2023 Research Updates

December Research Update

Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures
Summary provided by Sarah Doerrer, PhD, OTR/L, CHT, CLT

Over the past 15 years, there has been some discrepancies in reporting the validity and reliability of the hook test for diagnosis of distal biceps tendon ruptures. The initial description of this exam by O’Driscoll et al. (2007) reported 100% specificity and sensitivity with respect to diagnoses of complete distal biceps tendon ruptures in a retrospective study of 45 patients. Luokkala et al. (2020) also performed a retrospective study and reported a lower sensitivity of 83% in complete tears. The purpose of this study was to prospectively assess the validity and reliability of the hook test for complete distal biceps ruptures. This included both the sensitivity, specificity and interrater reliability.

The hook test is performed by asking the patient to actively flex the involved elbow to 90 degrees while fully supinating the forearm. The examiner’s index finger is brought in from the lateral border of the biceps tendon in the antecubital fossa and “hooked” beneath the tendon (if present). With an intact distal biceps tendon, the examiner’s finger is hooked onto the tendon while drawing it anteriorly. In this scenario, an intact DBT is noted (negative hook test). Care is taken to distinguish between intact biceps tendon and lacertus fibrosus (or bicipital aponeurosis). In cases in which the examiner cannot hook their finger under the tendon to draw it anteriorly (no cord-like structure), the HT result is considered abnormal (positive hook test).

Here is a link to a video on how to perform the hook test

In this prospective study, the authors followed these procedures:

Patients were included if they presented with an elbow complaint and had advanced imaging of the distal biceps tendon ordered by their provider.
The treating surgeon was blinded to the imaging and performed the hook test on the subject and a secondary examiner also performed the hook test. Both examiners were blinded to each other with respect to the results of the hook test.
Findings from the imaging studies were recorded in respect to the distal biceps tendon. The authors assessed the status of the distal biceps tendon on imaging to compare to the results of the hook test. On imaging distal biceps tears were only considered not intact if there was a complete rupture.
The status of the tendon at the time of surgery was the reference standard for this investigation.

Results

Total N was 64 with 28 cases undergoing surgery. There were 26 cases with a complete distal biceps rupture on imaging and 25 of those had surgery. All subjects were male with a mean age of 49 years.
In all surgical cases, there were no cases in which the imaging findings with respect to the distal biceps tendon differed from the intraoperative finding representing 100% specificity and sensitivity when intraoperative findings are used as reference standard.

Hook Test Result	Complete Distal Biceps Tendon Rupture Found During Surgery	Partial or No Distal Biceps Rupture Found During Surgery
(+) Hook Test	24	1
(-) Hook Test	1	2
Total	25	3

Sensitivity of the hook test =96% Specificity of the hook test = 67%.
The inter-rater reliability between the two examiners was substantial (Cohen, 0.71) with both examiners documenting the same agreement in 21 of the 25 complete distal biceps tendon cases.

Conclusion

Results of this study differed from the two prior retrospective studies with lower specificity.
Imperfect sensitivity and specificity of the hook test has implications for advanced imaging utilization and authors caution against use of the hook test alone to diagnose distal biceps tendon ruptures.
The hook test has substantial inter-rater reliability and can be used reliably as a screening and diagnostic tool by clinicians with a variety of experience levels.

Citation: Baylor, J. L., Rae, M., Manzar, S., Pallis, M., Olsen, H. P., Akoon, A., & Grandizio, L. C. (2023). Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures. The Journal of Hand Surgery (American Ed.), 48(11), 1091–1097.

Journal Source: Journal of Hand Surgery

References:
Luokkala, T., Siddharthan, S. K., Karjalainen, T. V., & Watts, A. C. (2020). Distal biceps hook test – Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction. Shoulder & Elbow, 12(4), 294–298. https://doi.org/10.1177/1758573219847146

O’Driscoll, S. W., Goncalves, L. B. J., & Dietz, P. (2007). The Hook Test for Distal Biceps Tendon Avulsion. The American Journal of Sports Medicine, 35(11), 1865–1869. https://doi.org/10.1177/0363546507305016

Access the Journal Article Here

Note: For non Journal of Hand Therapy articles: If you or your institution cannot access the complete article via the link, please contact Jenny M. Dorich, PhD, MBA, OTR/L, CHT, ASHT Research Division Director at jenny.dorich@cchmc.org.

