tested with traditional impairment measures at baseline and at two, three, and six months after fracture to determine construct and criterion validity. MAIN OUTCOME MEASURES: Reliability coefficients (ICCs) and validity correlations (Pearson product moment correlations). RESULTS: Patient opinions on pain and on ability to do activities of daily living and work were thought to be the most important dimensions to include in subjective outcome tools. Brevity and simplicity were seen as essential in the clinic environment. A fifteen-item questionnaire (the PRWE) was designed to measure wrist pain and disability. Test-retest reliability was excellent (ICCs > 0.90). Validity assessment demonstrated that the instrument detected significant differences over time (p < 0.01) and was appropriately correlated with alternate forms of assessing parameters of pain and disability. CONCLUSIONS: The PRWE provides a brief, reliable, and valid measure of patient-rated pain and disability.

Transmetacarpal intramedullary K-wire fixation of proximal phalangeal fractures.

The management of unstable phalangeal fractures has been associated with significant morbidity. Percutaneous transmetacarpal intramedullary Kirschner wire fixation of proximal phalangeal fractures has been described as a useful technique. We present a retrospective review of 35 digits in 24 patients with unstable fractures of the proximal phalanx treated using this technique between 1985 and 1995. Outcome measures, including radiological adequacy of reduction, total active range of motion, development of joint contracture, grip strength, and digital grip strength, were assessed. Good or excellent results were obtained in 76% of fractures (19 of 25) that were treated and followed. Thirty-two percent of digits (8 of 25) treated developed a proximal interphalangeal joint flexion contracture. Flexion contracture averaged 18.1 deg at the involved joints. Seven secondary procedures were required in 6 patients. Major complications noted during the study included loss of reduction with rotational deformity in four digits, and one nonunion. The use of skeletal traction devices was associated with three of the major complications observed. These devices should not be used concurrently on or adjacent to any digit treated by intramedullary pinning. We conclude that transmetacarpal axial Kirschner wire fixation is a technically simple method of treating unstable proximal phalangeal fractures, and good or excellent results can be obtained in the majority of appropriately selected patients.

The outcome of tendon transfers for C6-spared quadriplegics.

The purpose of this study was to review retrospectively and evaluate a uniform group of C6-spared quadriplegics who had similar surgical procedures. Eight patients undergoing 12 procedures were reviewed at an average of 3.8 years follow-up. There were three bilateral procedures. All patients had extensor carpi radialis longus to flexor digitorum profundus and brachioradialis to flexor pollicis longus transfers to improve grip strength and key pinch. All patients reported subjective improvements in quality of life, activities of daily living and patient-centred goals. There were six excellent and two good results. Objective improvements included mild improvements in key pinch and grip strength.

Movement diagram and "end-feel" reliability when measuring passive lateral rotation of the shoulder in patients with shoulder pathology.

BACKGROUND AND PURPOSE: Findings related to joint function can be recorded with movement diagrams or by characterizing the "end-feel" according to the procedure described by Cyriax. Because both methods are used to classify pain and resistance in relation to joint range of motion (ROM), the purpose of this study was to simultaneously evaluate the reliability of these categorizations in a patient sample. SUBJECTS: Two physical therapists performed 2 assessments of passive lateral rotation of the shoulder in 34 patients. METHODS: Pain and resistance findings were recorded using movement diagrams and end-feel categories. Intraclass correlation coefficients (ICC[2,1]) were used to analyze the ratio (movement diagram) data, and kappa statistics (kappa) were used to analyze the categorical (end-feel) data. RESULTS: Intrarater ICCs varied from .58 to .89. Interrater ICCs for locating maximum pain and resistance in joint ROM varied from .85 to .91. Other interrater ICCs were lower (ICC = .34-.88). Intrarater kappa values for end-feel were moderate (kappa = .48-.59), and interrater kappa values were substantial (kappa = .62-.76). CONCLUSION AND DISCUSSION: Movement diagram measures conceptually related to the end of joint ROM and end-feel were highly reliable. This finding and the fact that additional end-feel categories were introduced in the study may partially explain the end-feel reliability findings. Consideration of their use in future studies may help to determine their clinical utility.

Measurement of the scaphoid humpback deformity using longitudinal computed tomography: intra- and interobserver variability using various measurement techniques.

The intra- and interobserver variability of 3 techniques for measuring the humpback deformity of 37 scaphoids using longitudinal computed tomography was assessed. The 3 measuring techniques were the lateral intrascaphoid angle, the dorsal cortical angle, and the height-to-length ratio. The intraobserver reliability of the intrascaphoid angle was poor; the dorsal cortical angle was moderate to excellent, and the height-to-length ratio was excellent. The interobserver reliability of the intrascaphoid angle was poor to moderate, the dorsal cortical angle was moderate to excellent, and the height-to-length ratio was moderate to excellent. For all 3 observers, the intra- and interobserver reliability was the best for the height-to-length ratio and worst for the intrascaphoid angle. The height-to-length ratio is the most reproducible method of assessing the humpback deformity. Clinical correlation is required to establish whether the height-to-length ratio will be of value in predicting the outcome of fractures of the scaphoid.

Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures.

