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Evidence Based Nursing
I. Clinical Question What is the best detection of flexor tenosynovitis in early arthritis? II. Citation A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis III. Study Characteristics 1. Patient’s included 33 consecutive patients who had who were initially diagnosed with polyarthritis and suspected of polyarthritis and clinical suspicion of inflammatory arthritis of the hands and wrists were assessed during consecutive, routine presentations to the rheumatology outpatient clinic. 2. Interventions compared To compare what is the best detection of flexor tenosynovitis in early arthritis between ultrasound and clinical examination. 3. Outcomes monitored Flexor tenosynovitis was found in 17 patients (51.5%) onUS compared with 16 (48.4%) of 33 patients on clinical examination. The intra-reader reliability of reading both the US and clinical examination was good (kappa = 0.8). 4. Does the study focuses on a significant problem in clinical practice? Yes, the study focuses in the best detection of flexor tenosynovitis in early arthritis.
IV. Methodology / Design 1. Methodology used 1. Patients The local research ethics committee approved the studyprotocol and all patients gave informed written consent prior to their inclusion in the study. 33 consecutive patients who has originally presented with polyarthritis and clinical suspicion of inflammatory arthritis of the
palmar aspect) for signs of tenosynovitis. fourth. in each wrist and finger. routine presentations to the rheumatology outpatient clinic. symptoms were assessed in terms of volar pain involving the hand. Typical symptomsof flexor digitorum tenosynovitis were defined according to the Birmingham consensus criteria. However. Repetitive use of an extremity often precipitates tenosynovitis. Clinical examinations Clinical examinations were performed by a senior rheumatologist trained in the detection of musculoskeletal disorders (AS). Finally. 2.5 . The synovial sheath of the flexor tendon. we tried to conduct a multivariate analysis to detect the factors associated with the existence of tenosynovitis like tender joint count. Then. the clinical examinations and USwere performed on the same day.13 MHz linear array transducer. we investigate the prevalence of flexortenosynovitis in early arthritis. and fifth finger for signs of tenosynovitis. was clearly detectable at the edge of the tendon’s profile on the transverse scans. For the purpose of the study. 2. A binary scoring system (0-1) was used to assess each tendons as normal or abnormal (1) for tenderness. Ultrasound evaluation  For the screening of arthritic joint processes. presence of erosions. Statistical analysis As a first step. third. We wanted to eliminate the causes of degenerative tenosynovitis that could occur at the dominant hand. which was identified as a slightly hypoechoic area. the following procedures were used: 1. All gray-scale scans were performed using a HITACHI machine with a 7. the clinical examination by AS and US by BR. Longitudinal and transverse scan of the MCP jointsand the PIP joints II-V (dorsal. Longitudinal and transverse scan of the wrist (dorsal. who disregarded ultrasonographyfindings. One sonographer (RB) sequentially and independently performed scans on each patient. 3. Thus. Each joint was scanned across both volar and dorsal aspects in longitudinal and transverse planes to provide maximum coverage of the joint and avoid artefacts. swollen joint count. 5. The presence (1) or absence (0) of flexor tenosynovitis (Figure 1) was documented. US was performed by BR without knowledge of the clinical score assigned by AS or the tendon assessment. In all patients. As a rule. and the second. agreement statistics . wristor forearm during active movement of the tendon against resistanceincluding pinching and grasping. Only lesions in the non-dominant hand were taken into account therefore 165 flexor tendons were included in the study. crepitus and swelling. palmar aspect) for signs of synovitis. Gel was used to provide an acoustic interface. ulnar. The presence of a well-defined area of increased echogenicity within the tendon sheath was considered to indicate synovial thickening.hands and wrists (symptoms < 24 months) were assessed during consecutive. Intra-reader reliability Random ultrasounds from 10 patients were performed by a single experienced reader (BR). We studied 5 sites per hand: the wrist. tenosynovitis/tendinitis. 4. this approach did not result in any relevant association. the screening was per formed by HI and SN.
