Variation in Treatment for Trapeziometacarpal Arthrosis.

BACKGROUND: Treatment recommendations for trapeziometacarpal (TMC) arthrosis are highly variable from surgeon to surgeon. This study addressed the influence of viewing radiographs on a decision to offer surgery for TMC arthrosis. METHODS: In an online survey, 92 hand surgeons viewed clinical scenarios and were asked if they would offer surgery to 30 patients with TMC arthrosis. Forty-two observers were randomly assigned to review clinical information alone and 50 to review clinical information as well as radiographs. The degree of limitation of daily activities, time since diagnosis, prior treatment, pain with grind, crepitation with grind, and metacarpal adduction with metacarpophalangeal hyperextension were randomized for each patient scenario to determine the influence of these factors on offers of surgery. A cross-classified binary logistic multilevel regression analysis identified factors associated with surgeon offer of surgery. RESULTS: Surgeons were more likely to offer surgery when they viewed radiographs (42% vs. 32%, P = 0.01). Other factors associated variation in offer of surgery included greater limitation of daily activities, symptoms for a year, prior splint or injection, deformity of the metacarpophalangeal joint. Factors not associated included limb dominance, prominence of the TMC joint, crepitation with the grind test, and pinch and grip strength. CONCLUSION: Surgeons that view radiographs are more likely to offer surgery to people with TMC arthrosis. urgeons are also more likely to offer surgery when people do not adapt with time and nonoperative treatment. Given the notable influence of surgeon bias, and the potential for surgeon and patient impatience with the adaptation process, methods for increasing patient participation in the decision-making process merit additional attention and study.

Borderline Nerve Conduction Velocities for Median Neuropathy at the Carpal Tunnel.

PURPOSE: Patient knowledge of the frequency with which electrodiagnostic testing (EDx) for suspected median neuropathy at the carpal tunnel addresses nuance in the distinction between normal and abnormal neurophysiology might help them make an informed decision about whether or not to have this test. We reviewed a large set of consecutive EDx for possible carpal tunnel syndrome (CTS) and associated medical records to determine (1) the percentage of EDx measurements within 10% of threshold values; (2) discordance between clinician and EDx diagnosis of CTS using diagnostic performance characteristics; and (3) demographic and disease characteristics independently associated with EDx diagnosis of median neuropathy at the carpal tunnel. METHODS: We retrospectively reviewed nerve conduction study (NCS) results of 537 consecutive patients evaluated for possible idiopathic median neuropathy at the carpal tunnel. We measured the number of patients within 10% of 3 NCS diagnostic thresholds; the diagnostic performance characteristics comparing clinician and EDx diagnosis; and patient and disease characteristics associated with EDx diagnosis of CTS. RESULTS: The 3 NCS parameters were within 10% of the threshold for diagnosis of median neuropathy at the carpal tunnel in 2.6% to 33% of patients. Overall, 76% of EDx results were interpreted as median neuropathy at the carpal tunnel, 19% as normal, and 5% as another diagnosis (eg, cervical radiculopathy). Patients with normal EDx were significantly younger, more likely not to report paresthesias/numbness, more likely to have prior normal EDx, and less likely to have had a previous contralateral carpal tunnel release. CONCLUSIONS: This data set reflecting management strategies for suspected CTS at a large institution confirms inherent diagnostic uncertainty, relatively strong concordance between clinician and EDx diagnosis, and the importance of focusing on paresthesia rather than pain. These findings support the use of clinical prediction rules and may help inform a patient's decision regarding whether or not to have EDx. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Night Splinting for Idiopathic Trigger Digits.

BACKGROUND: This study assessed nighttime splinting for 6 weeks as treatment for recent onset idiopathic trigger fingers. METHODS: Patients over 18 years with a Quinnell grade 1 or 2, idiopathic trigger finger or thumb causing symptoms for less than 3 months were eligible for a custom-made hand-based orthoplast night orthotic. Improvement of symptoms and/or resolution of triggering were recorded. Patients also completed the short version of the Disabilities of the Arm, Shoulder and Hand and a numerical rating scale for pain at the initial visit, after 6 to 8 weeks, and after 3 months. RESULTS: Thirty-four patients wore a night orthotic for at least 6 weeks. At final evaluation, there was a substantial reduction in disability and pain. Symptoms of triggering resolved completely in 18 patients (55%). Sixteen patients did not resolve their triggering after splinting and therefore underwent a steroid injection. CONCLUSION: Night splinting is a noninvasive treatment option for idiopathic trigger fingers/thumb with symptoms for less than 3 months.

