Assessment of Medical Cannabis in Patients With Osteoarthritis of the Thumb Basal Joint.

PURPOSE: With the increasingly widespread availability of cannabidiol-derived products, more patients with hand and wrist pain are seeking evidence for use of these products. We explored current utilization practices of medical cannabis for treatment of pain in patients with a diagnosis of thumb basal joint arthritis. Secondary aims were to determine patient and thumb arthritis disease characteristics of cannabis users and nonusers and to investigate patient perceptions of the efficacy of medical cannabis in various formulations for the treatment of thumb arthritis pain. METHODS: Patients with thumb basal joint arthritis were identified using International Classification of Diseases, Tenth Revision codes between May and June 2020. All patients received an invitation to complete a survey regarding perceptions of cannabis and related products. Medical records were retrospectively reviewed to gather demographic information and thumb basal joint arthritis factors, including laterality, date of initial diagnosis, and prior treatment. RESULTS: The survey was completed by 103 patients. Twenty-five percent reported a history of oral medical cannabis use, and 21% reported topical medical cannabis use. Twelve of 25 oral users and 7 of 21 topical users believed that the product was effective in relieving pain and consequently worth the financial cost. Of the patients surveyed, 69% would be interested in trialing an oral formulation and 80% would be interested in trialing a topical formulation for treatment of their thumb pain. CONCLUSIONS: Patients with thumb basal joint arthritis use cannabis-related products, with mixed reports on efficacy. Large numbers of these patients would be interested in trialing either oral or topical formulations of medical cannabis for treatment of their thumb basal joint pain. CLINICAL RELEVANCE: It is important for medical providers to understand the current data available regarding analgesic properties of cannabidiol-related products to respond to patient inquiries about the use of cannabinoids in treating medical conditions.

Radial nerve palsy following humeral shaft fracture: a theoretical PNF rehabilitation approach for tendon and nerve transfers.

BACKGROUND: Humerus fracture-induced radial nerve injury can create severe and permanent disabilities. PURPOSE: Surgical management often relies on either tendon or nerve transfer. Regardless of which procedure is selected, physical therapists are challenged to restore functional outcomes without jeopardizing repair healing. Through synergistic, multi planar upper extremity movement patterns, neuromuscular irradiation, or overflow, and neuroplasticity, proprioceptive neuromuscular facilitation (PNF) may improve strength, range of motion and tone. METHODS: After reviewing the literature, a five phase PNF-based treatment approach is proposed with timing differences based on the selected procedure. FINDINGS: Phase I (2 or 4 weeks pre-surgery for tendon or nerve transfer, respectively) consists of comprehensive patient education; Phase II (4-6 or 1-2 weeks post-surgery for tendon or nerve transfer, respectively) explores variable duration peripheral and central nervous system motor learning during isometric activation to enhance central neuroplasticity; Phase III (7-12 or 3-20 weeks post-surgery for tendon or nerve transfer, respectively) incorporates low-intensity motor control including contralateral isotonic upper extremity loading to maximize overflow and neuroplastic effects; Phase IV (13-26 or 21-52 weeks post-surgery for tendon or nerve transfer, respectively) adds high-intensity strength and motor control using ipsilateral isotonic upper extremity loading to maximize overflow and neuroplastic effects. Phase V (27-52 or 53-78 weeks post-surgery for tendon or nerve transfer, respectively) progresses to more activity of daily living, vocational, or sport-specific training with higher intensity strength and motor control tasks. CONCLUSIONS: Through manually guided synergistic, multi planar movement, overflow, and neuroplasticity, a PNF treatment approach may optimize neuromuscular recovery. Validation strategies to confirm clinical treatment efficacy are discussed.

Headless Compression Screw Fixation for Proximal Phalanx Fractures: A Biomechanical Study.

