The 'M2 DASH'-Manchester-modified Disabilities of Arm Shoulder and Hand score

Psychometric properties of patient-reported outcomes measures used to assess upper limb pathology: a systematic review

BACKGROUND

With the continued development of patient-centred healthcare models, patient-reported outcome measures (PROMs) are increasingly used to evaluate outcomes in patients with upper limb pathology. The aim was to identify valid, reliable and responsive PROMs used to assess outcomes following upper limb pathology, and ascertain how their psychometric properties had been established. A secondary aim was to identify PROMs that have been validated to assess upper limb pathology in the paediatric population.

METHODS

A review of the Medline and EMBASE database was performed. Articles that analysed the validity of an established PROM used for upper limb pathology were included. Extracted study data included: author, country, PROM(s) investigated, year of publication, study type, sample size, demographics and duration of follow-up.

RESULTS

Twenty-five articles were included, which together investigated the psychometric properties of 23 different PROMs that have been used to assess outcomes in adults following upper limb pathology. No study evaluated the psychometric properties of PROMs used in the paediatric population. Among PROMs that have been used in adults, the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) had strong content- and construct-validity, reliability and responsiveness in comparison to others.

CONCLUSION

There are currently no studies that have analysed the content validity of PROMs used to assess upper limb pathology in the paediatric population. Prospective studies are required for the development of PROMs that can be utilized in children to assess upper limb pathology.

Clinical and radiographic assessment of peripheral joints in controlled acromegaly

PURPOSE

Acromegalic arthropathy is a well-known phenomenon, occurring in most patients regardless of disease status. To date, solely hips, knees, hands, and spinal joints have been radiographically assessed. Therefore, this study aimed to assess the prevalence of joint symptoms and radiographic osteoarthritis (OA) of new, and established peripheral joint sites in well-controlled acromegaly.

METHODS

Fifty-one acromegaly patients (56% female, mean age 64 ± 12 years) in long-term remission for 18.3 years (median, IQR 7.2-25.4) were included. Nineteen patients currently received pharmacological treatment. Self-reported joint complaints were assessed using standardized interviews. Self-reported disability of the upper and lower limbs, and health-related quality of life (HR-QoL) were evaluated using validated questionnaires. Radiographic OA [defined as Kellgren & Lawrence (KL) ≥ 2] was scored using (modified) KL methods.

RESULTS

Radiographic signs of OA were present in 46 patients (90.2%) with ≥ 2 joints affected in virtually all of these patients (N = 44; 95.7%). Radiographic MTP1 OA was as prevalent as radiographic knee OA (N = 26, 51.0%), and radiographic glenohumeral OA was similarly prevalent as hip OA [N = 21 (41.2%) vs. N = 24 (47.1%)]. Risk factors for radiographic glenohumeral OA were higher pre-treatment IGF-1 levels [OR 1.06 (1.01-1.12), P = 0.021], and current pharmacological treatment [OR 5.01 (1.03-24.54), P = 0.047], whereas no risk factors for MTP1 joint OA could be identified.

CONCLUSION

Similar to previously-assessed peripheral joints, clinical and radiographic arthropathy of the shoulder and feet were prevalent in controlled acromegaly. Further studies on adequate management strategies of acromegalic arthropathy are needed.

Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials

Introduction

Midshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes.

Methods

A systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe.

Results

Of the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails.

Conclusion

Surgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.

Low prevalence of neuropathic-like pain symptoms in long-term controlled acromegaly

PURPOSE

Pain is a common symptom of acromegaly, impairing health-related quality of life (HR-QoL) significantly despite long-term disease remission. Neuropathic-like pain (NP-like) symptoms are invalidating, with great impact on HR-QoL. Studies characterizing or investigating the etiology of pain in acromegaly are scarce. Therefore, we aimed to assess NP-like symptoms in a cohort of controlled acromegaly patients.

METHODS

Forty-four long-term controlled acromegaly patients (aged 62.6 ± 12.6 years; 56.8% female) were included in this cross-sectional study. NP-like symptoms were assessed using the validated painDETECT questionnaire. Patients were divided in three probability-based NP-like symptoms categories based on the total score (range 0-35): unlikely (≤ 12), indeterminate (13-18) and likely (≥ 19). HR-QoL (physical component score (PCS), and mental component score (MCS)), and self-reported pain were assessed using Short Form-36 (SF-36). Potential risk factors were determined using linear regression analyses.

