Relative motion splints versus metacarpophalangeal joint blocking splints in the management of trigger finger: Study protocol for a randomized comparative trial.

BACKGROUND: Evidence supports the use of hand-based metacarpophalangeal joint (MCPJ) blocking splints as an intervention for trigger finger (TF). In practice, finger-based relative motion (RM) splints are also implemented without evidence. PURPOSE: This randomized comparative trial (RCT) aims to evaluate implementation of MCPJ blocking and RM splints for effectiveness, function, occupational performance and wearability after 6 weeks of TF management. METHODS AND ANALYSIS: Priori analysis determined 36 individuals were needed for random assignment to the RM or MCPJ blocking splint groups. Individuals must be aged ≥21 years, and diagnosed with TF involving ≥1 finger. For blinding purposes, the primary author screens for eligibility, fabricates the splints and educates. Therapist A administers the primary outcome measures Week-1 and Week-6-stage of stenosing tenosynovitis and secondary outcome measures- number of triggering events in 10 active fists, visual analog scales (VAS) for pain, splint comfort and satisfaction, Disabilities of the Arm, Shoulder and Hand, and Canadian Occupational Performance Measure. Therapist B in Week-3 instructs participants in deep tissue massage and administers splint wearability VASs. The RM pencil test is used to determine the affected finger(s) MCPJ splint position i.e., more extension or flexion based on participant response. The MCPJ blocking splint holds the MCPJ in a neutral position. Analysis involves a mixed-effects ANOVA to compare Week-1 and Week-6 primary and secondary outcomes. RESULTS: Recruitment and data collection are ongoing. DISCUSSION: Biomechanically RM splints control tendon excursion and reduce passive tendon tension while allowing unencumbered finger motion and hand function. Hence clinicians use RM splints as an intervention for TF, despite the lack of implementation evidence. This RCT implements a function-focused as well as patient-centered approach with partial blinding of assessors and participants. CONCLUSION: We anticipate that this study will provide evidence for the implementation of RM splints to manage adults with TF. TRIAL REGISTRATION: Clinical trial registration This trial is registered with ClinicalTrials.gov (NCT05763017).

Pathomechanics of lumbrical and flexor digitorum profundus muscle tears in climbers: A cadaveric model.

Lumbrical muscles originate on the flexor digitorum profundus (FDP) tendons and, during fist making, they move in the same direction when FDP muscle produces maximal proximal tendon gliding. Injuries of the bipennate lumbricals have been described when a shear force acts between the origins on adjacent tendons of the FDP, as they glide in opposite directions in asymmetric hand postures. Other structures of the deep flexors complex can be affected during this injury mechanism, due to the so-called quadriga effect, which can commonly occur during sport climbing practise. Biomechanical studies are needed to better understand the pathomechanism. A cadaveric study was designed to analyse the effects of load during the fourth lumbrical muscle injury mechanism. The amount of FDP tendon gliding and metacarpophalangeal (MCP) joint flexion of the 5th finger were calculated. Ten fresh-frozen cadaveric specimens (ten non-paired forearms and hands) were used. The specimens were placed on a custom-made loading apparatus. The FDP of the 5th finger was loaded, inducing isolated flexion of the 5th finger, until rupture. The rupture occurred in all specimens, under a load of 11 kg (SD 4.94), at 9.23 mm of proximal tendon gliding (SD 3.55) and at 21.4° (SD 28.91) of MCP joint flexion. Lumbrical muscle detachment from the 4th FDP was observed, from distal to proximal, and changes in FDP tendons at the distal forearm level too. The quadriga effect can lead to injury of the bipennate lumbrical muscles and the deep flexors complex in the hand and forearm.

Metacarpophalangeal hyperextension in trapeziometacarpal osteoarthritis: Relationship to first metacarpal head shape, and clinical impact.

PURPOSE: The aim of this study was to determine whether the shape of the first metacarpal head influences metacarpophalangeal hyperextension, and to evaluate the influence of metacarpophalangeal hyperextension on hand pain and function in patients with trapeziometacarpal osteoarthritis. METHODS: 362 patients with painful basal thumb osteoarthritis were evaluated over a 2-year period. Pain rating on a visual analog scale, trapeziometacarpal and metacarpophalangeal motion, and grip and pinch strength were evaluated. The shape of the metacarpal head was assessed on strict lateral radiographs using the "A/r" ratio. RESULTS: Round metacarpal heads had significantly greater and more frequent metacarpophalangeal hyperextension than flat heads (28° vs. 8°, and 78% vs. 29%). Metacarpophalangeal hyperextension adversely impacted trapeziometacarpal motion in antepulsion (27° vs. 32°), abduction (25° vs. 30°) and pinch strength (3.6 vs. 4.6 KgF). CONCLUSION: Our findings indicate that the shape of the metacarpal head influences metacarpophalangeal hyperextension in trapeziometacarpal osteoarthritis. Metacarpophalangeal hyperextension adversely impacted pinch strength and trapeziometacarpal motion. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Non-invasive electroarthrography measures cartilage in live horses and correlates to direct measurements of cartilage streaming potentials in weight bearing regions of equine metacarpophalangeal joints.

