We developed a self-administered questionnaire for the assessment of severity of symptoms and functional status in patients who have carpal tunnel syndrome. The reproducibility, internal consistency, validity, and responsiveness to clinical change of scales for the measurement of severity of symptoms and functional status were evaluated in a clinical study. The scales were highly reproducible (Pearson correlation coefficient, r = 0.91 and 0.93 for severity of symptoms and functional status, respectively) and internally consistent (Cronbach alpha, 0.89 and 0.91 for severity of symptoms and functional status, respectively). Both scales had positive, but modest or weak, correlations with two-point discrimination and Semmes-Weinstein monofilament testing (Spearman coefficient, r = 0.12 to 0.42). In thirty-eight patients who were operated on in 1990 and were evaluated a median of fourteen months postoperatively, the mean symptom-severity score improved from 3.4 points preoperatively to 1.9 points at the latest follow-up examination, while the mean functional-status score improved from 3 to 2 points (5 points is the worst score and 1 point is the best score for each scale). Similar improvement was noted in twenty-six patients who were evaluated before and three months after the operation. We concluded that the scales for the measurement of severity of symptoms and functional status are reproducible, internally consistent, and responsive to clinical change, and that they measure dimensions of outcomes not captured by traditional measurements of impairment of the median nerve. These scales should enhance standardization of measurement of outcomes in studies of treatment for carpal tunnel syndrome.

A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome.

Tendon disorders are frequent and are responsible for substantial morbidity both in sports and in the workplace. Tendinopathy, as opposed to tendinitis or tendinosis, is the best generic descriptive term for the clinical conditions in and around tendons arising from overuse. Tendinopathy is a difficult problem requiring lengthy management, and patients often respond poorly to treatment. Preexisting degeneration has been implicated as a risk factor for acute tendon rupture. Several physical modalities have been developed to treat tendinopathy. There is limited and mixed high-level evidence to support the, albeit common, clinical use of these modalities. Further research and scientific evaluation are required before biological solutions become realistic options.

http://health120years.com/cn/pdf/hd_tendonopathy_tendinosis_healing_repair.pdf

Tendon injury and tendinopathy: healing and repair.

Based on anatomic and biomechanical studies and review of our clinical experience of the past 10 years, a classification of injuries to the triangular fibrocartilage complex is presented. This classification is based on the clinical examination, routine x-ray films, wrist arthrograms, wrist arthroscopy, and wrist arthrotomy. The classification recognizes both traumatic and degenerative lesions. Traumatic lesions are classified according to their location. Degenerative lesions are classified by the location and severity of degenerative changes of the triangular fibrocartilage complex, ulnar head, ulnocarpal bones and lunotriquetral ligament.

Triangular fibrocartilage complex lesions: A classification

This paper presents a conceptual model for the pathogenesis of work-related musculoskeletal disorders. The model contains sets of cascading exposure, dose, capacity, and response variables, such that response at one level can act as dose at the next. Response to one or more doses can diminish or increase the capacity for responding to successive doses. The model is used as a framework for discussing the development of work-related muscle, tendon, and nerve disorders. It is intended as a beginning, to be modified to explain new findings as they become available. In research, it can help to identify areas needing additional data for the development and expression of work-related musculoskeletal disorders. Researchers can use it to design laboratory and field studies. In practice, it demonstrates the relationship between common exposure factors and different responses. This information can be used to evaluate and design jobs for the prevention of work-related musculoskeletal disorders.

A Conceptual Model for work-related Neck and upper-limb Musculoskeletal Disorders

The sensitivity and specificity of nerve conduction studies (NCS's) and electromyography (EMG) for the diagnosis of carpal tunnel syndrome (CTS) were evaluated by a critical review of the literature. With a search of the medical literature in English through May 1991, 165 articles were identified and reviewed on the basis of six criteria of scientific methodology. The findings of 11 articles that met all six criteria and the results of 48 additional studies that met four or five criteria are presented. We concluded that median sensory and motor NCS's are valid and reproducible clinical laboratory studies that confirm a clinical diagnosis of CTS with a high degree of sensitivity and specificity. Clinical practice recommendations are made based on a comparison of the sensitivities of the several different median nerve conduction study (NCS) techniques.

Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM Quality Assurance Committee

Background: The number of total shoulder arthroplasties performed in the United States increased slightly between 1990 and 2000. However, the incidence of shoulder arthroplasty in recent years has not been well described. The purpose of the present study was to examine recent trends in shoulder hemiarthroplasty and total shoulder arthroplasty along with the common reasons for these surgical procedures in the United States.

Methods: We modeled the incidence of shoulder arthroplasty from 1993 to 2008 with use of the Nationwide Inpatient Sample. On the basis of hemiarthroplasty and total shoulder arthroplasty cases that were identified with use of surgical procedure codes, we conducted a design-based analysis to calculate national estimates.

Results: While the annual number of hemiarthroplasties grew steadily, the number of total shoulder arthroplasties showed a discontinuous jump (p < 0.01) in 2004 and increased with a steeper linear slope (p < 0.01) since then. As a result, more total shoulder arthroplasties than hemiarthroplasties have been performed annually since 2006. Approximately 27,000 total shoulder arthroplasties and 20,000 hemiarthroplasties were performed in 2008. More than two-thirds of total shoulder arthroplasties were performed in adults with an age of sixty-five years or more. Osteoarthritis was the primary diagnosis for 43% of hemiarthroplasties and 77% of total shoulder arthroplasties in 2008, with fracture of the humerus as the next most common primary diagnosis leading to hemiarthroplasty.