November Research Update

Psychometric properties of body structures and function measures in non-surgical thumb carpometacarpal osteoarthritis: A systematic review
Summary provided by Tauni Malmgren, OTD, OTR/L

This article focuses on the psychometric evaluation of clinical tools used in the assessment of non-operative thumb carpometacarpal osteoarthritis (CMC OA). The study aims to explore the psychometric properties of these tools, evaluate the quality of the related research studies and make recommendations for clinical practice and future research.

The systematic review encompassed 11 studies conducted between 2002 and 2022, involving individuals with non-operative thumb CMC OA, with an average age of 69 years. The studies examined various clinical tools used to assess thumb structures and function, including range of motion, strength and pain-pressure thresholds, among others.

The findings revealed that only a limited set of clinical assessments demonstrated excellent reliability and precision, including:

For mobility, the Kapandji index for thumb opposition, as well as the inter-metacarpal distance (IMD) test for radial and palmar abduction
For strength, three trials of pain-free maximal hand strength using a Jamar dynamometer, as well as a Baseline Pinch Gauge
For provocative testing, the thumb metacarpal adduction stress test or extension stress test; they notably do not recommend the grind compression test
For pain threshold, algometry
They do not provide recommendations for fine motor/dexterity or sensation/proprioception/perception and cite insufficient evidence

The article also highlighted issues with the methodological quality of the reviewed studies, with only a small percentage rated as "very good." It emphasized the need for more high-quality psychometric research in this field to better understand and improve body structure and function measures for non-operative thumb CMC OA. Various clinical tools were assessed, but many require further validation of their psychometric properties.

Citation: Corey McGee, PhD, OTR/L, CHT, Kristin Valdes, OTD, OTR/L, CHT, Caitlin Bakker, Cindy Ivy, M.ED, OTD, CHT. Psychometric properties of body structures and functions measures in non-surgical thumb carpometacarpal osteoarthritis: A systematic review. Journal of Hand Therapy. August 2023.

Journal Source: Journal of Hand Therapy

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October Research Update

Prevalence and factors associated with musculoskeletal complaints and disability in individuals with brachial plexus injury: A cross-sectional study
Summary provided by Katherine Loomis, MA, OTR/L, CHT

This cross-sectional study compared survey responses from adults with brachial plexus injuries (BPIs; n=70) to a healthy control group (n=113) to evaluate the prevalence of musculoskeletal complaints (MSCs) in unaffected body structures and identify factors related to musculoskeletal complaints and functional limitations. Patients with BPIs were identified via medical records at three outpatient rehabilitation centers in the Netherlands and were recruited to participate in the survey via mail. The control group was recruited from acquaintances of the research team and was matched to the patient group for age and gender. Across both groups, the average respondent age was early in the 50s and about two-thirds of respondents were male.

The 69-item survey elicited information on five domains: (1) participant demographics (birthdate, age, gender, marital status, education level, employment status and work hours/perception of work); (2) characteristics of BPI (cause, injury date, surgical status, affected side/structures, altered sensation, pain), general functional status (DASH) and functional ROM (self-report of 10 upper extremity movements); (3) prevalence and location of MSCs in body structures not affected by BPI (checklist of body parts); (4) MSC characteristics (type, duration, pain level via VAS and RAND36 pain subscale, healthcare use due to MSC) and disability due to MSCs (Pain Disability Index); and (5) factors potentially related to MSCs and disability, including upper extremity work demands (Upper Extremity Work Demands Scale), coping style (Utrecht Coping List) and general health (RAND36, comorbidities).

