Elbow, Wrist, Hand Pathology & QuickDASH PROM Study

Elbow, Wrist, Hand Pathology

• Presentation by Michael Garrison, PT, DSc, OCS, SCS at ECU

QuickDASH PROM Alteration Study

• Investigated if completing functional tasks before the QuickDASH PROM questionnaire impacts scores
• Patients complete functional tasks before filling out the PROM questionnaire
• Health systems and payers use PROMs to inform quality improvement and value-based payments
• QuickDASH questions involve tasks like opening jars and doing household chores
• The study sought to determine the effect of having patients complete functional tasks before filling out the PROM questionnaire
• QuickDASH Disability/Symptom Score is calculated by a formula considering responses and the number of completed responses
• In a study, one group completed tasks before QuickDASH, and another completed the QuickDASH at baseline and 5 minutes after

Outcome Measures Considerations

• Tasks 1-6 from the QuickDash are often replicated in the clinic
• Achieving the Minimally Clinically Important Difference (MCID) is possible after performing tasks
• Effect size of 0.6 was achieved in this study
• PROMs are utilized in reimbursement models and also used frequently to assess quality of care
• PT research often links interventions to PROM scores
• PROMs are only part of the overall examination

Agenda Topics

• Biceps issues including SLAP lesions
• Elbow dislocations and post-traumatic stiffness
• Ulnar collateral ligament injuries
• Nerve compressions
• Medial and lateral epicondylitis
• Carpal and cubital tunnel syndromes
• Wrist and hand injuries, including tendinopathies
• Flexor tendon repairs

Biceps Injuries and SLAP Lesions

• Include role of long head (LH) biceps in shoulder
• LH biceps is a common source of anterior shoulder pain
• LH biceps may contribute to anterior stability
• Assess rupture proximally vs distally, as distal ruptures are orthopedic emergencies
• SLAP Lesions are lesions to Superior Labral Anterior Posterior
• SLAP Lesions are classified with the Snyder Classification
• It is hard to distinguish between normal and symptomatic anatomy on advanced imaging

SLAP Lesion Treatment & Examination

• Distinguishing normal versus symptomatic anatomy is difficult on advanced imaging
• 72% of asymptomatic subjects over 40 have tears, illustrating challenge of what to treat
• Treatment trends include debridement or repair, dependent on tear type
• Another trend is releasing the LH biceps via tenodesis vs tenotomy
• Examination includes assessing age and onset, location of pain, chief complaint, and physical demands
• Special tests include active compression and Speed's test
• Management options include pain management (debridement and biceps tenodesis)

Evolving SLAP Treatment Trends

• Highly variable results exist with SLAP repair
• Over 35, less than 50% successful
• SLAP repair often results in need for 2nd procedure
• Recent evidence suggests tenodesis may be helpful
• There is no benefit to repair versus biceps tenodesis in military members under the age of 35

SLAP Current Trends & Diagnosis

• A trial of nonoperative care, addressing impairments like GIRD, post-cuff, and scapula issues is indicated
• 8 weeks is adequate for non-operative care trials
• Identify source of symptoms with a trial of injection
• Pain treatment options: SAPs, LHB tendonitis, ACJ
• Instability treatment option: larger labral tear
• Diagnosis is difficult, often requiring MRA or 3T MRI
• Variable anatomy affect diagnosis

Postoperative SLAP Management

• Includes factors like repair vs debridement and associated procedures such as RCR or instability procedures
• Also includes SAD, DCE and biceps tenodesis
• Considers period of immobilization
• Maintaining motion to prevent stiff shoulder
• Rehab progress should be based on impairments and healing with patient centered functional goals

SLAP Repair vs Biceps Tenodesis

• Sling immobilization lasts 2-4 weeks
• Immediate passive motion for biceps tenodesis
• SLAP repair involves motion restriction lasting 4-6 weeks
• Full motion is expected by 6-8 weeks
• Strength progressions begin by 6-8 weeks
• Return to sport: Biceps - 3 months, SLAP repair - 6 months

Distal Biceps Rupture

• Can be diagnosed via a hook test, visible deformity, ecchymosis, and palpable gap
• Tobacco use is related to distal biceps rupture
• Involves mechanism of injury and supination weakness
• Tenderness to palpation(TTP) on radial tuberosity