RESULTS

Self-reported pain was reported by 35 patients (79.5%). Likely NP-like symptoms were present in 4/44 patients (9.1%), and indeterminate NP-like symptoms in 6/44 patients (13.6%). All patients with likely NP-like symptoms were female. Higher painDETECT scores were negatively associated with HR-QoL (PCS: r = - 0.46, P = 0.003; MCS: r = - 0.37, P = 0.018), and SF-36 pain scores (r = - 0.63, P < 0.0001). Female sex was a risk factor for NP-like symptoms.

CONCLUSIONS

Pain was prevalent in controlled acromegaly patients, whereas NP-like symptoms were relatively infrequent, and only observed in females. NP-like symptoms were associated with lower HR-QoL in acromegaly. Since specific analgesic therapy is available, awareness for characterization, increased understanding, and clinical trials regarding neuropathic pain identification and treatment in acromegaly patients are warranted.

Patient-reported outcome measures for patients with hand-specific impairments-A scoping review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used to provide evidence for treatment effects and to guide rehabilitation. To our knowledge, no disease-specific PROM exists for the assessment of patients with flexor tendon lesions of the hand. We believe that PROMs used to assess hand function, regardless of diagnosis, contain relevant items for patients with flexor tendon lesions of the hand.

PURPOSE

The aim of our study was to identify and collect items from pre-existing PROMs used by clinical experts to assess the health status and function in patients with reduced hand function.

STUDY DESIGN

A scoping review searching for PROMs with hand-specific content was conducted to ensure face validity. As these items are assumed to have been through an evaluation process by the clinical specialists, they have the advantage and likelihood of being useful.

METHODS

We searched five bibliographic databases. All PROMs with hand-specific content used to assess hand function were considered for inclusion. Questionnaires written in English, Danish, Swedish, and Norwegian were included. An analysis of content redundancy was conducted, and items were grouped according to The World Health Organization's International Classification of Functioning, Disability and Health.

RESULTS

Seventy-three PROMs were included with a total of 1,582 items. The majority of the items were redundant across measurement instruments, and redundant items were consolidated, resulting in 179 nonredundant items. All nonredundant items were classified according to the International Classification of Functioning, Disability and Health components.

CONCLUSIONS

This review presents a collection of 179 items ensuring face validity for patients with hand-related disease/injury.

Hand osteoid osteoma: evaluation of diagnosis and treatment

Background

OO (osteoid osteoma) is a common, osteoblastic, benign bone tumor but rarely seen in the hand region. There is still some debate about the diagnosis and treatment of hand OOs. In the present study, we aimed to evaluate the epidemiology, radiologic features, surgical treatment options and functional outcomes.

Methods

Between January 2003 and December 2014, surgically treated and pathologically verified 9 hand OO cases were investigated retrospectively. The preoperative and postoperative clinical outcome scores were calculated using the M2-DASH (Manchester-Modified Disabilities of Arm Shoulder and Hand) Score.

Results

Lesion locations were as follows: middle phalanx in 2/9 (22%) patients (2nd and 4th digit), proximal phalanx in 6/9 (67%) patients (one 4th, two 2nd and three 5th digits) and metacarpal (2nd) in 1/9 (11%) patient. Incidence of nidus formation was 6/9 (67%) on X-ray, 7/9 (78%) on CT imaging and 2/9 (22%) on MR imaging. The mean time to diagnosis was 13.22 ± 5.44 months. Preoperative mean M2-DASH score was 41 ± 6 and postoperative was 7.4 ± 8.6.

Conclusion

Osteoid osteoma is usually seen below 25 years, and rarely found over 40 years of age. There is male dominance with a male to female ratio of 3:1. Delay of diagnosis may be encountered because of many differential diagnoses. When OO is suspected, CT imaging should be taken before the MR imaging. Because of superiority in soft tissue imaging, MR imaging should be an alternative tool in complex cases.

Complex clavicle fractures in children: Kids are not little adults

Background

The clavicle is the most commonly fractured bone in the body and accounts for 10–15% of all pediatric fractures. Adult patients with complete midshaft clavicle fractures often undergo surgical management. Pediatric patients have a thicker periosteum, more robust blood supply and a greater healing potential. Controversy exists as to whether to treat adolescents with surgery similar to adults versus with a sling as children are treated. Some orthopaedic surgeons are now operating on adolescent clavicle fractures.