The Prevalence of Unanticipated Hamate Hook Abnormalities in Computed Tomography Scans: A Retrospective Study.

BACKGROUND: It is possible that some hamate hook fractures are not diagnosed or treated, thereby affecting the study of their natural history. Study of the prevalence of incidental hamate hook fractures, nonunions, and other abnormalities on computed tomography (CT) ordered for another reason could document a subset of undiagnosed and untreated hamate hook fractures which might change our understanding about the natural history. METHODS: Reports of 2489 hand, wrist, and forearm CT scans for hamate hook abnormalities were searched. We excluded 19 patients with anticipated hamate fractures and 1 patient that had a hamate hook excision. Twenty-eight patients had an unanticipated hamate hook abnormality. RESULTS: There was a significant difference in the prevalence of incidental hamate hook abnormalities by sex but not by age. Among the 28 unexpected hamate hook abnormalities, there were 16 fractures of the base (12 acute, 1 nonunion, and 3 of uncertain age), 5 acute oblique fractures, and 7 tip abnormalities/ossicles. The patient with an incidental nonunion had a CT scan for wrist pain and was diagnosed with gout. All fractures involved a direct blow to the hand (distal radius or scaphoid fracture, or crush injury). The 7 patients with a hamate tip abnormality had a CT scan for a distal radius or metacarpal fracture, crush injury or wrist pain. Five acute fractures were treated operatively with excision and the other 23 fractures were treated nonoperatively. CONCLUSION: Hamate fractures can be diagnosed incidental to other hand and wrist problems on CT.

A Slightly Dorsally Tilted Lunate on MRI can be Considered Normal.

BACKGROUND: Abnormal angulation of the lunate can be an indication of intercarpal pathology. On magnetic resonance images (MRIs) the lunate often looks dorsally angulated, even in healthy wrists. The tilt on individual slices can also be different and might be misinterpreted as pathological, contributing to inaccurate diagnoses and unnecessary surgery. The primary aim of this study was to determine the average radiolunate angle on sagittal wrist MRI images as well as the radiolunate angle in the most radial, central and most ulnar part of the lunate; also the interobserver reliability was determined. METHODS: 140 MRIs from adult, non-pregnant patients presenting to the outpatient hand and upper extremity service between 2010 and 2013 with wrist pain were used for this retrospective study. One author measured the radiolunate and capitolunate angle (i.e., tangential and axial method) in all MRIs. Additionally, two authors measured the same angles independently in 46 MRIs to analyze interobserver reliability. RESULTS: The average radiolunate angle was 8.7 degrees dorsal. There were no significant differences in the radiolunate angles between the different parts of the lunate. A very good interrater agreement was measured considering the radiolunate angle and capitolunate angle (tangential and axial method). CONCLUSIONS: Our study showed that the lunate appears slightly dorsally angulated on an MRI of a healthy wrist. Regarding the radiolunate angle, 10 to 15 degrees of dorsal tilt can be considered normal. This study provides reference information of normal anatomy for carpal axial alignment that may facilitate diagnoses of wrist pathology.

The Trapeziometacarpal Arthrosis Symptoms and Disability Questionnaire: Development and Preliminary Validation.

