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Mitchell T, Hamilton N, Dean B, Rodgers S, Fowler-Davis S, McLean S. A scoping review to map evidence regarding key domains and questions in the management of non-traumatic wrist disorders. HAND THERAPY 2024; 29:3-20. [PMID: 38425437 PMCID: PMC10901165 DOI: 10.1177/17589983231219595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/21/2023] [Indexed: 03/02/2024]
Abstract
Introduction Non-traumatic wrist disorders (NTWD) are commonly encountered yet sparse resources exist to aid management. This study aimed to produce a literature map regarding diagnosis, management, pathways of care and outcome measures for NTWDs in the United Kingdom. Methods An interdisciplinary team of clinicians and academic researchers used Joanna Briggs Institute guidelines and the PRISMA ScR checklist in this scoping review. A mixed stakeholder group of patients and healthcare professionals identified 16 questions of importance to which the literature was mapped. An a-priori search strategy of both published and non-published material from five electronic databases and grey literature resources identified records. Two reviewers independently screened records for inclusion using explicit eligibility criteria with oversight from a third. Data extraction through narrative synthesis, charting and summary was performed independently by two reviewers. Results Of 185 studies meeting eligibility criteria, diagnoses of wrist pain, De Quervain's syndrome and ulna-sided pain were encountered most frequently, with uncontrolled non-randomised trial or cohort study being the most frequently used methodology. Diagnostic methods used included subjective questioning, self-reported pain, palpation and special tests. Best practice guidelines were found from three sources for two NTWD conditions. Seventeen types of conservative management, and 20 different patient-reported outcome measures were suggested for NTWD. Conclusion Substantial gaps in evidence exist in all parts of the patient journey for NTWD when mapped against an analytic framework (AF). Opportunities exist for future rigorous primary studies to address these gaps and the preliminary concerns about the quality of the literature regarding NTWD.
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Affiliation(s)
- Thomas Mitchell
- Health Research Institute, Sheffield Hallam University, Sheffield, UK
| | - Nick Hamilton
- Health Research Institute, Sheffield Hallam University, Sheffield, UK
| | - Ben Dean
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Sarah Rodgers
- The Hand Unit, Northern General Hospital, Sheffield, UK
| | | | - Sionnadh McLean
- Health Research Institute, Sheffield Hallam University, Sheffield, UK
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Andersson JK, Hagert EM, Fridén J. Patients With Triangular Fibrocartilage Complex Injuries and Distal Radioulnar Joint Instability Gain Improved Forearm Peak Pronation and Supination Torque After Reinsertion. Hand (N Y) 2020; 15:281-286. [PMID: 30081654 PMCID: PMC7076604 DOI: 10.1177/1558944718793198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Forearm peak pronation and supination torque measurements are reduced up to 30% in patients with triangular fibrocartilage complex (TFCC) 1B injuries with concomitant distal radioulnar joint (DRUJ) instability. The aim of our study was to evaluate whether patients with TFCC 1B injuries, with concomitant DRUJ instability, improve in forearm peak pronation and supination torque following TFCC reinsertion surgery where postoperative DRUJ stability was achieved. Methods: We report a retrospective case series with short-term follow-up (20 months) of the postoperative forearm peak torque in pronation and supination in 11 patients (9 women/2 men, average age at surgery 32 years) operated on by TFCC reinsertion. Two of the initial 13 patients were later on reoperated due to recurring DRUJ instability and were therefore excluded in this follow-up study. Nine were treated by arthroscopic TFCC reinsertion and 2 by open technique. The forearm peak pronation and supination torque were measured pre- and postoperatively and compared with the uninjured side. Results: On average, a 16% improvement of the forearm peak torque was achieved in the injured wrist, as well as clinically assessed DRUJ stability. Functional postoperative improvement was noted in all patients, with reduced pain, good satisfaction, and acceptance of the surgery and the final result. Conclusion: We conclude that patients with TFCC injuries and DRUJ instability gain improved forearm peak pronation and supination torque after reinsertion. We also conclude that forearm peak pronation and supination torque is a valuable tool in the preoperative diagnostics of TFCC injuries with DRUJ instability as well as in the postoperative follow-up.
