Clinicians › Medicolegal

Psychosocial Factors & Screening in Musculoskeletal Recovery

Barriers to rehabilitation engagement and recovery — kinesiophobia, fear-avoidance, catastrophising, distress, significant disability. Psychosocial screening (Örebro, STarT-Back). Return-to-work factors. Why some patients plateau earlier than expected.

93 citationsUpdated Sep 2026

Overview

Psychosocial factors significantly influence musculoskeletal recovery, affecting both mental health and functional outcomes. Making a financial compensation claim is associated with poor injury recovery following motor vehicle related orthopaedic trauma, primarily regarding mental health [1]. Injury-related and psychosocial factors also affect the duration of time away from work following orthopaedic injury [2]. Posttraumatic stress disorder occurs in 20% to 51% of patients with musculoskeletal injury, and orthopaedic outcomes suffer considerably in these patients [5]. Occupational groups and psychosocial working conditions represent risk factors for disability pension due to musculoskeletal diagnoses, independent of familial confounding [6].

Early attention to psychological and social concerns alongside physical health presents an opportunity to improve overall health in orthopaedic trauma care [3]. Screening at 3 months after hand trauma may detect posttraumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes [7]. The Örebro Musculoskeletal Pain Questionnaire serves as a 'yellow flag' screening tool that predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury [14]. For the upper extremity limb salvage population, early consideration of factors affecting psychological prognosis is indicated [8].

Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores in numerous knee scoring systems [10]. In patients with ulnar-sided wrist pathology, a more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively, though these patients showed similar improvement as those with a more feasible psychosocial profile [9]. Conversely, psychosocial factors were not associated with patient-reported outcomes after intervention in patients with rotator cuff tears [11]. Surviving patients experience measurable gains in function and well-being in the 3 years after a hip fracture [12]. Understanding the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy [13]. Hand therapists play a critical role in facilitating physical and psychosocial recovery by using patient-centered, culturally relevant assessments and interventions to positively affect adjustment and improve outcomes [18]. Effective communication with patients regarding treatment modalities, risks and benefits, and prognosis of their injury is important following humeral fractures [19]. Patients may take longer to recover from outpatient surgery than previously recognized [21]. Orthopedic shoulder patients with preoperative mental health disorders were prescribed significantly more opioids postoperatively compared to those without mental health disorders [60].

Anatomy & Pathophysiology

Psychosocial Determinants of Pain and Recovery

Psychosocial factors, rather than pathophysiology, are the major determinant of symptom intensity in orthopaedic patients [122]. The traditional biomedical model assumes a direct relationship between nociception and pain, but this model has limits in orthopaedic surgery [122]. The biopsychosocial model of illness emphasizes the complex interplay of biological, psychological, cultural, and social factors on symptoms [122]. Surgeons are familiar with psychosocial mediators between nociception and pain, such as secondary gain [122]. Surgeons may be less familiar with the influence of depression and the tendency to misinterpret or over-interpret nociception, as in catastrophizing [122].

Clinical Correlates: * Increased depression prior to lumbar spinal surgery is associated with a poorer outcome three months postoperatively [122]. * Increased limitation of movement of the fingers after volar plate fixation of a distal radial fracture is associated with increased catastrophic thinking [122]. * Patients with greater self-efficacy are more likely to return to sports after anterior cruciate ligament reconstruction [122]. * An increased intensity of pain after a steroid injection for trigger finger was associated with increased symptoms of depression [122]. * In both total hip and knee arthroplasty, lower mental health status has been shown to be associated with worse outcomes [122].

Many injury-related and psychosocial factors affect the duration of time away from work following orthopaedic injury [2]. Several psychological and physiological factors predicted change in the number of musculoskeletal pain sites among Norwegian employees [22]. A multidimensional approach to classification based on psychological and psychosocial characteristics can distinguish different groups in a working population with neck and/or low back pain [29]. Making a claim was associated with poor injury recovery following motor vehicle related orthopaedic trauma, mainly for mental health [1].

Opioid Use and Coping: * Patients with poor coping strategies after orthopedic trauma have an increased risk of ongoing opioid use for a longer time than patients with robust strategies [34]. * Patients who take more opioids after injury actually report increased pain and less satisfaction with their pain relief [34]. * Self-efficacy was the most correlated factor with satisfaction in pain management for orthopedic trauma patients [34].

In a study of patients with work-related injuries, a much higher percentage of psychiatric disorders was seen following injury, and these patients had greater rates of pain disability [34]. Depression, occupational mental stress, job satisfaction, intensity of concentration, anxiety, and marital status can be involved in occupational back pain [32]. There is some evidence that psychologic stresses occur before complaints of pain in some patients with back pain [32]. Experienced spinal surgeons were able to identify distressed patients only 26% of the time based on patient interviews [32]. Physicians are unable to detect psychosocial factors adequately without using specific instruments designed for this purpose in patients with back pain [32].

Surgical Predictors and Waddell Signs: * Being off work more than 8 weeks before surgery is an independent predictor of poorer outcome in patients with intervertebral disc disease [40]. * The presence of multiple Waddell signs correlates with poor operative outcome and may temper the decision to offer a particular patient operative consideration [40]. * The MMPI has predictive value for failure of operative treatment but has no predictive value for successful operative treatment in patients with intervertebral disc disease [40].

Waddell et al. defined abnormal illness behavior as "maladaptive overt illness related behavior, which is out of proportion to the underlying physical disease (including IDD) and more readily attributable to associated cognitive and affective disturbances" [40]. Waddell et al. identified five nonorganic signs and seven nonorganic symptom descriptions to detect the presence of abnormal illness behavior [40]. The presence of three or more Waddell signs is required to show abnormal illness behavior [40]. Waddell signs cannot be used to predict return to work [40]. In patients with low back pain, three of five Waddell signs must be present for the pain to be considered nonorganic [56]. Failure to respond at all to multiple, usually reliable treatments of common diagnoses suggests a nonorganic response to injury in workers' compensation cases [56]. The worker’s perception of events compared with those depicted in the medical records should be analyzed to assess credibility in workers' compensation cases [56].

Work History Factors: * A high-demand–low-control (stressful) work environment is a factor to consider in the work history of injured workers [56]. * Recent job changes such as increased workload resulting from layoffs are factors to consider in the work history of injured workers [56]. * Conflicts with a supervisor or associates are factors to consider in the work history of injured workers [56]. * Job satisfaction is a factor to consider in the work history of injured workers [56].

The overall validity of the "Blue flags" short clinical questionnaire on work-related psychosocial risk factors is considered acceptable [57].

Prevalence and Impact of Mental Health Disorders

PTSD occurs in 20% to 51% of patients with musculoskeletal injury and orthopaedic outcomes suffer considerably in patients with PTSD [5]. Post-traumatic stress disorder has been shown to occur in up to half of newly injured patients [33]. Pre-existing mental illness is common in orthopedic trauma patients, with recent studies reporting mental illness in up to 39% of patients with presentation of new injury [33]. Depression occurs most often among pre-existing mental illnesses in orthopedic trauma patients [33]. Crichlow et al. identified 45% of their patients with depression after orthopedic trauma [33]. Existing mental illness is exacerbated by new injury, and new mental health diagnoses are frequent among trauma patients [33].

Clinical Consequences: * Mental illness after trauma has been associated with poor adherence to treatment recommendations and with higher rates of complications [33]. * Mental illness after trauma has been associated with greater potential for recidivism, returning with a new, otherwise unrelated trauma event [33]. * Patients debilitated with anxiety, depression, and other mental illness experience more pain with greater narcotic consumption [33]. * Patients debilitated with anxiety, depression, and other mental illness experience more catastrophizing [33]. * Patients debilitated with anxiety, depression, and other mental illness experience more self-reported disability [33]. * Patients debilitated with anxiety, depression, and other mental illness experience lower levels of patient satisfaction [33].

Orthopedic surgeons have historically been ineffective at both identifying prior mental illness and providing appropriate referrals for treatment [33]. PTSD was the strongest predictor of an adverse outcome one year after injury, stronger even than the severity of the injury itself [17]. Psychological conditions such as posttraumatic stress disorder have a substantial negative effect on outcome [17]. Psychological conditions such as posttraumatic stress disorder appear to have a substantial effect on the patient’s report of outcome [17]. Psychological factors play an influential role in patients’ reports of physical symptoms [17]. A serious extremity injury has a negative impact on the quality of life [17]. Poor physical health after severe lower-extremity trauma is strongly predictive of psychological distress [17].

Specific Injury Populations: * PTSD affects 19% of patients with brachial plexus injury [127]. * 17% of brachial plexus injury patients reported suicidal ideation [127]. * Hospitalized individuals aged 7 to 26 years had three times greater risk of suicide compared with the general population [127]. * Hand injuries can result in psychological impacts including pain, loss of function, frustration, fear, anger, altered body image, anxiety, depression, and post-traumatic stress disorder [127].