OBJECTIVE: To perform non-invasive Electroarthrography (EAG) on live horses and establish relationships between EAG and direct measurements of cartilage streaming potentials in weight bearing areas of the equine metacarpophalangeal joint. DESIGN: EAG was performed bilaterally on the metacarpophalangeal joints of live horses (n = 3). Separate experiments used metacarpophalangeal joint explants (n = 11) to measure EAG obtained during simulated loading followed by direct measurements of cartilage streaming potentials on joint surfaces using the Arthro-BST probe. Joints were assigned to relatively normal (n = 5) and mildly degraded (n = 6) groups based on histological scoring of Safranin-O/Fast Green stained sections. RESULTS: EAG, involving application of electrodes to skin surrounding the joint and repeated weight shifting, was well-tolerated in live horses. One pair of distal forelimbs were available for analogous ex vivo EAG testing and measurements were strongly correlated to in vivo EAG measurements obtained on the same joints (r = 0.804, p = 0.016, n = 8). Both indirect (EAG) and direct (Arthro-BST) measurements of cartilage streaming potentials distinguished between normal and mildly degraded cartilage with statistically significant differences at 5 of 6 and 4 of 6 electrodes during simulated standing and walking, respectively. Strong and moderate correlations for weight bearing regions on the dorsal phalanx and central metacarpus were detected during both standing and walking. At the metacarpus/sesamoid interface a moderate correlation occurred during walking. CONCLUSION: Non-invasive EAG was used successfully in a clinical scenario and correlated to direct measurements of streaming potentials in weight bearing cartilage. These data support the potential of EAG to contribute to the diagnosis and treatment of degenerative joint diseases.

Treatment of trigger finger with metacarpophalangeal joint blocking orthosis vs relative motion extension orthosis: A randomized clinical trial.

BACKGROUND: The metacarpophalangeal joint blocking orthosis (MCPJ-BO) is one of the first-line orthotic treatment for patients with trigger finger (TF). Relative motion extension orthosis (RME-O) has recently emerged as a treatment option for various hand disorders involving TF. PURPOSE: The primary objective of this study was to compare the effectiveness of 6 weeks of orthotic treatment with the MCPJ-BO and the RME-O for pain relief. Function and satisfaction with the orthosis were assessed as secondary objectives. STUDY DESIGN: Randomized clinical study. METHODS: Thirty patients with an average age of 50 years with Froimson stage 1-3 A1 pulley triggering participated in the study. They were randomly assigned to either the MCPJ-BO (n = 15; 10 females, five males) or the RME-O group (n = 15; 12 females, three males). The orthoses were worn full time for 6 weeks. All patients received patient education, activity modification, and flexor tendon gliding exercises as part of the rehabilitation program. Pre- and post-assessments included Numeric Pain Rating Scale, Disability of the Arm, Shoulder, and Hand questionnaire, and Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire. The Mann-Whitney U test was conducted to analyze the difference between the two groups. RESULTS: There were no significant differences between the two groups in pain and function before treatment (p < 0.05). Within-group comparisons indicated that both orthoses relieved pain, but the MCPJ-BO group achieved greater pain relief (p = 0.001). There was a significant improvement in function in the MCPJ-BO group, with a mean change of 12.7 (p = 0.0001). The overall success rates for the MCPJ-BO group and RME-O group were 60% and 27%, respectively. Patients in both groups had high satisfaction with the orthosis. CONCLUSIONS: MCPJ-BO and RME-O could be used for pain relief in the treatment of TF. The MCPJ-BO appears to be more effective than the RME-O in improving function.

A four-year community hospital experience regarding procedures for the replantation and revascularization of fingers.

OBJECTIVES: This study aims to evaluate the clinical results and experiences in a community hospital regarding procedures for the replantation and revascularization of fingers. PATIENTS AND METHODS: Between June 2015 and December 2019, a total of 58 patients (51 males, 7 females; mean age: 33.4±6.3 years; range, 23 to 46 years) who were followed after total and/or subtotal amputation and replantation were retrospectively analyzed. The patients were evaluated at nine months in terms of cold intolerance, static two-point discrimination, and functional results using the range of motion (ROM) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. RESULTS: The majority of the patients presented with work-related injuries (70%), most commonly by the mechanism of guillotine (64%), and to the dominant hand (76%) and the third finger (36%) most frequently. The overall success rate of digit salvage was 72.9% (n=51). Of 19 digits with unsuccessful surgical outcomes, seven were from total and 12 were from subtotal amputations. In the long-term, cold intolerance was observed in 14 patients (24.1%) according to the cold intolerance severity scale. The mean static two-point discrimination value was 6.0±0.7 mm and the mean QuickDASH score was 22.3±5.0. The mean ROM measured at nine months after surgery in the metacarpophalangeal and interphalangeal joints of the third and fourth digits was significantly lower than that in the others (p<0.05). CONCLUSION: The predictors of survival of a replanted digit indicated in this study can be used as a guide and decision-making aid for any attempts for replantation.

