Effectiveness of proximal interphalangeal joint-blocking orthosis vs metacarpophalangeal joint-blocking orthosis in trigger digit management: A randomized clinical trial.

STUDY DESIGN: Patients with Green's classification grade 2 or 3 A1-pulley trigger digit (TD) were recruited and randomized to receive the proximal interphalangeal joint-blocking orthosis (PIPJ-BO) or metacarpophalangeal joint-blocking orthosis (MCPJ-BO). INTRODUCTION: TD is a common hand condition that can affect one's performance in activities of daily living. Conservative management of TD involves prescription of orthoses to facilitate recovery. No studies have evaluated the effectiveness of PIPJ-BO, optimal orthosis wear regime, and other factors affecting orthotic effectiveness. PURPOSE OF THE STUDY: To compare the effectiveness of PIPJ-BO vs MCPJ-BO in TD management. METHODS: Outcome measures included pain numerical rating scale, Green's classification grading, and Quick Disability of the Arm, Shoulder and Hand. Orthosis wear duration was also collated. Patients were followed up for 2 months, and changes between initial and final assessment score within each group and between both groups were analyzed. RESULTS: Thirty-five patients with 43 TD were included in final analysis. Twenty-three TD were allocated PIPJ-BO while 20 with MCPJ-BO. Pain reduction was observed in both groups, but reduction was greater in PIPJ-BO group (P = .02). About 47.83% in PIPJ-BO group and 40% in MCPJ-BO group improved by at least 1 Green's classification grade. There was only significant improvement in Quick Disability of the Arm, Shoulder and Hand score for PIPJ-BO group (P = .0007), and duration of orthosis wear was significantly longer in the PIPJ-BO group (P = .0010). Advancing age was found to have higher rate of orthosis failure. DISCUSSION: Findings suggest that both orthoses are effective in reducing pain and disability and improve in triggering symptoms, with PIPJ-BO being more superior. Moreover, PIPJ-BO is less restrictive, has better cosmesis and allowed better functional performance than MCPJ-BO. CONCLUSION: PIPJ-BO is more effective than MCPJ-BO in pain reduction and achieved better functional outcome. Orthosis wear of 24 hours for more than 8 weeks is recommended.

Outcomes and indications for early hand therapy after multiple concomitant elective hand procedures.

STUDY DESIGN: Retrospective comparative study. INTRODUCTION: Trigger finger and carpal tunnel surgery are common, but not without complications including pain and edema, which are treated with hand therapy (HT). There are limited data for the outcomes of multiple trigger finger releases (MTFRs) or combined trigger finger and carpal tunnel surgery and the subsequent need for HT. PURPOSE OF THE STUDY: Based on our hypothesis that patients with more than 1 procedure may benefit from an early HT visit, we performed this study to compare the frequency of HT orders after single trigger finger releases (STFRs) and MTFRs and determine the reasoning for variation in the rate of HT orders after releases. METHODS: Subjects receiving either an STFR or an MTFR were identified. Patient-reported outcomes were recorded preoperatively and 2 weeks postoperatively. RESULTS: One hundred fifty-nine eligible subjects were identified; 33 MTFRs and 126 STFRs. MTFR subjects were prescribed postoperation HT at a higher rate compared with STFR subjects (66.7% vs 34.1%; P < .001). Of the HT subjects, MTFR subjects received prescriptions for edema management at a significantly higher rate compared with STFR subjects (P = .02). DISCUSSION: Patients with soft tissue dissection, edema, and stiffness would most likely benefit from HT services. It is important to identify these at-risk subpopulations to potentially alter their postoperative trajectories and improve outcomes. CONCLUSIONS: Higher rates of referral to HT occur when there are multiple concomitant hand procedures. This suggests surgeons triage HT services based on need. Policies that disallow postoperative therapy will have a greater impact on patients with these indications.

Long-term functional outcome of trigger finger.

PURPOSE: The purpose of this study was to explore the long-term functional outcomes of trigger finger (TF) as perceived by the patient. METHODS: Three study groups were included in the study: prolonged follow up TF group (at least 1-year post-treatment) (PF-TF), patients with acute TF and a control group. The first group was recruited retrospectively and included all patients who were diagnosed with TF in one orthopedic clinic and were contacted by phone, 109 agreed to participate. The acute TF and healthy controls participated in a previous controlled study. The Quick Disabilities of the Arm Shoulder and Hand (QuickDASH) and numeric pain scale (NPS) were the main outcome measures. RESULTS: Both TF groups reported significantly higher levels of disability, particularly in activities requiring strength and more severe pain in comparison with the control group. The acute TF group reported significantly higher levels of disability and pain than the PF-TF group. Seventy-two percent of acute TF group reported moderate to severe pain, in comparison with 37% of the PF-TF group. CONCLUSION: According to these data, substantial long-term disability and pain persist in both the acute and chronic settings. Implications for rehabilitation Recovery from TF may be a prolonged process and a long term follow up should be considered in clinical practice. The present study found that TF leads to significant disability, therefore, activity and participation should be addressed in practice. Assessment of TF interventions should include outcomes that address the client's perspective using standardized measures of disability, such as the QuickDASH.