Though between group comparisons revealed a difference in reported MSCs for participants with BPIs (49%) and the control group (35%), this difference was not statistically significant (p=0.078). The groups differed in the prevalence of joint disease comorbidities (14% of patients with BPI vs. 2% of controls) and education level (medium/high education for 49% of patients with BPI and 85% of controls). For patients with BPI, MSCs most often occurred in the neck (29%), upper back (20%) and unaffected upper extremity (34%). These percentages were significantly higher than those of control group respondents (note: unaffected upper extremity MSCs in patients were compared to dominant upper extremity MSCs in controls). Comparative analyses of responses from patients with BPIs revealed that presence of MSCs were associated with worse self-reported AROM (p<0.001), DASH scores (p<0.001), and RAND36 scores (p=0.034), indicating higher levels of disability and poorer general health. Furthermore, for this same group, multivariable regression modeling indicated that greater disability levels (via DASH score) were associated with education level (p=0.037), history of nerve surgery (p=0.041) and self-reported AROM of the affected upper extremity (p=0.001).

The authors conclude that, throughout the course of care, clinicians should be aware of the high prevalence of MSCs among patients with BPIs, especially in the unaffected upper extremity, neck and upper back, as well as the fact that these MSCs are associated with higher levels of disability. Additionally, clinicians should understand that disability within this patient population can simultaneously be related to other factors such as patient background, prior medical intervention and AROM of the affected upper extremity.

Citation: van der Laan, T. M. J., Postema, S. G., van Bodegom, J. M., Postema, K., Dijkstra, P. U., & van der Sluis, C. K. (2022). Prevalence and factors associated with musculoskeletal complaints and disability in individuals with brachial plexus injury: a cross-sectional study. Disability and Rehabilitation, ahead-of-print.

Journal Source: Disability and Rehabilitation

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September Research Update

Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures
Summary provided by April Bryant OTD, OTR/L, CHT

Proximal Interphalangeal (PIP) joint extension contractures can result from injuries to bones, muscle and connective tissue. Surgical management of PIP joint extension contractures yields variable results and can increase edema and scar tissues and even decrease PIP ROM. Passive manipulation of PIP joint extension contractures is an alternative option to consider when the patients have plateaued with other conservative measures. This study aimed to evaluation immediate and more long-term ROM changes to the PIP joint following PIP joint manipulation.

Twenty-eight patients (46 fingers) were selected in this retrospective study that used medical records from 2015 to 2019. Inclusion criteria were the patients were at least 12 weeks post injury/incident, adequate PIP joint architecture and pre-manipulation PROM measurements present. Gentle and gradual passive PIP flexion was applied to address both intrinsic and extrinsic tightness by one of three surgeons in either the clinic with a digital nerve block or in the operating room. Post-intervention, patients were educated on ROM exercises and were referred to hand therapy until they were able to transition to a home exercise program.

Passive PIP flexion improved by 50 degrees post manipulation. This decreased to improvements of 26 degrees, 10 degrees and 18 degrees at before six weeks, six to 12 weeks and over 12 weeks, respectively. These improvements are comparable to those seen after surgical intervention.

Limitations of the study include lack of control group, discharge of patients who did not require further intervention after manipulation, small sample size and relatively short length of follow-up.

This study demonstrates that passive manipulation to improve PIP flexion secondary to PIP extension contractures may be a safer and less invasive, yet equally effective option compared to surgical intervention.

Citation: Gary, C. S., Wang, J. S., Shubinets, V., Sanghavi, K. K., Katz, R. D., Giladi, A. M., & Means, K. R. (2023). Passive manipulation for proximal interphalangeal joint extension contractures. The Journal of Hand Surgery, 48(7).

Journal Source: The Journal of Hand Surgery

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August Research Update

A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty
Summary Provided by Priya Bakshi, OTD, OTR, CHT

This study compared early rehabilitation (therapy initiated at one week post-surgery) to delayed therapy (six weeks post-surgery) following reverse total shoulder arthroplasty (rTSA). Initial enrollment was 107 shoulders; 86 that completed one year follow up were included for analysis (44 shoulders in the delayed therapy group and 42 in the immediate therapy group).

