Chaitanya S. Mudgal

Predictors of Pain Intensity and Disability After Minor Hand Surgery

PURPOSE To test the null hypothesis that there is no relationship between coping mechanisms and depression measured before surgery, and pain intensity and disability after surgery, as assessed at the time of suture removal. METHODS A total of 120 patients (39 electing surgery for carpal tunnel syndrome, 65 for trigger finger, and 16 for a benign tumor) completed questionnaires measuring depression, pain self-efficacy (confidence that one can perform various activities despite pain), pain anxiety (fear and anxiety in response to pain sensations), and pain catastrophizing (maladaptive cognitive activities such as pain-related rumination, magnification, and helplessness) before surgery. Before the surgery and at the time of suture removal (10 to 14 days after surgery) participants completed the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and a numerical pain intensity rating scale. RESULTS At the time of suture removal, there was a significant correlation between pain intensity and depression (r = 0.45, p<.001), pain catastrophizing (r = 0.41, p<.001), pain anxiety (r = 0.32, p<.01), and self-efficacy (r = -0.29, p<.01). Disability correlated with self-efficacy (r = -0.34; p<.001) and depression (r = 0.49; p<.001), but not with pain anxiety and catastrophizing (p>.05). In multivariate analyses, depression was the sole predictor of both disability and pain intensity and accounted for 26% of the variance in DASH scores and 25% of the variance in pain intensity, after removing the influence of preoperative DASH and diagnosis, which accounted for 14% variance. CONCLUSIONS Psychosocial factors, especially depression, explain a notable proportion of the variation in pain intensity and disability after minor hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic I.

Wrist Mobilization Following Volar Plate Fixation of Fractures of the Distal Part of the Radius

BACKGROUND Plate fixation of the distal part of the radius is believed to improve wrist motion by allowing earlier exercises. We performed a clinical trial comparing mobilization of the wrist joint within two weeks (early motion) or at six weeks (late motion) after volar plate fixation of a fracture of the distal part of the radius in order to test the null hypothesis that there are no differences in the flexion-extension arc three and six months after surgery. METHODS Sixty patients with an isolated fracture of the distal part of the radius that was treated with a single, fixed-angle volar plate and screws were enrolled. Thirty patients were randomized to the early motion group, and thirty were randomized to the late motion group. Three and six months after surgery, patients underwent range of motion measurements, grip strength measurements, and radiographic evaluation. The patients also were evaluated according to the modified Gartland and Werley score and the Mayo wrist score, rated pain on a 10-point ordinal scale, and completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS There were no significant differences between the early motion group and the late motion group with regard to the average flexion-extension arc of the injured wrist at three months (104 degrees compared with 107 degrees; p = 0.61) or six months (124 degrees compared with 126 degrees; p = 0.65) after surgery. In secondary analyses, there were no significant differences in terms of selected other motions, grip strength, radiographic parameters, or the Gartland and Werley, Mayo, pain, or DASH scores. CONCLUSIONS The initiation of wrist exercises six weeks after volar plate fixation of a fracture of the distal part of the radius does not lead to decreased wrist motion compared with the initiation of wrist motion within two weeks after surgery.

Complications of total elbow arthroplasty.

Abstract Modifications in implant design and improvements in surgical technique have expanded the applications of total elbow arthroplasty. Complications associated with reconstructive elbow surgery persist, however, often leading to profound and sometimes nonsalvageable disability. The most recognized complications include implant loosening, periprosthetic fracture, implant failure, infection, triceps insufficiency, and nerve palsy. Although far fewer elbow arthroplasties than lower extremity arthroplasties are performed, the proportion of complications is greater with elbow arthroplasty, and the outcomes of secondary reconstruction are less favorable.

A Prospective Randomized Controlled Trial of Injection of Dexamethasone Versus Triamcinolone for Idiopathic Trigger Finger

PURPOSE This study was designed to test the null hypothesis that there is no difference in resolution of triggering 3 months after injection with either a soluble (dexamethasone) or insoluble (triamcinolone) corticosteroid for idiopathic trigger finger. METHODS Eighty-four patients were enrolled in a prospective randomized controlled trial comparing dexamethasone and triamcinolone injection for idiopathic trigger finger. Sixty-seven patients completed the 6-week follow-up (35 triamcinolone arm, 32 dexamethasone arm), and 72 patients completed the 3-month follow-up (41 triamcinolone arm, 31 dexamethasone arm). Outcome measures included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, trigger finger grading according to Quinnell, and satisfaction on a visual analog scale. To preserve autonomy, patients were permitted additional injections and operative treatment at any time. Twenty-five patients requested a second injection (10 triamcinolone arm, 15 dexamethasone arm), and 21 elected operative treatment (10 triamcinolone arm, 11 dexamethasone arm) during the study period. The analysis was according to intention to treat principles. RESULTS Six weeks after injection, absence of triggering was documented in 22 of 35 patients in the triamcinolone cohort and in 12 of 32 patients in the dexamethasone cohort. The rates 3 months after injection were 27 of 41 in the triamcinolone cohort and 22 of 31 in the dexamethasone cohort. The triamcinolone cohort had significantly better satisfaction and Quinnell grades than did the dexamethasone cohort at the 6-week follow-up but not at the 3-month follow-up. There were no significant differences between Disabilities of the Arm, Shoulder, and Hand scores at the 6-week follow-up and the 3-month follow-up. After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort. CONCLUSIONS Although there were no differences 3 months after injection, our data suggest that triamcinolone may have a more rapid but ultimately less durable effect on idiopathic trigger finger than does dexamethasone.