Objective

The objective of the study was to evaluate the outcomes of displaced midshaft clavicle fractures in adolescent who were treated conservatively with a sling.

Methods

We performed a retrospective chart review of 25 pediatric patients aged 12–16 with complete midshaft clavicle fracture. The outcomes of the study were bony union and functional outcomes such as pain, problems with ADL measured by the modified Disability of Arm, Shoulder, and Hand (DASH) score.

Results

All patients in our cohort had excellent outcomes at follow-up visits with no complaints of pain or limitations of activities of daily living. Mean follow-up time was 12 months. All patients had perfect modified DASH score of 18. Injury radiographs demonstrated an average of 13 mm shortening initially and 8 mm shortening in final follow-up. Average fracture angulation at final follow-up was 15°. Normal clavicle angulation at the mid shaft is 8°. All clavicles healed completely with no case of malunion or non-union reported.

Conclusion

Clavicle fractures are common. Although operative treatment of clavicle fractures in the adult population is gaining popularity due to issues in adults with non-union and malunion, the adolescent population is different. The adolescent clavicle fracture demonstrates robust healing and remodeling and complete return to full function. We therefore recommend that adolescent patients aged 12–16 with complete clavicle fracture be treated conservatively with a sling.

Bite injuries to the hand: microbiology, virology and management

Bites to the human hand, be it from a pet, a stray animal or even a fellow human, may often have dire consequences for the person suffering the insult. Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms, in the UK. Clenched fist injuries to the mouth ('fight bite') are notorious for being the worst human bites. Bite injuries of the hand and their related infections must be monitored vigilantly and managed proactively, by experts in this field of surgery. In this review article we discuss the associated microbiology and virology of these injuries as well as their management.

Bite injuries to the hand - review of the literature

Patients presenting to the emergency department with bite injuries to the hand sustain them through a number of causes including domesticated as well as stray animal bites, and human bites commonly sustained as a result of violence. The nature of the injuries sustained can be very deceptive. A small tooth mark on the exterior can be a fulminant infection in the tissues deeper down. Tendon injuries, fractures of the metacarpals and phalanges and management of the wound are critical issues faced by a surgeon in dealing with such patients. Similarly the less common bite injuries to the hand, often with disastrous and sometimes fatal complications, do also present to the emergency department. A high incidence of suspicion is needed in dealing with these injuries effectively. In our article we discuss the common as well as uncommon causes of bite injuries to the hand and their management. In addition to reviewing the literature to ascertain the management of such injuries, we also discuss interesting and rare case reports.

Analysis of functional outcome after posttraumatic thumb reconstruction in comparison to nonreconstructed amputated thumbs at the proximal phalanx of the thumb ray: a mid-term follow-up with special attention to the Manchester-modified M2 DASH questionnaire and effect size of Cohen's d

BACKGROUND

Pollicization, toe to thumb transfer, and osteoplastic thumb reconstruction, along with free tissue transfer, are the most reported reconstructive procedures after traumatic amputation at the proximal and middle third of the thumb. We will present our clinical studies on functional outcomes with special attention to the M2 DASH questionnaire and effect size of Cohen's d.

METHODS

Eleven patients (2 women and 9 men) with posttraumatic thumb reconstruction (three pollicizations of the index or index stump, four free lateral arm osteocutaneous neurosensory flaps, and four microvascular second toe to thumb transfers), performed during the period 2000 to 2007, were reexamined after 4.2 (SD ±2.1) years (range, 2-7 years postinjury). To ensure homogeneity among the patients' data, we selected only patients with isolated thumb amputations at the level of the proximal phalanx.

RESULTS

The total M2-DASH score after thumb reconstruction was 18.55 (SD ±16.79). The M2-DASH score of patients with nonreconstructed thumbs was 32.77 (SD ±18.87). Pairwise comparisons between reconstructed and amputated thumbs showed statistically significant differences (Wilcoxon rank-sum test, p value = 0.03) and a highly effective improvement of hand function (Cohen's d = 1.10) after thumb reconstruction relative to amputated thumbs.

CONCLUSION

Before selecting a candidate for thumb reconstruction, it is critical to decide on an individualized treatment plan. Factors such as the patient's occupation and the importance of the aesthetic appearance of the thumb must be carefully considered. The surgeon must investigate the patient's current use pattern and functional requirements before considering a reconstructive treatment.