Outcome measures included active and passive ROM (forward flexion, abduction, external rotation at 0 degrees abduction and cross body adduction), American Shoulder and Elbow Surgeons (ASES) scores, radiographic grading of scapular notching (Nerot-Sirveaux classification system) and adverse event recording. Blinded research assistant assessed outcome measures at six weeks, three months, six months, one year and two years postoperatively.

Within group analysis showed clinically significant improvement in active and passive ROM in flexion and abduction by three months post-surgery. No significant improvement in external rotation or cross body adduction occurred, with an initial decline in external rotation from preoperative range at six weeks. The authors report that other studies show optimization of external rotation with positioning of the glenosphere laterally and inferiorly. Statistical and clinical improvement was seen in ASES scores at six weeks post-surgery, but functional component score did not improve until three months postoperatively.

Between group analysis showed no difference between groups in change in ROM from preoperative motion at all time points. Similarly, no difference between groups was seen in ASES scores at any time point except at six months favoring delayed therapy group. A 30-point improvement in ASES score at one year was maintained at two-year follow up. Scapular notching was statistically the same between groups at one year follow up. No difference between groups was found in dislocation rates (2%) and complications were rare.

The authors concluded that both early and delayed therapy groups showed significant improvements in ROM and ASES scores and that the results support the safety of early rehabilitation programs following rTSA to minimize limitations of prolonged immobilization; however, early ROM did not have an immediate impact on ASES scores.

Citation: Hagen, M. S., Allahabadi, S., Zhang, A. L., Feeley, B. T., Grace, T., & Ma, C. B. (2020). A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery, 29(3), 442–450.

Journal Source: Journal of Shoulder and Elbow Surgery

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July Research Update

Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care
Summary Provided by Sophie Goloff, MS, OTR/L, CHT

Health equity and health equality are often used interchangeably; however, each represents a different concept. Health equity is “an ethical principle driven by social justice, which means that everyone has a fair and just opportunity to be as healthy as possible.” Health equality is defined by equal resources provided to all. Health equity must target systemic disparities in healthcare that affect marginalized groups. Currently, populations such as racial/ethnic minority groups, rural residents and socio-economically disadvantaged families have reduced quality and access to healthcare.

Research regarding social determinants of health in hand surgery is limited, but showed that race, socioeconomic status and rural location all are associated with poorer surgical outcomes. Community based barriers to health equity can arise due to poor Medicaid reimbursements, leading to fewer community-based hand surgeons accepting Medicaid. This increases the travel burden, out-of-pocket costs and time required to receive adequate care. Rural and socioeconomically disadvantaged areas similarly are less likely to be served by specialty hand surgeons. Although there is extensive research regarding social, environmental and economic factors that serve as barriers for health equity, we still do not have conclusive strategies to reduce health inequities. Research has shown a collaborative, interdisciplinary approach is necessary.

Opportunities to advance health equity are present at an institutional level. Awareness is important – a 2016 cross sectional study showed only 37% of surgeons believe health disparities exist, and only 5% recognize them in their own practice. All medical professionals must be educated regarding cultural competence and antiracism education, and more research is required on how to reduce implicit bias. Greater diversity in hand surgery is required to improve health equity and must start at the education level.

There is a need for improved pre- and post-operative care for vulnerable patients. Hand therapy is important for optimal surgical outcomes; however, patients insured by Medicaid are less likely to receive hand therapy services. Insurance limitations, geographical location, care coordination and decreased health literacy all contribute to this disparity. Public policy contributes to surgeon willingness to accept insurance, improving reimbursement and accuracy of success metrics can contribute to more equitable healthcare.

Health equity will be best achieved through addressing research and policy at individual, community, institutional and healthcare system levels.

Citation: Myers, Paige L., and Kevin C. Chung. “Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care.” Hand Clinics, no. 1, Elsevier BV, Feb. 2023, pp. 17–24. Crossref.