The most important outcome measure after a mangled injury is the degree to which the patient incorporates the reconstructed extremity into daily activities and is able to resume a normal life [31]. Important contributors to the outcome of a mangled injury include appearance and psychological factors associated with the injury [31]. The degree of the injury and the functional loss do not correlate with the psychological impact on the patient [31]. Sometimes injury to a single digit can be more devastating to a patient than a mangled injury involving the entire forearm [31]. Posttraumatic stress disorder has been described for patients after mangled injuries in work-related injuries, where merely revisiting the site of injury can elicit severe symptoms and be a significant impediment to returning to the job [31]. Enlisting the assistance of rehabilitation psychologists early after an injury is very important when signs of emotional stress are noted [31].

Chronic Pain and Neuropathy: * Patients with CRPS may experience permanent impairment and disability [39]. * Many patients with CRPS face work incapacity, changes in occupation, and/or psychological disorders [39]. * Chronic pain is known to play a role in psychological well-being, with 58% of 283 consecutive patients admitted to pain centers fulfilling the criteria for personality disorder [68]. * The quality of life of patients with chronic neuropathic pain is significantly reduced [71].

Pain will develop in up to 80% of patients with a traumatic brachial plexus injury and will persist in 20% [71]. Intractable pain is very rarely reported to develop in Asian patients with traumatic brachial plexus injury, whereas severe neuropathic pain develops in many American and European patients [71]. Effective management of neuropathic pain in patients with traumatic brachial plexus injuries requires identification and targeting of physiologic as well as social and psychological factors [71]. Nonsurgical options for neuropathic pain include psychosocial interventions such as counseling, relaxation therapy, biofeedback, and support groups [71]. The pathogenesis of neuropathic pain in traumatic brachial plexus injury may include postganglionic neuromas in some patients and central mechanisms of deafferentation pain attributed to segmental hyperactivity in the dorsal horn cells in patients with avulsion injuries [71].

Surgical Decision-Making and History: Early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health [3]. Understanding both the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy [13]. Therapists appear to be biomechanically oriented which may impact outcomes in hand and upper limb injury and trauma [30]. The patient’s psychological state must be noted during the clinical examination of the hand and wrist [41]. Activity level and expectations of treatment are an essential part of the overall decision-making process and discussion with the patient regarding rotator cuff tears [27]. Social factors affecting rehabilitation after potential surgery are variables that should be taken into account when deciding between nonoperative and operative care for rotator cuff tears [27].

Rotator Cuff Specifics: * Patients with labor-intensive occupations will most often be symptomatic after rotator cuff repair [28]. * Those with lower education level and a Workers’ Compensation claim are more likely to do poorly after rotator cuff repair [28]. * The social history and review of systems are important factors to assess in the evaluation of failed cuff surgery [28]. * The patient’s work and recreational activity status are important considerations when discussing therapeutic options for failed cuff surgery [28].

The patient’s professional background determines the manual requirements and influences the potential for recovery in hand and wrist function [41]. The history should elicit precise functional handicaps of daily life, professional and recreational activities, which have to be ranked in order of importance determined by that particular patient [41]. A comprehensive history is the first and arguably the most important aspect of a complex decision-making process in evaluating a patient with a suspected rotator cuff tear [27]. The patient’s physiologic and chronologic age should be considered throughout history and examination for rotator cuff tears [27]. Hand dominance, smoking, genetic predisposition, medical comorbidities, and social factors affecting rehabilitation after potential surgery are variables that should be taken into account when deciding between nonoperative and operative care for rotator cuff tears [27].

Failed Cuff Surgery Evaluation: * The use of tobacco products, history of diabetes, and obesity may have bearing on the likelihood of cuff healing [28]. * The patient should be asked about fevers, chills, or malaise, and whether there were any problems with wound healing after the initial surgery as possible indications of postoperative infection [28]. * Whether there was a period of time after the initial surgery and rehabilitation when the patient was pain-free and regained shoulder function should be determined in the evaluation of failed cuff surgery [28]. * History of a new traumatic event versus insidious onset of shoulder pain and dysfunction is also important in determining possible failure mechanisms [28]. * The length of physical therapy and rehabilitation after the initial cuff surgery as well as compliance with sling immobilization, the duration of immobilization, and compliance with physical therapy should be assessed [28]. * The specifics of the index surgery should be sought from the patient as well as reviewing the reports of the previous surgeries [28]. * Original imaging prior to surgery may also help in determining the size of the original tear, the degree of muscle atrophy, and fatty infiltration [28]. * Details should be sought regarding the location of the pain, duration before and after the index surgery, and the current intensity and quality in the evaluation of failed cuff surgery [28].

Radiation of pain past the elbow into the distal extremity, numbness, tingling, and burning symptoms may indicate an extrinsic etiology, such as cervical radiculopathy [28]. The neck should also be examined as cervical spine radiculopathy is a common extrinsic etiology for shoulder pain [28]. Proper evaluation of the cervical spine should include range-of-motion and specific tests for nerve root compression such as Spurling’s test and upper motor neuron signs such as Hoffman’s sign and clonus [28]. A thorough neurovascular examination of both upper extremities will help identify possible brachial plexus lesions, and rare conditions such as thoracic outlet syndrome may be detected [28].

Physical Examination: * The shoulder exam should progress in the usual systematic fashion, starting with observation of both shoulders and noting asymmetry [28]. * Atrophy of the supraspinatus and infraspinatus musculature should be closely evaluated on visualization of both fossae on the posterior shoulder [28]. * Palpation of the acromioclavicular joints and the biceps within the intertubercular groove may elucidate possible intrinsic etiologies of pain [28]. * Bilateral shoulder motion is checked actively and passively [28]. * Particular attention is directed at the examination for stiffness in flexion, internal rotation, and external rotation [28]. * Bilateral rotator cuff strength is tested and compared for deficits [28]. * Biceps tension tests such as Speed’s, Yergason’s, and O’Brien’s active compression test can be helpful to assess the long head of the biceps [28]. * Cross-body adduction may confirm the acromioclavicular joint as an origin of pain [28]. * Evaluation of scapulothoracic motion to assess for scapular winging and/or scapular dyskinesis is important, as these conditions may cause chronic shoulder pain [28].

Imaging and Diagnosis: * Imaging studies should begin with standard radiographs of the shoulder, including AP, Grashey, scapular Y, and axillary lateral views [28]. * Radiographs will help to diagnose other sources of pain such as AC joint arthropathy, glenohumeral joint arthritis, superior humeral head migration, and acromial stress fracture [28]. * Often, MRI is helpful in the setting of prior cuff repair surgery as it can detect failed cuff repair-while also providing information about the size of the re-tear, degree of tendon retraction, muscle atrophy, and fatty infiltration [28].

The possible etiologies for pain and shoulder dysfunction after prior rotator cuff surgery can be categorized into those that are extrinsic and intrinsic to the shoulder itself [28]. The differential diagnosis can be narrowed down by detailed history and thorough physical examination aided by appropriate radiographic assessment [28]. Patients with continued pain and dysfunction after rotator cuff repair present a significant diagnostic and therapeutic challenge as the etiology of their persistent symptoms can often be difficult to identify and treatment outcomes of revision surgery can be unpredictable [28].

Outcomes and Natural History: * Surgical management of rotator cuff tears (both repair and nonrepair surgery) leads to successful outcomes in the majority of patients [28]. * For arthroscopic repair, greater than 90% of patients report satisfactory outcomes in terms of improvements in pain and shoulder function [28]. * Approximately 25% of rotator cuff repairs will re-tear at a mean of about 2 years after surgery [28]. * Of patients that have re-tears, approximately half will still have a “successful” outcome [28].

Rotator cuff tears—even ones of substantial size—can be asymptomatic [27]. The amount of shoulder discomfort experienced by the patient is not related to the size of the tear [27]. Pain may not be the primary symptom of rotator cuff failure, which may also produce weakness, stiffness, crepitus, or instability [27]. Degenerative tearing typically occurs in older patients, while a greater injury is required to tear the cuff of persons at the younger end of the age distribution [27]. Traumatic glenohumeral dislocations in persons older than 40 years have a strong association with rotator cuff tears [27]. Age is thought to be a strong predictor of rotator cuff healing if operative intervention is a consideration—older patients are less likely to achieve a durable repair [27]. Chronicity is one of many important tear characteristics that have an impact on healing potential [27]. Acute rotator cuff tears from a distinct injury causing weakness

Classification

Psychosocial Risk Profiles: Making a claim for financial compensation is associated with poor injury recovery following motor vehicle-related orthopaedic trauma, primarily affecting mental health outcomes [1]. In ulnar-sided wrist pathology, a more negative psychosocial profile correlates with higher pain levels and dysfunction both preoperatively and postoperatively [9]. For total knee arthroplasty, demographic variables including advanced age, low family income, and multiple medical conditions significantly affect scores across numerous scoring systems [10].

Screening Instruments: The Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) functions as a 'yellow flag' screening tool that predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury [14]. A risk classification schema using recommended cut-off scores with items similar to the STarT-Back demonstrated limited ability to identify persons who progressed to chronic pain in a primary care population with strictly defined acute low back pain [54].

Other Considerations: In cervical spine populations, depressive symptoms were associated with poorer health outcomes in seven studies classified as 'low quality' regarding pain with or without radiculopathy [35]. Distress and anxiety symptoms were associated with poorer health outcomes in cervical spine radiculopathy populations and non-specific neck pain in two studies with 'very low-level' quality [35]. Additionally, stress and higher job strain were negatively associated with poorer health outcomes measured by the presence of pain in two very low-quality studies sampling non-specific neck pain populations [35]. Surviving patients with hip fractures experience measurable gains in function and well-being in the 3 years after the fracture [12].