BACKGROUND: Symptoms and disability at the trapeziometacarpal (TMC) joint are typically assessed with general measures that may not be able to accurately discriminate between TMC arthrosis-specific versus other hand and arm condition concerns. The objective was to develop and preliminary validate the Trapeziometacarpal Arthrosis Symptoms and Disability (TASD) questionnaire designed to assess symptoms and disability at the TMC joint. METHODS: English-speaking patients (50 years or older) were enrolled in 1 of 2 samples (sample 1, 64 patients specifically presented for treatment of TMC arthrosis; sample 2, 64 patients received an incidental diagnosis of previously undiagnosed TMC arthrosis when presenting for treatment of another, not thumb-related condition). Principal component analysis identified the number of subscales (factors) and factor loadings of all items (ie, structural construct validity). Internal consistency was assessed with Cronbach alpha. Convergent, discriminant, and known-groups construct validity of the subscales were assessed with Spearman correlations. RESULTS: The final TASD has 12 items and 2 subscales, as confirmed by principal component analysis: symptoms (7 items) and disability (5 items). The subscales' internal consistency was good to excellent in both samples. The TASD showed good convergent validity as evidenced by moderate to strong correlations between both subscales and upper extremity disability, pain intensity, depression, self-efficacy, and key pinch strength (sample 1). The TASD also showed good discriminant, and good known-groups validity. CONCLUSIONS: The concise TASD is useful in assessing symptoms and disability related to TMC arthrosis, has a simple scoring system and administration mode (self-administered), and is free.

Interobserver Agreement of the Eaton-Glickel Classification for Trapeziometacarpal and Scaphotrapezial Arthrosis.

PURPOSE: To determine whether simplification of the Eaton-Glickel (E-G) classification of trapeziometacarpal (TMC) joint arthrosis (eliminating evaluation of the scaphotrapezial [ST] joint) and information about the patient's symptoms and examination influence interobserver reliability. We also tested the null hypotheses that no patient and/or surgeon factors affect radiographic rating of TMC joint arthrosis and that no surgeon factors affect the radiographic rating of ST joint arthrosis. METHODS: In an on-line survey, 92 hand surgeons rated TMC joint arthrosis and ST joint arthrosis separately on 30 radiographs (Robert, true lateral, and oblique views) according to the (modified) E-G classification. We randomly assigned 42 observers to review radiographs alone and also informed 50 of the patient's symptoms and examination. Information about symptoms and examination was randomized. Interobserver reliability was determined with the s* statistic. Because of the hierarchical data structure, cross-classified ordinal multilevel regression analyses were performed to identify factors associated with the severity of arthrosis. RESULTS: Shortening the E-G classification to the first 3 stages significantly improved the interobserver reliability, which approached substantial agreement. Providing clinical information to observers marginally improved interobserver reliability. Factors associated with a lower E-G stage for TMC joint arthrosis, among observers who rated the severity of TMC joint arthrosis based on radiographs and clinical information, included female surgeon, practice setting, supervising surgical trainees in the operating room, self-reported number of patients with TMC joint arthrosis typically treated annually, male patient, higher patient age, pain limiting daily activities, and shoulder sign. A self-reported larger number of patients with TMC joint arthrosis treated annually was the only variable associated with a higher modified E-G classification to rate ST joint arthrosis. CONCLUSIONS: Our findings suggest that simpler classifications that focus on a single anatomical area are reliable and that surgeon and patient factors can bias interpretation of objective pathophysiology such as radiographic findings. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Early Patient Satisfaction with Different Treatment Pathways for Trigger Finger and Thumb.

Little is known about factors related to patient satisfaction with treatment for trigger digits. This study tested the null hypothesis that there are no factors associated with treatment satisfaction 2 months after completion of treatment (absence of triggering) or 4 months after the last visit for patients with a trigger thumb or finger. Secondary null hypotheses were: 1) There are no factors associated with a change in patients' preferred treatment before and after consultation with a hand surgeon; and 2) Initial treatment provided is not different from final received treatment. In an observational study, 63 English-speaking adult patients were enrolled after being diagnosed with one or more new idiopathic trigger digits by one of two hand surgeons, but before the hand surgeon discussed treatment options. Patients were asked to fill out questionnaires at enrollment. Final evaluation was by phone. Satisfaction with treatment was not related to the initial treatment or other patient or disease factors. Twenty-three patients (37 %) had a different preference for treatment after talking with a hand surgeon. Involvement of the long and ring fingers were the only factors associated with staying with pre-visit treatment preferences. There was a significant difference in proportions of the various treatments provided at enrollment and final treatment recorded at the final phone evaluation, 14 patients (22 %) had a subsequent alternative form of treatment. Patients' preferences for trigger finger treatment often change after consulting with a hand surgeon and during treatment, but these choices do not affect treatment satisfaction.