Journal Source: Hand Clinics

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June Research Update

A prospective clinical trial comparing denervation with suspension arthroplasty for treatment of carpometacarpal arthritis of the thumb.
Summary Provided by Stephanie Strouse, OTD, OTR/L, CHT

One of the most popular treatments for thumb carpometacarpal arthritis is a trapeziectomy with suspensionplasty; however, a recent procedure involving denervation of the carpometacarpal joint has been found to be favorable in reducing pain in a younger population and to “buy time” until they progressed to the point where they needed to have a suspension arthroplasty. Those who underwent this procedure not only reported decreased pain but also reported improved quality of life as noted in functional outcome surveys.

For this study, the authors performed a prospective clinical trial between June 2020 and December 2021 to compare the functional outcomes of subjects who underwent denervation versus arthroplasty. All 48 participants underwent procedures by the same surgeon and the study was designed as a “patient choice” comparative study. Inclusion criteria to participate in the study included a diagnosis of CMC arthritis as well and failure of non-surgical management with anti-inflammatories, bracing, or corticosteroid injections. Exclusions to the study were those individuals who were concurrently diagnosed with peripheral neuropathy or cervical radiculopathy. The subjects were provided with the options of surgical denervation or arthroplasty with suture suspensionplasty. A total of 34 patients underwent denervation and 14 underwent suspension arthroplasty of the thumb CMC joint.

Hand function was determined by the Michigan Hand Outcomes Questionnaire (MHQ), pain using the visual analog scale (VAS), and quality of life was determined by the EuroQol-5D (EQ-5D). These scales are considered patient-reported outcome measure and data was collected pre- and post-surgery. In addition to the above outcome measures, each subject was asked several qualitative questions after surgery. The questions included “Compared to before surgery, how is your hand pain currently?” and “compared to before surgery, how well does your hand function?” Responses were limited to “slightly worse,” “about the same,” “slightly better” or “much better.” In addition to questions regarding pain, subjects were also asked about sensation. These questions included “Do you have numbness around the incision site?” and “Do you have numbness over the distal thumb?” Reponses to these two questions were limited to “yes” or “no.” One final questions regard function included “How long after surgery did you return to full function?” Responses for this question ranged from “never,” “worse” or “several weeks.”

Results of the study found similar short-term surgical outcomes in patient treatment with denervation and suspensionplasty. Both groups had improvements in MHQ function scores, decreased pain as reflected by VAS scores. There was a difference in the length of time the subjects reported improved symptoms, denervation patients generally noted a decrease in symptoms in 3-4 weeks compared to the arthroplasty patients reported improvement in 4-5 months. Another difference was the absence of post-operative paresthesia throughout the dorsal radial sensory nerve in the subjects who underwent denervation. The study states the denervation procedure may be a favorable alternative treatment for CMC pain, but did imply that this procedure was superior to arthroplasty. One downfall of the study was the short-term follow up and the authors did reference to further studies with longer term follow-ups. In addition to the short term follow up, the authors also expressed a concern with using patient-reported outcome measures and the possibility of bias and having a preconceived perception of expected outcomes.

In conclusion, the authors supported the findings of the study despite the limitations. These results, with other studies, do offer support of denervation for pain control, improved quality of life and quicker recovery times.

Citation: J.W. Hustedt, S.T. Deeyor, C.H. Hui, A.Vohra, A.C. Llaes, & B.L. Silvestri. A prospective clinical trial comparing denervation with suspension arthroplasty for treatment of carpometacarpal arthritis of the thumb. American Journal of Hand Surgery 2023: 48(4); 348-353.

Journal Source: American Journal of Hand Surgery

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May Research Update

Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair
Summary Provided by Melanie Hubbuck, MS, OTD, OTR/L

TFCC injury is a frequent cause of ulnar-sided wrist pain with the need for surgical repair in both acute and chronic or degenerative cases. There is ongoing debate over optimal surgical technique for repair, specifically arthroscopic versus open. This article reviewed the literature to date surrounding TFCC injury.

