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.

Steroid versus placebo injections and wrist splints in patients with carpal tunnel syndrome: a systematic review and network meta-analysis.

A network meta-analysis of randomized controlled trials compared the effectiveness of corticosteroid injections with placebo injections and wrist splints for carpal tunnel syndrome, focusing on symptom relief and median nerve conduction velocity. Within 3 months of the corticosteroid injection, there was a modest statistically significant difference in symptom relief compared to placebo injections and wrist splints, as measured by the Symptom Severity Subscore of the Boston Carpal Tunnel Questionnaire; however, this did not meet the minimum clinically important difference. Pain reduction with corticosteroids was slightly better than with wrist splints, but it also failed to reach clinical significance. Electrodiagnostic assessments showed transient changes in distal motor and sensory latencies in favour of corticosteroids at 3 months, but these changes were not evident at 6 months. The best current evidence suggests that corticosteroid injections provide minimal transient improvement in nerve conduction and symptomatology compared with placebo or wrist splints.

Mental health is strongly associated with capability after lower extremity injury treated with free flap limb salvage or amputation.

BACKGROUND: Knowledge about factors associated with long-term outcomes, after severe traumatic injury to the lower extremity, can aid with the difficult decision whether to salvage or amputate the leg and improve outcome. We therefore studied factors independently associated with capability at a minimum of 1 year after amputation or free flap limb salvage. METHODS: We included 135 subjects with a free flap lower extremity reconstruction and 41 subjects with amputation, between 1991 and 2021 at two urban-level 1 trauma centers with a mean follow-up of 11 ± 7 years. Long-term physical functioning was assessed using the Physical Component Score (PCS) of the Short-Form 36 (SF36) and the Lower Extremity Functional Scale (LEFS) questionnaires. Independent variables included demographics, injury characteristics, and the Mental Component Score (MCS) of the SF36. RESULTS: Greater mental health was independently and strongly associated with greater capability, independent of amputation or limb reconstruction. Mental health explained 33% of the variation in PCS and 57% of the variation in LEFS. Injury location at the knee or leg was associated with greater capability, compared to the foot or ankle. Amputation or limb reconstruction was not associated with capability. DISCUSSION: This study adds to the growing body of knowledge that physical health is best regarded through the lens of the bio-psycho-social model in which mental health is a strong determinant. This study supports making mental health an important aspect of rehabilitation after major lower extremity injury, regardless of amputation or limb salvage.

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.

Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound.

BACKGROUND: Although idiopathic median neuropathy at the carpal tunnel (IMNCT) is objective and verifiable, distinction of normal and abnormal nerves is imprecise and probabilistic. The associated symptoms and signs (carpal tunnel syndrome [CTS]) vary, particularly for nonsevere (mild and moderate) median neuropathy. Discordance between diagnosis of mild or moderate median neuropathy at the carpal tunnel using symptoms and signs and diagnosis based on objective tests is a measure of the potential for overdiagnosis and overtreatment. QUESTION/PURPOSE: What is the difference in the estimated prevalence of mild-to-moderate IMNCT using nonsevere signs and symptoms compared with the estimated prevalence using electrodiagnostic studies (EDS) and ultrasound (US)? METHODS: We used data from an existing cross-sectional data registry. To create this registry, between January 2014 and January 2019, we considered all new adult English-speaking people who had an EDS that included the median nerve or people with a diagnosis of CTS who did not have surgery yet. A small and unrecorded number of people declined participation. The cross-sectional area of the median nerve at the distal wrist crease using US in people who already had EDS was measured. People with a diagnosis of CTS underwent both EDS and US. The six signs and symptoms of Carpal Tunnel Syndrome 6 (CTS-6, a validated tool to estimate the probability of IMNCT using ratings of symptoms and signs of CTS) were recorded. This resulted in a registry of 185 participants; we excluded 75 people for obvious, severe IMNCT (defined as nonrecordable nerve conduction velocity, thenar atrophy, or greater than 5 mm 2-point discrimination). Three of the 110 qualifying patients had missing information on ethnicity or race, but we accounted for this in our final analysis. Without a reference standard, as is the case with IMNCT, latent class analysis (LCA) can be used to establish the probability that an individual has specific pathophysiologic findings. LCA is a statistical method that identifies sets of characteristics that tend to group together. This technique has been used, for example, in diagnosing true scaphoid fractures among suspected fractures based on a combination of demographic, injury, examination, and radiologic variables. The prevalence of mild-to-moderate IMNCT was estimated in two LCAs using four signs and symptoms characteristic of mild-to-moderate IMNCT, as well as EDS and US measures of median neuropathy. RESULTS: The estimated prevalence of mild-to-moderate IMNCT based on signs and symptoms was 73% (95% CI 62% to 81%), while the estimated prevalence using EDS and US measurements was 51% (95% CI 37% to 65%). CONCLUSION: The notable discordance of 22% between the estimated prevalence of mild-to-moderate IMNCT using signs and symptoms and prevalence based on EDS and US criteria, and the overlapping CIs of the probability estimations, indicate considerable uncertainty and a corresponding notable potential for underdiagnosis or overdiagnosis. When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as EDS or US, to increase the probability of actual median neuropathy that can benefit from surgery. We might benefit from a more accurate and reliable diagnostic strategy or tool for mild-to-moderate IMNCT; this might be the focus of a future study. LEVEL OF EVIDENCE: Level III, diagnostic study.