Symptoms During or Shortly After Isolated Carpal Tunnel Release and Problems Within 24 hours After Surgery.

This study used the National Survey of Ambulatory Surgery (NSAS) database to measure the incidence of and risk factors for symptoms in the ambulatory surgery center and problems within 24 h after isolated carpal tunnel release (CTR). The NSAS contained records on 400,000 adult patients with carpal tunnel syndrome who were treated with CTR in 2006, based on ICD-9 codes. The type of anesthesia used and factors associated with symptoms and problems were sought in bivariate and multivariable statistical analyses. The mean duration of the procedure was 16 ± 8.8 min. Only 5 % were performed under local anesthesia without sedation, 45 % with IV sedation, 28 % regional anesthesia, and 19 % general anesthesia. Symptoms in the ambulatory surgery center or a problem within 24 h after discharge were recorded in 10 % of patients, all of them minor and transient, including difficulties with pain and its treatment. The strongest risk factors were male sex, age of 45 years and older, and participation of an anesthesiologist. Local anesthesia and regional anesthesia were associated with more perioperative symptoms and postoperative problems. Most CTR are performed with some sedation in the United States. CTR is a safe procedure: one in 10 patients will experience a minor issue in the perioperative or immediate postoperative period.

How prevalent are hazardous attitudes among orthopaedic surgeons?

BACKGROUND: So-called "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied. QUESTIONS/PURPOSES: We surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety? METHODS: We asked the members of the Science of Variation Group-fully trained, practicing orthopaedic and trauma surgeons from around the world-to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited. RESULTS: Thirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots were supervision of surgical trainees in the operating room (p = 0.003); location of practice in Canada (p = 0.059), Europe (p = 0.021), and the United States (p = 0.005); and being an orthopaedic trauma surgeon (p = 0.046) (when compared with general orthopaedic surgeons), but accounted for only 5.3% of the variance (p < 0.001). On average, 19% of surgeon responses to the Modified Safety Climate Questionnaire implied absence of a safety climate. CONCLUSIONS: Hazardous attitudes are common among orthopaedic surgeons and relate in small part to demographics and practice setting. Future studies should further validate the measure of hazardous attitudes among surgeons and determine if they are associated with preventable adverse events. We agree with aviation safety experts that awareness of amelioration of such attitudes might improve safety in all complex, high-risk endeavors, including surgery-a line of thinking that merits additional research.

Medical services and associated costs vary widely among surgeons treating patients with hand osteoarthritis.