An assessment of patient satisfaction with nonoperative management of clavicular fractures using the disabilities of the arm, shoulder and hand outcome measure

BACKGROUND

Clavicle fractures historically have been managed without internal fixation. Current literature is raising questions regarding this management as opposed to offering operative fixation in some instances. This study addresses the use of the Disabilities of the Arm, Shoulder and Hand (DASH) outcomes measure to identify those that have the least satisfaction with nonoperative care of the clavicle fracture based upon clavicular deformity and variation in fracture location based upon Allman Classification.

METHODS

Patients having suffered clavicle fractures were mailed the DASH Outcomes Questionnaire to be completed and returned. A total of 113 surveys were returned completed with 92 being of value for evaluation. Patient chest or clavicle radiographs were evaluated, and measurements were made of the clavicle fractures for amount of separation or shortening and grade according to Allman Classification. Statistical evaluation compared DASH Scores (patient satisfaction as outcome measure) to the Allman Classification and the degree of separation or shortening. Comparison of categorical variables was performed using Fisher's exact test. Comparison of continuous variables was preformed using Student's t test. Statistical significance was demonstrated by a p value of less than 0.05.

RESULTS

Patients with clavicular shortening of greater than 2 cm were found to have the highest DASH score indicating dissatisfaction and disability with their outcome postinjury (p = 0.0001). Separation or lengthening seemed to be associated with lower DASH Scores. Patients with Allmen Classification I (midshaft clavicle) fractures had higher DASH score than other fracture locations (p = 0.0001).

CONCLUSIONS

Patients with midshaft clavicle fractures with shortening of greater than 2 cm may be good candidates for operative repair given the degree of dissatisfaction with nonoperative management of these fractures as assessed by long-term outcome measures of disability.

An investigation of the relationship between measures of pain intensity, pain affect, and disability, in patients with shoulder dysfunction

OBJECTIVES

Numerous outcomes measures can be used to capture and differentiate change in different constructs comprising recovery. Consequently, patients are often burdened by completing a number of measures which involves considerable time and effort. The purpose of this longitudinal, observational study was to identify the number of dimensions in a battery of self-report findings in a patient population who received shoulder injections to investigate the association of the instruments.

METHODS

Ninety-nine subjects, with diagnoses of adhesive capsulitis, labral injuries, rotator cuff injuries, and osteoarthritis completed outcomes measures including five different forms of pain intensity measures, the McGill Short Form Questionnaire, and the Disabilities of the Arm, Shoulder, and Hand Questionnaire. Change scores were calculated at 4 weeks and an exploratory factor analysis (EFA) with varimax rotation was used to analyze dimensionality. The relationship between the raw scores of the seven measures was investigated using a correlation matrix.

RESULTS

The EFA yielded only one factor and the raw score correlations demonstrated very strong, significant associations. The finding of a single factor suggests that in this sample of patients, only one dimension of change, most likely a change in pain, is represented by the seven individual outcomes measures.

DISCUSSION

In this isolated example, one outcomes measure would have been sufficient in determining outcome and could have reduced the administrative burden to the caregivers and the patients.

The validity, reliability, responsiveness, and bias of the Manchester-Modified Disability of the Arm, Shoulder, and Hand score in hand injuries

The Manchester-Modified Disability of Arm, Shoulder and Hand questionnaire (M(2) DASH) was developed by the authors as a modification to the original DASH questionnaire. In this study, we assessed the validity, reliability, responsiveness, and bias of the M(2) DASH questionnaire for hand injuries using completed M(2) DASH, Patient Evaluation Measure, and Michigan Hand Outcome questionnaires from 40 patients. The M(2) DASH scores showed significant positive correlations with the Patient Evaluation Measure and Michigan Hand Outcome scores suggesting validity. There was also no evidence of a statistical difference in the M(2) DASH scores when the condition had stabilized suggesting good test-retest reproducibility and reliability. The effect size and the standardized response mean for the M(2) DASH score were greater than those for the Patient Evaluation Measure and Michigan Hand Outcome scores establishing that the M(2) DASH is highly responsive. There was no gender, hand dominance, or dominant side injured bias for the M(2) DASH score. There was, however, a relatively weak association between age and the M(2) DASH score at presentation. We conclude that the M(2) DASH questionnaire is a robust region-specific outcome measure. It is a valid and responsive questionnaire with test-retest reliability proven for hand injuries in this study. Gender, handedness, and side injured did not cause bias in the responses.