Pin vs plate fixation for metacarpal fractures: a meta-analysis.

BACKGROUND: The differences in the clinical and functional outcomes of closed reduction and percutaneous pin fixation and open reduction with internal fixation (ORIF) using plate and screws have been systematically synthesized by one meta-analysis. With newer studies being published, an effort to update the earlier meta-analysis is necessary. METHODS: Comprehensive searches were done systematically through PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Google scholar databases. Randomized controlled trials, quasi-experimental studies, prospective comparative non-randomized studies, and even studies reporting findings from retrospective chart review were eligible to be included. Statistical analysis was done using STATA version 13.0. GRADE assessment was done to assess the quality of pooled evidence. RESULTS: A total of 9 studies were included. The pooled estimates did not suggest any significant differences in the disabilities of the arm, shoulder, and hand (DASH) score [WMD - 0.77; 95% CI, - 3.55, 2.00; I2 = 75.5%], range of movement (ROM) of the metacarpophalangeal joint (o) [WMD 4.44; 95% CI, - 4.19, 13.07; I2 = 86.0%], and grip strength [WMD - 4.63; 95% CI, - 14.52, 5.26; I2 = 86.9%] among the two intervention modalities. No difference was seen in the risk of complications between the two interventions (RR 0.93; 95% CI, 0.57, 1.53; I2 = 31.2%). For all the outcomes, the quality of pooled evidence was judged as low to very low. CONCLUSION: No significant long-term differences were noted in the functional outcomes suggesting that both these techniques are comparable. The choice of modality should be made based on the skills and preference of the surgeon and availability of resources.

Pin Insertion to the Interosseous Hood Minimize the Finger Motion Restriction for the Proximal Phalangeal Percutaneous Fixation: A Cadaveric Study.

Background: The purpose of this study was to identify the optimal pin insertion point to minimize finger motion restriction for proximal phalangeal fixation in cadaver models. Methods: We used 16 fingers from three fresh-frozen cadavers (age, 82-86 years). Each finger was dissected at the level of the carpometacarpal joint and fixated to a custom-built range of motion (ROM)-measuring apparatus after skin removal. The pin was inserted into the bone through four gliding soft tissues: the interosseous hood, dorsal capsule, lateral band, and sagittal band. Then, each tendon was pulled by a prescribed weight in three finger positions (flexion, extension, and intrinsic plus position). Changes in the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) angles were measured before and after pinning. We compared the differences between the insertion points using the Tukey-Kramer post hoc test. Results: Placement of pins into the sagittal band significantly restricted MCP joint flexion, while placement into the dorsal capsule and lateral band significantly restricted PIP joint flexion. Only placement into the interosseous hood showed no significant difference in joint angles between the three finger positions compared to pre-pin insertion. There were no significant effects on MCP, PIP, and DIP joint extension. Conclusions: The ROM of the MCP joint was obstructed due to pinning in most areas of insertion. However, pin insertion to the interosseous hood did not obstruct the finger flexion ROM compared to that of other gliding soft tissues; therefore, we believe that the interosseous hood may be a suitable pin insertion point for proximal phalangeal fixation.

Contribution of tenosynovitis of small joints to the symptom morning stiffness in patients presenting with undifferentiated and rheumatoid arthritis.

Objective: Morning stiffness (MS) is characteristic of rheumatoid arthritis (RA). Despite its association with functional disability, the extent to which local inflammatory processes contribute to this symptom is unknown. Magnetic resonance imaging (MRI)-detected tenosynovitis of small joints is recognized as an early feature of RA, which is also associated with functional impairments. It has been proposed that tenosynovitis contributes to MS. Therefore, we assessed the relationship between MS and MRI-detected inflammation, in particular tenosynovitis.Method: In total, 286 consecutive patients newly presenting with undifferentiated arthritis and RA underwent contrast-enhanced 1.5 T MRI of (2-5) metacarpophalangeal, wrist, and (1-5) metatarsophalangeal joints. Scans were scored for tenosynovitis according to Haavardsholm, and for synovitis by Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS). MS was dichotomized as ≥ 60 min or not. Associations between MS and tenosynovitis/synovitis were tested with logistic regression, data were categorized (solitary or simultaneous presence of synovitis/tenosynovitis), and the presence of an additive interaction was assessed.Results: MS was present in 40% of patients. Tenosynovitis was more often present in patients with MS than without MS [80% vs 65%, odds ratio (OR) 2.11, 95% confidence interval (1.21;3.69)]. Synovitis was more often present in patients with MS [58% vs 44%, OR 1.79 (1.11;2.91)]. In categorized analyses, concurrent synovitis and tenosynovitis had the largest association [OR 2.43 (1.30;4.54)], in contrast to solitary synovitis [OR 0.85 (0.21;3.47)]. The additive interaction was non-significant. The variance explained in all analyses was small (range 4-5%).Conclusion: Tenosynovitis, combined with synovitis, at small joints is associated with MS and contributes to the pathophysiology of MS.