Effectiveness of Occupational Therapy Interventions for Adults With Musculoskeletal Conditions of the Forearm, Wrist, and Hand: A Systematic Review.

Occupational therapy practitioners are key health care providers for people with musculoskeletal disorders of the distal upper extremity. It is imperative that practitioners understand the most effective and efficient means for remediating impairments and supporting clients in progressing to independence in purposeful occupations. This systematic review provides an update to a previous review by summarizing articles published between 2006 and July 2014 related to the focused question, What is the evidence for the effect of occupational therapy interventions on functional outcomes for adults with musculoskeletal disorders of the forearm, wrist, and hand? A total of 59 articles were reviewed. Evidence for interventions was synthesized by condition within bone, joint, and general hand disorders; peripheral nerve disorders; and tendon disorders. The strongest evidence supports postsurgical early active motion protocols and splinting for various conditions. Very few studies have examined occupation-based interventions. Implications for occupational therapy practice and research are provided.

Isoforce: A new outrigger system for static progressive orthotic interventions of the proximal interphalangeal joint with constant force transmission-Results of a biomechanical study.

STUDY DESIGN: Bench research-biomechanical study. INTRODUCTION: Static progressive orthotic devices are efficient in treating contractures. However, current outriggers are unable to keep force transmission and the force application angle (FAA) constant. PURPOSE OF THE STUDY: To evaluate the biomechanical performance of the Isoforce outrigger, a novel extension orthosis. METHODS: A hand model was used to measure the required force at the outrigger and FAA, while simulating resolution of different contracture angles. We also tested feasibility in a small patient series. RESULTS: The force required with the Isoforce device never exceeded 2.4 N, and the FAA did not change more than 6°. Corresponding figures for the reference devices exceeded 16 N and 20°. The 7 patients testing the Isoforce extension device showed an extension deficit that decreased from 40° at baseline to 25° at 6 weeks. They rated the device as very comfortable to wear. CONCLUSIONS: Isoforce maintains constant force transmission and FAA throughout the full range of motion, promotes the lengthening of contracted structures, and is comfortable to wear. LEVEL OF EVIDENCE: Not applicable.

Percutaneous A1 pulley release by the tip of a 20-g hypodermic needle before open surgical procedure in trigger finger management.

The objective of the study was to assess the safety, the efficacy, and the result of percutaneous A1 pulley release, using the tip of a 20-G hypodermic needle; the study included 17 patients with 27 trigger digits (18 grade IIIA, 8 grade IIIB, and 1 grade IV). All the patients were assessed by the total range of motion of the affected digit, the visual analog scale score, and the Disability of Arm Shoulder Hand score, before and after the procedure and during the follow-up at 2, 6, 12, and 24 weeks, and then every 3 months, and the improvement was assessed by one sample t test. Sixteen patients with 26 trigger digits (95.4%) showed complete relief of symptoms with no recurrence and a statistically significant improvement in the range of motion, the visual analog scale score, and the Disability of Arm Shoulder Hand score with a P-value <0.0001, which concludes that the procedure is safe, effective, and highly successful with good results and lower complications, comparable to those reported in papers on open release for grade III and IV trigger fingers.

A retrospective review to determine the long-term efficacy of orthotic devices for trigger finger.

PURPOSE: To evaluate the use of orthotic devices (splints) in an attempt to resolve trigger finger. METHODS: Data were extracted from 46 charts during a five-year period from January 2005 to December 2010. At ten weeks, patients were seen for follow-up assessment of pain and stage of stenosing tenosynovitis (SST). One-year follow-up was performed to determine if the patients required further surgical intervention or steroid injection. The data were analyzed to determine the efficacy of orthosis intervention. RESULTS: Mean pain score preorthotic is 5.63 and postorthotic is 1.20. Mean SST score preorthotic is 3.93 and postorthotic is 1.21. There was an 87% (40 patients) success rate with the orthotic intervention; 4.3% (two patients) had surgery and 8.5% (four patients) received a steroid injection in the year after orthotic application. CONCLUSION: This study demonstrated the efficacy of orthoses for the reduction of pain and SST score for patients who have trigger finger. LEVEL OF EVIDENCE: 3.

Outcome of corticosteroid injection versus physiotherapy in the treatment of mild trigger fingers.