tendons and tendon sheaths. Klasens JH. Ventura R. 4. Philadelphia: Saunders. Cervini C: Sonographic imaging of tendons. Kappa values were calculated for intra-reader reliability. Pirani O. specificity. 24:591-596. and negative predictive value for clinical examination using US as the gold standard. Chicago. 38:786794. De Flaviis L. Emery P: The optimal management of early rheumatoid disease: the key to preventing disability. Smith GR: The hand and wrist. 10. Grassi W. Heikal A. . Titarelli E. All statistical analyses were carried out using SPSS 13. Farina A. Arthritis Rheum 2000.0 (SPSS. Skeletal Radiol1995. Hand Clin 1989. Filippucci E. 43:969-976. 5:883925. 7. Algra PR.Edited by: Kelley WN. 6. Maricic MJ. Bijlsma JW: Comparison of sonography and magnetic resonance imaging for the diagnosis of partial tears of finger extensor tendons in rheumatoid arthritis. 39:55-62. Calori G: Ultrasonography of the hand in rheumatoid arthritis. Rheumatology 2000. 8. Leslie BM: Rheumatoid extensor tendon ruptures. Nessi R. Ann N Y AcadSci 2009. IL).were used to calculate the sensitivity. Scaglione P. Design The study was a sampling or observational design. 9. Backhaus M: Ultrasound and structural changes in inflammatory arthritis: synovitis and tenosynovitis. Pirani O. 5:191-202. Arthritis Rheum 1995. 11. Tittarelli E. 2. Sledge CB. positive predictive value. Blastetti P. Bywaters EG: Lesions of bursae. ActaRadiol 1988. 3. Ruddy S. 33:765-768. 5. 1154:139-151. 1997:1647-1654. Grassi W. 2. Avaltroni D. 3. Lund PJ. Jacobs JW. In Textbook of Rheumatology.Sources 1. Grassi W. Clin Rheum Dis 1979. Cervini C: Finger tendon involvement in rheumatoid arthritis: evaluation with high frequency sonography. Setting North Africa: Morocco country 4. Simmons BP. 22:243-247. Cervini C: Ultrasound examination of the metacarpophalangealjoints in rheumatoid arthritis. Swen WA. Williams CS: Ultrasonographicimaging of the hand and wrist in rheumatoid arthritis. Hubach PC. Harris ED Jr. Br J Rheumatol 1994. Scand J Rheumatol 1993. 29:457-460. Krupinski EA.
Faehndrich TP. Carter JT. Tan AL. Subject Criterion a. Arthritis Rheum 2003. Backhaus M. Arthritis Rheum 1999. ultrasound. 57:1158-1164. Terslev L.biomedcentral. 16:223-230. von der Recke P. 22. Birrel L. 5. O’Connor PJ. Gohlke F: Correlation of power Doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis. McGonagle D. . Klausen T.scintigraphy. 44:2018-2023. distribution. 225:225-231. Themean age was 43 years and the mean duration of diseasewas 52 weeks. 13.12. Loreck D. In Structural and dynamic bases of hand surgery. Krenn V. Arthritis Rheum 2007. Østergaard M. and contrast-enhanced magnetic resonanceimaging. Brown C. Zancolli E: Normal balance of the metacarpophalangeal joint during finger flexion.com/1471-2474/12/91Page 5 of 6resonance imaging of synovial inflammation of the hand in rheumatoid arthritis: a comparative study. 16. 2 edition. and associated rheumatic features. McGonagle D: Role of metacarpophalangeal joint anatomic factors in the distribution of synovitis and bone erosion in early rheumatoid arthritis. 15. Raber H. Conaghan PG. Hensor EM. Gray RG. Edited by: Zancolli E. Arthritis Rheum 2003. Krenn V. Arthritis Rheum 2001. 19. Gibbon WW. 20. Radke S. Radjenovic A.. Sandrock D. 12:91 http://www. Conaghan PG. Inclusion Criterion Thirty-three patients were included in the study. Qvistgaard E. 1979:330-331. Wiell C: Ultrasonography in rheumatoid arthritis: a very promising method still needing more validation. Wolf KJ. 44:331-338. 21. 42:1232-1245. Østergaard M: Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging. Savnik A. Walther M. Brown AK. 48:1214-1222. Harrington JM. 14. 