Incidental Flexor Carpi Radialis Tendinopathy on Magnetic Resonance Imaging.

Background: Wrist pain is often nonspecific. Magnetic resonance imaging (MRI) is regularly obtained to evaluate wrist pain. Variations and pathophysiology identified on MRI may not account for patient's clinical symptoms. This study aims to quantify the prevalence of flexor carpi radialis (FCR) tendinopathy on MRI and the coexistence of trapeziometacarpal (TMC) or scaphotrapeziotrapezoid (STT) osteoarthritis. Methods: Using an institutional research database, we identified 3631 adult patients who obtained an MRI of the wrist during a 15-year period. Text search in the radiology reports identified 302 patients with possible FCR signal abnormalities. After reviewing the medical records, 98 patients were identified with FCR tendinopathy. Furthermore, medical records were used to identify pain located on the volar radial part of the wrist. In the absence of a documented examination consistent with FCR tendinopathy, we considered any signal change in the FCR incidental. Results: We identified 55 patients (55%) with incidental FCR tendinopathy. In a bivariate analysis, we found FCR signal changes on the MRI were associated with older age, white race, clinically suspected FCR tendinopathy, volar-radial sided wrist pain, and TMC and STT arthritis. Using multivariable logistic regression to account for confounding, older age and volar-radial sided wrist pain were independently associated with FCR signal changes on MRI. Conclusions: Signal changes in the FCR are infrequent and often incidental (asymptomatic) or associated with peritrapezial osteoarthritis.

Discretionary Surgery: A Comparison of Workers' Compensation and Commercial Insurance.

BACKGROUND: Workers' compensation is intended for injuries that occur at work and is expected to be mostly for trauma and mostly nondiscretionary conditions. We tested the null hypothesis that there is no difference in the ratio of likely discretionary to likely nondiscretionary surgery between patients treated under workers' compensation compared with commercial insurance controlling for age, sex, and anatomical site for either traumatic or nontraumatic diagnoses. METHODS: Using claims data from the Texas workers' compensation database and Truven Health commercial claims we classified International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedure codes as likely discretionary or likely nondiscretionary, and as traumatic or nontraumatic. Ratios of likely discretionary to likely nondiscretionary surgery were calculated and compared. RESULTS: Among patients treated under workers' compensation, the ratio of likely discretionary to likely nondiscretionary surgery was significantly higher for traumatic diagnoses (0.57 [95% confidence interval, CI, = 0.56-0.61] vs 0.38 [95% CI = 0.37-0.40], P < .05) and significantly lower for nontraumatic diagnoses (9.4 [95% CI = 9.20-9.42] vs 13.2 [95% CI = 12.9-13.3], P < .05) compared with commercial insurance. CONCLUSIONS: Workers' compensation often covers likely discretionary musculoskeletal surgery, and insurance type may influence treatment.

Complex Regional Pain Syndrome After Distal Radius Fracture Is Uncommon and Is Often Associated With Fibromyalgia.

BACKGROUND: Complex regional pain syndrome (CRPS) is frequently diagnosed in patients recovering from surgery or injury. The symptoms and signs included in consensus diagnostic criteria for CRPS are expected after injury. Categorizing symptoms and signs that occur on a continuum as disproportionate or not is subjective and prone to bias. Psychiatrists and psychologists do not diagnose CRPS and instead measure and treat anxiety and catastrophic thinking on its continuum. Given the expected variation in subjective diagnoses such as CRPS, this study addresses factors associated with use of this diagnosis and how it influences care. QUESTIONS/PURPOSES: (1) Among patients recovering from fracture of the distal radius, what factors are associated with the diagnosis of CRPS? (2) Are patients diagnosed with CRPS after distal radius fractures, as opposed to those without CRPS, more likely to have a bone scan, stellate ganglion block, therapy, or subsequent surgery? METHODS: Using the Truven database, we identified 59,765 patients treated for a distal radius fracture from 2012 to 2014, of whom 114 (0.19%) were diagnosed with CRPS. The Truven Health MarketScan database is an administrative claims data set of commercially insured patients and this analysis only included patients with complete enrollment from 2012 through 2014. Bivariate analyses sought differences between patients diagnosed with and patients not diagnosed with CRPS. All factors with p < 0.05 were included in a multivariable logistic regression model. RESULTS: The covariates older age (odds ratio [OR], 1.029; 95% confidence interval [CI], 1.011-1.048; p = 0.002), gender (women at greater risk, OR, 3.86; CI, 1.99-7.49; p < 0.001), concomitant fracture of the distal ulna (OR, 1.54; CI, 1.05-2.23; p = 0.029), open fracture (OR, 0.414; CI, 0.192-0.895; p = 0.025), and comorbid fibromyalgia (OR, 16.0; CI, 4.92-51.8; p < 0.001) were independently associated with a diagnosis of CRPS among patients recovering from a fracture of the distal radius. Patients diagnosed with CRPS are more likely than other patients with a distal radius fracture to have had a bone scan (OR, 66.0; CI, 8.19-532; p < 0.001), physical or occupational therapy (OR, 3.89; CI, 2.68-5.67; p < 0.001), and subsequent wrist surgery (OR, 2.52; CI, 1.65-3.84; p < 0.001). No one had a stellate ganglion injection. CONCLUSIONS: We found that a coded diagnosis of CPRS is uncommonly applied to patients on the higher range of pain, stiffness, and limitations after fracture of the distal radius-most commonly in women and in association with another nonspecific, objectively unverifiable diagnosis (fibromyalgia)-and that this label may lead to more testing and invasive treatment. Future research should address the utility and value of diagnoses that create subjective categories for aspects of human illness that occur on a continuum. LEVEL OF EVIDENCE: Level III, prognostic study.

Articular Gap and Step-off Revisited: 3D Quantification of Operative Reduction for Posterior Malleolar Fragments.

OBJECTIVES: Despite advanced imaging techniques, classic measurements of fracture reduction have not been revisited to date. The purpose of this study was to evaluate the reliability of innovative measurement techniques to quantify operative fragment reduction of posterior malleolar fractures by quantification of three-dimensional computed tomography (Q3DCT). METHODS: Twenty-eight ankle fractures including a posterior malleolar fragment (AO/OTA type 44) were evaluated using 2DCT and Q3DCT to postoperatively quantify fragment reduction. "Classic" maximum gap and step-off of the posterior fragment were measured on 2DCT and Q3DCT. In addition, 2 innovative Q3DCT parameters were introduced and their reliability was tested using intraclass correlations (ICCs): gap surface (mm) and multidirectional 3D-displacement (mm). RESULTS: "Classic" measurements showed a median maximum step-off of 1.1 mm [interquartile range (IQR) 0.0-1.8 mm] on 2DCT versus a median step-off of 0.6 mm (IQR 0.0-1.1) on Q3DCT. Median maximum gap was 1.2 mm (IQR 0.0-3.8) on 2DCT, and its equivalent on Q3DCT showed no median displacement. Q3DCT measurements revealed a median gap surface of 14.5 mm (IQR 4.7-30.0) and a median multidirectional 3D-displacement of 0.7 mm (IQR 0.0-1.1). Interrater reliability of these new Q3DCT parameters of displacement was excellent (ICC 0.92, 95% CI 0.79-0.98) for gap surface and good (ICC 0.64, 95% CI 0.28-0.88) for 3D-displacement. CONCLUSIONS: Q3DCT is a reliable and promising technique for postoperative evaluation of fracture fragment reduction. In addition to "classic" gap and step-off measurements, we propose to explore total gap surface and 3D-displacement as innovative radiographic measurements in future clinical studies. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.