Arthroscopy was used to assess the soft tissue injuries associated with distal radial fractures in 118 acute intra- and extra-articular fractures. The triangular fibrocartilage complex (TFCC) was torn in 46 of 118 patients--in 35% of intra-articular fractures and in 53% of extra-articular fractures. No correlation between ulnar styloid fractures and TFCC injuries could be found. Scapholunate (SL) ligament injuries with instability were present in 21.5% of intra-articular fractures and in 6.7% of extra-articular fractures. Lunotriquetral (LT) ligament injuries with instability were present in 6.7% of intra-articular fractures. and in 13.3% of extra-articular fractures. Combined SL and LT injuries were present in 5.6% of intra-articular fracture. Preoperative radiographs correlated with TFCC injury. Patients with TFCC tears had greater shortening and dorsal angulation on the preoperative radiographs. Preoperative radiographs had no predictive value for interosseous ligament injury. Ligamentous injuries are commonly associated with both intra-articular and extra-articular distal radial fractures.

Clenched-fist injury complicated by methicillin-resistant Staphylococcus aureus.

Hand infections are a common sequela of clenched-fist injuries. The majority of these infections are due to Staphylococcus and Streptococcus species. Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly being isolated in Canadian health care facilities. In addition, MRSA now needs to be considered in community acquired hand infections that fail to respond to common empiric therapy. A 51-year-old man with MRSA due to a hand injury was treated successfully with vancomycin. The prevalence, mechanism of resistance and treatment of MRSA are briefly reviewed.

Inter-rater agreement and accuracy of clinical tests used in diagnosis of Carpal Tunnel Syndrome.

A sample of 42 subjects (84 hands) with complaints of pain, numbness and/or tingling were used to study the inter-rater agreement and accuracy of seven clinical tests which can be used to assist in the diagnosis of carpal tunnel syndrome (CTS). A 'gold standard diagnosis', defined as a clinical diagnosis of CTS rendered by one of two hand surgeons and supported by electrodiagnostic evidence of CTS, was used to classify the 84 hands as to the presence of CTS. Two therapists were blinded to patient history, electrophysiology, diagnosis and all evaluations performed by the other therapist, until clinical testing was completed. Tests performed included: wrist flexion, wrist extension, Tinel's, tethered median nerve (TMN), pinch, vibration and Semmes-Weinstein monofilament (SWMF) tests. Substantial inter-rater agreement was observed between the two therapists for five of the clinical tests (k > 0.71) with SWMF and TMN having lower agreement. The most accurate test was Phalen's wrist flexion test. Good accuracy was demonstrated by pinch and vibration tests. Tinel's test was characterized by lower sensitivity, but false positives were rare. Wrist extension and TMN tests had poor sensitivity. SWMF testing was very sensitive, but a high number of false positives occurred when 'normal' was classified as 2.83. Reliability and accuracy of these tests supports their use as components of a clinical diagnosis of CTS.

Plate fixation of comminuted olecranon fractures: an in vitro biomechanical study.

The stiffness, cyclic stability, and failure strength of posterior and lateral plating were compared in an in vitro model of a comminuted olecranon fracture. Loading was applied to the brachialis and triceps while displacements of the olecranon were measured with an electromagnetic tracking device in six degrees of freedom. No statistical difference was seen in the cyclic or static stability of either plating method. The triceps tendon suture attachment failed during destructive testing in each case between 300 and 500 N of applied loading. No gross failure of the bony fixation of the implant occurred before suture failure. These results suggest that both plating methods are likely to afford adequate stability to permit early protected postoperative range of motion.

Intrafocal (Kapandji) pinning of unstable distal radius fractures: a preliminary report.

Seventeen consecutive patients (17 wrists) who underwent intrafocal pinning of unstable distal radius fractures, as described by Kapandji, were retrospectively reviewed at a mean of 42 weeks after surgery (range, 13-88 weeks). The patients were immobilized for 6 weeks postoperatively. All patients were assessed by a single physician and were asked a set of questions regarding subjective and functional status. All patients underwent physical examination of their upper extremities, and bilateral wrist PA and lateral x-rays were taken. There were 13 females and four males; the average age was 49 years. Ten dominant and seven nondominant extremities were involved. Average volar tilt on follow-up lateral wrist radiography was 7 degrees. This compares with -20 degrees at initial presentation, -12 degrees preoperatively, 6 degrees immediately postoperatively, and 10 degrees in the normal wrists. Radial shortening (average) was -2 mm at initial presentation, -1mm preoperatively, 1 mm postoperatively, 0 mm at follow-up, and 1 mm in the normal wrists. Radial inclination was 17 degrees initially, 20 degrees preoperatively, 23 degrees immediately postoperatively, 23 degrees on follow-up, and 24 degrees in the normal wrists. There was a trend for patients with osteopenic bone to lose their postoperative reduction. However, this was not statistically significant. Patients older than 65 years of age had significantly inferior radiologic results. Loss of pronation and supination averaged 2 degrees (range 0-10 degrees) compared with the uninjured wrist. Loss of dorsiflexion averaged 6.5 degrees, and palmar flexion averaged 7.6 degrees. The patients' subjective complaints were minimal. Average pain on visual analog scale (VAS) was 0.44/10. Function measured 8.64/10 (VAS). Sixteen of the patients were happy with the surgery and the outcome of their wrists. Complications included extensor tendon rupture (one patient), pin migration requiring premature removal (one patient), and initial loss of reduction requiring reoperation (one patient). Intrafocal pinning of unstable distal radius fractures provides an effective means to stabilize these complex injuries. Early follow-up suggests that the patients have a satisfactory functional outcome. The complications in this series were preventable. Intrafocal pinning should be added to the surgical armamentarium in treating distal radius fractures.