Distal Bicep Rupture Considerations

• Early surgical repair is advocated
• Inferior outcomes can occur if delayed by more than 4 weeks
• Tendon retraction requires a graft
• Short Head(SH) attaches distally and is more relevant with elbow flexor
• The long head (LH) is a strong supinator
• Experiences 40-60% loss of supination strength
• Experiences 30% loss of elbow flexion
• Non-op is seen with older patient with co-morbidities

Post-Op Distal Bicep Rupture Considerations

• Involves complications such as rupture, infection, fracture
• Tendon integrity is crucial for strength return
• It is important to check the PIN (Posterior Interosseous Nerve)
• Requires a period of immobilization, should avoid full extension, and several weeks of controlled motion with a brace
• Return to full motion by 6-8 weeks
• Return to work/sport dependent on job
• Most return fully within 2-4 months

Ulnar Collateral Ligament

• 50% valgus stability comes from bony constraint, the other half comes from soft tissue
• Soft tissue contributors include flexor pronator mass, FCU, and joint capsule
• UCL structure :anterior and posterior bands
• Reciprocal function exists
• Anterior Band(AB) is tight in extension and laxer in flexion
• Posterior Band(PB)is tight in flexion and laxer in extension
• The Anterior Bundle gives the most valgus resistance

UCL Injuries

• Common in overhead throwers and athletes such as baseball, football, and javelin
• Also common in gymnastics, wrestling, and swimming
• Attenuation injury is usually from constant strain/stretch
• Acute trauma can heal with bracing while attenuation injury will not heal without surgery

UCL Risk Factors

• Fatigue: High pitch counts, exceeding 100 innings per year
• Fatigue: Pitching on consecutive days across multiple teams
• Other risk factors include high velocity pitching, GIRD (Glenohumeral Internal Rotation Deficit), hip internal rotation deficits
• Decreased rotator cuff strength and Core Weakness

UCL Injury Management

• Preventable risk factors
• UCLR (Ulnar Collateral Ligament Reconstruction) and revisions increasing in frequency
• UCLR known as Tommy John surgery
• Nonoperative management is attempted for most
• Timing for athletes dictates treatment
• Pre-op rehab can address shoulder/hip deficits
• Preop Rehab should emphasize conditioning and explain process

Post-Op UCLR Rehab

• Period of immobilization
• Bracing and return of motion by 6-8 weeks
• Monitor motion progress
• Can depend on concomitant procedures
• Risk of Ulnar nerve involvement
• Hamstring autograft done as rehab graft site
• Return to throwing typically takes 10-18 months
• Return to throwing can depend on timing and career trajectory
• Dependent on position (pitcher vs DH)

UCL Summary

• Rising injury rates in high school athletes
• Athlete must be willing to stop throwing
• Conservative trial appropriate for most
• Surgeries will be an option otherwise
• Most athletes return to sport after surgery with an 80% success rate
• Return to sport is not return to prior level of function (PLOF)
• Post-op return to throwing averages 12-18 months

Elbow Dislocation

• Posterolateral elbow dislocation is the most common
• Named for direction of the ulna
• Simple dislocations involve no fracture but are treated in a hinged brace for immediate motion, enabling return to sport within weeks
• Complex dislocations are often unstable and associated with a fracture
• Complex dislocations are treated with controlled motion after cleared by ortho, potentially requiring surgical fixation for early motion

Terrible Triad Elbow

• Elbow dislocation
• Radial head fracture
• Coronoid fracture
• Injury from FOOSH (fall on outstretched hand) with rotation
• Majority are treated operatively via ORIF, LCL reconstruction, and UCL reconstruction
• Results in pain, instability, stiffness

Stiff Elbow

• Presents frequently with a capsular pattern and a loss of flexion greater than extension
• Due to elbow predisposition to contracture, prolonged immobilization should be avoided
• Elbow predisposition to contracture due to congruity of ulnohumeral articulation
• Elbow predispositions to contracture consists of three articulations in one capsule along with blended ligaments
• Elbow motion for ADLs requires 100-degree arc for extension/flexion (30-130 degrees)
• Requires 50-degree rotation, 50 pronation, 50 supination
• Functional impact varies depending on the patient

Physical Therapy for Stiff Elbow

• Includes motion exercises based on impairments
• TherEx (therapeutic exercises) integrated with functional tasks
• Implement dynamic splinting or low load long duration flexibility training
• Weighted stretching
• Mobilization with Movement
• Contract relax techniques