Correspondence of the Boston Carpal Tunnel Questionnaire with severity of median neuropathy.

The Boston Carpal Tunnel Questionnaire is one of the most popular patient-reported outcome measures designed specifically for people with idiopathic median neuropathy at the carpal tunnel. We used electrophysiological and ultrasound measures of median neuropathy from one hand in 185 people to create a single measure of median neuropathy severity as a continuum (through exploratory factor analysis). We assessed if our single measure of median neuropathy severity is independently associated with Boston Carpal Tunnel Questionnaire item groupings. Median neuropathy severity measured as a continuum had modest independent associations with Boston Carpal Tunnel Questionnaire magnitude of capability (adjusted R2 0.063) and paraesthesia intensity (adjusted R2 0.12) items but not with items related to pain intensity. Considering the lack of association of Boston Carpal Tunnel Questionnaire pain items with objective pathophysiology, combined with their notable association with mental health measures in previous studies, it is probably best to omit items related to pain.Level of evidence: III.

Volar Plate Advancement and Abductor Pollicis Brevis Tenodesis for Thumb Metacarpophalangeal Joint Hyperextension Correction.

First carpometacarpal (CMC1) osteoarthritis can be accompanied by the collapse of the first ray, with hyperextension of the first metacarpophalangeal (MCP1) joint. It is suggested that failure to address substantial MCP1 hyperextension during CMC1 arthroplasty may diminish post-operative capability and increase collapse reoccurrence. An arthrodesis is recommended in case of severe MCP1 joint hyperextension (>400). We describe a novel combination of a volar plate advancement and abductor pollicis brevis tenodesis to address MCP1 hyperextension at the time of CMC1 arthroplasty as an alternative to joint fusion. In 6 women, mean MCP1 hyperextension with pinch before surgery was 450 (range 300-850) and improved to 210 (range 150-300) of flexion with pinch six months after surgery. No revision surgery has been necessary to date, and there were no adverse events. Long-term outcome data is needed to establish the longevity of this procedure as an alternative to joint fusion, but early results are promising.

Unhelpful thoughts and distress regarding symptoms are associated with recovery from upper extremity fracture.