Clinical Presentation

Psychosocial Impact on Recovery and Outcomes

Psychosocial factors significantly influence musculoskeletal recovery, often outweighing injury severity. Posttraumatic stress disorder is the strongest predictor of adverse outcomes one year after injury, surpassing the severity of the injury itself [17]. In patients with ulnar-sided wrist pathology, a more negative psychosocial profile correlates with higher preoperative and postoperative pain levels and dysfunction, although these patients demonstrate similar improvement following treatment compared to those with a more feasible psychosocial profile [9]. For cervical spine pain, whether with or without radiculopathy, depressive symptoms and distress or anxiety symptoms are associated with poorer health outcomes [35]. In non-specific neck pain, stress and higher job strain negatively associate with health outcomes measured by the presence of pain [35].

Financial and occupational contexts further complicate recovery. Making a financial compensation claim is associated with poor injury recovery following motor vehicle-related orthopaedic trauma, primarily regarding mental health [1]. Patients with rotator cuff tears who have lower education levels and a Workers’ Compensation claim are more likely to experience poor outcomes [28]. Conversely, psychosocial factors were not associated with patient-reported outcomes after intervention for rotator cuff tears in other studies [11]. Fatigue frequently co-occurs with musculoskeletal pain, adding to the burden of disability [55]. Treatment-related reductions in fatigue prospectively predict the resumption of occupational activities [55]. Participation in a behavioral activation intervention is associated with a 20% reduction in fatigue, corresponding to a moderate effect size (d = 0.66) [55]. Reductions in fatigue of 20% have been shown to be sufficient to translate into meaningful clinical outcomes such as return to work [55].

Specific pathologies present distinct psychosocial challenges. Psychological consequences of limb amputation vary by patient and are influenced by factors such as etiology and personal interpretation [37]. Early consideration of factors affecting psychological prognosis is needed for the upper extremity limb salvage population [8]. Patients with complex regional pain syndrome may face work incapacity, changes in occupation, and/or psychological disorders [39]. Psychological assessment and support are essential for patients with thoracic outlet syndrome [107]. The statement regarding the prevalence of symptom exaggeration in workers' compensation claims was unsubstantiated and misleading [128]. Focusing on detecting exaggerated symptoms will not eliminate costs or reduce litigation, and comprehensive initiatives to assist workers in returning to work are more effective [128].

Clinical Evaluation and History Taking

The comprehensive history and physical examination are the initial interactions set on delivering the correct diagnosis and subsequent treatment recommendations [104]. The evaluation begins with elucidating an accurate history, including symptom location, severity, onset, duration, quality and character, aggravating or alleviating factors, and previous related treatments [104]. Additional attention should be given to the patient’s other medical diagnoses during history taking [104]. Caution should be taken attributing symptoms to underlying medical diagnoses as symptoms can often be multifactorial [104]. In the acutely injured patient, specific attention should be given to the mechanism of injury and associated injuries [104]. By completing a comprehensive history, the provider can often develop an appropriate differential diagnosis, which can be further narrowed by the examination [104].

For rotator cuff tears, activity level and expectations of treatment are an essential part of the overall decision-making process and discussion with the patient [27]. Hand dominance, smoking, genetic predisposition, medical comorbidities, and social factors affecting rehabilitation are variables to consider when deciding between nonoperative and operative care [27]. The patient’s professional background determines manual requirements and influences the potential for recovery in hand and wrist injuries [41]. The patient’s psychological state must be noted during the clinical examination of the hand [41].

In fracture nonunion, the initial evaluation should include a thorough history to investigate potential causes of nonunion [105]. The evaluation of a patient with fracture nonunion should include a thorough history investigating health and nutritional status, medical comorbidities, medications, drug and alcohol use, injury mechanism, prior treatment strategies, and history of infection [105]. Associated injuries and functional limitations must be identified to educate the patient regarding functional expectations [105]. The history of events surrounding the index injury provides insight into deviations from the normal course of fracture healing [113]. The mechanism of injury and the energy associated with injury have implications regarding fracture healing [113]. The nature of the associated soft tissue injury may be prognostic for delayed bone healing [113]. Details of prior treatments and subsequent recovery complete the history of the problem at hand [113].

It is critical to distinguish if secondary debridement procedures were done as planned prophylactic procedures or for the treatment of a documented infection [113]. Causative organisms, antibiotic susceptibilities, and details of antibiotic treatments should be elucidated in the history of nonunion [113]. The clinical response to prior treatments can provide valuable insight into future responses to similar treatment [113]. The nature of prior surgical procedures aimed at augmenting fracture healing provides useful information regarding the diagnosis and helps direct future treatments [113]. It is important to distinguish prior implant removal performed for pain from similar procedures done to promote fracture healing such as nail dynamization [113]. If there was treatment with bone growth stimulators, such devices may be incorporated in future treatments with little or no additional patient expense [113].

For periprosthetic humeral fractures, the workup should begin with a thorough history including review of the operative note and underlying diagnosis [116]. Any red flags concerning periprosthetic infection should be ruled out and a clear understanding of preinjury shoulder function should be elicited [116]. If preinjury function was impaired, this should be further characterized and correlated with the clinical situation [116]. History should identify risk factors for nonunion such as smoking, which has been correlated with nonunion, periprosthetic infection, higher overall complications, and periprosthetic fracture [116]. Underlying causes for future falls should be identified and treated including cardiac disease, syncope, visual impairment, gait imbalance, and living independence [116]. Engagement of medical management and a social worker can be immensely helpful in the workup for periprosthetic humeral fractures [116].

The assessment of the spine should include a comprehensive, accurate history, a review of all pertinent records available at the assessment, and a comprehensive description of the individual's current symptoms and their relationship to daily activities [103]. The AMA Guides require a narrative history of the medical condition(s) with the onset and course of the condition, symptoms, findings on previous examination(s), treatments, and responses to treatment [48]. The AMA Guides require information that may be relevant to onset, such as an occupational exposure or injury [48]. The AMA Guides require a work history with a detailed, chronological description of work activities, specific type and duration of work performed, materials used in the workplace, any temporal associations with the medical condition and work, frequency, intensity, and duration of exposure and activity, and any protective measures [48]. The AMA Guides require an assessment of current clinical status, including current symptoms, review of symptoms, physical examination, and a list of contemplated treatment, rehabilitation, and any anticipated reevaluation [48]. The AMA Guides require a list of diagnostic study results and outstanding pertinent diagnostic studies [48]. The AMA Guides require a discussion of the medical basis for determining whether the person is at maximum medical improvement (MMI) [48]. The AMA Guides require a discussion of diagnoses, impairments, causation and apportionment, impairment rating criteria, prognosis, residual function, and limitations [48]. The AMA Guides require an explanation of any conclusion about the need for restrictions or accommodations for standard activities of daily living or complex activities such as work [48].

The history must address the key features of the problem to elucidate the medical problem and to cover subsidiary requirements for billing purposes [49]. The social history and past medical history are important because they change billing codes without necessarily affecting outcome or success of care [49]. The physical examination must cover the essentials necessary for diagnosis, and frequently the confirmation of the diagnosis is based on physical exam [49]. Considerations such as skin condition and blood supply must be documented despite the fact that this process is also part of the surgical evaluation [49].

The clinical examination of the hand involves a series of specific examinations to appraise the skin cover, circulation, trophic changes and sweating, bones and joints, muscles and tendons, the overall motor performance of the hand, tactile sensibility, and deep sensibility [41]. All the information given by clinical examination must provide a basis for further understanding [41]. Each examination should be objective, repeatable and preferably numerical to give the basis for a clear picture of the development of the patient’s condition [41]. The clinical examination must be preceded by a full history from the patient noting timing of any trauma and variation of symptoms [41]. Examination is not complete without noting the patient’s dominant hand, the function of the whole upper limb and the function of the opposite limb [41]. The history should elicit precise functional handicaps of daily life, professional and recreational activities [41]. Functional handicaps have to be ranked in order of importance, which will be determined by that particular patient [41].

A comprehensive preoperative evaluation that includes a detailed history, physical examination, imaging, and electrodiagnostic evaluation is essential to determine the location and severity of the brachial plexus injury and appropriate management [51]. The goal of preoperative evaluation for brachial plexus injury is first to determine whether there is potential for spontaneous and functionally significant recovery, which warrants further observation [51]. If no recovery is seen within the first 2 to 3 months in patients with stretch injury, surgery is indicated [51]. In cases in which surgery is indicated, determining whether the injury is preganglionic or postganglionic will also help in planning the surgical approach and possible reconstructive options [51]. The presence of a preganglionic injury at one or more levels indicates a more severe injury with a lower probability of spontaneous recovery; thus earlier surgical intervention may be warranted [51]. No single finding or evaluation can tell the surgeon whether the injured plexus requires a surgical intervention [51]. All the information must be analyzed and each patient requires an individualized approach for brachial plexus injury [51]. Patients at the institution described are evaluated in a multidisciplinary clinic, first by a neurologist and then by a team of surgeons skilled in primary and secondary reconstruction [51]. A physiatrist (with expertise in pain management) and a physical/occupational therapist are also involved in the care of each patient with brachial plexus injury [51]. Some groups have also incorporated social workers and psychological evaluation into the care of patients with brachial plexus injury [51]. Decisions regarding management are discussed and planned collectively in a multidisciplinary team approach [51].

