Surgeons Receiving Information About Patient Language Reflecting Unhelpful Thoughts or Distress About Their Symptoms Identify Such Language More Often Than Those Who Do Not Receive This Information.

BACKGROUND: Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient's symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience. QUESTIONS/PURPOSES: In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon's identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? METHODS: Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as "priming") once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors. RESULTS: After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement). CONCLUSION: The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts. LEVEL OF EVIDENCE: Level I, therapeutic study.

Factors Associated With Comfort Using Telemedicine for Upper Limb Specialty Care.

PURPOSE: There is a growing interest in diagnosis and treatment through telemedicine because of its convenience, accessibility, and lower costs. There are clinician and patient barriers to wider adoption of telemedicine. To support the effective and equitable use of telemedicine, we investigated the patient, illness, and surgeon factors associated with the specialist level of comfort in providing upper limb care via telemedicine. METHODS: Seventy-five upper-extremity musculoskeletal specialists completed an online survey-based experiment in which they viewed 12 patient scenarios with randomized patient age, gender, diagnosis, pain intensity, and patient preference for surgical treatment (yes or no) and rated their comfort with telemedicine from 0, no comfort, to 10, complete comfort. The participants were able to provide a rationale for their stance in open text boxes. We recorded the following specialist factors: gender, location of practice, years in practice, subspecialty, the supervision of trainees, and surgeon-rated importance of a physical examination. RESULTS: In a multivariable analysis, greater surgeon comfort using telemedicine was associated with nontrauma conditions, four specific diagnoses, and patients who did not have severe pain. Lower surgeon comfort with telemedicine was associated with the higher clinician-rated importance of a hands-on physical examination and supervising trainees. Text-based reasons provided for relative comfort with telemedicine included nonsurgical treatment and facility of diagnosis based on interviews alone. Text-based reasons for relative discomfort with telemedicine included a perceived need for a hands-on physical examination and a preference for an in-person conversation for specific discussions, including scheduling surgery. CONCLUSIONS: Greater specialist enthusiasm for telemedicine is associated with personal preferences regarding the upper-extremity condition, patients with less severe pain, and a willingness to forego a hands-on examination. CLINICAL RELEVANCE: Utilization of telemedicine for upper-extremity specialty care may be facilitated by diagnosis-specific care strategies and strategies for video examination, with a focus on tactics that are effective for people with more intense symptoms.

Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability.

BACKGROUND: Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity. QUESTION/PURPOSE: What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale? METHODS: One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings. RESULTS: After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1]). CONCLUSION: Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability. CLINICAL RELEVANCE: Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.

Randomized Controlled Trial Comparing Nylon and Chromic Gut Sutures After Minor Hand Surgery.

PURPOSE: We sought to compare overall satisfaction with treatment and satisfaction with initial wound healing after closure of office hand and upper extremity surgery wounds using polyamide compared to Chromic gut sutures. METHODS: We compared 62 patients randomized to polyamide suture closure of an office hand and upper extremity incision (mostly carpal tunnel release and trigger finger release) to 50 patients closed with Chromic gut suture. Patients rated overall treatment satisfaction, satisfaction with initial healing, pain intensity, and upper extremity-specific activity tolerance. RESULTS: Accounting for potential confounding in multivariable linear and logistic regression analysis, we found the following: (1) overall satisfaction with care was unrelated to suture type; (2) satisfaction with initial wound healing and appearance was lower among people with no other comorbidities, but unrelated to suture type; (3) there were no factors independently associated with pain intensity; and (4) excisional biopsy was associated with greater activity tolerance. CONCLUSIONS: Our findings suggests that Chromic sutures are a viable alternative to polyamide sutures after office hand surgery, provided that the care team anticipates and develops strategies for concerns that may arise if the sutures take an extended period to fall off. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

A Comparison of Nerve-Specific, Condition-Specific, and Upper Extremity-Specific Patient-Reported Outcome Measures in Patients With Carpal and Cubital Tunnel Syndrome.