Surgical intervention is considered for acute injuries in high demand patients, patients who have failed conservative management with persistent ulnar sided wrist pain (typically at least 3-6 months), chronic degenerative tears with ulnar impaction, and persistent DRUJ instability. Surgical options are divided into open or arthroscopic treatments. Peripheral TFCC tear with DRUJ instability can be treated with either open or arthroscopic foveal repair. Due to the proximity to the rotational axis of the forearm, foveal detachment often results in DRUJ instability. Alternatively, peripheral tears without DRUJ instability can be repaired by directly repairing the torn TFCC to the wrist capsule. If ulnar positive, the authors encourage consideration of ulnar shortening osteotomy (USO) rather than TFCC debridement or repair alone with high fail rate/return for USO. There are many fixation techniques described for both open and arthroscopic repair. From a biomechanical standpoint, the suture anchor technique performs the best in terms of load to failure rate and load to gap formation. Johnson et al demonstrated foveal repair with knotless suture anchor resulted in DRUJ stiffness and ulnar translation similar to native forearm rotation. Thus, from a biomechanical standpoint, direct foveal repair (either open or arthroscopic) with suture anchor may be best, especially if pre-operative DRUJ instability was noted. Central and radial portions of the TFCC are poor in blood supply, so typically best treated with debridement over repair.

Postoperative rehabilitation is dependent on surgical technique and intraoperative findings. Generally, progression is dependent on capsular repair of peripheral TFCC tears with deep fibers intact versus patients with concurrent DRUJ instability treated with foveal repair. For patients who undergo capsular repair with deep fibers still intact, recommended original immobilization includes Muenster orthosis in full supination for three weeks. At that time, patients can be transitioned to short removable orthosis with start of pronation. Comparatively, patients who have concurrent DRUJ instability with foveal repair, forearm rotation may be restricted for up to six weeks post op. At that time, splinting can be discontinued with initiation of wrist/forearm range of motion. Gradual light strengthening can be resumed at 10 weeks post op. For both types of repairs, sports are typically not resumed until at least 12 weeks post op.

There is limited evidence comparing open versus arthroscopic TFCC repair. Both open and arthroscopic repair to the capsule or fovea have demonstrated improved pain scores, and functional outcomes with comparable post-operative residual DRUJ instability, range of motion, grip strength, and DASH score (Andersson et al., 2018). Future research with adequately powered trials is needed to compare clinical and functional outcomes of open versus arthroscopic repair.

Andersson, J. K., Åhlén, M., & Andernord, D. (2018). Open versus arthroscopic repair of the triangular fibrocartilage complex: A systematic review. Journal of Experimental Orthopaedics, 5(1), 6. https://doi.org/10.1186/s40634-018-0120-1

Johnson, J. C., Pfeiffer, F. M., Jouret, J. E., & Brogan, D. M. (2019). Biomechanical analysis of capsular repair versus arthrex TFCC ulnar tunnel repair for Triangular Fibrocartilage Complex tears. Hand, 14(4), 547-553. https://doi.org/10.1177/1558944717750920

Citation: Srinivasan, R. C., Shrouder-Henry, J. J., Richard, M. J., & Ruch, D. S. (2021). Open and arthroscopic triangular fibrocartilage complex (TFCC) repair. Journal of the American Academy of Orthopaedic Surgeons, 29(12), 518-525.

Journal Source: Journal of the American Academy of Orthopaedic Surgeons

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April Research Update

Non-surgical management of displaced bony mallet injuries using dorsal hyperextension splint: An early-term outcome analysis
Summary Provided by Renee McDade, MOT, OTR/L, CHT

Bony mallet injuries are commonly seen as a result of sports injuries, daily activities or work related injury. These occur as a result of forced flexion on and extended DIP joint which causes an avulsion fraction and disruption of the terminal extensor tendon. The management of these injuries varies based on both the fracture pattern and surgeon preference.