Hand therapists play a critical role in facilitating physical and psychosocial recovery by using patient-centered, culturally relevant assessments and interventions [18]. Therapists appear to be biomechanically oriented, which may impact outcomes in patients with hand and upper limb injury [30].

Screening Instruments and Risk Assessment

The inability of physicians to detect psychosocial factors adequately without using specific instruments designed for this purpose is evident in patients with back pain [32]. A risk classification schema using items similar to the STarT-Back in a primary care population with strictly defined acute low back pain had limited ability to identify persons who progressed to chronic pain [54]. The SF-36 mental health subscale and mental component summary can be used to screen for depressive and anxiety disorders in rheumatoid arthritis patients [106]. Patients with MMPI and MMPI-2 findings of depressed-pathologic profile and a conversion V profile reported greater dissatisfaction with operative outcomes for intervertebral disc disease [111]. Patients identified as psychologically distressed using the Distress and Risk Assessment Method (DRAM) are three to four times more likely to have a poor outcome after any form of treatment for back pain [111].

The senior author uses a 20-page survey when assessing a new patient, which includes pain diagrams, duration of symptoms, severity of pain, impact on daily activities, Quick-DASH questionnaire, occupational activity questions, SF-36 general health outcome measure, demographic questions, and documentation of medical comorbidities [108]. The presence of medical comorbidities can have an impact on patient responses on outcome measures [108]. Baseline data are very useful in assessing a patient’s response to treatment, providing that follow-up data are obtained in a similar fashion [108]. Patients’ responses have been observed to change as a function of time and the effects to treatment [108]. Documentation of baseline data is critically important [108].

The Shoulder Rating Questionnaire includes six separately scored domains: global assessment, pain, daily activities, recreational and athletic activities, work, and satisfaction [110]. A final, nongraded domain allows the patient to select two areas in which he or she believes improvement is most important [110]. The global assessment domain consists of a 10-cm long visual analog scale from 0 (very poorly) to 10 (very well) [110]. Each of the other scored domains consists of a series of multiple-choice questions with five selections scored from 1 (poorest) to 5 (best) [110]. The possible score for each domain ranges from 2 (poorest) to 10 (best) [110]. The pain domain consists of four questions that assess the severity of pain at rest and during activities, the frequency of pain that interferes with sleep, and the frequency of severe pain [110]. The daily activities domain consists of six questions, including one that requires a general assessment of the limitation of daily activities and a series of questions that assess difficulty with typical daily activities [110]. The recreational and athletic activities domain consists of three questions, one asking for a general assessment of limitation during recreational and athletic activities, another requiring an assessment of the degree of difficulty in throwing a ball overhand or serving in tennis, and the third allowing the patient to select an activity [110].

The Musculoskeletal Function Assessment questionnaire demonstrated good reliability, validity, and responsiveness, with better content validity than other questionnaires and no ceiling or floor effects [25]. The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation [36]. Self-administered questionnaires have been shown to be more responsive than observer-based physical measures such as ROM, strength, dexterity, and sensation [108]. Self-administered questionnaires are not subject to observer bias [108]. Comparisons between studies that use different scoring systems are generally not valid and the categoric rankings of different instruments are not interchangeable [108]. When categoric rankings are used, the data should also be reported in terms of aggregate scores [10

Investigations

Psychosocial Screening & Assessment

Psychosocial factors significantly influence orthopaedic recovery and must be integrated into the diagnostic workup. Making a claim for financial compensation is associated with poor injury recovery following motor vehicle-related orthopaedic trauma, primarily regarding mental health [1]. Posttraumatic stress disorder (PTSD) is the strongest predictor of an adverse outcome one year after injury, exerting a stronger effect than the severity of the injury itself [17]. PTSD has a substantial negative effect on outcome and the patient’s report of outcome, and civilian patients can develop this condition [17]. However, the prevalence of PTSD after orthopaedic trauma compared to other types of trauma, or specific fracture associations with high risk, has not been determined by prior studies [17].

Screening at 3 months after hand trauma may detect posttraumatic stress disorder, anxiety, depression, and chronic pain [7]. In patients with chronic shoulder pain, clinician and patient-reported outcomes are associated with psychological factors [24]. These psychological factors include psychiatric diagnosis, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, Hospital Anxiety and Depression Scale scores, and the psychological subscale of the INTERMED tool [24]. Social factors assessed in this population include educational level, qualified work status, ability to speak the native language of the clinic, and the social subscale of the INTERMED tool [24]. Biological factors include diagnosis category, Abbreviated Injury Scale score, Cumulative Illness Rating Scale, and the biological subscale of the INTERMED tool [24].

Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores on numerous knee-related scoring systems [10]. Several psychological and physiological factors predicted change in the number of pain sites among Norwegian employees [22]. In ulnar-sided wrist pathology, patients with a more negative psychosocial profile showed similar improvement as patients with a more feasible psychosocial profile [9]. Therapists appear to be biomechanically oriented, which may impact outcomes in the use of psychosocial services post hand and upper limb injury [30]. The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation in patients with scapula alata [36]. In breast cancer patients, the increase in health-related quality of life was lower in subgroups with incident fracture but was not influenced by recent prior fracture [26].

The use of the RLS diagnostic criteria helps to differentiate between rheumatoid arthritis arthritic symptoms and restless legs syndrome [144]. Advanced head imaging for evaluation of total joint arthroplasty patients with a change in mental status is of low yield [130].

Imaging & Diagnostic Workup

Plain radiography: Roentgenography is the most cost-effective and most important initial diagnostic test in the orthopaedicist’s armamentarium [49]. Almost every patient should have a radiograph prior to going to a more sophisticated imaging study [49]. Plain radiographs provide information sufficient to diagnose any fracture or dislocation in the immediate setting for the orthopedic trauma patient [102]. In most instances, imaging studies are used to confirm or exclude diagnoses already suggested by the clinical history, mechanism of injury, and physical examination findings [114]. Plain radiographs must be made of all potential musculoskeletal injuries as soon as possible so that appropriate early treatment decisions are made in multitrauma patients [114].

For neck pain with no history of trauma, more than 4 weeks’ duration, and age younger than 35 years, anteroposterior, lateral, and odontoid views are indicated [49]. For neck pain with no history of trauma, more than 4 weeks’ duration, and age older than 35 years, oblique views are indicated [49]. For neck pain with a history of trauma, flexion/extension laterals should be obtained on the first visit [49]. For thoracic spine pain and tenderness in patients younger than 40 years with no reason to suspect malignancy, AP and lateral views are indicated if there is a history of trauma or possibility of osteoporosis on the first visit, otherwise at 4 weeks [49]. For lumbar-sacral spine pain in patients younger than 40 years with no reason to suspect malignancy after 4 weeks’ duration of pain, AP and lateral views are indicated [49]. Oblique views should be added for chronic low back pain to evaluate for spondylolisthesis [49].

For hips, AP pelvis and lateral of the affected hip are indicated [49]. A lumbar-sacral series should be considered if hip pain is in the buttock rather than in the groin [49]. For knees in patients older than 40 years or with a history of meniscectomy, Rosenberg, lateral, and sunrise films are indicated [49]. For other knees, AP, lateral, and sunrise views are indicated [49]. In children up to age 16 with knee pain and a negative physical exam referable to the knee, a pelvis film should be considered [49]. For femur, tibia, humerus, and forearm trauma, palpable lesions, or suspected tumors, AP and lateral views are indicated [49]. For ankle evaluation, AP, lateral, and mortise views are indicated [49]. For routine foot evaluation, AP, lateral, and oblique views are indicated [49]. For shoulder evaluation, AP, axillary, scapular Y, and outlet views are indicated [49]. For elbow evaluation, AP and true lateral views are indicated [49]. For hand evaluation, PA and lateral views are indicated [49]. For wrist evaluation, PA, lateral, and oblique views are indicated [49]. For suspected wrist instability, clenched fist PA in radial and ulnar deviation is indicated [49].

Conventional radiographs have considerably better spatial resolution than cross-sectional imaging techniques [121]. The limiting spatial resolution of screen film radiography is 6 lp/mm or 0.08 mm [121]. The limiting spatial resolution of digital radiography is 3 lp/mm or 0.17 mm [121]. Digital radiography remains inferior to conventional radiography in terms of image spatial resolution [118]. Teleradiology allows emergency physicians and/or house staff to send digital images of radiographs or clinical photographs to off-site attending orthopedic staff [118]. The routine use of digitized radiographs improved fracture management, resulting in a change of management in 21% of fractures in a study of 123 consecutive fractures [118]. No further changes in management were decided on after review of the original radiographs compared to digitized radiographs in the study by Ricci and Borrelli [118].