PURPOSE: Arm-, region-, tissue-, and condition-specific patient-reported outcome measures (PROMs) are available to address idiopathic mononeuropathy. This study compared PROMs with varying specificities in patients with idiopathic neuropathy of the upper extremity with respect to correlations with each another, sources of variation in scores, and floor and ceiling effects. METHODS: One hundred fifty patients (130 with carpal tunnel syndrome, 30 with cubital tunnel syndrome, and 10 with both conditions) completed a nerve-specific PROM (Impact of Hand Nerve Disorders), a condition-specific PROM (Boston Carpal Tunnel Syndrome Questionnaire and/or Patient-Rated Ulnar Nerve Evaluation), and an upper extremity-specific PROM (Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity 7). We also gathered demographic and condition-related data (side, electrodiagnostic studies present, muscle atrophy, static loss of sensibility), and patients completed questionnaires measuring self-efficacy, kinesiophobia, and symptoms of depression. Correlation of the PROMs with each another and factors accounting for their variation were assessed, as well as the number of items to complete, time to complete, and floor and ceiling effects. RESULTS: Pearson correlations between PROMs were moderate to strong (0.56-0.90). Self-reported symptoms of depression were best able to account for the variations in symptom intensity and activity intolerance on all PROMs (adjusted R2 between 0.09 and 0.31). The Impact of Hand Nerve Disorders is a long questionnaire and took the most time to complete. All instruments had comparable floor effects; Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity had a ceiling of effect of 16%. CONCLUSIONS: This study adds to the evidence that specific and general PROMs correlate with each another, perhaps in part through their correlation with mental health. Based on this line of evidence and pending testing of potentially greater responsiveness in specific settings, we prefer to use a single simple, brief, and general PROM to quantify symptom intensity and activity intolerance for both routine patient care and research. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

A Randomized Controlled Trial of Decision Aids for Upper-Extremity Conditions.

PURPOSE: Decision aids (DAs) are tools designed to correct misconceptions, help people weigh the pros and cons of each option, and choose an option consistent with their values. This randomized controlled trial tested the difference in decision regret between patients who reviewed a DA at the end of the visit and those who did not. Secondary study questions addressed differences in pain self-efficacy, pain intensity, satisfaction, physical function, and treatment choice. METHODS: We enrolled 147 patients who visited an orthopedic upper-extremity surgeon for a condition that could be treated surgically or nonsurgically. We randomized 76 of these patients to review a DA as part of the visit (52%). At baseline, we measured results using the Pain Self-Efficacy short form, PROMIS Physical Function computer adaptive test, pain intensity on an 11-point ordinal scale, and satisfaction with the visit on an 11-point ordinal scale, as well as whether patients understood all received information and felt adequately educated to decide (no/yes), and choice of surgery, injection, or another treatment. Four to six weeks later, the survey by phone consisted of the PROMIS Physical Function computer adaptive test, pain intensity, satisfaction with the visit, the sense of a well-informed decision, and the Decision Regret Scale. We assessed factors independently associated with each measure. RESULTS: People who reviewed a DA had significantly less decision regret 4 to 6 weeks after the visit compared with those who did not. High pain self-efficacy was associated with lower likelihood to choose surgery during the initial visit, better physical function rates, and lower reported pain. CONCLUSIONS: Decision aids reduce decision regret, which suggests that they help people organize their thoughts and make decisions more consistent with their values. CLINICAL RELEVANCE: Hand surgeons can consider the use of DAs as a method for improving the quality of shared decisions.

Volar Tilt of the Lunate After Open Reduction Internal Fixation of a Distal Radius Fracture.

The pathophysiology of carpal adaptations after fracture of the distal radius is incompletely understood. We report 5 patients who had normal carpal alignment on injury radiographs that developed marked volar angulation of the lunate during recovery from volar plate fixation of a fracture of the distal radius. There were no signs of alteration of the carpal ligaments. Two patients had similar volar tilt on the contralateral side. The cause and optimal treatment of carpal malalignment after restoration distal radial alignment are unclear.

Does Intolerance of Uncertainty Affect the Magnitude of Limitations or Pain Intensity?