BACKGROUND: There is evidence that thoughts and emotions regarding symptoms are strongly associated with levels of comfort and capability for a given injury or disease. Longitudinal data from a large cohort of people recovering from an upper extremity fracture provided an opportunity to study how these mindset factors evolve during recovery. METHODS: Seven hundred and four adults (66% women, mean age 59 ± 21 years) recovering from upper extremity fracture completed two measures of reaction to symptoms (the Pain Catastrophizing Scale and the Tampa Scale of Kinesiophobia), a visual analog scale of pain intensity, and two measures of magnitude of incapability 1 week, 3 to 4 weeks, and 6 to 9 months after fracture. RESULTS: Exploratory factor analysis identified distinct groupings of questions addressing unhelpful thoughts and feelings of distress regarding symptoms. The number of distinct question groupings of mindset factors diminished over time. Variations in those groupings of mindset factors were associated with a notable amount of the variation in comfort and capability at all time points. Questions pertaining to unhelpful thoughts about symptoms had stronger associations with comfort and capability than questions measuring distress about symptoms, more so as recovery progressed. CONCLUSIONS: The need to integrate mental health into musculoskeletal is bolstered by the observation that mindsets-interpretation of symptoms in particular-are key contributors to comfort and capability.

Are Radiographic Characteristics Associated With Outcome in Surgically Treated Distal Radius Fractures?

PURPOSE: Evidence to date shows that distal radius fracture displacement measured on radiographs does not correlate with patient-reported outcomes. Quantitative 3-dimensional computed tomography (CT) (Q3DCT) potentially captures fracture displacement more accurately. We aimed to assess the independent association between radiographic, CT, and Q3DCT measures of residual displacement and change in disability, quality of life, range of motion (ROM), and grip strength 12 weeks and 1 year after volar plating of intra-articular distal radius fractures. METHODS: We performed a secondary analysis of data from a prospective multicenter trial. Seventy-one patients underwent volar plating of their AO Foundation/Orthopaedic Trauma Association type B or C distal radius fracture and were available at 12 weeks; 67 (94%) were available at 1 year. We recorded demographics, postoperative periapical radiographs (radial height, ulnarward inclination, ulnar variance, gap, and step off), lateral radiographs (palmar tilt, scapholunate angle, teardrop angle, and anteroposterior distance), postoperative CT scans (gap [coronal, sagittal and axial]) and step off [sagittal and coronal]), and in 3-dimensional models (number of articular fragments, mean fragment articular surface area, 3-dimensional fragment displacement, and gap surface area). Radiographs and CT scans were obtained within 10 working days after fracture fixation. Outcome measures were change in Patient-Rated Wrist Evaluation (PRWE) scores, EuroQol Group 5-Dimension questionnaire (EQ5D) results, grip strength, and composite wrist ROM at 12 weeks and 1 year compared to preinjury level. RESULTS: At 1 year, greater recovery in PRWE scores was independently associated with older age. Greater recovery in composite ROM at 1 year was associated with injury to the dominant side and less step-off on posteroanterior radiographs. CONCLUSIONS: Less posteroanterior step-off was associated with a small improvement in composite wrist ROM at 1 year. This should be considered when counseling patients on the risks and benefits of surgical treatment when radiographic and CT measures of displacement fall within the range found in this study, and in older, low-demand patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Surgeons Attitude toward Psychosocial Aspects of Trapeziometacarpal Osteoarthritis.

Background There is notable evidence that unhelpful thoughts (symptoms of anxiety and depression) increase symptom intensity among patients with trapeziometacarpal osteoarthritis (TMC OA). Surgeons may or may not be mindful of this line of evidence when interacting with patients. In a survey-based experiment, we randomized surgeons to be prompted about the psychosocial aspects of TMC OA. We aimed to measure the influence of mindfulness of mental health on treatment recommendations and willingness to discuss mental health interventions. Methods We randomized 121 hand surgeons to read one of two paragraphs: (A) about biomedical treatment options for TMC OA, or (B) about the impact of mental and social aspects on TMC OA. Thereafter, surgeons were asked several questions about their opinions and treatment recommendations. Results We found that prompting surgeons with information about the psychosocial aspects of TMC OA did not influence their attitudes or treatment recommendations. Most surgeons were willing to offer patients a workbook (92%) or psychologist referral (84%). Among the few surgeons declining to refer, their reasoning was "it would not be of any help" and "stigmatization." Conclusion The observation that a paragraph to encourage mindfulness about the psychosocial aspects of TMC OA, which had no influence on surgeon opinions, suggests that awareness may not be a major factor accounting the relatively limited implementation of this evidence in practice to date. Surgeons seem aware of the importance of psychological influence and barriers may include availability, stigma, and a sense of futility. This is a diagnostic study that reflects level of evidence III.