In elderly female patients with trauma to the proximal femur and/or pelvis, plain radiographs are not nearly as accurate for the diagnosis of fractures as magnetic resonance imaging [114]. Plain radiographs often fail to capture the occipitocervical and cervicothoracic junctions, occipital condylar fractures, occipitocervical dislocations, and upper cervical injuries [120]. Plain radiographs are reserved for patients with isolated cervical injuries from low-energy mechanisms or those who are treated at nontrauma centers [120]. The NEXUS low-risk criteria recommend against screening plain film images in an awake, alert patient without evidence of intoxication or other injury, no history of cervical spine tenderness or any tenderness on examination, and no neurologic signs or symptoms [120].

MRI: MRI should be reserved for clarifying a particular problem and should not be used when the diagnosis can be made with a less expensive test [49]. The use of MRI in knee studies in patients older than 45 years should always be preceded by plain films of the knee [49]. Distortion of the magnetic field by metallic implants may limit the usefulness of MRI studies of conditions such as total knee or hip replacement, or fracture fixation devices [49]. MRI shows superior soft tissue contrast resolution compared with CT [121]. The limiting spatial resolution of MRI is 0.5 lp/mm or 1.0 mm [121].

MRI is the most sensitive modality to evaluate the cervical spine and will detect discoligamentous injuries that would otherwise be missed by CT scanning alone [120]. In a meta-analysis regarding the use of MRI and CT versus CT alone for the evaluation of occult cervical spine injuries, MRI was found to identify abnormalities altering treatment in 6% of cases [120]. The pooled sensitivity of MRI for detecting clinically significant cervical injury was 100%, with a 94% pooled specificity [120]. In a study by Satahoo et al., 7% of patients with a negative CT had positive MRIs, but only 2 required surgery [120]. In an analysis of 512 patients by Khanna et al., no change in management resulted from the use of MRI and CT [120].

MRI of the brachial plexus is rapidly improving, but has not yet been found to be as helpful as CT-myelography in identifying root avulsions [109]. Shoulder MRI has been used to assess patients with nerve injuries to ensure rotator cuff integrity and to identify ganglia in isolated suprascapular nerve lesions [109]. Magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint [141].

CT: CT has better spatial resolution than MRI and is more commonly performed for evaluating finer bony abnormalities, such as avulsion fractures and calcification within tumor matrix [121]. The limiting spatial resolution of CT is 1 lp/mm or 0.4 mm [121]. CT as a screening modality for cervical spine trauma is considered more cost effective and sensitive when compared with plain radiographs [120]. In a propensity-matched analysis, CT alone missed 8% of injuries, but very few required surgery [120]. In a recent analysis of 9,227 patients by Duane et al., no patient with a normal CT had a cervical spine injury [120]. A growing body of evidence supports CT alone for C-spine clearance [120]. Some authors have advocated a “rule of three,” requiring that two out of three components (reliable physical examination in a cooperative patient, negative CT, and/or negative MRI) be present to definitively declare a patient free of injury [120].

Thoracic paravertebral muscle size and attenuation on computed tomography imaging are associated with mortality in patients aged 65 or older with hip fractures [114]. Tissue damage volume scores as measured on CT are predictive of systemic inflammatory response syndrome and multiorgan failure [114]. CT will remain the most common method of imaging the spine in the early evaluation of the trauma patient due to inconsistent after-hours availability of MRI and logistic problems of transporting and monitoring a trauma patient within an MRI unit [102]. CT-myelography should be performed when a supraclavicular lesion has been diagnosed and a preganglionic injury is being considered [109].

Other Considerations:

The diagnosis of brachial plexus injuries can be suspected from a good history supported by physical examination and confirmed by electrodiagnostic or imaging studies [109]. Electrodiagnostic studies are most useful about 3 weeks after the injury for brachial plexus injuries [109]. Plain radiographs of the chest might reveal an elevated diaphragm from a phrenic nerve injury in brachial plexus evaluation [109]. Radiographs of the cervical spine and other bones might demonstrate fractures in brachial plexus evaluation [109]. Angiography should be performed if vascular injury is suspected, especially when an acute brachial plexus injury is present in conjunction with an expanding hematoma, first-rib fracture, widened mediastinum, or upper limb pulse abnormality [109]. Features suggesting a preganglionic injury include deafferentation pain, Horner syndrome, weak rhomboids or serratus anterior muscles, or the absence of Tinel’s sign in the neck [109]. Electrical studies showing fibrillations in the paraspinal muscles or rhomboids or preserved sensory nerve action potentials in an anesthetic hand with absent motor nerve action potentials suggest a preganglionic injury [109]. An elevated hemidiaphragm or associated cervical fractures on radiographs and pseudomeningoceles or absent nerve rootlets on myelography suggest a preganglionic injury [109].

The assessor should not order additional radiographic or other investigations purely for the purpose of conducting an assessment of permanent impairment [101]. The report for permanent impairment assessment should contain factual information based on all available medical information and results of investigations, the assessor’s own history taking and clinical examination [52]. Other reports or investigations relied upon in arriving at an opinion should be appropriately referenced in the assessor’s report [52].

In a random survey of 5% of US emergency departments (n = 262), CT scanners were present in 96% of institutions and were available 24 hours a day in 94% [102]. In the survey of US emergency departments, 39% had access to 16-slice or greater CT scanners [102]. On-site MRI was available in two-thirds of the institutions surveyed, with another 20% having mobile MRI available [102]. Smaller and rural hospitals had less access to CT and MRI, and when available, CT tended to be lower resolution [102]. Access to ultrasound and nuclear medicine is likely to be similarly variable to CT and MRI, and may be available only on an “on-call” basis or not available at all after hours [102]. Digital radiography and teleradiology provide a means to obtain after-hours interpretation of images by trained radiologists [102]. The limiting spatial resolution of fluoroscopy is 4 lp/mm or 0.125 mm [121]. The limiting spatial resolution of nuclear medicine planar imaging is less than 0.1 lp/mm or 7 mm [121]. The limiting spatial resolution of SPECT is less than 0.1 lp/mm or 7 mm [121]. The limiting spatial resolution of PET is 0.1 lp/mm or 5 mm [121]. The limiting spatial resolution of ultrasound is 1.7 lp/mm or 0.3 mm at 5 MHz [121]. Conventional radiographs typically have poor soft tissue contrast resolution, whereas CT and MRI have much better contrast resolution [121]. Medical imaging in the setting of acute musculoskeletal trauma contributes greatly to the initial diagnosis and subsequent management of orthopedic injuries [114]. The primary exception to using plain radiographs for immediate diagnosis is in the evaluation of the spine, especially in the comatose patient and in the setting of specific injury patterns, where both CT and MRI have well-defined roles [102].

Treatment

Screening and Assessment

Screening at three months post-injury may detect posttraumatic stress disorder, anxiety, depression, and chronic pain following hand trauma, potentially allowing for early intervention and improved treatment outcomes [7]. To provide the most comprehensive evaluation of a patient’s response to treatment, the inclusion of a combination of measures including a generic health measure, a disease-specific instrument, and a pain scale is recommended [53]. Patient-reported outcomes seem most representative of how a patient is actually doing and help eliminate observer bias that may be introduced when physician evaluations are performed [53]. The clinical use of patient-reported outcome measures (PROMs) among orthopedic surgeons was negligible, even though an overwhelming majority were interested in using PROMs [125]. Some groups have incorporated social workers and psychological evaluation into the multidisciplinary clinic for brachial plexus injuries [51]. The American Academy of Orthopaedic Surgeons Clinical Practice Guideline for Limb Salvage or Early Amputation emphasizes the importance of psychosocial factors affecting patient outcomes [90]. This guideline recommends against using plantar sensation or extremity-specific scores to determine treatment between amputation and limb salvage [90]. It further recommends that the entire burden of injury be evaluated when discussing treatment options [90]. Outcomes were measured at four and eight weeks postoperatively for extensor tendon repairs, incorporating the three domains of the International Classification of Functioning, Disability and Health model [59].

Psychological Interventions and Management

Enlisting the assistance of rehabilitation psychologists early after a mangled injury is very important when signs of emotional stress are noted [31]. Patients may benefit from antidepressant or anxiolytic therapy following mangled injuries [31]. Targeted interventions to educate patients, to improve communication, and to promote self-efficacy hold promise in mitigating the detrimental effects of mental illness on recovery [33]. A multidisciplinary team approach to the management of mangled extremities involving physicians, physical therapists, and behavioral therapists will give the patient the best outcome regardless of treatment choice [99]. The American Academy of Orthopaedic Surgeons Clinical Practice Guideline for Limb Salvage or Early Amputation emphasizes the importance of rehabilitation to improve both psychologic and functional outcomes [90]. Early referral to psychological intervention for patients found to be at moderate and severe levels of anxiety or depression within 3 months of injury could be beneficial in reducing the risk of prolonged suffering from pain [43]. Before beginning treatment for pediatric limb lengthening, the team should discuss various options, likely problems, and outcomes with the patient and family, ideally conducted with a psychologist who works with children and is knowledgeable in orthopaedics [47]. A decision not to proceed with pediatric limb lengthening may be made when there is a demonstrated inability to adhere to care and exercises, significant psychological disorders, family disharmony, and/or poor understanding of treatment [47]. During pediatric limb lengthening treatment, factors such as coping with complications, sleep disturbance, returning to school, hospitalization, and patience with the process should be addressed to maximize successful outcome [47]. After apparatus removal in pediatric limb lengthening, transitioning from being a patient to being a child can be a challenge, and discontinuing pain medications with minimal side effects and addressing any issues of addiction are aspects of this phase of care [47]. Optimal care of the pediatric hand patient requires that surgeons be attuned to multiple considerations including direct communication with the child, suspicion of nonaccidental trauma, judicious use of radiation and sedation, and appropriate postoperative management to optimize patient and parent experiences [138].