BACKGROUND: There are substantial variations in medical services that are difficult to explain based on differences in pathophysiology alone. The scale of variation and the number of people affected suggest substantial potential to lower healthcare costs with the reduction of practice variation. Our study assessed practice variation across three affiliated urban sites in one city in the United States and related healthcare costs following the diagnosis of hand osteoarthritis (OA) in patients. QUESTIONS/PURPOSES: (1) What are the factors associated with increased costs and surgery in the first year after diagnosis of hand OA? (2) How much practice variation exists among hand surgeons in terms of the number of patient visits, use of imaging tests, use of injections, occupational therapy use, and surgery? (3) What proportion of total cost is accounted for by patients who consult with an additional provider? METHODS: Patients receiving a new diagnosis of primary hand OA between January 1, 2007, and December 31, 2011, were identified from the research database of three affiliated urban hospitals in a single city in the United States. We included 2814 patients (69%, 1929 women) treated by six hand surgeons. We recorded all visits, imaging tests, injections, occupational therapy visits, and surgical procedures in the first year after that diagnosis. Costs were extracted from the Medicare Physician Fee Schedule. Reliability of the database was assessed by manual checking of 120 patient charts (4.3% of all data); reliability was determined to be 94% (113 of 120) for diagnoses, 97% (116 of 120) correct surgeon, 100% (120 of 120) second surgeon, 99% (278 of 282) visits, 99% (132 of 134) imaging procedures, 92% (11 of 12) injections, 95% (21 of 22) surgical procedures, and 85% (102 of 120) prescribing occupational therapy. RESULTS: Predictors of increased costs included younger patient age (regression coefficient [ß] -3.5, semipartial R(2) 0.0049, 95% confidence interval [CI] -5.4 to -1.7, p < 0.001), seeing a second surgeon (ß 283, semipartial R(2) 0.0095, 95% CI 176-391, p < 0.001), and specific surgeons (surgeon 1: ß -243, semipartial R(2) 0.026, 95% CI -298 to -188, p < 0.001; surgeon 2: ß -177, semipartial R(2) 0.0090, 95% CI -246 to -109, p < 0.001; surgeon 6: ß 124, semipartial R(2) 0.0050, 95% CI 59-189, p < 0.001) (adjusted R(2) = 0.056). Similarly, factors associated with increased surgical intervention included younger patient age (ß -0.0026, semipartial R(2) 0.0071, 95% CI -0.0037 to -0.0015, p < 0.001), male sex (ß 0.041, semipartial R(2) 0.0028, 95% CI -0.069 to -0.012, p = 0.005), seeing a second surgeon (ß 0.16, semipartial R(2) 0.0091, 95% CI 0.094-0.22, p < 0.001), and specific surgeons (surgeon 1: ß -0.14, semipartial R(2) 0.026, 95% CI -0.18 to -0.11, p < 0.001; surgeon 2: ß -0.13, semipartial R(2) 0.014, 95% CI -0.17 to -0.091, p < 0.001). There were large variations in the average number of visits (1.5-fold), imaging tests (threefold), use of injections (51-fold), occupational therapy (twofold), and surgery rates (sevenfold) among providers. One hundred twenty patients (4.3%) consulted a second surgeon within the first year after receiving the diagnosis of hand OA, which accounted for 8.1% (USD 68,826/USD 845,304) of the total costs. CONCLUSIONS: Patients who saw additional providers and who were of younger age incurred higher costs and a greater likelihood of undergoing surgery; the latter was also greater in male patients. Use of medical services and associated costs vary widely among providers treating patients with hand OA. Initiatives addressing practice variation-increased use of decision aids, for example-merit additional study. LEVEL OF EVIDENCE: Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Progression of carpal tunnel syndrome according to electrodiagnostic testing in nonoperatively treated patients.

BACKGROUND: This study tested the null hypothesis that nonoperatively treated patients would not show disease progression of carpal tunnel syndrome (CTS) over time according to median nerve distal motor latency (DML) on two electrodiagnostic tests. METHODS: This retrospective study analyzed sixty-two adult nonoperatively treated patients who were diagnosed with CTS confirmed by a minimum of two electrodiagnostic tests at our institution between December 2006 and October 2012. A Wilcoxon signed-rank test was conducted to test the difference between electrodiagnostic measurements between the first and last test. RESULTS: The mean time between the first and last electrodiagnostic test was 26±12 months (range, 12 to 55 months). The only electrodiagnostic measurement that increased significantly was the difference between median and ulnar DML on the same side (r=0.19, P=0.038). The time between the electrodiagnostic tests was significantly longer for patients with at least 10% worsening of the DML at the second test compared to cases of which the DML did not worsen or improve a minimum of 10% (P=0.015). CONCLUSIONS: There is evidence that-on average-idiopathic median neuropathy at the carpal tunnel slowly progresses over time, and this can be measured with electrodiagnostics, but studies with a much longer interval between electrodiagnostic tests may be needed to determine if it always progresses.

Predictors of missed research appointments in a randomized placebo-controlled trial.