We compared the effectiveness of physiotherapy and corticosteroid injection treatment in the management of mild trigger fingers. Mild trigger fingers are those with mild crepitus, uneven finger movements and actively correctable triggering. This is a single-centred, prospective, block randomized study with 74 patients; 39 patients for steroid injection and 35 patients for physiotherapy. The study duration was from Jun 2009 until August 2010. Evaluation was done at 6 weeks, 3 months and 6 months post-treatment. At 3 months, the success rate (absence of pain and triggering) for those receiving steroid injection was 97.4% and physiotherapy 68.6%. The group receiving steroid injection also had lower pain score, higher rate of satisfaction, stronger grip strength and early recovery to near normal function (findings were all significant, p < 0.05). At 6 months, only those who were successfully treated were further questioned on recurrence (presence of pain and triggering). Those who received corticosteroid injections had a significant recurrence rate of pain but not triggering. The physiotherapy group had no recurrence of pain or triggering due to the type of triggering responsive to physiotherapy or possibly due to awareness of physiotherapy exercises. Perhaps they were able to institute self-treatment on early onset of symptoms of trigger fingers. We conclude that corticosteroid injection has a better outcome compared to physiotherapy in the treatment of mild trigger fingers but physiotherapy may have a role in prevention of recurrence.

Surgical release of the pediatric trigger thumb.

PURPOSE: The spontaneous recovery rate for locked pediatric trigger thumb (PTT) has recently been reported at between 24% and 66%; these studies concluded that a conservative approach for this condition could be adopted. The aims of this study were to review our results of surgical release of the PTT and to survey pediatric hand surgeons regarding their practice patterns for treatment of the PTT. METHODS: After institutional review board approval, we retrospectively reviewed 173 consecutive patients with 217 thumbs treated surgically at our institution. An e-mail survey of 27 pediatric hand surgeons questioned treatment of a 2-year-old child with a 6-month history of a locked trigger thumb and of an intermittently triggering thumb. RESULTS: The retrospective review demonstrated that preoperative range of motion averaged 36° loss of extension (range, 0° to 90°; SD, 22°); postoperative range of motion averaged 1° loss of extension (range, 0° to 30°; SD, 7°) at 27-day follow-up. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or recurrences identified. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries. The practice pattern survey demonstrated that 85% of pediatric hand surgeons would treat a locked PTT in a 2-year-old with surgical release and 52% would treat an intermittently triggering thumb in a 2-year-old with continued observation if the triggering thumb was not painful. CONCLUSIONS: The surgical results reported in this study, along with the practice pattern survey, confirm that surgical release is a short, safe, and effective procedure when performed by specialty trained hand surgeons, and it is the treatment of choice for a locked PTT.

ICF components of corresponding outcome measures in flexor tendon rehabilitation - a systematic review.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) delivers a holistic approach to health conditions. The objective of the present study is to provide an overview of flexor tendon rehabilitation outcome measures with respect to ICF components. Furthermore, it aims to investigate to which extent current assessments measure aspects of health according to these components primarily focussing on activity and participation. METHODS: A systematic literature review was conducted to identify all studies meeting the inclusion criteria. Studies were only included if they assessed more than body function and body structure and referred to the ICF components activity and participation. The outcome measures were analysed and their linkage to the ICF components were investigated to examine to which degree aspects of health outcome as defined by the ICF were considered. RESULTS: As anticipated, the application of outcome measures after flexor tendon repair is non conform. In many studies the emphasis still lies on physical impairment neglecting activity limitations and participation restrictions.Aspects of health after flexor tendon repair could be assessed more adequately and cover patients' needs more sufficiently by choosing outcome measures which refer to all aspects of functioning. CONCLUSION: The ICF can help to identify aspects of health which are not being considered. The ICF can help promote further development of adequate outcome measures including activity limitation and participation restrictions by targeting patient centred goals and respecting patients' needs.

The natural history of pediatric trigger thumb.

BACKGROUND: Pediatric trigger thumb is a condition of flexion deformity of the interphalangeal joint in children. Although the surgical outcome is satisfactory, the indications for nonoperative treatment for this condition are not clear. The aim of the present study was to determine the rate of resolution of untreated pediatric trigger thumb. METHODS: Data on seventy-one thumbs in fifty-three children were collected prospectively. The dates of the first visits ranged from April 1994 to March 2004. Patients were diagnosed with pediatric trigger thumb during initial outpatient department visits. During the present study, no treatment such as passive stretching or splinting was applied. The amount of flexion deformity at the thumb interphalangeal joint was measured at every six-month follow-up visit, and the duration of follow-up was at least two years after diagnosis. The end point of follow-up was when the deformity caused pain or secondary deformity or prevented normal use of the hand. The median duration of follow-up was forty-eight months. RESULTS: Of the seventy-one trigger thumbs, forty-five (63%) resolved spontaneously. The median time from the initial visit to resolution was forty-eight months. There was no significant difference in the pattern of resolution between patients with unilateral and bilateral trigger thumb. Although resolution was not observed in the remaining twenty-six thumbs, flexion deformities improved in twenty-two thumbs. For the first two years after the initial visit, the mean flexion deformity significantly decreased over the one-year intervals (p < 0.05). CONCLUSIONS: Pediatric trigger thumb can be expected to resolve without treatment in >60% of patients. Moreover, the flexion deformity can be expected to show an improving pattern in patients who do not have resolution. This information may help both parents and surgeons to make decisions regarding the treatment of pediatric trigger thumb.