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Thank you for joining our CM presentation today. I'm Doctor David Bennett EE VP of Clinical Value Based Care for health care Outcomes Performance Company, also known as Hop O. Our topic for today is the initial management of declare 10 before we get started on the topic uh for today as we do for all CM E events, I want to assure the audience that I have no financial or nonfinancial um uh relationships to disclose as it relates to this topic and subsequent uh discussion as a reminder uh to those of you who have attended other CM topics uh We've presented in the series. Our objective is to improve the continuum of care uh and outcomes for musculoskeletal patients by defining the role of primary care providers in musculoskeletal value based care. We also aim to provide uh diagnostic and management pearls to pcps and other providers referring to M SK specialists. So the providers who manage the initial presentation of many common M SK issues can uh more accurately diagnose and treat these uh conditions. In addition, we aim to help providers identify red flags and other clinical factors. Uh necessitating urgent imaging uh or specialist referrals. At the end of today's sessions, we hope the audience will be able to accurately diagnose vain steno pseudo tis by symptomatology and physical examination, determine which patients with symptoms of deque stenosis novi would be most likely to benefit from therapy and diagnostic imaging and determine which patients should be referred to a specialist for an injection and or surgical management. In order to achieve these objectives, we'll briefly review the HCO specialty Care network tip sheet. Um Then we'll do a brief run through multiple uh important topics in the initial management of this condition starting with a background. Uh then moving to evaluation of the hand and thumb, um and then moving on to tips for conservative treatment testing. And finally, we'll touch on um when a specialist referral may be clinically warranted. HCO and HOP hop specialty Care Network also abbreviated as HS CN. Um believes this information is important to distribute to our referral network um including pcps and all other upstream providers as a way of context. HSC N uh network um comprises more than 230 orthopedic surgeons and musculoskeletal providers across Arizona who have joined forces to follow standardized evidence based clinical pathways. Uh Never before. As a network of uh muscle specialists across the state come together to align around best practice uh delivery and education. And our network is the first of its kind in the country and is already managing and improving outcomes for United Healthcare Medicare advantage patients across Arizona. Uh We anticipated adding additional patient populations uh in the near future. HCO specialty care network is a clinically integrated network which is a type of value based care uh program. Uh by definition, value based care programs incentivize health care providers to provide improved quality of care while reducing unnecessary cost. Uh Of note, HSEN was recently recognized by a top national accreditation organization um uh for its commitment to clinical integration and high quality care. HSEN is actually the first specialty network in the country to be awarded accreditation uh as a high quality clinically uh integrated network. Uh HSEN also collaborates with other providers including yourselves who encounter uh M SK conditions with the goal of improving uh patient outcomes and experience. And as all of you are well aware, a lot of the initial management of MSK conditions occurs not at the specialist level but upstream including in the PCP clinic. Uh in saying this, it's clear that a population health program uh clearly relies on pcps to help reduce unnecessary M SK costs as uh PCPs are the most common gatekeeper uh for M SK care. Before we dive into the topic of the day, it's important to mention that this information shared in this talk is evidence based and consensus driven uh with a recommended practice designed to be implemented for patients with M SK conditions. But um as we said in uh other um uh talks in this series. Uh And for any clinical program, clinical discretion should be used uh with these guidelines for patients, especially if there's concomitant clinical uh factors or comorbid conditions that may alter the clinically appropriate treatment path. If you've seen other, uh talks in the series, this is uh probably starting to look, um, a little familiar with this tip sheet and we're gonna start with a review of the HSN uh HSEN tip sheet. Um, We sent out this tip sheet to all of you. Um And if you don't have a copy of it, uh please feel free to email us at HSEN at ho dot com. We'd be happy to send you a, a copy of so you could hang this in your clinic as well for reference. Uh The tip cheat is more specifically older Medicare uh advantage uh and Medicare uh population, but the tips here are relevant to a younger population as well. Um Today, we're gonna focus on thumb and hand pain due to larva and stenos innovates. This is the fourth line on this tip sheet uh with recommendations um for initial management um for these categories similar to that of carpal tunnel syndrome, uh we will go through each column in more detail, but it's a good way to, to see the overall suggestions of the specialist for initial management. Um As you can see from the tip sheet for deque vein related uh pain. Um initial management uh comprises of conservative care which may include activity modification and possible uh DM E uh prescriptions but does not include therapy or advanced imaging. Uh As you can see here, uh notated by a red icons, Quean steno sotis, um also known as Quean steno vaginitis, is uh named after Swiss surgeon, uh Fritz Deer vein. Uh as a review deque steno sotis, uh is inflammation of the first extensor compartment of the wrist located proximal to the thumb. I may be taking a little bit back to anatomy class. Here. The first extensor compartment uh comprises tendons of the APL and TB. Um, uh spelled out the