Background: Proximal phalanx fractures are common injuries of the hand with multiple treatment options. Intramedullary (IM) screw fixation has become more widely used, and early outcomes are promising. However, biomechanical data regarding this type of fixation are sparse. Methods: Two methods of IM screw fixation of proximal phalanx fractures were tested in cadaver specimens. All specimens were treated with a single antegrade headless compression screw, with half getting the addition of a blocking screw. To test the most common deforming force of flexion-extension, each phalanx was subjected to apex volar 3-point bending using the Materials Testing System test frame. Results: There was no significant difference in the stiffness of 3-point bending with single antegrade screws alone and with a blocking screw (mean, 63.1 vs 52.2 N/mm; P = .27). When comparing smaller with larger specimens, stiffness of the small group was significantly greater than that of the large group when both fixation methods were included (85.3 vs 30.1 N/mm; P < .0002). When comparing stiffness with percent fill of the screw within bone, there was a moderately positive correlation (0.51). Conclusions: Addition of a blocking screw did not increase the stability of the IM screw fixation construct for proximal phalanx fractures. When comparing specimen size, the smaller bones were stiffer under 3-point bending load, regardless of the type of fixation. In addition, those specimens that had a larger longitudinal screw length to bone length ratio were stiffer. These findings provide valuable information as techniques for IM screw fixation of proximal phalanx fractures continue to evolve.

What Is the Evidence in Treating Distal Radius Fractures in the Geriatric Population?

Distal radius fractures are common in the elderly population, second only to hip fractures in frequency. Historically, these injuries were treated almost exclusively without surgery, but an increase in operative management has occurred with development of volar locked plating in the early 2000s. Functional outcomes are similar between conservative and surgical treatment, but most studies assume low functional demands in older patients. Many elderly individuals today are active and independent. Decision-making in this higher-demand population is difficult. This article provides current evidence to facilitate informed, individualized decision-making when treating distal radius fractures in geriatric patients.

Tibia fractures and NSAIDs. Does it make a difference? A multicenter retrospective study.

PURPOSE: The purpose of this study was to compare healing time for diaphyseal tibia fractures (OTA/AO 42 A, B, C) treated with intramedullary nailing (IMN) in one geographic cohort using nonsteroidal anti-inflammatory drugs (NSAIDs) for post-operative pain control to that of another geographic cohort using opioid medications. The groups represent differing cultural approaches to post-operative pain control. We hypothesized there would be no difference in healing time. METHODS: Tibia fractures presenting at two level I trauma centers located in different countries between January 1, 2010 and December 31, 2017 were retrospectively screened for enrollment. Fractures classified as OTA/AO 42 A, B, or C that were treated with IMN and had radiographic follow up to union were included. At hospital discharge, one cohort (n = 190) was prescribed NSAIDs and the other (n = 182) was prescribed opioids for pain control. Each analgesic method represented the standard of care for that location. Fracture union was defined as cortical bridging in at least 3 out of 4 cortices on AP and lateral radiographs. The primary outcome was healing time on radiographic evaluation. RESULTS: There was no statistically significant difference in healing time between the opioid and NSAID groups: 185 vs 180.5 days respectively (p = 0.64). Both groups had similar mean age. Student t-tests were run to compare rates of tobacco use, diabetes mellitus (DM), open fractures, and polytrauma between the two groups. The opioid cohort had statistically significant higher rates of tobacco use, DM, and polytrauma. The NSAID cohort, however, had a larger number of open fractures. CONCLUSION: The difference in healing time between the NSAID and opioid groups was not statistically significant. The deleterious effect of NSAID use on fracture healing has been debated for decades. Numerous animal studies have supported this theory; however, high quality clinical studies in humans have not provided convincing evidence to substantiate this negative effect. Our study suggests that NSAIDs may be used safely and effectively in the acute phase of fracture healing without significantly increasing the risk of delayed union or nonunion. Prospective randomized studies are necessary to rule out the negative effect of NSAIDS on bone healing.

Eccentric Capitellar Ossification Limits the Utility of the Radiocapitellar Line in Young Children.