Epicondylitis

• Lateral epicondylitis causes pain with extension and supination
• Medial epicondylitis causes pain with flexion and pronation
• Typically onset in 4th and 5th decades
• Repetitive stress injuries occur from sport, occupation, and/or recreation
• Ergonomic considerations and inadequate physical conditioning are risk factors
• Increased risk with tobacco use
• Can be related to impairments beyond the elbow

Lateral Epicondylitis

• Degenerative condition of the Extensor Carpi Radialis Brevis(ECRB)
• Caused by repetitive wrist extension motions
• Rule out the cervical spine and TOS (Thoracic Outlet Syndrome)
• Special tests include Mill's, Maudsley, and Cozen's tests
• Tenderness at the lateral epicondyle
• Treatment-reassurance and strengthening
• Eccentric exercises for chronic conditions and loading the tendon

Medial Epicondylitis

• Degenerative condition vs inflammatory condition
• Inflammatory - use anti-inflammatory methods
• Degenerative - load tendons, some discomfort
• Overuse in sports and occupational tasks
• Rule out cervical spine and TOS
• Rule out other medial elbow conditions
• Special tests – resisted pronation and flexion
• Tenderness at the medial epicondyle
• Rx - education and resistance training

Epicondylitis PT Management

• Education – natural history, reassurance
• Local Rx - ice, heat, medicated patches
• Grip modifications include palms down, hammer, palm up and change grip size
• Use wrist splinting/forearm support brace (FSB)
• Implement eccentric vs concentric training
• No role for passive interventions in isolation
• Objectively measure progress

Posterior Elbow Pain

• Olecranon bursitis
• It is Primarily inflammatory or septic
• With septic bursitis consider open wound and previous aspiration
• Use compressive wrapping, elevation, NSAIDs
• In addition to tricep tendinitis, check for relative rest and address the impairments
• Implement progressive tendon loading
• With Tricep rupture, monitor for pop, swelling, weakness

Common Nerve Entrapments

• Ulnar Nerve: cubital tunnel syndrome and guyon's canal
• Median Nerve: carpal tunnel syndrome and pronator syndrome
• Radial Nerve: radial nerve proper injury with humeral fx and PIN entrapment at radial tunnel

Cubital Tunnel Syndrome

• Consider Cervical spine (C8-T1), TOS, brachial plexus
• Consider it to be Associated with UCL injuries, and assess tension
• Second most common Upper Extremity (UE) compression neuropathy
• Anatomy includes:
• Roof – FCU and Osborne's ligament
• Floor – Capsule and UCL
• Medial - Medial epicondyle
• Lateral - Olecranon

Cubital Tunnel Syndrome Mechanisms

• Compression vs traction mechanisms
• Narrows during elbow flexion causing pain with prolonged postures
• The pain in the morning (AM pain).
• Role for night splinting
• Traction with valgus stress is associated with throwing
• Transposition procedures with UCLR
• Risk of complications increase with decompression
• Decompression - Arcade of Struthers to FCU, also Transposition – alleviate tension

Cubital Tunnel Syndrome Non-Op Tx

• Education – positional nature of the diagnosis
• Patient must be active part of treatment plan
• Consider Ergonomic changes
• Also consider Compliance with night splinting
• Implement Activity modification – resting elbow
• Towel wrap more tolerable at night
• Can also use soft padding: eliminate compression
• If Patients does not have any motor involvement, try PT
• Continued neuro monitoring for worsening

Guyon's Canal

• Hook of hamate and pisiform
• Handlebar palsy, computer use
• Distinguish from other sites
• Zones of injury:
  • I - motor and sensory
  • II - motor only
  • III - sensory only
• Sparing of FCU and FDP 4&5
• Look to evaluate for hypothenar and intrinsic weakness

Ulnar Neuropathy Diagnosis

• Froment's sign tests: for loss of adductor pollicis and also for Compensatory FPL (Flexor Pollicis Longus AIN)
• Wartenberg can also can also assist
• Tests for Unapposed 5th digit ABD
• Involves the EDM (Extensor Digiti Minimi) and EDC (Extensor Digitorum Communis) which are radial nerve innervated
• Tinel's sign
• Pressure provocation test
• Elbow flexion test are used.