BACKGROUND: The primary aim of this study was to determine predictors of missed research appointments in a prospective randomized placebo injection-controlled trial with evaluations 1 to 3 and 5 to 8 months after enrollment. METHODS: This study represents a secondary use of data from 104 patients that were enrolled in a prospective randomized controlled trial of dexamethasone versus lidocaine (placebo) injection for various diagnoses. Patients were enrolled between June 2003 and February 2008. Sixty-three patients (61%) had lateral epicondylosis, 17 patients (16%) had trapeziometacarpal arthrosis, and 24 patients (23%) had de Quervain syndrome. Each patient completed a set of questionnaires at time of enrollment. Bivariable and multivariable analyses were used to determine factors associated with missed research appointments. RESULTS: Fourteen patients (13%) did not return for the first follow-up and 33 patients (32%) did not return for the second follow-up. The best multivariable logistic regression model for missing the first research visit explained 35% of the variability and included younger age, belief that health can be controlled, and no college education. The best model for missing the second research visit explained 17% of the variability and included greater pain intensity, less personal responsibility for health, and diagnosis (trapeziometacarpal arthrosis and de Quervain syndrome). CONCLUSIONS: Younger patients with no college education, who believe their health can be controlled, are more likely to miss a research appointment when enrolled in a randomized placebo injection-controlled trial.

Excisional biopsy of suspected benign soft tissue tumors of the upper extremity: correlation between preoperative diagnosis and actual pathology.

BACKGROUND: Tumors of the upper extremity are common and mostly benign. However, the prevalence of discordant diagnosis of a solid hand tumor is less studied. The objectives of this retrospective study were (1) to determine the proportion of patients with a different (discrepant or discordant) pathological diagnosis compared to the preoperative diagnosis, (2) to determine the prevalence of the types of pathologies encountered at excisional biopsy for suspected benign tumors, and (3) to determine the types of tumors diagnosed when the surgeon does not make a preoperative diagnosis. METHODS: One hundred and eighty-two suspected benign soft tissue tumors of the upper extremity with a preoperative diagnosis other than ganglion cyst were excised by one of three surgeons over a 10-year period. A preoperative diagnosis was applied for 125 tumors. No preoperative imaging was used. RESULTS: Only 26 of the 125 tumors (21 %) with a preoperative diagnosis were discrepant. The tumors that were most likely to have a discrepant diagnosis were vascular tumors (32 %) and other less common benign tumors (33 %). Among the entire cohort of 182 tumors, lipomas (19 %), giant cell tumors of tendon sheath (GCTTS; 19 %), and vascular tumors (16 %) were the most frequent pathological diagnoses. Among the 57 tumors that did not have a preoperative diagnosis, most were vascular tumors (23 %), fibromas (14 %), and GCTTS (11 %). One tumor without a preoperative diagnosis was a malignant tumor, but we consider this unusual and possibly spurious. CONCLUSIONS: A hand surgeon's preoperative diagnosis without imaging is usually correct prior to excision of a mass in the hand. Discrepant diagnoses are usually benign and do not alter treatment. LEVEL OF EVIDENCE: Prognostic II.

Disability in patients with trapeziometacarpal joint arthrosis: incidental versus presenting diagnosis.

PURPOSE: To test the hypothesis that there is no difference in trapeziometacarpal (TMC) joint arthrosis-related symptoms and disability between patients seeking treatment for symptoms of TMC arthrosis and those with incidental TMC joint arthrosis. METHODS: We compared 64 patients presenting for care of TMC joint arthrosis with 64 with incidental TMC joint arthrosis. For both groups, the diagnosis was based on crepitation on examination. Bivariate and multivariate analyses assessed factors associated with symptoms and disability related to TMC joint arthrosis. RESULTS: In bivariate analysis, patients presenting for care of TMC joint arthrosis had significantly more symptoms and disability from TMC joint arthrosis than those with incidental TMC joint arthrosis. The best multivariate linear regression model for fewer TMC joint arthrosis-related symptoms and disability included patients with incidental TMC joint arthrosis, male sex, no other painful conditions, less catastrophic thinking, and fewer depressive symptoms and explained 74% of the variability. Having incidental TMC joint arthrosis (25%) and more adaptive coping strategies (less catastrophic thinking; 5%) were the most important contributors to fewer symptoms and less disability. CONCLUSIONS: Future studies are merited to determine whether training in better coping strategies (eg, less catastrophic thinking and fewer depressive symptoms) can decrease symptoms and disability in patients with TMC joint arthrosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Relationships between pain misconceptions, disability, patients' goals and interpretation of information from hand therapists.