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Affiliation(s)
- Jonny K. Andersson
- SportsMed, Göteborg, Sweden,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Jonny K. Andersson, SportsMed, Carlanderska Hospital, SE-405 45 Göteborg, Sweden.
| | - Elisabet M. Hagert
- Karolinska Institute, Stockholm, Sweden,ARCADEMY Stockholm, Sophiahemmet Hospital, Stockholm, Sweden
| | - Jan Fridén
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Sahlgrenska University Hospital, Mölndal, Sweden,Swiss Paraplegic Centre, Nottwil, Switzerland
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Andersson JK, Axelsson P, Strömberg J, Karlsson J, Fridén J. Patients with triangular fibrocartilage complex injuries and distal radioulnar joint instability have reduced rotational torque in the forearm. J Hand Surg Eur Vol 2016; 41:732-8. [PMID: 26701974 DOI: 10.1177/1753193415622342] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/17/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED A total of 20 patients scheduled for wrist arthroscopy, all with clinical signs of rupture to the triangular fibrocartilage complex and distal radioulnar joint instability, were tested pre-operatively by an independent observer for strength of forearm rotation. During surgery, the intra-articular pathology was documented by photography and also subsequently individually analysed by another independent hand surgeon. Arthroscopy revealed a type 1-B injury to the triangular fibrocartilage complex in 18 of 20 patients. Inter-rater reliability between the operating surgeon and the independent reviewer showed absolute agreement in all but one patient (95%) in terms of the injury to the triangular fibrocartilage complex and its classification. The average pre-operative torque strength was 71% of the strength of the non-injured contralateral side in pronation and supination. Distal radioulnar joint instability with an arthroscopically verified injury to the triangular fibrocartilage complex is associated with a significant loss of both pronation and supination torque. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- J K Andersson
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - P Axelsson
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - J Strömberg
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
| | - J Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - J Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
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Kirchberger MC, Unglaub F, Mühldorfer-Fodor M, Pillukat T, Hahn P, Müller LP, Spies CK. Update TFCC: histology and pathology, classification, examination and diagnostics. Arch Orthop Trauma Surg 2015; 135:427-37. [PMID: 25575720 DOI: 10.1007/s00402-015-2153-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 02/09/2023]
Abstract
The TFCC is a crucial stabilizer of the DRUJ. Based on its superficial and deep fibers, the TFCC guarantees unrestricted pronation and supination which is essential for performing sophisticated tasks. The ability to perform complex movements is of uppermost importance for hand function. Therefore, a functional intact TFCC is a prerequisite in this context. The articular disc of the TFCC is a fibrocartilaginous extension of the superficial zone of hyaline articular cartilage which arises from the radius. The peripheral 10-40 % of the TFC is vascularized. Degeneration of the articular disc is common with increasing age. Even though the central part of the articular disc is avascular, potential regeneration of lesions could be detected. The Palmer and Atzei classifications of TFCC lesions are complementary. TFCC innervation is based on different nerves. There is a high variability. A diligent clinical examination facilitates specific tests which help to allocate symptoms to the pathology. Therefore, a thorough clinical examination is not dispensable. Wrist arthroscopy remains the "gold standard" for diagnosing TFCC pathologies despite technical progress in imaging modalities. MR arthrography may have the potential to become a real alternative to wrist arthroscopy for diagnosing TFCC pathologies with technical progress in the future.