The origin and course of the infrapatellar branch of the saphenous nerve: An anatomical study.

Nerve injury of the saphenous nerve or infrapatellar branch seems to be a frequent complication following knee surgery or trauma. Denervation results vary, and in some cases, no pain relief is achieved. This might be due to anatomic variation. The purpose of this anatomical study is to identify the variation in the course of the infrapatellar branch and saphenous nerve. We dissected 18 cadavers from adult donors. Medial to the knee, the saphenous nerve and infrapatellar branch were identified and followed proximally to the point where the infrapatellar branch branched from the saphenous nerve. The location where the infrapatellar branch came off from the saphenous nerve relative to the knee joint and where it passed the knee joint were measured. A total of 23 infrapatellar branches were found. We identified 10 branches between 0-10 cm proximal to the knee joint, 3 branches at 10-20 cm, and 9 branches at >20 cm. Between the patella and semitendinosus tendon, the knee joint was crossed by 5 branches in the anterior, 15 in the middle, and 2 in the posterior one-third. The origin of the infrapatellar branch and the location at which it passes the knee are highly variable. This, in addition to people having multiple branches, might explain why denervation is frequently unsuccessful. Based on the anatomical findings, we propose a more proximal diagnostic nerve block to help differentiate between a distal-middle or proximal origin of the infrapatellar branch. Appropriate placement of the nerve block might help identify people who benefit from denervation.

The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence.

PURPOSE: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. METHODS: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. RESULTS: The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48). CONCLUSIONS: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. CLINICAL RELEVANCE: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

Surgeons' Recommendations for Neurodiagnostic Testing With High Pretest Probability of Idiopathic Median Neuropathy at the Carpal Tunnel.

PURPOSE: The utility of electrodiagnostic tests (EDx) for patients with a high pretest probability of idiopathic median neuropathy at the carpal tunnel (IMNCT) based on characteristic symptoms and signs is debated. Decision-making and care strategies could be informed by a better understanding of factors associated with surgeon recommendations for electrodiagnostic testing. METHODS: Ninety-one upper-extremity surgeons participated in an online, survey-based experiment. Participants viewed 7 vignettes of patients with carpal tunnel syndrome, with the following factors randomized in each vignette: patient age, gender, magnitude of incapability, symptom intensity and the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. We sought patient and surgeon factors associated with ordering EDx and surgeon-rated comfort with performing carpal tunnel release (CTR) without EDx. RESULTS: Surgeons recommended EDx for over half of the patient vignettes, with notable variation (median, 57%; interquartile range, 14-100), and felt relatively neutral, on average, offering CTR without EDx. Twenty-six (29%) out of 91 surgeons ordered EDx for all patient scenarios, and 18 surgeons (20%) did not order testing for any scenario. A lower likelihood of EDx was associated with older age and positive provocative tests results. Greater surgeon comfort offering CTR without EDx was associated with older patients, the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. CONCLUSIONS: Upper-extremity surgeons are neutral regarding diagnosing IMNCT based on electrodiagnostic evidence of pathology and are relatively more comfortable offering surgery without EDx in older patients that present with key aspects of carpal tunnel syndrome. There is notable variation in care, with half of all surgeons always or never ordering EDx. CLINICAL RELEVANCE: Future studies can investigate whether a treatment strategy offering surgery to patients with a high pretest probability of IMNCT and only using EDx in intermediate probability scenarios can limit use of testing without affecting patient health.