For this study, the authors completed a retrospective review of the medical records and radiographs of patients with a diagnosis of a bony mallet who underwent conservative treatment with a dorsal hyperextension splint from a single institution from March 2019-March 2020. The selection criteria included acute (up to three weeks) displaced and closed bony mallet injuries, and no volar subluxation of the DIP joint after splint application. Exclusion criteria included any lacerations, comminuted fractures, persistent volar subluxation after splint application and non-compliance with the treatment protocol.

Aluminum finger splints padded with cell foam were used. The splint was cut to the length form the PIP dorsal crease to the tip of the nail and bent to 10-15 degrees of hyperextension at the level of the DIP joint. It was held in place by porous medical tape in two layers. Patient were asked to keep the splint away from water, not to change it at home by themselves, and to strap the same type of tape over the existing splint if it loosened. Patients were encouraged to move their PIP and were monitored every 2-3 weeks for up to six weeks for cleaning, reapplication and assessment of the fracture. After an appropriate union was achieved, the splint was worn an additional two weeks at night time and weaned into motion thereafter.

Seventeen patients were enrolled with mean treatment delay of seven days. Healing was achieved in all patients with mean duration between 4-6 weeks. Early complications included skin maceration in two patients, a wound in one patient and long term complications included two slight swan neck deformities and one patient developed complex regional pain syndrome.

Using a dorsal hyperextension splint does provide overall good results in terms of bony mallet injuries. Overall, there is a consensus that conservative treatment of mallet fractures is an acceptable level of treatment. Splint material whether aluminum based or thermoplastic, if placed in slight hyperextension is preferred versus a stack splint which is not customizable. Frequent outpatient assessment and solving any splint related discomfort are essential components of successful nonsurgical treatment.

BO, Arık A. Non-surgical management of displaced bony mallet injuries using dorsal hyperextension splint: an early-term outcome analysis. Hand and Microsurgery 2022: 11(3): 127-134.

Journal Source: Hand and Microsurgery

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March Research Update

Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study
Summary Provided by Jenny M. Dorich, PhD, MBA, OTR/L, CHT

Recurrent elbow flexion contractures are common sequelae among children who sustain a brachial plexus birth injury (BPBI). As such, children with BPBI and their families are commonly faced with weighing the rehabilitative and surgical options to address elbow flexion contractures. This interpretivist qualitative study sought to explore the lived experience of youth with respect to shared decision-making when seeking care for elbow flexion contracture management.

This study involved individual semi structured interviews with six youth/young adults and 13 youth and parent dyads or triads (mom only n=9; parents n=4). Data analysis included deductive and inductive coding to elucidate youth’s and parent’s experiences with the child having an elbow flexion contracture, deciding between intervention options, and undergoing treatment. Additionally, researcher-created drawings were analyzed along with coding for thematic analysis.

Four themes respective to shared decisioning making evolved from the data. The first theme, Trust in the expertise of the clinician, was characterized by trust being discovered as both a facilitator and a barrier in the shared decision-making experience. For some participants the trust in the clinician facilitated an ease of open discussion about treatment options and the child’s preferences and concerns. At the same time, youth were found to have developed a trust that led them to accept the clinicians’ recommendations based upon their trust in the provider more than weighing all options and their associated pros and cons. The second theme was Youth’s role in the shared decision. The extent to which parents considered the youth’s perspectives in the decision was dependent on the child’s developmental stage, with increasing autonomy being extended in the teenage years and the preteen years being most characterized by conflict between the child’s desire to have a say in the decision and the parents’ unwillingness to defer to the child’s preferences. A third theme, Parental perceived responsibility, illustrates how parents feel a need to try anything possible that may achieve improvements in their child’s arm even if maintaining range of motion is to keep the mobility with the hope of medical future medical advancements. Youth-parent decision discord was the fourth theme. The experience of parents choosing treatment, especially trying rehabilitative treatment, over the child’s preference to forego treatment was observed. Furthermore, some young adults shared that they chose not to vocalize their dissent with their parents’ desire for treatment in the context of the medical consultation. Additionally, it was discovered that youth can experience undergoing rehabilitative care negatively because the treatment intervention drew more attention from their peers to their arm.