Impact on Outcomes and Recovery

Many injury-related and psycho social factors affect the duration of time away from work following orthopaedic injury [2]. Occupational groups and psychosocial working conditions seem to be independent of familial confounding, and hence represent risk factors for disability pension due to musculoskeletal diagnoses [6]. A more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively for ulnar-sided wrist pathology, but these patients showed similar improvement as patients with a more feasible psychosocial profile [9]. Although mortality is high, surviving patients experience measurable gains in function and well-being in the 3 years after hip fracture [12]. Patients who take more opioids after injury actually report increased pain and less satisfaction with their pain relief, while self-efficacy was the most correlated with satisfaction [34]. Patients with a mangled extremity have significant disability and poor SIP profiles over a long term, regardless of whether amputation or limb salvage is performed [99]. Limb reconstruction patients fared better than the amputees when comparing psychological outcomes in a meta-analysis of mangled lower limb injuries [43]. Patients with lower education level and a Workers’ Compensation claim are more likely to do poorly after rotator cuff repair [28]. Workers’ compensation is an important comorbidity, and patients insured for on-the-job injuries have poorer outcomes than patients with other types of insurance coverage [77]. If a patient is out of work for 1 year, the chances of going back to work are slim [77]. Poorer outcomes are seen in patients with lateral epicondylitis who complain of severe pain, have concomitant neck pain, are involved in workers’ compensation claims, have concomitant depression, or have poor coping skills [95]. Surgical intervention for lateral epicondylitis is offered with extreme caution to patients with concomitant depression, catastrophic thinking, and poor coping skills due to poor outcomes and disappointing results [95]. Distress and anxiety symptoms were associated with poorer health outcomes in cervical spine radiculopathy populations and non-specific neck pain [35]. Stress and higher job strain was negatively associated with poorer health outcomes measured by the presence of pain in non-specific neck pain populations [35]. The types of injury seen and their causes in agricultural accidents are discussed, with particular reference to the design of the agricultural machinery commonly involved [16]. These findings highlight the importance of effective communication with patients regarding treatment modalities, risks and benefits, and prognosis of their injury following humeral fractures [19]. Therapists appear to be biomechanically oriented which may impact outcomes in hand and upper limb injury [30]. This study indicates the need for early consideration to factors that affect psychological prognosis for the upper extremity limb salvage population [8]. This study is among the first to examine psychological outcomes for the upper extremity limb salvage population [15]. Mental illness after trauma has been associated with poor adherence to treatment recommendations and with higher rates of complications, as well as greater potential for recidivism [33]. Patients debilitated with anxiety, depression, and other mental illness experience more pain with greater narcotic consumption, more catastrophizing, more self-reported disability, and lower levels of patient satisfaction [33]. In a prospective study of the effect of posttraumatic stress and problem drinking on functional outcomes after injury, posttraumatic stress disorder was the strongest predictor of an adverse outcome, stronger even than the severity of the injury itself [17]. The data provide no evidence that orthopaedic surgeons are subject to a more litigious culture within the NHS [64]. Long-term results are required to assess the survivorship of the Discovery Elbow System [4]. Patients are expected to present similar performance at 1 year postoperatively following total knee replacement with preoperative strengthening plus balance training [23]. Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture [20]. Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes [62]. Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in coxa vara in childhood, while moderate nonprogressive deformity often does not require surgery [131]. Understanding the current evidence and appropriate indications of emerging technologies is of critical importance for their utilization [61]. In this section, we discussed the clinical presentation and radiologic evaluation of patients presenting with musculoskeletal tumors, noting that functional testing in orthopaedic oncology is gaining importance in the care and follow-up of patients [50]. The orthopaedic approach to patients with neuromuscular diseases can be challenging as both surgical and supportive methods of interventions are available, and the timing of each should be chosen carefully and be placed in context of the patients’ overall function and the point in time of recovery [78]. In general, an interdisciplinary approach with regular longitudinal follow-ups will hopefully provide patients and their family an improved day-to-day satisfaction alongside with optimal clinical outcomes for neuromuscular diseases [78]. The advancement of the genetic field holds a promise in improvements of both diagnostic methods and treatments directed at modifying the course of the disease for rare genetic bone diseases [78]. Orthopaedic treatment strategies will likely change in the future as a result of this pharmacologic alteration of the natural history for rare genetic bone diseases [78]. For successful management of compression neuropathies, evaluation and treatment should be directed at all levels of nerve compression and any soft tissue disorders that are present [89]. Changes in quality of life parallel improvement in pain scores after nerve surgeries [89]. Combined use of generic questionnaires such as the DASH, MHQ, PROMIS, and a pain evaluation questionnaire in combination with the PSFS may provide a more comprehensive self-report evaluation for nerve compression [89]. Patients with any previous cervical fractures or cervical spine surgery, signs of myelopathy, rapidly progressive paresis or paresis < grade 4, pregnancy, arthritis involving the cervical spine, infection or active cancer, generalised pain syndrome, serious psychiatric or somatic disease that excludes one of the treatment alternatives, concomitant shoulder disorders that may interfere with the outcome, abuse of medication/narcotics, inability to understand written Norwegian, and unwillingness to accept one of the treatment alternatives were excluded from the cervical radiculopathy trial [123].

Complications

Psychological and Psychiatric Complications

Posttraumatic stress disorder (PTSD) affects 20% to 51% of patients with musculoskeletal injury [5], significantly compromising orthopaedic outcomes [5]. Pre-existing mental illness is present in up to 39% of patients presenting with new injury, with depression being the most common condition [33]. Following orthopedic trauma, depression is identified in 45% of patients [33]. Mental illness after trauma correlates with poor adherence to treatment recommendations, higher rates of complications, and greater potential for recidivism, defined as returning with a new, otherwise unrelated trauma event [33]. Patients debilitated by anxiety, depression, or other mental illness experience more pain [33], consume greater amounts of narcotics [33], exhibit more catastrophizing [33], report more self-reported disability [33], and have lower levels of patient satisfaction [33]. Psychological conditions such as PTSD substantially affect the patient’s report of outcome [17].

In the LEAP study, 25.7% of patients were categorized as having severe depression or anxiety at the 3-month follow-up [43]. Patients with severe depression or anxiety at 3 months were at the highest risk (40%) for suffering from chronic pain at 7 years postdischarge after adjusting for pain intensity at 3 months [43]. In a meta-analysis of mangled lower limb trauma, limb reconstruction patients fared better than amputees regarding psychological outcomes [43]. Patient satisfaction with treatment of lower extremity trauma was independent of injury details, treatment option, patient demographics, or psychological profile [43]. Instead, physical function, pain intensity, the absence of depression, and the ability to return to work at 2 years were the most important factors affecting patient satisfaction [43]. PTSD has been described in patients after mangled work-related injuries, where merely revisiting the site of injury can elicit severe symptoms and significantly impede returning to work [31].

Psychological consequences following amputation vary by patient and are influenced by factors such as etiology and personal interpretation [37]. Emotional balancing is a key theme for returning to normal life after amputation [37].

Impact on Recovery, Function, and Outcomes

The presence of multiple Waddell signs correlates with poor operative outcome in patients with intervertebral disc disease [40]. Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores in total knee arthroplasty outcome evaluations [10]. Early consideration of factors affecting psychological prognosis is necessary for the upper extremity limb salvage population [8]. In pediatric orthopaedic cases, psychological disorders, family support, pain tolerance and management, compliance with treatment, and the family’s goals of treatment can affect the treatment outcome [47]. If a child or family member has a significant, untreated mental health disorder, this may be exacerbated by the stress of a long, demanding treatment and may negatively affect the outcome [47]. A decision not to proceed with treatment may be made when there is a demonstrated inability to adhere to care and exercises, significant psychological disorders, family disharmony, and/or poor understanding of treatment [47].

Higher rates of substance use and abuse are associated with more pain and greater post-injury narcotic consumption [119]. A vicious cycle of unrelenting pain resulting in catastrophizing, which results in greater substance use and abuse, portends poor physical and mental outcomes after trauma [119]. Alcohol abuse is associated with early and late complications as well as greater hospital stays and costs of care [119]. Alcoholics are malnourished and have reduced protein synthesis due to hepatic dysfunction, resulting in higher rates of infections and poor wound healing [119]. Alcohol abuse results in deficient bone healing and muscle recovery [119].

Screening and Assessment Tools

The presence of three or more Waddell signs or symptoms was required to show abnormal illness behavior [40]. Waddell signs and symptoms cannot be used to predict return to work [40]. Formal psychologic testing, consisting of the MMPI, is recommended for patients being considered for operative treatment with the working diagnosis of intervertebral disc disease [40].

Recovery

Psychosocial Impact on Outcomes: Psychological consequences in patients with limb amputation vary by individual and are influenced by factors such as etiology and personal interpretation [37]. Emotional balancing is a key theme for returning to normal life in these patients [37].