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Affiliation(s)
- Michael C Kirchberger
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
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Prosser R, Hancock MJ, Nicholson LL, Harvey LA, LaStayo P, Hargreaves I, Scougall P, Herbert R. Prognosis and prognostic factors for patients with persistent wrist pain who proceed to wrist arthroscopy. J Hand Ther 2013; 25:264-9; quiz 270. [PMID: 22794500 DOI: 10.1016/j.jht.2012.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 02/27/2012] [Accepted: 03/08/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED Wrist pain is common. People with persistent pain commonly undergo arthroscopic investigation. Little is known about the prognosis or prognostic factors for these patients. The purpose of the study was to evaluate prognosis and prognostic factors for pain and functional disability in patients with persistent wrist pain who proceed to arthroscopic investigation. The study design used was a prospective cohort study. One hundred and five consecutive participants who underwent arthroscopic investigation for undiagnosed wrist pain for at least four-week duration were recruited. Patient-rated wrist and hand evaluation (PRWHE) scores were determined at baseline (before arthroscopy) and one year after arthroscopy. One-year follow-up data were obtained for 97 (92%) of 105 participants. Mean PRWHE total score declined from 49 of 100 (standard deviation [SD] 18.5) at baseline to 26 of 100 (SD 20.4) at one year. Two prognostic factors were identified: baseline PRWHE and duration of symptoms. These factors explained 19% and 5% of the variability in the final PRWHE score, respectively. Results of provocative wrist tests and arthroscopic findings did not significantly contribute to prognosis in this cohort. This study provides the first robust evidence of the prognosis of persistent wrist pain. Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability. Duration of pain and PRWHE at baseline explained 24% of the one-year PRWHE score. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Rosemary Prosser
- Sydney Hand Therapy and Rehabilitation Centre, Level 6, 187 Macquarie Street, Sydney 2000, Australia.
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Prosser R, Harvey L, Lastayo P, Hargreaves I, Scougall P, Herbert RD. Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study. J Physiother 2012; 57:247-53. [PMID: 22093123 DOI: 10.1016/s1836-9553(11)70055-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
QUESTION What is the diagnostic value of provocative wrist tests and magnetic resonance imaging (MRI) for suspected wrist ligament injuries? DESIGN Cross-sectional study. PARTICIPANTS 105 people presenting to hand clinics with wrist pain and suspected wrist ligament injuries were evaluated prospectively. OUTCOME MEASURES The integrity of wrist ligaments was tested with seven provocative tests. The results were compared to the reference standard of arthroscopy. In a subgroup of 55 participants, MRI findings were also compared to arthroscopy. The provocative tests were the scaphoid shift test (SS test), lunotriquetral test (LT test), midcarpal test (MC test), distal radioulnar joint test (DRUJ test), triangular fibrocartilage complex (TFCC) stress test (TFCC test), TFCC stress test with compression (TFCC comp test), and the gripping rotatory impaction test (GRIT). RESULTS Most provocative tests and MRI findings were of little or no value for diagnosing wrist ligament injuries. Exceptions were the SS test (+ve LR 2.88 and -ve LR 0.28), MC test (+ve LR 2.67) and DRUJ test (-ve LR 0.30), all of which were of mild diagnostic usefulness. MRI was moderately useful for diagnosing TFCC injuries (+ve LR 5.56, -ve LR 0.15), and was mildly useful for diagnosing scapholunate (SL) ligament injuries (+ve LR 4.17, -ve LR 0.32) and lunate cartilage damage (+ve LR 3.67, -ve LR 0.33). Adding MRI to provocative tests improved the accuracy of diagnosis of TFCC injuries slightly (by 13%) and lunate cartilage damage (by 8%). CONCLUSION Provocative wrist tests of SL ligament injuries and midcarpal ligament injuries are mildly useful for diagnosing wrist injuries. MRI diagnostic findings of SL ligament injuries, lunate cartilage damage, and TFCC are mildly to moderately useful. MRI slightly improves the diagnosis of TFCC injury and lunate cartilage damage compared to provocative tests alone.
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Prosser R, Herbert R, LaStayo PC. Current practice in the diagnosis and treatment of carpal instability--results of a survey of Australian hand therapists. J Hand Ther 2007; 20:239-42; quiz 243. [PMID: 17658417 DOI: 10.1197/j.jht.2007.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A postal survey of all 85 full Australian Hand Therapy Association (AHTA) members was carried out to determine the current practice of the diagnosis and treatment of carpal instability by AHTA members. There was an 87% return rate. On average therapists saw 3.8 patients/month with carpal instability. Time from onset of pain or injury was a median of eight weeks (inter-quartile range 0-26 weeks). Ulnar pain was reported in 39% of patients, central pain in 17%, radial pain in 13%, and combined in 34%. Mean pain intensity at rest was 3.5/10 (SD 2.8), and with aggravating activity was 7.7 (SD 2.2). Forty-seven percent of patients reported difficulties with grip-related activities. Mean grip strength was 67% of the contralateral side. The most commonly used tests used were scaphoid shift, lunotriquetral ballotment, triangular fibrocartilage complex, and midcarpal stress tests. The most used treatments were patient education (advice and activity modification), splinting the wrist, and isometric exercising of the wrist musculature.