Pronator Syndrome

• Median nerve compressed at C5 – T1 root levels
• Two heads of pronator teres
• Proximal aspect of FDS
• Patients also experiences forearm pain and tenderness
• Numbness of first three digits
• This pain could be Exacerbated by repetitive physical activity
• Differentiate from carpal tunnel compression
• Sparing of the palmar cutaneous branch and Forearm pain

Anterior Interosseous Nerve

• Terminal motor branch of median nerve
• AIN compression usually transient neuritis
• Motor only palsy – deep anterior forearm
• FDP injury
• Weakness of Pronator quadratus and FPL
• OK sign where it is difficulty to flex thumb IP joint

Carpal Tunnel Syndrome

• Most common compressive neuropathy
• Accounts for nearly 50% of work injuries
• Compression of the median nerve
• Repetitive wrist motions, pregnancy, DM, RA cause it
• Symptoms: Pain and tingling at night with Thenar atrophy
• Phalen's, reverse Phalen's, Tinel's, compression can help Dx
• Always rule out cervical radiculopathy

Carpal Tunnel Syndrome Symptom Presentation

• Pregnancy increased risk related to edema and hormones
• Intermittent nocturnal paresthesia is indicative
• Symptoms that progress to thenar weakness and atrophy
• Phalen's and Tinel's during a physical examination
• Also AbPB strength seen with hand dynamometry vs MMT with Pinch dynamometry
• Distinguish from cervical radiculopathy, TOS

CTS 6 Scale

• Numbness predominantly or exclusively in median nerve distribution > 3.5
• Nocturnal symptoms >4
• Thenar atrophy or weakness >5
• Positive Phalen test >5
• Loss of 2-point discrimination (>5 mm) >4.5
• Positive Tinel sign >4
• Reference standard clinical tool

• 12 = 0.80 probably of carpal tunnel syndrome

• 5 = 0.25 probably of carpal tunnel syndrome

Carpal Tunnel Treatment

• Activity modification and education
• Avoidance of repetitive stress with proper Ergonomic considerations
• Implement Splinting and night splinting
• Implement Impairment based rehab interventions through Therapeutic exercises
• Implement Mobilizations
• Aggressive observation, reassurance
• Surgical intervention for release

Radial Nerve Considerations

• Nerve roots:C5-T1
• Always rule out C-spine and TOS
• Humeral shaft fractures
• 10 – 20% of fractures
• Saturday night palsy: Compressive neuropraxia
• Also seen with improper crutch use
• Radial tunnel syndrome: only pain
• PIN entrapment: only motor loss

Radial Tunnel Syndrome

• Commonly confused with lateral epicondylitis
• Provocation tests: Resisted supination, resisted wrist extension, and middle finger extension
• Consider elbow extension, pronation, wrist flexion palpation
• Radial tunnel palpation: only 3 cm distal to LE
• Painful condition: no motor or sensory loss

Posterior Interosseous Nerve (PIN) Syndrome

• Distinct from Radial Tunnel Syndrome (RTS): significant motor loss
• Arcade of Frohse: common site of compression
• Consider Supinator arch and radial deviation
• Weakness of thumb and finger EXT
• Extensor Carpi Ulnaris (ECU) – PIN innervation
• ECRL – innervated by Radial nerve proper
• Potential for nerve damage as a complication after distal biceps repair

Extensor Compartments

• Compartment 1 consists of Extensor pollicis brevis & Abductor pollicis longus
• Compartment 2 consists of Extensor carpi radialis brevis & Extensor carpi radialis longus
• Compartment 3 consists of Extensor pollicis longus
• Compartment 4 consists of Extensor indicis & Extensor digitorum
• Compartment 5 consists of Extensor digiti minimi
• Compartment 6 consists of Extensor carpi ulnaris
• Extensor Carpi Radialis Longus is radial nerve innervated

Proximal/Distal Innervations

• Ulnar nerve: Proximal – Flexor Carpi Ulnaris, Distal – Intrinsics
• Median nerve: Proximal – Pronator teres, Distal – Lumbricals 1st and 2nd
• Radial nerve: Proximal – Triceps, Distal – Extensor indices

Hand & Wrist Innervations

• Understanding functional loss from nerve innervations:
• Ulnar nerve supports fine motor tasks
• Median nerve involves pronation weakness
• Turning a key involves ulnar nerve
• Buttoning a shirt involves Anterior Interosseous Nerve (AIN)
• Writing involves median nerve at carpal tunnel and also AIN
• Unscrewing top on a jar involves CTS, AIN
• Swiping a key card involves ulnar nerve