Screening and Assessment: Screening at 3 months after hand trauma potentially allows for early intervention and improved treatment outcomes [7]. The Musculoskeletal Function Assessment questionnaire demonstrated good reliability, validity, and responsiveness [25]. This instrument had better content validity than other questionnaires and no ceiling or floor effects [25].

Rehabilitation and Intervention: The effect size for fatigue reduction via behavioral activation was higher (d = 0.71) in the subsample of participants who initially presented with severe (> 6/10) symptoms of fatigue [55]. Symptoms of fatigue prospectively predict the later emergence of pain symptoms in primary care patients [55].

Key Evidence

• [L2] Making a claim was associated with poor injury recovery following motor vehicle related orthopaedic trauma, mainly for mental health. [1] (10.1186/s12891-016-1152-2)
• [L2] Many injury-related and psycho social factors affect the duration of time away from work following orthopaedic injury. [2] (10.1186/1471-2474-11-6)
• [L5] Early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health. [3] (10.5435/jaaos-d-20-00637)
• [L4] Long-term results are required to assess the survivorship of this system. [4] (10.1016/j.jse.2014.08.013)
• [L4] PTSD occurs in 20% to 51% of patients with musculoskeletal injury and orthopaedic outcomes suffer considerably in patients with PTSD. [5] (10.5435/00124635-201109000-00001)
• [L2] Occupational groups and psychosocial working conditions seem to be independent of familial confounding, and hence represent risk factors for disability pension due to musculoskeletal diagnoses. [6] (10.1186/1471-2474-14-268)
• [L4] Despite a limited evidence base, screening at 3 months may detect posttraumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes. [7] (10.1016/j.jht.2016.11.006)
• [L4] This study indicates the need for early consideration to factors that affect psychological prognosis for the UE limb salvage population. [8] (10.1016/j.jht.2017.05.020)
• [L3] A more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively, but these patients showed similar improvement as patients with a more feasible psychosocial profile. [9] (10.1186/s12891-022-05045-x)
• [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. [10] (10.2106/00004623-199706000-00009)
• [L2] However, these factors were not associated with patient-reported outcomes after intervention. [11] (10.1007/s11999.0000000000000087)
• [L2] Although mortality is high, surviving patients experience measurable gains in function and well-being in the 3 years after the fracture. [12] (10.5435/jaaos-d-19-00530)
• [L1] Understanding both the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy. [13] (10.1016/j.arthro.2022.05.003)
• [L4] This study is among the first to examine psychological outcomes for the UE limb salvage population. [15] (10.1016/j.jht.2017.09.003)
• [L4] The types of injury seen and their causes are discussed, with particular reference to the design of the agricultural machinery commonly involved. [16] (10.1016/s0020-1383(71)80124-9)
• [L2] [17] (10.2106/00004623-200406000-00001)
• [L5] Hand therapists play a critical role in facilitating physical and psychosocial recovery by using patient-centered, culturally relevant assessments and interventions to positively affect adjustment and improve outcomes. [18] (10.1016/j.jht.2010.11.001)
• [L4] These findings highlight the importance of effective communication with patients regarding treatment modalities, risks and benefits, and prognosis of their injury. [19] (10.1177/17585732231201976)
• [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. [20] (10.2106/00004623-199802000-00010)
• [L2] Patients may take longer to recover from outpatient surgery than previously recognized. [21] (10.1007/s11999-013-3270-6)
• [L2] Several psychological and physiological factors predicted change in the number of pain sites. [22] (10.1186/s12891-017-1503-7)
• [L2] Patients are expected to present similar performance at 1 year postoperatively. [23] (10.1007/s00167-020-06029-x)
• [L3] [24] (10.1007/s11999-016-4894-0)
• [L3] The Musculoskeletal Function Assessment questionnaire demonstrated good reliability, validity, and responsiveness, with better content validity than other questionnaires and no ceiling or floor effects. [25] (10.2106/00004623-199709000-00006)
• [L3] The increase in HRQoL was lower in the subgroups with incident fracture but was not influenced by recent prior fracture. [26] (10.1186/1477-7525-7-11)
• [L2] The study shows that a multidimensional approach to classification based on psychological and psychosocial characteristics can distinguish different groups in a working population with neck and/or low back pain. [29] (10.1186/1471-2474-12-81)
• [L4] Therapists appear to be biomechanically oriented which may impact outcomes. [30] (10.1177/1558944717725373)
• [L1] [35] (10.1186/s12891-023-06343-8)
• [L4] The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation. [36] (10.1186/s12891-020-03284-4)
• [L4] The findings suggest that psychological consequences vary by patient and are influenced by factors such as etiology and personal interpretation, with emotional balancing being a key theme for returning to normal life. [37] (10.3389/fpsyg.2021.537493)
• [L2] A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. [54] (10.1002/ejp.615)
• [L3] [55] (10.1186/s12891-022-05162-7)
• [L4] In summary, the overall validity is considered acceptable. [57] (10.1186/s12891-017-1677-z)
• [L1] [59] (10.1016/j.jht.2018.10.003)
• [L3] Orthopedic shoulder patients with preoperative mental health disorders were prescribed significantly more opioids postoperatively compared to those without mental health disorders. [60] (10.1016/j.jseint.2023.06.013)
• [L5] Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes. [62] (10.2106/00004623-199806000-00015)
• [L4] The data provide no evidence that orthopaedic surgeons are subject to a more litigious culture within the NHS. [64] (10.1302/0301-620x.95b1.30908)
• [L2] [106] (10.1186/s12891-016-1083-y)
• [L5] [122] (10.1302/0301-620x.99b7.bjj-2016-1350.r1)
• [L1] [123] (10.1186/s12891-020-3188-6)
• [L4] The clinical use of PROMs among orthopedic surgeons was negligible, even though an overwhelming majority were interested in using PROMs. [125] (10.1186/s13018-020-02135-1)
• [L2] [127] (10.1177/17531934221117429)
• [L5] The authors argue that the statement regarding the prevalence of symptom exaggeration in workers' compensation claims was unsubstantiated and misleading, emphasizing that focusing on detecting exaggerated symptoms will not eliminate costs or reduce litigation, and that comprehensive initiatives to assist workers in returning to work are more effective. [128] (10.1016/j.jhsa.2008.02.023)
• [L3] Advanced head imaging for evaluation of total joint arthroplasty patients with a change in mental status is of low yield. [130] (10.1016/j.arth.2013.12.030)
• [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. [131] (10.5435/00124635-199803000-00003)
• [L5] Optimal care of the pediatric hand patient requires that surgeons be attuned to multiple considerations including direct communication with the child, suspicion of nonaccidental trauma, judicious use of radiation and sedation, and appropriate postoperative management to optimize patient and parent experiences. [138] (10.1016/j.jhsa.2018.10.020)
• [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. [141] (10.1177/0363546507306465)
• [L3] This finding supports use of the RLS diagnostic criteria in helping to differentiate between RA arthritic symptoms and RLS. [144] (10.1186/1471-2474-15-378)

References

[1] The association between seeking financial compensation and injury recovery following motor vehicle related orthopaedic trauma. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1152-2

[2] Bio-psychosocial determinants of time lost from work following non life threatening acute orthopaedic trauma. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-6

[3] The Psychological Effects of Musculoskeletal Trauma. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00637

[4] Total elbow arthroplasty: a prospective clinical outcome study of Discovery Elbow System with a 4-year mean follow-up. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.08.013

[5] Posttraumatic Stress Disorders in Civilian Orthopaedics. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201109000-00001

[6] Register-based data of psychosocial working conditions and occupational groups as predictors of disability pension due to musculoskeletal diagnoses: a prospective cohort study of 24 543 Swedish twins. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-268

[7] Systematic review: Predicting adverse psychological outcomes after hand trauma. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2016.11.006

[8] Psychosocial reactions to upper extremity limb salvage: A cross-sectional study. Journal of Hand Therapy. 2018. DOI: 10.1016/j.jht.2017.05.020

[9] The impact of psychosocial variables on initial presentation and surgical outcome for ulnar-sided wrist pathology: a cohort study with 1-year follow-up. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05045-x

[10] Demographic Biases of Scoring Instruments for the Results of Total Knee Arthroplasty. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199706000-00009

[11] Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? A Systematic Review. Clinical Orthopaedics & Related Research. 2018. DOI: 10.1007/s11999.0000000000000087

[12] The Pronounced Impact of Hip Fractures on Psychosocial Well-being. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-19-00530

[13] The Influence of Psychosocial Factors on Hip Surgical Disorders and Outcomes After Hip Arthroscopy: A Systematic Review. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.05.003

[14] Örebro Musculoskeletal Pain Screening Questionnaire (scoring + interpretation). WorkCover. 2007.