Scapho-lunate diastasis in fractures of the distal radius. Pathomechanics and treatment options

The concurrence of scapho-lunate diastasis and distal radial fractures is now well established. External fixation is considered to be one of the best methods of treating distal radial fractures, but in the presence of ligament injury, distraction fixation may lead to carpal instability and chronic wrist pain. We have reviewed existing English literature and analyzed possible mechanisms of injury, and offer some suggestions towards treatment of this combination of injuries.

Radiocarpal fracture-dislocation.

Radiocarpal fracture-dislocation is an uncommon but complex injury that is often the result of high energy trauma. The combination of ligamentous and osseous injuries demands meticulous attention to restoration of anatomy, especially of the radial styloid. Open reduction and internal fixation is often necessary to restore the relationship of the end of the radius to the carpus and distal ulna. We present a retrospective review of 12 patients treated over a 10-year period and review the literature.

A Prospective Randomized Controlled Trial of Dynamic Versus Static Progressive Elbow Splinting for Posttraumatic Elbow Stiffness

BACKGROUND Both dynamic and static progressive (turnbuckle) splints are used to help stretch a contracted elbow capsule to regain motion after elbow trauma. There are advocates of each method, but no comparative data. This prospective randomized controlled trial tested the null hypothesis that there is no difference in improvement of motion and Disabilities of the Arm, Shoulder and Hand (DASH) scores between static progressive and dynamic splinting. METHODS Sixty-six patients with posttraumatic elbow stiffness were enrolled in a prospective randomized trial: thirty-five in the static progressive and thirty-one in the dynamic cohort. Elbow function was measured at enrollment and at three, six, and twelve months later. Patients completed the DASH questionnaire at enrollment and at the six and twelve-month evaluation. Three patients asked to be switched to static progressive splinting. The analysis was done according to intention-to-treat principles and with use of mean imputation for missing data. RESULTS There were no significant differences in flexion arc at any time point. Improvement in the arc of flexion (dynamic versus static) averaged 29° versus 28° at three months (p = 0.87), 40° versus 39° at six months (p = 0.72), and 47° versus 49° at twelve months after splinting was initiated (p = 0.71). The average DASH score (dynamic versus static) was 50 versus 45 points at enrollment (p = 0.52), 32 versus 25 points at six months (p < 0.05), and 28 versus 26 points at twelve months after enrollment (p = 0.61). CONCLUSIONS Posttraumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of six to twelve months, and patience is warranted. There were no significant differences in improvement in motion between static progressive and dynamic splinting protocols, and the choice of splinting method can be determined by the patients and their physicians.

Scapho-lunate diastasis : a component of fractures of the distal radius

Ten cases of fractures of the distal radius associated with scapho-lunate diastasis are reported. The mechanism of injury has been described and an attempt made to analyse the implications in treating such an injury.

Computerized adaptive testing of psychological factors: relation to upper-extremity disability.

BACKGROUND Psychological factors are important mediators of the differences between impairment and disability. The most commonly used measures of disability and psychological factors are lengthy and are usually administered as paper questionnaires. The aim of this study was to assess the correlation between perceived disability and psychological factors with use of the user-friendly, web-based Patient Reported Outcomes Measurement Information System initiative, and to compare its correlation with a frequently used, paper-based, pain self-efficacy questionnaire. METHODS A cohort of 213 patients completed a web-based version of the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the pain self-efficacy questionnaire, the Patient Reported Outcomes Measurement Information System-based computerized adaptive testing Pain Interference questionnaire, and the Patient Reported Outcomes Measurement Information System-based computerized adaptive testing Depression questionnaire. Bivariate and multivariable analyses measured the correlation of these psychological measures with QuickDASH. RESULTS There was large correlation between QuickDASH and the Pain Interference computerized adaptive testing (r = 0.74; p < 0.001), between the Pain Interference computerized adaptive testing and the pain self-efficacy questionnaire (r = -0.72; p < 0.001), and between QuickDASH and the pain self-efficacy questionnaire (r = -0.76; p < 0.001). The Depression computerized adaptive testing showed a medium correlation both with QuickDASH (r = 0.37; p < 0.001) and with the Pain Interference computerized adaptive testing (r = 0.40; p < 0.001). The best multivariable model for QuickDASH included the Pain Interference computerized adaptive testing, prior treatment received, and smoking, and accounted for 57% of the variability. Fifty-one percent of the variability in the QuickDASH was explained by pain interference alone. CONCLUSIONS Maladaptive responses to upper-extremity pain are accurately measured by the relatively user-friendly Patient Reported Outcomes Measurement Information System-based computerized adaptive testing questionnaire.

Plate Fixation of Osteoporotic Fractures of the Distal Radius

Fractures of the distal radius in patients with osteoporosis constitute a unique challenge for the surgeon. They are by nature most commonly seen in the elderly population. Our understanding of the age, physiology, and functionality of the elderly has evolved considerably over the last two decades. Often these fractures simply affect a patients already-compromised functional status. However, in active elderly adults they can also substantially reduce the functionality, and this can have a significant impact on their ability to care for themselves, pursue avocational activities, or both. In carefully selected patients, even in the face of osteoporosis, plate fixation of these fractures has satisfying outcomes for both the patient and the surgeon and must be considered part of a surgeons armamentarium in the contemporary treatment of osteoporotic fractures of the distal radius.