Hand Deformities

• Claw Hand deformity involves injury to the ulnar nerve
• Causes loss of interossei and the lumbricals 4 and 5 with 2 and 3 mostly unaffected
• EDC action is unopposed causing hyperextension at the Metacarpophalangeal joint and hyperflexion at the Interphalangeal joints

Ape Hand

• High median nerve injury.
• There are also Thenar muscles paralyzed,
• This also causes Unopposed adductor pollicis
• Loss of Thumb movement and positioning
• Hand then lies in the same plane

Sign of Benediction

• High median nerve injury
• Active sign when making fist
• Resting position is ape hand
• Loss of Flexor Digitorum Superficials, Flexor Pollicis Longus, Flexor Pollicis Brevis and Flexor DIgitorum Profundus 2 & 3
• FDP 4 and 5 remain innervated
• Similar appearance to claw hand which occurs during rest from ulnar damage
• In contrast Benediction is from median nerve and occurs when making fist

Wrist and Hand Imaging

• Important for identifying wrist and hand ailments

Scaphoid Fracture

• Most commonly injured carpal bone that results from hyperextension, radial deviation, pronation
• Causing pain with swelling and can also be chronic with remote history of injury
• Anatomic snuff box tenderness will be involved with palpating- Extensor Pollicis Longus (EPL) at ulnar border and Extensor Pollicis Brevis (EPB) at radial border
• Also involves Radial styloid at proximal border
• Testing occurs with axial thumb loading

Scaphoid Fracture Imaging and Outcomes

• High risk of avascular necrosis (AVN) due to retrograde blood supply
• Proximal and displaced fractures must involve ortho
• Fractures aren't always present on 1st X-ray
• Treat like fracture (thumb spica) because fractures may not always be obvious Use X-ray again later if still symptomatic, but Advanced imaging indicated if symptomatic but no Xray evidence
• Always watch for AVN

Scaphoid Study Points

• Proximal carpal row
• Most commonly injured carpal bone
• Anatomic snuffbox tenderness
• Risk of AVN due to retrograde blood supply
• Treat like a fracture
• Fracture not always visible on acute plain films
• CT or MRI may be needed if films normal

Scapholunate Injuries

• Range of hyperextension injuries with sprain from no scapholunate widening and
• From having a unstable dissociation
• This requires a Clenched fist view to demonstrate widening
• Terry Thomas sign is used in the clinical setting
• With normal films treat as a sprain
• If separation occurs then consult ortho
• Test via the Watson Scaphoid Test

Kienbock's Disease

• Avascular necrosis of the lunate that stems from skeletal variations where ulna bone is too short
• Exact other causes are unknown and it rarely affects both wrists
• This causes pain, swelling, stiffness in the Early stages of splinting and or activity modifications
• Important to restore motion and limit functional loss at these times
• Will likely require surgical approach as Later stages of symptom progression

DeQuervain's Tenosynovitis

• Repetitive stress injury, thumb EXT and ABD
• 1st EXT compartment (EPB, AbPL) inflamed
• Positive Finkelstein's test
• Requires a Thumb spica with ergonomic adjustments
• Anti-inflammatory treatments and impairment-based rehab plans implemented, injections, and surgical release

Intersection Syndrome

• Repetitive use injury – 1st and 2nd compartments
• Causes include repetitive APL, EPB and ECRL, ECRB usage
• Common in rower, clenched fist, thumb Abd and in positions that put 4-6 cm proximal to Lister's tubercle
• Requires Activity modification, reassurance, steroid injection (CSI)

Ulnar Sided Wrist Injury - TFCC

• Triangular fibrocartilage complex of the ulnar wrist side consists of soft tissue
• It Supports distal radial ulnar joint during gripping and rotating
• And Provides cushion during weightbearing
• Can be injured from Hyperextension injuries and Repetitive stress through rotation/grabbing
• Can be diagnosed through Palpation, Mechanical symptomology, Imaging

Management of TFCC Issues

• TFCC injury period of immobilization
• Treated with NSAIDs
• Has options of a Cortisone injection or Impairment based rehab
• Surgical options for Debridement of the complex
• Repair with sutures with open or arthroscopic methods
• A surgical option also exist for if there's a Correction of ulnar variance

Ulnar Abutment Syndrome

• For a standard Ulnar neutral wrist: 20% of force goes through the ulna, therefore the majority of force travels through the DRUJ
• Abnormal Ulnar positive wrist condition: forces increased ulnocarpally and increase incidence of wrist pain
• Can be related to TFCC injury as well.