18. Emery P: Finger tendon disease in untreated early rheumatoid arthritis: a comparison of ultrasound and magnetic resonance imaging. Kirschner S. Strandberg C. Gohlke F: Synovial tissue of the hip at power Doppler US: correlation between vascularity and power Doppler US signal. Torp-Pedersen S. O’Connor P. Harms H. Kamradt T. 55:264-271. Burnester GR. Harms H. Wakefield RJ. Szkudlarek M. Walther M. Radiology 2002. Gompertz D: Surveillance case definitions for work related upper limb pain syndromes. Bollow M: Arthritis of the finger joints: acomprehensive approach comparingconventional radiography. BMC Musculoskeletal Disorders 2011. 48:2434-2441. Tanner SF. Philadelphia: JB Lippincott Company. Danneskiold-Samsøe B. 17. Radke S. CurrOpinRheumatol2004. Fritz J. Klarlund M. Occup Environ Med 1998. Emery P. Arthritis Rheum 2001. Gottlieb NL: Hand flexor tenosynovitis in rheumatoid arthritis: prevalence. Hamm B. 20:1003-1008. Court-Payen M. Arthritis Rheum 1997. Bliddal H: Doppler ultrasound and magnetic Hmamouchi et al.
V. What overall contribution to nursing knowledge does the study make? . 2. second to compare clinical examination with ultrasound (US) using the latter as the gold standard. and fourth. because several studies have previously highlighted the ability of US for detecting tendons disease in the RA had [2-6]. Has the original study been replicated? No. Further work is recommended to standardize definitions and image acquisition forperitendinous inflammation for US. but a negative clinical examination does not exclude inflammation and an US should be considered. Both modalities demonstrated more pathology on the second and third metacarpophalangeal (MCP) compared with the fourth and fifth MCP.b. A joint-by-joint comparison of US and clinical examination demonstrated that although the sensitivity. fifth.4%) of all patients on clinical examination. Author’s Conclusions/ Recommendations 1. and some have described US as the gold standard imaging method for assessing tendon involvement in rheumatic diseases. What contribution to the client health status does the nursing action or intervention make? The data show that that clinical examination can be a valuable tool for detecting flexor disease in view of its high specificity and positive predictive values. Discuss briefly the results of the study Flexor tenosynovitis was found in 17 patients (51. specificities and positive predictive values of clinical examination were relatively high. 7. negative predictive value of clinical examination was low (0. What were the risks and benefits of the nursing action/ intervention tested in the study? The aims of this study were first to investigate the frequency and distribution of finger flexor tenosynovitis using ultrasound in early arthritis.5%) on ultrasound compared with 16 (48. Results of the study 1. Exclusion Criteria Exclusion criteria included detection of flexor tenosynovitis in early arthritis 6.23) VI. Most commonly damaged joint involved on US was the second finger followed by the third.
VIII.The study’s contribution to nursing knowledge that the valuable tool for detecting flexor disease in early arthritis is clinical examination. Applicability Does the study provide a direct answer to your clinical question in terms of type of patients. but a negative clinical examination does not exclude inflammation and an US should be considered. Reviewer’s conclusion/ Commentary This article is useful for us especially for the patient who suffer from arthritis but further study need to develop because the researcher said that that clinical examination can be a valuable tool for detecting flexor disease in view of its high specificity and positive predictive values. it is feasible to carry out nursing action in our country since the arthritis is the one of the disease that elderly patient encounter these days. intervention and outcome? Yes. because clinical examination can be a valuable tool for detecting flexor disease in view of its high specificity and positive predictive values Is it feasible to carry out the nursing action in the real world? Yes. . VII.Further work is recommended to standardize definitions and image acquisition forperitendinous inflammation for US.
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