BACKGROUND: Intolerance of uncertainty-the tendency to overestimate the chance of and be unwilling to accept potential, but unlikely, negative outcomes in uncertain situations-is a cognitive construct that has been shown to affect symptoms and limitations for patients with traumatic and nontraumatic upper-extremity conditions. Cognitive flexibility and tolerance of uncertainty can be trained and practiced, with the potential to increase musculoskeletal health. However, to our knowledge, the degree to which intolerance of uncertainty might be associated with symptom intensity and the magnitude of limitations in adults with upper-extremity problems has not been characterized. QUESTIONS/PURPOSES: After accounting for personal and social factors, is intolerance of uncertainty independently associated with (1) the magnitude of physical limitations and (2) pain intensity? METHODS: In this cross-sectional, observational study, 139 new and returning patients presenting to one of four orthopaedic offices in a large urban area completed the Intolerance of Uncertainty Scale (a validated measure of the level of comfort with uncertain situations), the Patient-reported Outcomes Measurement Information System-Physical Function Upper Extremity computer adaptive test (to measure the magnitude of limitations), and an 11-point ordinal measure of pain intensity. The mean age of the 139 participants was 51 years ± 16 years and 55% (76 of 139) were men. Participants presented to the clinics with a wide variety of upper-extremity conditions, such as trigger finger, distal radius fractures, lateral epicondylitis, or non-specific shoulder pain. We also assessed sex, race, marital status, education level, income, public versus private insurance, area deprivation index, and the participant's self-perception of their healthcare experience through a multiple-choice question (answer choices: none, some, a little, and a lot of experience). The following patient characteristics were more common in our study participants: white, employed, part of a married or unmarried couple, and private insurance coverage. We created two multivariable linear regression models to assess factors independently associated with the magnitude of limitations and pain intensity. RESULTS: After controlling for potentially confounding variables including sex, insurance, area deprivation index, and type of visit, we found that fewer physical limitations were associated with a greater intolerance of uncertainty (regression coefficient [ß] -0.30; 95% confidence interval, -0.50 to -0.10; p = 0.003; semi-partial r = 0.07; adjusted r for the full model = 0.16), as was being a man (ß 3.2; 95% CI, 0.08-6.3; p = 0.045; semi-partial r = 0.03) and having private insurance coverage (ß 5.2; 95% CI, 2.1-8.2; p = 0.001; semi-partial r = 0.08). After controlling for one important potentially confounding variable, the level of education, greater pain intensity was associated with a greater intolerance of uncertainty (ß 0.08; 95% CI, 0.02-0.14; p = 0.009; semi-partial r = 0.05; adjusted r for the full model = 0.08). CONCLUSIONS: Intolerance of uncertainty-a byproduct of cognitive bias and error, which are elements of the normal functioning of the human mind-increases limitations and pain intensity across diagnoses, independent of demographic and social factors. Future studies can address the effect of strategies that incorporate mindset training (for example, cognitive behavioral therapy and its derivatives) on musculoskeletal symptoms and limitations. LEVEL OF EVIDENCE: Level II, prognostic study.

Patient Perspectives on Decision Making for Carpal Tunnel Syndrome.

PURPOSE: Interventions that improve a patient's understanding of the problem and their options might reduce surgeon-to-surgeon variation, activate healthier patient behaviors and mindset, and optimize stewardship of resources while improving quality of care. Patients with carpal tunnel syndrome (CTS) have more uncertainty about which course of action to take (so-called decision conflict) than hand surgeons. We studied patient preferences regarding shared decision making (SDM) for different parts of the treatment for CTS. We assessed the following hypotheses: (1) Younger age does not correlate with a preference for greater involvement in decisions; (2) Demographic and socioeconomic factors are not independently associated with (A) preferences for decision making (separated into preoperative, operative, postoperative, and the full SDM scale) and (B) the Control Preference Scale; (3) the SDM scale does not correlate with the Control Preference Scale. METHODS: We prospectively invited 113 new and postoperative patients with CTS to participate in the study. We recorded their demographics and they completed the SDM scale and the Control Preference Scale. RESULTS: The full SDM scale and all subsets showed a patient preference toward sharing the decisions for treatment with the surgeon with a moderate tendency toward patients wanting more surgeon involvement in decision making. On multivariable analysis, having commercial insurance compared with Medicare was independently associated with a preference for less surgeon involvement (ie, higher SDM scores) in decision making (regression coefficient, 0.60; 95% confidence interval, 0.03-1.2). CONCLUSIONS: Patients with CTS generally prefer to share decisions with their surgeon with a tendency for more surgeon involvement especially in the operative and postoperative period. CLINICAL RELEVANCE: Decision aids and preference elicitation tools used to ensure diagnostic and treatment decisions for CTS that are aligned with patient preferences are needed. Future studies might address the routine use of these tools on patient outcomes.