Managing Ulnar Abutment

• Always start by implementing a short period of immobilization and managing inflammation (modified activity/NSAIDs)
• Consider Impairment based rehab with a TFCC evaluation
• Distal ulnar shortening osteotomy is a surgical intervention
• Amount of distance is dependent on level of variance
• Maybe combined with TFCC repair/debridement

Forearm Fractures

• Colles fracture:
  • Distal radius fracture
  • Involves Dorsal angulation and FOOSH mech
  • Causes dinner fork deformity
• Smith fracture
• Distal radius fracture causing volar angulation
• Can also be caused by a Fall on the flexed wrist

Other Forearm Fractures

• Barton fracture: distal radius fracture involving a radiocarpal dislocation. Mostly in MVAs for younger populations, and/or fall on the osteoporotic wrists for older pops.
• Monteggia fracture: damage to the upper 1/3 of the ulnus and radial head dislocation. Typically between the ages of 4 and 10 stemming from a FOOSH situation with pronation

Hand and Finger Injuries: Gamekeeper's Thumb

• Injury of the UCL thumb
• Causes Acute (Skier's thumb) and Chronic insufficiency
• ABD stress: 1st MCP joint

More on Hand & Finger Injuries related to Gamekeepers

• Can diagnose through stress examination of the thumb with Plain films to r/o UCL avulsion
• Requires Impairment based rehab progression
• Always Avoid stress on UCL region
• Watch for Stener lesion
• May show: Adductor aponeurosis between torn UCL and Proximal Phalanx
• Surgical intervention might be necessary

Hand and Finger Central Slip Injuries

• Results in: Boutonniere deformity
• Involves forced PIP flexion; lateral bands migrating volarly
• Typical to find in Common athletes from basketball and volleyball
• Typical to find PIP flexion with DIP extension
• Dx through injury-tenderness and limited movement of DIP motion

Conservative & Physical Therapy

• Aimed for acute stages
• Need to recognize early
• Roles in full extension,
• And allow DIP to move freely
• Difficult to mange
• Splint and monitor-care for over vs under managing

Hand and Jersey Finger

• Also known as the "jammed finger"
• Can be managed if noticed
• Requires eval
• • Hold PIP and contract DIP

Management (Jersey)

• Eval-hold PIP and contract DIP, is early awareness for management
• Requires repair
• Graft/fusion for a more delayed response

Mallet Finger

• Forceful extended DIP joint(baseball finger)
• Early awareness-
• Fingertip drooped in flexion

Other management tools

• Hard to extend PIP or hold in correct extension, will commonly have pain/swelling
• A slight hyper extension on DIP extension (24/7 for 6 months)
• Need X-rays

Hand and Swan Neck Deformity

• Hyperextension injury of the PIP joint as opposed to mallet finger
• Direct or indirect trauma (volar plate)
• Commonly due to Mallet finger and rheumatoid arthritis

Hand Injury Management

• Plate tenderness on Exam
• Needs ring and splint.

Rheumatoid Arthritis

• Systemic autoimmune disorder
• Common: MCP deviations, radio deviations,
• Will want more of a supportive PT management plan
• Should be supportive and also medical

Osteoarthritis

• Heberdens nodes at DIP
• Bouchards nodes at PIP

Dupuytren’s Contracture

• Genetic, palmar fascia contracture
• Collagen
• Alcohol and tobacco increase risk
• Tabletop test to DX and to monitor
• Splinting/ROM
• Surgucal

Hand anatomy

• Five annnular ligaments
• Three cruciate

Healing

• Two pathways-intrinstic/extrinsic

###Flex Heal

• Some sugreries can be done wide awake to see all ROM or adhesion

Always co-ord to all parts of healing - improves with time - enhances outcomes

Presentation on elbow, wrist, and hand pathology by Michael Garrison. Study investigates the impact of completing functional tasks before the QuickDASH PROM questionnaire on scores. It seeks to determine the effect of task completion on patient-reported outcome measures.