INTRODUCTION: Patient interpretation of advice from hand therapists may be related to nonadaptive pain thoughts (automatic, overprotective, unduly pessimistic statements triggered by nociception and exacerbated by psychological distress). PURPOSE OF THE STUDY: This study aimed to determine whether there were correlations between participants' hand therapy goals, interpretation of advice from hand therapists, nonadaptive pain thoughts, and upper extremity-specific disability. METHODS: One hundred and five participants completed questionnaires assessing nonadaptive pain thoughts, upper extremity-specific disability, lessons from hand therapists, and hand therapy goals. RESULTS: Nonadaptive pain thoughts correlated with disability and were bi-directionally related to participant goals and interpretation of advice from hand therapists. DISCUSSION: Patients' nonadapative pain thoughts and the words/concepts used by hand therapists are both important in recovery from upper extremity illness. CONCLUSIONS: Hand therapists should be mindful that nonadaptive pain thoughts are an important determinant of disability and that such thoughts can affect and be affected by their recommendations. LEVEL OF EVIDENCE: n/a.

Diagnosis of carpal tunnel syndrome: interobserver reliability of the blinded scratch-collapse test.

The reliability of the scratch-collapse test for diagnosis of carpal tunnel syndrome (CTS) has not been tested by independent investigators. This study measured the reliability of the scratch-collapse test comparing the treating hand surgeon and blinded evaluators. We performed a prospective observational study of 41 patients with a provisional diagnosis of CTS or a combination of CTS and cubital tunnel syndrome and prescribed electrodiagnostic testing. The treating hand surgeon performed the scratch-collapse test. Next, the test was administered by one of the six observers, unaware of the patient's symptoms and the diagnosis made by treating hand surgeon. The kappa statistic (κ) was used to calculate the interrater reliability between the treating hand surgeons and blinded scratchers. The agreement between the blinded observers and the hand surgeons on the scratch-collapse test was substantial 0.63 (95 % CI, 0.34-0.87; p < 0.001). The sensitivity of the blinded scratch test in our sample was 32 %. In a small study with a spectrum bias favoring electrophysiologically confirmed CTS the reliability was lower than that reported by the inventors of the test, but was still substantial. We propose a larger study of patients with a greater variety of electrodiagnostic test results using fewer observers with more experience.

Abbreviated psychologic questionnaires are valid in patients with hand conditions.

BACKGROUND: The Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) can help hand surgeons identify opportunities for psychologic support, but they are time consuming. If easier-to-use tools were available and valid, they might be widely adopted. QUESTIONS/PURPOSES: We tested the validity of shorter versions of the PCS and SHAI, the PCS-4 and the SHAI-5, by assessing: (1) the difference in mean scaled scores of the short and long questionnaires; (2) floor and ceiling effects between the short and long questionnaires; (3) correlation between the short questionnaires and the outcome measures (an indication of construct validity); and (4) variability in disability and pain, between the short and long questionnaires. METHODS: One hundred sixty-four new or followup adult patients in one hand surgery clinic completed the SHAI-18, SHAI-5, PCS-13, PCS-4, Patient Health Questionnaire (PHQ)-9, PHQ-2, DASH, and QuickDASH questionnaires, and an ordinal pain scale, as part of a prospective cross-sectional study. Mean scores for the short and long questionnaires were compared with paired t-tests. Floor and ceiling effects were calculated. Pearson's correlation was used to assess the correlation between the short and long questionnaires and with outcome measures. Regression analyses were performed to find predictors of pain and disability. RESULTS: There were small, but significant differences between the mean scores for the DASH and QuickDASH (QuickDASH higher), SHAI-18 and SHAI-5 (SHAI-18 higher), and PCS-13 and PCS-4 (PCS-4 higher), but not the PHQ-9 and PHQ-2. Floor effects ranged between 0% and 65% and ceiling effects between 0% and 3%. There were greater floor effects for the PHQ-2 than for the PHQ-9, but floor and ceiling effects were otherwise comparable for the other short and long questionnaires. All questionnaires showed convergent and divergent validity and criterion validity was shown in multivariable analyses. CONCLUSIONS: Content validity, construct convergent validity, and criterion validity were established for the short versions of the PCS and SHAI. Using shorter forms creates small differences in mean values that we believe are unlikely to affect study results and are more efficient and advantageous because of the decreased responder burden.