Satisfaction With Specific and Nonspecific Diagnoses.

PURPOSE: Nonspecific upper extremity illnesses (eg,. wrist pain, forearm pain)-where no objectively verifiable pathology is detectable-are common and usually self-limiting. For some patients, a nonspecific diagnosis can contribute to mistrust and disappointment. METHODS: This study tested the primary null hypothesis that there is no difference in mean overall satisfaction between patients given a specific compared with a nonspecific diagnosis. Second, we assessed factors associated with satisfaction and with nonspecific upper extremity diagnosis. RESULTS: There was no significant difference between mean satisfaction with nonspecific and specific diagnoses in bivariate analysis. However, when treated as a categorical variable, 22% of the patients with a nonspecific diagnosis had a satisfaction score of 8 or lower compared with 11% of the patients given a specific diagnosis. First visit and greater pain intensity were significantly associated with a nonspecific diagnosis in bivariate analysis. In the multivariable models, no factors were independently associated with satisfaction or with nonspecific diagnoses. CONCLUSIONS: Although nonspecific diagnoses can sometimes be frustrating for both physician and patient, in this small study using a satisfaction measure with a strong ceiling effect, they were no less satisfying to patients on average and corresponded with slightly greater pain intensity than specific diagnoses. CLINICAL RELEVANCE: The degree to which nonspecific diagnoses (perhaps in combination with compassionate care and incremental monitoring) can be part of a satisfying treatment experience merits additional investigation.

The Effect of the Content of Patient-Reported Outcome Measures on Patient Perceived Empathy and Satisfaction: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to examine whether positively or negatively phrased Patient-Reported Outcome Measures (PROMs) prior to a visit with the hand surgeon affect patient perceived empathy and patient satisfaction (Patient-Reported Experience Measures [PREMs]). METHODS: Between June 2017 and July 2017, we enrolled 134 patients who presented to 3 hand surgeons at 2 outpatient offices. They were randomly assigned to 1 of 2 groups: completion of negatively framed questionnaires (Patient Health Questionnaire [PHQ-2], Pain Catastrophizing Scale [PCS-4], and Patient-Reported Outcomes Measurement Information System [PROMIS] depression Computer Adaptive Test [CAT]) or completion of positively framed questionnaires (Pain Self-Efficacy Questionnaire [PSEQ-2]) prior to the visit. At the end of the visit, all patients completed questionnaires on patient-perceived physician empathy and patient satisfaction. Five patients were excluded from the analysis after randomization. RESULTS: There was no statistically significant differences between groups on patient-perceived physician empathy and patient satisfaction. CONCLUSIONS: Our findings suggest that the content of psychological questionnaires completed prior to the visit does not affect patient satisfaction and perceived empathy recorded after the visit. CLINICAL RELEVANCE: Given the degree to which PROMs are influenced by psychosocial factors, and prior evidence that PROMs are primed by negatively framed questionnaires, it is reassuring that negatively framed PROMs did not affect PREMs, but more research is merited.

Quantitative Analysis of Cervical Flexion-Extension Radiographs in Rheumatoid Arthritis Patients.

STUDY DESIGN: Diagnostic retrospective case series. OBJECTIVE: To evaluate cervical intersegmental motion in rheumatoid arthritis patients using specialized tracking software (QMA) and compare the findings with a previously published cohort of "normal" subjects. SUMMARY OF BACKGROUND DATA: Rheumatoid arthritis follows 3 patterns of cervical involvement, atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. Deformities present are sometimes considered "unstable" to the point where surgery can be recommended based on the interpretation of cervical radiographs. METHODS: Cervical flexion-extension radiographs of 99 subjects with rheumatoid arthritis were evaluated. Angular and translational segmental motions were determined at each level using specialized tracking software. Findings were compared with previously published normative data using the same device. RESULTS: Relative to controls, patients with rheumatoid arthritis demonstrated significantly less overall sagittal motion. Segmental analysis at C1-C2 demonstrated a 10% prevalence of dynamic motion outside the 95% confidence interval for "normal" patients. In contrast, segmental analysis at C2-C7 demonstrated no intersegmental motion outside the 95% confidence interval for "normal" subjects. CONCLUSIONS: In patients with rheumatoid arthritis, abnormal motion at C1-C2 was consistent with truly dynamic deformity and should be closely evaluated. Conversely, subaxial subluxations, although frequently present, were relatively fixed deformities and in most cases, may not represent an unstable condition.

