March Research Update
First dorsal interosseous and opponens pollicis loading upon thumb CMC joint subluxation: a cadaver study.
Do cadaveric studies demonstrate a dose dependent relationship for loading of the OP and the FDI for thumb CMC joint subluxation?
A recent cadaveric study examined the effect of applying 0%, 25%, 50%, 75% and 100% loads to the first dorsal interosseous (FDI) and opponens pollicis (OP) on subluxation at the thumb CMC joint. Findings suggest that selective activation of the OP alone did reduce subluxation, while activation of the FDI alone did not. Activation of both the OP and FDI improved subluxation to within 10% of pre-subluxed state with 75% or greater load to the FDI and OP. The authors conclude that activation of the FDI and OP reduces subluxation of the thumb CMC joint in a dose-dependent fashion and that the OP is likely the major reducing force and therefore requires emphasis in a hand therapy program for arthritis at the thumb CMC joint.
Journal Source: HAND
Adams JE, O’Brien V, Magnusson E, Rosenstein B, Nuckley DJ. First dorsal interosseous and opponens pollicis loading upon thumb CMC joint subluxation: a cadaver study. Hand. 2018. 13: 40-44.
April Research Update
Surgical and nonsurgical management of mallet finger: A systematic review.
What does the evidence say regarding surgical versus nonsurgical management in the treatment of mallet finger injuries?
This systematic review included forty-four studies examining clinical outcomes of mallet finger management. Twenty-two of the studies evaluated operative treatment, seventeen conservative treatment, and five compared operative versus nonoperative treatment. The included articles studied a variety of surgical techniques and orthotic interventions. Fracture size of >1/3 the joint surface area and subluxation of the distal phalanx were the most frequently described indications for surgery. However, the authors of this study concluded that there is insufficient evidence to determine when surgical intervention is indicated. One conservative management study specifically examined fracture sizes >1/3 of the joint surface area, and achieved an average 9-degree extension lag with thermoplastic orthotic intervention, supporting the use of an orthosis in the management of these cases. Across studies, the average DIP joint extension lag for surgical treatment was 5.7 degrees, with a complication rate of 14.5%. For nonsurgical management, the average DIP extension lag was 7.6 degrees with a complication rate of 12.8%. The study concluded both interventions result in favorable clinical outcomes, and that an individualized treatment approach is appropriate.
Journal Source: Journal of Hand Surgery
Lin JS, and Samora JB. Surgical and nonsurgical management of mallet finger: A systematic review. Journal of Hand Surgery. 2017. DOI: https://doi.org/10.1016/j.jhsa.2017.10.004
June Research Update
Necessity of Immobilizing the Metacarpophalangeal Joint in Carpometacarpal Osteoarthritis: Short-Term Effect.
A prospective randomized study investigated if inclusion of the thumb MCP joint is necessary in orthoses for individuals with thumb CMC joint osteoarthritis.
Sixty six patients were randomly assigned to equal groups. One group had a custom fabricated orthosis that included the MCP joint while the other group’s orthosis immobilized the CMC joint only. Both groups received identical wearing schedules and were fabricated from the same thermoplastic material. The main outcome measures were the Quick DASH and the VAS. Both groups achieved statistically significant differences for pain and function. No significant differences were found by including or not including the MCP joint of the thumb for pain or function. Likewise, an orthosis is found to be an effective sole treatment intervention in the conservative treatment of thumb CMC joint OA.
Cantero-Téllez R, Valdes K, Schwartz DA, Medina-Porqueres I, Arias JC, Villafañe JH. Necessity of Immobilizing the Metacarpophalangeal Joint in Carpometacarpal Osteoarthritis: Short-Term Effect. Hand. 2017 1-6.
July Research Update
Function, Shoulder Motion, Pain, and Lymphedema in Breast Cancer With and Without Axillary Web Syndrome: An 18-Month Follow-Up.
Impact of Axillary Web Syndrome on Function, Shoulder Motion, Pain and Lymphedema in Post-surgical breast cancer.
A longitudinal prospective cohort study followed 36 women using a repeated measures design. Physical therapy treatment was only provided if ordered by the subject’s physician and was not necessarily provided by the authors. Axillary web syndrome (AWS) can develop following breast cancer surgery and may present either as a visible or palpable cord in the axilla. Subjects were divided into two groups based on presence or absence of AWS, regardless of when it occurred. Measures assessed included presence of AWS, DASH, shoulder active and passive range of motion, pain and lymphedema. These measures were recorded at 2, 4, and 12 weeks, and again at 18 months post-surgically. At the 12-week assessment, subjects were provided verbal and written education by a physical therapist in lymphedema precautions, signs and symptoms, and description of lymphedema treatment. This may have resulted in a treatment effect in that 12 women received lymphedema treatment during the 18-month period. Thirty-two subjects completed all assessments (4 were lost to follow up for the 18-month assessment). Physical impairments in one or more areas were noted in 66-97% of subjects at one or more visits. The cumulative prevalence of AWS was 50% and it was found to persist at least as long as 18 months, recur after resolution, and to develop beyond the early post-operative period. The authors found that women with AWS had lower BMI and a greater number of lymph nodes removed. AWS was also found to be associated with reduced shoulder range of motion and long term functional impairment. There was no apparent effect by AWS on pain and lymphedema (possible treatment effect from education). The findings of AWS-related impairments and that only 36% of subjects received rehabilitative treatment at least once indicates a need for increased attention to physical impairments in this population.