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Abstract
A briefcase report is presented that demonstrates the advantage of the therapist's viewing of a series of wrist x-rays in guiding the clinical management of a patient with an ulnar plus configuration. The positive findings revealed on these images facilitated an improved outcome. This case is offered to encourage therapists to routinely look at x-rays in their clinical practice.
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Tay SC, Berger RA, Tomita K, Tan ET, Amrami KK, An KN. In vivo three-dimensional displacement of the distal radioulnar joint during resisted forearm rotation. J Hand Surg Am 2007; 32:450-8. [PMID: 17398354 DOI: 10.1016/j.jhsa.2007.01.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Revised: 01/05/2007] [Accepted: 01/08/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The in vivo displacement of the distal radioulnar joint (DRUJ) while under resisted pronation or supination has never been previously quantified. Being a joint with 3 dimensions of motion (dorsopalmar translation, changes in ulnar variance, and radioulnar coaptation), our purpose was to determine its 3-dimensional (3D) displacement during resisted rotational torque. METHODS Ten normal subjects (aged 31.8 years+/-7.8; F, 5; M, 5) were recruited. Computed tomography scans of a subjects' distal forearms were obtained while grasping the handles of a custom apparatus to keep the fist and forearm in neutral rotation. Scanning was performed in 3 conditions: no rotational torque (control), maximum isometric supination, and maximum isometric pronation. The 3D displacement of the DRUJ, using the ulnar fovea as the reference point, during isometric rotational torque was determined using markerless bone registration techniques. RESULTS The mean 3D displacement of the ulnar fovea during maximum isometric pronation and maximum isometric supination was 3.09 mm+/-0.94 and 2.17 mm+/-1.55, respectively. During maximum isometric pronation, the ulnar fovea displaced a mean of 0.51 mm+/-1.79 dorsally. During maximum isometric supination, the ulnar fovea displaced a mean of 0.13 mm+/-2.07 volarly. In both conditions, ulnar variance increased (0.23 mm+/-2.52 for isometric pronation and 0.44 mm+/-1.57 for isometric supination), and there was increased radioulnar coaptation (0.37 mm+/-0.86 for isometric pronation, 0.039 mm+/-0.66 for isometric supination). CONCLUSIONS Resisted rotational torque can be applied to the DRUJ while in neutral rotation during computed tomography imaging, producing measurable displacements in 3D. This technique of studying the DRUJ has the potential to improve our ability to detect and quantify instabilities of the DRUJ.
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Affiliation(s)
- Shian Chao Tay
- Orthopaedics Biomechanics Laboratory, the Division of Hand Surgery, the Department of Radiology, and the Mayo Graduate School, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Abstract
The forearm complex is comprised of the proximal radioulnar joint, middle radioulnar joint/interosseous membrane, and the distal radioulnar joint. These three areas function in a coordinated manner to rotate the hand in space and allow performance of functional tasks. If a structure or structures in one of these three areas is disrupted, this can adversely affect the function at any of the other two remaining areas. Surgical intervention focuses on restoring anatomical alignment to preserve the function of the forearm complex. Rehabilitation is guided by the relationships between the three areas of the forearm complex and the awareness of clinical signs, symptoms, and complications. The purposes of this paper are to 1) describe the anatomy and biomechanical function of the forearm complex and 2) discuss clinical correlates pertaining to select forearm injuries (excluding peripheral nerve injuries) that may affect forearm function.
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Affiliation(s)
- Paul C LaStayo
- University of Utah, Division of Physical Therapy, Department of Orthopedics and Exercise and Sport Sciences, Salt Lake City, Utah 84108, USA.
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