Measurement of ulnar variance from the lateral radiograph: a comparison of techniques.

PURPOSE: To determine the reliability of measuring ulnar variance on lateral wrist radiographs and to compare this technique with previously described methods. METHODS: Ulnar variance was measured in 100 normal wrist radiographs using the methods of perpendiculars, central reference point, and the lateral radiograph by 3 surgeons on 2 occasions. Intraobserver repeatability and agreement between raters and methods were assessed and compared. RESULTS: Intra- and interobserver reliability and agreement were both excellent using all 3 methods within a ± 1.0-mm cutoff. However, there was substantial pairwise disagreement in measures of ulnar variance between all 3 methods. CONCLUSIONS: This study demonstrates that, for measurement of ulnar variance, the methods of perpendiculars, central reference point, and lateral radiographic measurement each have clinically acceptable intraobserver repeatability and interobserver agreement. Despite their independent reliability, each method of radiographic determination of ulnar variance had considerable disagreement with the other methods, indicative of inherent inaccuracies in the techniques. The lateral radiograph uniquely allows for visualization of the amount of ulnar head protruding proximal or distal to the concave lunate facet and allows for a rapid estimation of pronosupination, which is known to affect ulnar variance. CLINICAL RELEVANCE: Determination of ulnar variance can be an important component of surgical decision making in various pathological conditions of the hand and wrist. Traditionally, it has been measured through methods using the posteroanterior wrist radiograph, but there are potential shortcomings with these methods, and use of the lateral radiograph may provide a more clinically relevant picture of ulnar variance. This study shows that measurement from the lateral radiograph provides similar reliability to previously accepted techniques.

Medical Metaphors That May Reinforce Misconceptions Are Associated With Increased Trust in the Clinician.

BACKGROUND AND OBJECTIVES: This study measured patient reactions to medical metaphors used in musculoskeletal specialty offices and asked: (1) Are there any factors associated with patient thoughts and emotions in response to common metaphors? (2) Is there a difference between patient ratings of metaphors rated as potentially reinforcing misconceptions and those that are more neutral? METHODS: In a cross-sectional study, 228 patients presenting to multiple musculoskeletal specialty offices rated reactions to 4 metaphors presented randomly from a set of 14. Two were categorized as potentially reinforcing common misconceptions and 2 as relatively neutral. Bivariate tests and multivariable regression identified factors associated with patient ratings of levels of emotion (using the standard assessment manikins) and aspects of experience (communication effectiveness, trust, and feeling comfortable rated on 11-point ordinal scales) in response to each metaphor. RESULTS: Levels of patient unhelpful thinking or distress regarding symptoms were not associated with patient ratings of patient emotion and experience in response to metaphors. Metaphors that reinforce misconceptions were associated with higher ratings of communication effectiveness, trust, and comfort (P < .05). CONCLUSION: The observation that metaphors that validate a person's understanding of his or her illness may elicit trust even if those metaphors have the potential to reinforce misconceptions may account for the common usage of such metaphors. Clinicians can work to incorporate methods for building trust without reinforcing misconceptions.

Does lidocaine reduce pain intensity during corticosteroid injection? A double-blind randomized controlled equivalence trial.

Of the strategies considered to limit the discomfort of corticosteroid injection, one is to inject without lidocaine to reduce the total volume and avoid acidity. In a Bayesian trial, adults receiving corticosteroid injections were randomized to receive 0.5 mL of triamcinolone with or without 0.5 mL of lidocaine. Serial analysis was performed until a 95% probability of presence or absence of a 1.0-point difference in pain intensity on the 0-10 Numerical Rating Scale was reached. Injections with lidocaine were associated with a median of 2.4-point lower pain intensity during injection with a 95% probability of at least a 1-point reduction. The 95% probability was confirmed in 90% of the repeated analysis (36/40). Lidocaine is associated with lower immediate pain intensity during corticosteroid injection for hand and wrist conditions.Level of evidence: I.

Gross anatomy of the elbow capsule: a cadaveric study.