Conclusions: The number of shoulder arthroplasties, particularly total shoulder arthroplasties, is growing faster than ever. The use of reverse total arthroplasty, which was approved by the United States Food and Drug Administration in November 2003, may be part of the reason for the greater increase in the number of total shoulder arthroplasties. A long-term follow-up study is warranted to evaluate total shoulder arthroplasty in terms of patient outcomes, safety, and implant longevity.

Increasing Incidence of Shoulder Arthroplasty in the United States

A 10-center randomized prospective multicenter study of endoscopic release of the carpal tunnel was carried out. Surgery was performed with a new device for transecting the transverse carpal ligament while control hands were treated with conventional open surgery. There were 122 patients in the study; 25 had carpal tunnel surgery on both hands and 97 had surgery on one hand. Of the surgical procedures, 65 were in the control group and 82 were in the device group. The endoscopic device was coupled to a fiberoptic light and a video camera. A trigger-activated blade was used to incise the transverse carpal ligament. After surgery, the best predictors of return to work and to activities of daily living were strength and tenderness variables. For patients in the device group with one affected hand, the median time for return to work was 21½ days less than that for the control group. Two patients treated with the endoscopic device required reoperation by open surgical decompression; only one of these had incomplete release with the device. Two patients in the device group experienced transient ulnar neurapraxia.

Endoscopic release of the carpal tunnel: A randomized prospective multicenter study

We encountered a high incidence of complications related to the technique of tension-band wire fixation of displaced fractures of the olecranon in a five-year retrospective study of twenty patients (twenty fractures). All had been treated with primary open reduction using the AO technique of tension-band wiring. Twenty patients were followed at least to union as determined radiographically. The most frequent complication was symptomatic prominence of the Kirschner wires at the elbow in sixteen patients. There was skin breakdown in four patients, and infection developed in one. Measurable proximal migration of the Kirschner wires, however, occurred in only three patients. Prominence of the Kirschner wires usually was due to improper seating at the time of surgery (twelve of sixteen patients). Most complications that are related to this method of fixation may be avoided by careful attention to surgical technique.

Complications of tension-band wiring of olecranon fractures.

OBJECTIVE: The objective of this study was to evaluate the occurrence of emergency department (ED) visits due to humerus fractures in the United States (U.S.). METHODS: We analyzed the 2008 Nationwide Emergency Department Sample, which contained approximately 28 million ED records. We identified the cases of interest using diagnostic codes for proximal, shaft, and distal humerus fractures. RESULTS: In 2008, approximately 370,000 ED visits in the U.S. resulted from humerus fractures. Proximal humerus fractures were the most common, accounting for 50% of humerus fractures. The incidence rate of proximal humerus fractures followed the shape of an exponential function in the ages 40-84 for women (R(2) =97.9%) and 60-89 for men (R(2) =98.2%). After the exponential increase in these age intervals, the growth rate of proximal humerus fracture slowed and eventually decreased. The peak occurrence of distal humerus fractures was in children aged 5 to 9 years; yet, elderly women had an increased risk. As the baby boomer generation ages, unless fracture prevention programs improve, more than 490,000 ED visits are expected due to humerus fractures in 2030 when the youngest of the baby boomers turn 65 years old. CONCLUSIONS: Compared to epidemiologic studies in Japan and European countries, the incidence rates of humerus fractures are substantially higher in the U.S. The high incidence rate of humerus fractures in the expanding elderly population may contribute to the recent trend of rapid increase in shoulder arthroplasty in the U.S. Rigorous safety measures to reduce falls and improved preventive treatments of osteoporosis are needed. © 2011 by the American College of Rheumatology. Language: en

Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008.

Sensibility testing in peripheral-nerve compression syndromes was investigated in an experimental study in humans. Twelve volunteer subjects had controlled external compression of the median nerve at the carpal tunnel at a level of forty, fifty, sixty, and seventy millimeters of mercury. The subjects were then monitored for thirty to 240 minutes with four sensory tests: two-point discrimination, moving two-point discrimination, Semmes-Weinstein pressure monofilaments, and vibration. Sensory and motor conduction, subjective sensations, and motor strength were also continuously tested. The threshold tests (vibration and Semmes-Weinstein monofilaments testing) consistently reflected gradual decreases in nerve function in both subjective sensation and electrical testing, while the innervation density tests (two-point discrimination and moving two-point discrimination) remained normal until nearly all sensory conduction had ceased. Decreased muscle strength occurred late, and not until changes had already occurred in each of the sensory tests. Threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies, and are being evaluated for clinical use in a variety of peripheral-nerve compression syndromes.

Robert M. Szabo

Papers

Increasing Incidence of Shoulder Arthroplasty in the United States

Endoscopic release of the carpal tunnel: A randomized prospective multicenter study

Complications of tension-band wiring of olecranon fractures.

Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008.

Sensibility testing in peripheral-nerve compression syndromes. An experimental study in humans.