[15] Psychosocial reactions to upper extremity limb salvage: A case series. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2017.09.003

[16] Accidents in agriculture. Injury. 1972. DOI: 10.1016/s0020-1383(71)80124-9

[17] Symptoms of Posttraumatic Stress Disorder After Orthopaedic Trauma. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200406000-00001

[18] Psychosocial Issues after a Traumatic Hand Injury: Facilitating Adjustment. Journal of Hand Therapy. 2011. DOI: 10.1016/j.jht.2010.11.001

[19] Medical malpractice litigation following humeral fractures in the United States. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231201976

[20] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

[21] Burden Incurred by Patients and Their Caregivers After Outpatient Surgery: A Prospective Observational Study. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-013-3270-6

[22] Psychological predictors of change in the number of musculoskeletal pain sites among Norwegian employees: a prospective study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1503-7

[23] A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06029-x

[24] Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-016-4894-0

[25] Comparison of the Musculoskeletal Function Assessment Questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile Health-Status Measures. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199709000-00006

[26] Responsiveness of the EQ-5D in breast cancer patients in their first year after treatment. Health and Quality of Life Outcomes. 2009. DOI: 10.1186/1477-7525-7-11

[27] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > CLINICAL EVALUATION AND PHYSICAL EXAMINATION.

[28] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > APPROACH TO FAILED CUFF SURGERY.

[29] Using a psychosocial subgroup assignment to predict sickness absence in a working population with neck and back pain. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-81

[30] The Use of Psychosocial Services Post Hand and Upper Limb Injury and Trauma: A Pilot Study. HAND. 2017. DOI: 10.1177/1558944717725373

[31] Green S Operative Hand Surgery. EVOLUTION IN THE TREATMENT OF MANGLING INJURIES > EXPECTED OUTCOMES.

[32] Campbell S Operative Orthopaedics 4 Volume Set. OVERVIEW OF LUMBAR AND THORACIC DISC DEGENERATION AND HERNIATION > AXIAL LUMBAR PAIN.

[33] Rockwood And Green S Fractures In Adults. 13: Management of the Multiply Injured Patient > Mental Illness.

[34] Rockwood And Green S Fractures In Adults. 21: Psychosocial Aspects of Recovery After Trauma > Mental Health and Pain Management.

[35] The association between psychosocial factors and mental health symptoms in cervical spine pain with or without radiculopathy on health outcomes: a systematic review. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06343-8

[36] A quality of life questionnaire for patients with scapula alata (SA-Q): development and validation. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03284-4

[37] Psychological Consequences in Patients With Amputation of a Limb. An Interpretative-Phenomenological Analysis. Frontiers in Psychology. 2021. DOI: 10.3389/fpsyg.2021.537493

[39] Green S Operative Hand Surgery. A Practical Guide for Complex Regional Pain Syndrome in the Acute Stage and Late Stage > GENERAL CONSIDERATIONS IN COMPLEX REGIONAL PAIN SYNDROME > Budapest Criteria and Definitions.

[40] Campbell S Operative Orthopaedics 4 Volume Set. OVERVIEW OF LUMBAR AND THORACIC DISC DEGENERATION AND HERNIATION > PATIENT SELECTION PROCESS.

[41] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[43] Rockwood And Green S Fractures In Adults. Effect of Blast on the Musculoskeletal System > Psychological Considerations.

[47] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Plate 19.7 Correction of Hammer Toe by Resection and Arthrodesis of the Proximal Interphalangeal Joint > Treatment > Psychological and Social Factors.

[48] AMA Guides to the Evaluation of Permanent Impairment, 5th edition. AMA Guides to the Evaluation of Permanent Impairment, 5th edition > Chapter 2 — Chapter 2 > Section 2.6a, p. 21.

[49] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 1General Considerations in Orthopedic Surgery > DIAGNOSTIC WORKUP.

[50] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Evaluation and Treatment of Musculoskeletal Tumors > Summary.

[51] Green S Operative Hand Surgery. PREOPERATIVE EVALUATION.

[52] Queensland Guidelines for Evaluation of Permanent Impairment, 2nd edition. Queensland Guidelines for Evaluation of Permanent Impairment, 2nd edition > Intent and legislative basis, p. 7.

[53] Rockwood And Matsen S The Shoulder. Shoulder and Elbow Specialty Clinic Workers’ Survey > EDITOR COMMENTARY.

[54] Can a back pain screening tool help classify patients with acute pain into risk levels for chronic pain?. European Journal of Pain. 2015. DOI: 10.1002/ejp.615

[55] The temporal relation between pain and fatigue in individuals receiving treatment for chronic musculoskeletal pain. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05162-7

[56] Aaos Comprehensive Orthopaedic Review 3. Occupational Health/Work-­Related Injury and Illness > I. Workers’ Compensation.

[57] “Blue flags”, development of a short clinical questionnaire on work-related psychosocial risk factors - a validation study in primary care. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1677-z

[59] A randomized clinical trial comparing early active motion programs: Earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. Journal of Hand Therapy. 2020. DOI: 10.1016/j.jht.2018.10.003

[60] Mental health disorders and pain modulation in orthopedic shoulder patients. JSES International. 2023. DOI: 10.1016/j.jseint.2023.06.013

[61] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[62] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[64] Litigation after hip and knee replacement in the National Health Service. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b1.30908

[68] Green S Operative Hand Surgery. A Practical Guide for Complex Regional Pain Syndrome in the Acute Stage and Late Stage > Psychological Factors and Effects.

[71] Green S Operative Hand Surgery. NEUROPATHIC PAIN MANAGEMENT.

[77] Rockwood And Matsen S The Shoulder. Risk Factors for Failure of Arthroscopic Stabilization > SENIOR EDITOR COMMENTARY—cont’d.

[78] Orthopaedic Basic Science Fifth Edition Print Ebook. Rare Genetic Bone Diseases of Orthopaedic Significance > Summary.

[89] Green S Operative Hand Surgery. Median Nerve Compression at the Elbow and Forearm > EVALUATION OF COMPRESSION NEUROPATHIES.

[90] Orthopaedic Knowledge Update Trauma. Amputations in Patients With Trauma > Clinical Practice Guidelines.

[95] Green S Operative Hand Surgery. Surgical Treatment > Expected Outcomes.

[99] Orthopaedic Knowledge Update Trauma. The Mangled Lower Extremity > Summary.

[101] Queensland Guidelines for Evaluation of Permanent Impairment, 2nd edition. Queensland Guidelines for Evaluation of Permanent Impairment, 2nd edition > Intent and legislative basis > Ordering of additional investigations, p. 6.

[102] Rockwood And Green S Fractures In Adults. 3: Biologic and Biophysical Technologies for the Enhancement of Fracture Repair > Availability.

[103] Queensland Guidelines for Evaluation of Permanent Impairment, 2nd edition. Queensland Guidelines for Evaluation of Permanent Impairment, 2nd edition > Spine > Assessment of the spine, p. 27.

[104] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spine Evaluation, Clinical Examination, and Imaging > Physical Examination.

[105] Orthopaedic Knowledge Update Trauma. Nonunions > Evaluation.

[106] Usefulness of the SF-36 Health Survey in screening for depressive and anxiety disorders in rheumatoid arthritis. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1083-y

[107] Green S Operative Hand Surgery. CONCLUSION.

[108] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > Senior Author’s Current Practice.

[109] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Diagnosis.

[110] Classifications And Scores Of The Shoulder. 19.10 Self-administered questionnaire for assessment of symptoms and function of the shoulder according to L’Insalata et al. [74]*.

[111] Campbell S Operative Orthopaedics 4 Volume Set. OVERVIEW OF LUMBAR AND THORACIC DISC DEGENERATION AND HERNIATION > DIFFERENTIAL SPINAL ANESTHETIC > PSYCHOGENIC PAIN.

[113] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > History and Physical Examination Related to Nonunion.

[114] Rockwood And Green S Fractures In Adults. 3: Biologic and Biophysical Technologies for the Enhancement of Fracture Repair > General Considerations.

[116] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Signs and Symptoms of Periprosthetic Humeral Fractures About Shoulder Arthroplasty.

[118] Rockwood And Green S Fractures In Adults. 3: Biologic and Biophysical Technologies for the Enhancement of Fracture Repair > Digital Imaging and Teleradiology in Orthopedics.

[119] Rockwood And Green S Fractures In Adults. 13: Management of the Multiply Injured Patient > Social Factors.

[120] Rockwood And Green S Fractures In Adults. Imaging of Cervical Spine Fractures and Dislocations > Imaging and Other Diagnostic Studies for Cervical Spine Fractures and Dislocations.

[121] Rockwood And Green S Fractures In Adults. 3: Biologic and Biophysical Technologies for the Enhancement of Fracture Repair > Image Resolution.

[122] An epidemic of the use, misuse and overdose of opioids and deaths due to overdose, in the United States and Canada. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b7.bjj-2016-1350.r1

[123] A randomised controlled trial comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3188-6

[125] Use of patient-reported outcome measures (PROMs) by orthopedic surgeons in Saudi Arabia. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-02135-1

[127] Psychological sequelae of hand injuries: an integrative review. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221117429

[128] Overstating the Prevalence of Symptom Exaggeration in Workers' Compensation Cases. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.023

[130] Head_Computed_Tomography_Is_Not_Useful_for_Evaluating_Patients_Change_in_Mental_S0883540313009406. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.12.030

[131] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[138] Upper Extremity Care for Children: Unique Medical and Psychosocial Aspects. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.10.020

[141] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[144] Increased nocturnal periodic limb movements in rheumatoid arthritis patients meeting questionnaire diagnostic criteria for restless legs syndrome. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-378