Study findings uncover that among youth with a BPBI the shared decision-making experience for elbow flexion contracture management is complex and can be characterized by discord between the youth and the parents, yet not realized in the medical consultation. Furthermore, variables such as trust the medical professionals, parental perceived responsibility to maximize their child’s arm abilities, and the parents’ perceptions of their child’s developmental readiness for making care decisions all contribute to the dynamics of the shared decision-making experience. As such, decision making supports may be valuable to facilitate empowering youth to fully participate in their care decisions.

Ho, E. S., Parsons, J. A., Davidge, K. M., Clarke, H. M., & Wright, F. V. (2021). Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study. Patient Education and Counseling, 104(10), 2586-2591.

Journal Source: Patient Education and Counseling

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February Research Update

Prospective Randomized Clinical Trial Comparing 3-point Prefabricated Orthosis and Elastic Tape Versus Cast Immobilization for the Nonsurgical Management of Mallet Finger
Summary Provided by Lori Algar, OTD, OTR/L, CHT

Does the use of elastic tape and a 3-point prefabricated orthosis for non-surgical mallet finger have improved outcomes over other forms of immobilization that do not allow the orthosis to get wet?

A randomized clinical trial compared the outcomes of using a 3-point prefabricated orthosis (Oval 8) with elastic tape (Kinesiotape), which may get wet during immobilization versus casting for the management of nonsurgical mallet finger. A total of 70 participants were randomized to the treatment groups. Outcomes were assessed at 12 weeks and 6 months post initiation of immobilization for the mallet injury. There were no statistically or clinically significant differences between groups for extensor lag, DIP joint flexion deficit, function according to the Brief MHQ, and pain on the NPRS. The researchers suggest that both methods of immobilization are appropriate options for mallet injury immobilization each with clinical advantages (i.e. being able to get wet versus providing circumference pressure for edema).

Algar L, Backe H, Richer R, Andruskiwec S, Zalenski P, Lengyel A, Svogun C. Prospective randomized clinical trial comparing 3-point prefabricated orthosis and elastic tape versus cast immobilization for the nonsurgical management of mallet finger. J Hand Surg. 2022; epub ahead of print.

Journal Source: Journal of Hand Surgery

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January Research Update

Task-oriented exercises improve disability of working patients with surgically-treated proximal humeral fractures. A randomized controlled trial with one-year follow-up
Summary provided by Nancy Naughton, OTD, OTR/L, CHT

A randomized controlled trial n=70, studied individuals with a diagnosis of proximal humeral fracture and were s/p an open reduction and internal fixation. The participants’ mean age was 49 years. The participants were randomized into two groups.

The experimental group (n=35) included early motion beginning a 1-week post op which included a rehab program of task-oriented exercises tailored to their specific occupational demands and received O.T. along with physiotherapy. The control group (n=35) included traditional physiotherapy initiated at 1-week post-op. Both groups had 4 reassessments time points; Pre-surgery and pre- therapy, at the end of therapy and at 1 year follow up.

The primary outcome (DASH) had a clinically meaningful difference between groups. Although the primary or secondary outcomes did not achieve statistical significance and effect size was not assessed, the authors found that the experimental group achieved significantly larger improvements over time with respect to the control group.

The authors conclude that task-oriented exercises and occupational therapy (experimental group) was superior to general physiotherapy (control group) in improving disability, pain, and the quality of life of working patients with surgically treated PHFs.

Monticone, M., Portoghese, I., Cazzaniga, D. et al. Task-oriented exercises improve disability of working patients with surgically-treated proximal humeral fractures. A randomized controlled trial with one-year follow-up. BMC Musculoskelet Disorder 22, 293 (2021).

Journal Source: BMC Musculoskeletal Disorders

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