PURPOSE: The elbow is an inherently stable joint because of its bony articulation and surrounding capsuloligamentous structures. Anatomic and biomechanical studies have focused on the medial and lateral collateral ligamentous contributions to stability. In 1918, Gray provided a qualitative description of the elbow capsule and its fibers. Our study was performed to detail the gross anatomy of the elbow capsule. METHODS: We evaluated the elbow capsule of 6 paired, fresh-frozen cadaveric specimens to detail gross capsular anatomy. RESULTS: We identified 3 distinct bands within the anterior capsule and 3 distinct bands within the posterior capsule. CONCLUSIONS: Further study is needed to delineate the functional meaning of these anatomic findings. CLINICAL RELEVANCE: Greater understanding of elbow capsule gross anatomy may lead to improved understanding of acute and chronic elbow pathoanatomy and treatment modalities.

Elbow lateral collateral ligament injuries.

The lateral collateral ligament (LCL) of the elbow is a complex capsuloligamentous structure critical in stabilizing the ulnohumeral and radiocapitellar articulations. LCL injury can result in elbow instability, allowing the proximal radius and ulna to externally rotate away from the humerus as a supination stress is applied to the forearm. Elbow dislocation is the most common cause of LCL injury, followed by iatrogenic injury. LCL pathology resulting in late recurrent instability is rare but disabling. The diagnosis requires a high index of suspicion, detailed history, and focused physical examination maneuvers. Stress radiographs are often the most useful imaging modality. Despite controversy over the anatomy of the LCL complex and the relative importance of its component structures, treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes.

Osteology of the coronoid process with clinical correlation to coronoid fractures in terrible triad injuries.

BACKGROUND: Terrible triad complex elbow fracture-dislocations are represented by elbow dislocations associated with fractures of the coronoid and radial head. Published literature has focused on classifying coronoid fractures by their radiographic morphology on plain x-ray images and computed tomography imaging. No study has specifically related native coronoid osteology to in situ fracture morphology. We identified 3 distinct bony regions of the coronoid, (medial, intermediate, and lateral ridges) with correlation to common fracture patterns associated with terrible triad injuries. METHODS: Coronoid osteology in 8 fresh frozen cadaveric elbows was examined, and three distinct ridges were identified and dimensions measured. RESULTS: The measurements were compared with retrospective intraoperative measurements taken of coronoid fracture fragments being stabilized during terrible triad injury repair. CONCLUSION: Classification of native coronoid process anatomy into functional ridges (medial, intermediate, lateral) may improve our understanding of coronoid fracture patterns in unstable terrible triad injuries. LEVEL OF EVIDENCE: Basic Science, Anatomic Study, Cadaver and In Vivo.

Measurement of Upper Extremity-Specific Comfort and Capability.

Patient-reported outcome measures (PROMs) quantify symptom intensity and magnitude of capability. Upper extremity PROMs were developed shortly after the advent of general health PROMs. PROMs are still primarily research tools, and their use with individual patients is still evolving. When PROMs were developed, the initial and intuitive expectation was a strong correlation of comfort and capability with pathophysiology severity. In other words, people with greater radiographic arthritis or larger degenerative tendon defects were expected to feel worse and do less. After more than 20 years of research using PROMs, it is clear that mindset and circumstances account for more of the variation in PROMs than pathophysiology severity. Mounting research establishes upper extremity PROMs and PROMs in general as useful tools for anchoring and developing comprehensive, biopsychosocial approaches to care.

Do Items Addressing Thoughts and Emotions Regarding Symptoms Measure Distinct Aspects of Musculoskeletal Health?

A prior experiment identified separate thought and feeling item groupings among items in measures of unhelpful thinking (ie, catastrophic thinking, kinesiophobia). This study sought to confirm the utility of separating these factors using a subset of selected items. One hundred and thirty-six adult patients visiting a musculoskeletal specialist completed the surveys. Confirmatory factor analysis measured the association between variation in scores on a specific item with variation in scores in separate groupings for thoughts and feelings, and a combined item grouping. Cronbach alpha (internal consistency) and Spearman correlation with magnitude of capability were also measured for the three separate item groupings. The association of variation in specific items with variation in a group of items addressing thoughts, a group of items addressing feelings, and the combination of all items was comparable. The internal consistency and strength of association with magnitude of capability were also comparable. The finding of no advantage to separation of items addressing thoughts and feelings regarding symptoms suggests that just a few items may be able to represent unhealthy mindsets regarding musculoskeletal symptoms.