abductor po uh poly Longus and the extensor pollicis brevis. The swelling in, in declaring skin citti impacts the tendons that run run along the thumb, uh thumb side on the wrist, uh and the thumb side of the wrist and attach to the base of the thumb when the tendons are constricted by a sheath that they uh uh run through. I take it from the wrist of the hand. Uh, pain can uh uh occur on the thumb side of the wrist. It's most notable when, um, someone's moving the thumb, making a fist, uh gripping or grasping something or lifting with the thumb, uh pointed up, um, like lifting a child, for instance, uh decorum pseudo synovitis is most common in women between the ages of 3050. Um And it has increased uh risk of uh risk in rheumatoid arthritis. Uh but it's also um a very common as well in men and in other um with other comorbidities as well. After eliciting a thorough um examination, suggestive uh of this condition, an examination should be done to help confirm the diagnosis. A palpation exam of the area commonly shows tenderness along the tendons of the first extensor compartment. Uh and at the radial styloid, uh the bony uh protuberant, right at the end of the radius just proximal to the thumb. A range of motion examination is usually pretty normal. Um But that range of motion could be uh painful for people uh with queer veins, uh uh issues. There are also some maneuvers that can add to the exam that are more specific for uh declaring stenos innovates. The first one here is uh the ico uh maneuver um in this exam, uh the patient moves the wrist ulnarly uh in the direction of the fifth digit. When clenching the thumb in a fist. This test is positive if the, if this activity elicits pain. Um and it's relieved once a thumb is extended or released from the fist. Um Even if the wrist remains ulnar deviated, the test, almost everyone may have learned about it in training is the Finkelstein uh maneuver. Uh For this test, you can have the patient make a fist around the thumb and perform an ulnar deviation. There's a modified version of this test uh which is shown here um in which the examiner rotates the patient's affected hand ulnar ward uh and pulls the thumb across the palm. Uh The test is positive when this mo maneuver results in pain at the radial styloid um on grasping the patient's thumb and quickly abducting the hand ulnar ulnar uh in the ulnar direction, it causes pain over the radial styloid. Um and this pain can also radiate up the arm for patients with a history and exam consistent with aquarian teno synovitis. The initial treatment is uh non surgical and even prior to surgical referral, conservative, conservative non surgical treatment is appropriate for at least six months. And the initial treatment um includes an over the counter velcro thumb spike, a wrist brace, um non steroidal antiinflammatory drugs or Tylenol uh and activity modifications. Quite important, avoiding activities that, that cause uh pain. Uh not, I emphasize over the counter um uh for the brace because there's no clinical indication for a custom brace as part of initial management. Um and any specialized bracing uh should be ordered by a specialist if the patient gets to the point of requiring a specialist referral, um which we'll um uh talk about in a couple slides. Um The brace shown here um on the size of velcro, velcro thumb spica um brace. Um It's a um I and again, non custom braces are, are usually cheaper uh than over the counter. Um I mean, sorry, uh over the counter, uh braces are usually cheaper than those uh through a prescription. But your patients may want to research this more before purchasing uh the brace. If they like a de direct comparison on price between those two options, I ski to the slide a little bit early but um it should be mentioned that um A as it noted on a tip sheet as well. Uh physical therapy and occupational therapy are not indicated for tar and steno synovitis for some patients um with a prolonged uh and severe symptoms, corticosteroid injections into the tendon sheath, uh can be effective in addressing um uh the condition by reducing swelling and relieving pain. Um but it's not a first line treatment. Uh injection of steroids should be done by a specialist um especially because of the anatomy here. Uh We wanna reduce the risk of uh tendon rupture and complication uh due to the proximity of the tendons and risk for damage. A hand specialist have recommended a lifetime limit to two injections. Uh And these injections should be a minimum of three months apart. This may come as no surprise uh to most, but when it comes to diagnostic testing, there's no test that's clinically indicated for symptoms of veins. Uh tenis synovitis, uh specifically X ray CT and MRI are not indicated and should be uh and should not be ordered. Uh for this condition. We've touched a little bit in this talk already about specialist referrals. Um And in this case, a referral to an orthopedic hand specialist. Uh These referrals should be reserved for failure of conservative treatments such as activity modifications, spun and the use of nsaids for at least six months. Um At that point, uh, the orthopedic hand specialist can provide additional therapeutic options including a Glucocorticoid injection, uh and surgery uh, if needed. At the end of each talk in the series, I'd like to uh add some, uh, take home points for Declarant Tenosynovitis to take home points, uh include uh conservative treatment prior to specialist referral and diagnostic imaging is typically the most appropriate uh initial treatment. A conservative trial should last six months to avoid unnecessary referrals uh and testing. Um Additionally, patients who require DM E should research the cost of attaining non custom DM E at a drug store instead of through insurance. Um and advanced imaging uh and physical occupational therapy are not um clinically indicated and should not be ordered uh for uh declaring tenosynovitis. Uh Thank you for joining us uh today uh for this presentation. And we hope you enjoy the talk and I hope you join us again as we explore other topics in M SK care. Have a great day.