BACKGROUND: The radiocapitellar line (RCL) has long been used for the radiographic evaluation of elbow alignment. In children, the capitellar ossific nucleus serves as a proxy for the entire capitellum, but this substitution has not been verified. Using magnetic resonance imaging (MRI), we sought to understand how maturation of the ossific nucleus of the capitellum affects the utility of RCL throughout skeletal maturation of the elbow. METHODS: The RCL was drawn on coronal and sagittal MRIs in 82 children (43 boys, 39 girls; age range, 1 to 13 y) with at least 3 patients in each 1-year interval age group. The perpendicular distance of the RCL from the center of both the cartilaginous capitellum and the capitellar ossific nucleus was measured relative to its total width, and a percent offset for each measurement was calculated. Logarithmic regression analysis was performed to analyze the effect of age and sex on percent offset. RESULTS: The RCL reliably intersected with the central third of the cartilaginous capitellum at all ages in both planes. Although the RCL intersected with the ossified capitellum in all but 3 measurements, it intersected with the central third of the ossified capitellum less often in younger children in both sagittal (B=0.47, P<0.001) and coronal (B=0.31, P=0.002) planes. Percent offset decreased significantly with age in a logarithmic manner in both sagittal (r=0.57, P<0.001) and coronal (r=-0.47, P<0.001) planes. 95% confidence intervals predict that the sagittal plane RCL will accurately intersect the central third of the ossified capitellum by age 10 years in girls and age 11 years in boys but not in the coronal plane. CONCLUSIONS: Eccentric ossification of the capitellum explains RCL variability in young children. The RCL does not reliably intersect the central third of the ossified capitellum until ages 10 years in girls and 11 years in boys in the sagittal plane. The RCL should be used within its limitations in skeletally immature children and should be combined with advanced imaging if necessary.

Hip Strength Is Greater in Athletes Who Subsequently Develop Patellofemoral Pain.

BACKGROUND: Hip and knee strength abnormalities have been implicated in patellofemoral pain (PFP) in multiple studies. However, the relationship is unclear, as many of these studies have been retrospective. PURPOSE: To compare prospective hip and knee isokinetic strength in young female athletes who subsequently went on to develop PFP relative to their uninjured, healthy peers. STUDY DESIGN: Descriptive epidemiology study. METHODS: Adolescent female athletes (N = 329) were tested for isokinetic strength of the knee (flexion and extension) and hip (abduction) and screened for the prevalence of PFP before their basketball seasons. After exclusion based on current PFP symptoms, 255 participants were prospectively enrolled in the study. A 1-way analysis of variance was used to determine between-group differences in incident PFP and the referent (no incident PFP) participants. RESULTS: The cumulative incidence rate for the development of PFP was 0.97 per 1000 athlete-exposures. Female athletes who developed PFP demonstrated increased normalized hip abduction strength (normalized torque, 0.013 ± 0.003) relative to the referent control group (normalized torque, 0.011 ± 0.003) (P < .05). Unlike hip strength, normalized knee extension and knee flexion strength were not different between the 2 groups (P > .05). CONCLUSION: The findings in this study indicate that young female athletes with greater hip abduction strength may be at an increased risk for the development of PFP. Previous studies that have looked at biomechanics indicated that those with PFP have greater hip adduction dynamic mechanics. CLINICAL RELEVANCE: Combining the study data with previous literature, we theorize that greater hip abduction strength may be a resultant symptom of increased eccentric loading of the hip abductors associated with increased dynamic valgus biomechanics, demonstrated to underlie increased PFP incidence. Further research is needed to verify the proposed mechanistic link to the incidence of PFP.

MR imaging of capitellar ossification: a study in children of different ages.

BACKGROUND: The capitellar ossification center is used routinely to evaluate elbow alignment on radiography. However, whether capitellar ossification is central and concentric to support this practice is unknown. OBJECTIVE: To define the pattern of capitellar ossification at different ages of childhood. MATERIALS AND METHODS: This HIPAA-compliant study was IRB approved. MR imaging examinations from 81 children (ages 1-13 years, at least 3 boys and 3 girls in each age group) were included. We determined the center points of the ossified capitellum and the cartilaginous capitellum on the sagittal and coronal sequences that best showed differentiation between cartilage and bone. Percentage offset of the center of the ossified capitellum from the center of the cartilaginous capitellum was calculated in anterior-posterior, proximal-distal and medial-lateral dimensions, and compared across age groups and between genders. Linear regressions were used to ascertain the effect of age on percentage offset for all patients and for each gender. RESULTS: Capitellar ossification begins eccentrically with sagittal anterior proximal offset and coronal medial offset. With age, ossification proceeds posteriorly, distally and laterally. Percentage offset gradually diminishes with age. The ossified capitellum centralizes in the sagittal plane by 12-13 years. In the coronal plane, the capitellum ossifies medially beyond the proximal radioulnar joint and remains eccentric at 12-13 years. Centralization in boys lags in the anterior-posterior dimension. CONCLUSION: Capitellar ossification is an eccentric process, with lag in anterior-posterior centralization in boys. Medial offset persists at 12-13 years. Recognition of this eccentric ossification may allow for more accurate assessment of elbow alignment on radiographs, especially in younger children.