Journal Source: Physical Therapy
Linda A Koehler, David W Hunter, Anne H Blaes, Tufia C Haddad; Function, Shoulder Motion, Pain, and Lymphedema in Breast Cancer With and Without Axillary Web Syndrome: An 18-Month Follow-Up. Physical Therapy, https://doi.org/10.1093/ptj/pzy010
August Research Update
Low-Intensity Pulsed Ultrasound for Nonoperative Treatment of Scaphoid Nonunions: A Meta-Analysis
Scaphoid fractures have high nonunion rates, which can be from 5% to 10% in nondisplaced fractures and up to 45% in displaced fractures. Standard treatment in these cases is surgery. However, not all patients are optimal surgical candidates or amenable to surgical intervention; a comprehensive review of current literature is needed to assess these nonoperative methods of healing. Low-intensity pulsed ultrasound (LIPUS), a noninvasive treatment using a pulsed 30 mW/cm2 ultrasound signal for 20-minute intervals per day over a period of several weeks, has been shown to improve fracture nonunion healing. This study performed a meta-analysis to determine LIPUS success for treatment of scaphoid nonunion. The authors found 166 nonunions across five studies with a combined healing percentage of 78.6% and average time to union of 4.2 months. These high success rates were seen with multiple fracture types, as well as in cases where LIPUS was attempted following different failed treatments. The results are encouraging in which these challenging fractures can heal without further surgical intervention in the majority of patients.
Journal Source: Hand
Edward W. Seger, Julio J. Jauregui, Steven A. Horton, Gerardo Davalos, Erika Kuehn, and Michael A. Stracher
September Research Update
A Prospective, Randomized Trial of Mobilization Protocols Following Ligament Reconstruction and Tendon Interposition.
The purpose of this study was to compare the disability and hand function of persons who underwent LRTI and either an “immobilization” or “early mobilization” rehabilitation protocol. 223 patients (238 thumbs) were randomized to one of these postoperative rehabilitation protocols. The “immobilization” protocol included a forearm-based thumb-spica splint for 7 days, forearm-based thumb-spica cast for 5 weeks, and a custom forearm-based thermoplastic thumb-spica splint for an additional 6 weeks with active range of motion (ROM) starting 6 weeks postoperatively. The “early mobilization” protocol involved the same postoperative splint for 7 days followed by use of a forearm-based thermoplastic thumb-spica splint for 3 weeks, a hand-based thumb-spica splint for an additional 4 weeks with active ROM starting at 4 weeks postoperatively.
Outcomes were measured preoperatively and at 6, 12, 26, 52, and 104 weeks postoperatively. There were no significant differences in DASH scores, VAS pain scores, VAS patient satisfaction scores, and pinch/grip strength between groups at any time point. Nine-hole Peg Test, Wrist and thumb ROM outcomes were significantly better for the early mobilization group at 6 weeks postoperatively, with no differences observed between groups at 12 weeks and beyond and the complication rates were indifferent. The authors concluded that “a conservative immobilization protocol does not improve functional outcomes, satisfaction, strength, or ROM following LRTI compared with an early mobilization protocol”.
Given that these protocols often diverge much earlier than 6 weeks, future research might be enhanced by earlier measurements (i.e., at 3-4 weeks) and future studies might also be enhanced by a “region-specific” disability outcome measure which might be more responsive to thumb/wrist related-disability. Although limited to the approaches taken in this study, these findings support that there are early benefits to an early mobilization approach following LRTI and that long term outcomes/complications between groups are indifferent.
Journal Source: J Bone Joint Surg
Hutchinson D, Sueoka S, Wang A, Tyser A, Papi-Baker K, Kazmers N. A Prospective, Randomized Trial of Mobilization Protocols Following Ligament Reconstruction and Tendon Interposition. J Bone Joint Surg, 2018; 100 (15): 1275-1280.
December Research Update
The effect of isolated finger stiffness on adjacent digit function.
What exactly is the impact of an injury limiting flexion of one digit on the function of the other digits of the involved hand?
Researchers investigated the impact of isolated finger stiffness on adjacent digit function (measured via centimeters to the distal palmar crease) and flexor tendon pull/range of motion via gonimetric measurement of each digit’s flexion with one finger placed in a finger extension orthosis at all three joints. This was performed experimentally and sequentially on the index, middle, ring and small digits with flexion measured at the digits not in the orthosis for 25 healthy, non-hand injured participants. It was found that the fingers immediately adjacent to the digit in the orthosis were more heavily impacted compared to non-adjacent digits and the loss of flexion at the ring digit produced the greatest range of motion and finger flexion limitations in the other digits in comparison to the loss of flexion at the index, middle, and small digits.
Journal Source: HAND
Baaqeel R, Wu K, Chinchalkar SJ, Ross DC. The effect of isolated finger stiffness on adjacent digit function. HAND. 2018; 13: 296-300.