BACKGROUND:When an adult with rotator cuff tendinopathy reports feeling or hearing a pop along with new pain, both the clinician and the patient may inaccurately and unhelpfully expect (framing heuristic) an injury and consider it a compensable work claim. METHODS:We retrospectively reviewed medical records of 118 people that filed work claims for new shoulder pain where aspects of their care or recovery trajectory triggered a peer review. We collected data on age, sex, reports of hearing or feeling a pop (25%; 29 of 118 patients), and reports of new numbness or tingling (11%; 13 of 118 patients). Five (4%) patients had a possible acute rotator cuff rupture (relatively large defect with good muscle) and 11 (9%) had a long head of biceps rupture, age indeterminate. RESULTS:Accounting for confounding variables using logistic regression, possibly acute rotator cuff defects and age-indeterminate long head of biceps ruptures were associated with older age (odds ratio [OR], 1.10; 95% CI, 1.02-1.18) and the presence of a degenerative rotator cuff defect (OR, 6.0; 95% CI, 1.5-24) but not with sensation of a "pop." CONCLUSIONS:Based on this evidence, among people claiming injury at work, when a "pop" is reported the clinician should not expect new pathophysiology. Level of evidence: III.

INTRODUCTION:Evidence suggests that the distal radioulnar joint injury associated with an operatively treated displaced fracture of the distal radius does not benefit from specific treatment after the radius is realigned. To better understand variation in treatment of the distal radioulnar joint we performed a scenario-based experiment presenting radiographs of displaced distal radial fractures accompanied by clinical scenarios with randomized aspects. METHODS:In a survey-based experiment, participants of the Science of Variation Group viewed a random subset of five of 10 sets of radiographs showing displaced fractures of the distal radius before and after anterior plate fixation. Each was accompanied by a clinical scenario with trauma energy level, age and gender randomized. Participants indicated their preferred distal radioulnar joint treatment: none, cast immobilization, operative reattachment of ligaments or ulnar styloid fixation, or distal radioulnar joint pinning. Factors associated with any treatment and with reattachment were sought in multivariable regression. RESULTS:Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios, most commonly cast immobilization in 41% (247 of 607). Recommendation for any distal radioulnar joint treatment was associated with younger patient age, and for reattachment specifically, was associated with younger patient age, high-energy trauma and fracture of the base of the ulnar styloid. CONCLUSIONS:The observation of frequent recommendation for distal radioulnar joint treatment, relatively more so for younger patients with higher energy injuries, and some tendency to repair an aligned ulnar styloid base fracture may diverge from existing evidence.

INTRODUCTION:Large language models (LLMs) can generate plausible diagnoses from patient symptom descriptions and convey complex medical information in conversational, empathetic language. Given that LLMs may struggle with the vague symptom descriptions characteristic of less healthy mindsets, discordance between LLM and clinician diagnoses might signal misinterpretation of sensations. Among new musculoskeletal outpatients, we studied factors associated with (1) diagnostic discordance between an LLM and a clinician and (2) patient rating of experience interacting with the LLM. METHODS:One hundred forty English-speaking patients described their symptoms to an LLM prompted to provide a single most likely diagnosis. Clinician diagnoses were recorded after the visit. Patients completed a survey assessing perceptions of the LLM interaction, demographics, and psychosocial factors-including measures of unhelpful thoughts and distress (eg, catastrophic thinking, misperception of pain as necessarily signifying injury, rumination about pain, and fear of losing cherished roles). Linear regression sought associations between personal factors, diagnostic concordance, and experience with the LLM. RESULTS:Discordance between clinician and LLM diagnoses was common 45% (67 of 140), but was not associated with any factors. Discordance often reflected diagnostic ambiguity (eg, knee osteoarthritis and meniscal tear) or clinician use of specific diagnoses for nonspecific symptoms (eg, myofascial pain syndrome, complex regional pain syndrome, and piriformis syndrome). Hispanic ethnicity, unmarried status, lower educational attainment, and lower annual income were associated with more favorable patient-rated experience with the LLM. CONCLUSION:Clinician use of speculative and ambiguous diagnostic labels may limit the usefulness of LLM-clinician discordance as a signal of patient unhelpful thinking and distress. LLMs may support personal health agency, particularly in the setting of social disadvantage.

PURPOSE:New symptoms from established idiopathic or senescent pathophysiology are often misinterpreted as an injury (damage to tissues by an external force). Misinterpretation of age-related imaging abnormalities as damage from an external force introduces potential for overdiagnosis, overtreatment, overprotection, and misplacement of a condition under work insurance. Evidence from the shoulder and knee suggests that awareness of the bilateral nature of many idiopathic and senescent pathophysiologies can limit erroneous diagnosis of traumatic pathophysiology. METHODS:Sixty-four scrutinized work injury claims with unilateral wrist symptoms underwent bilateral wrist magnetic resonance imaging (MRI) as part of routine care. The radiologist's interpretation of the MRIs was reviewed. Abnormalities were documented for each side and rated as either corresponding with or incidental to the location of the symptoms. We analyzed factors associated with MRI abnormalities present in the symptomatic wrist alone. RESULTS:MRI signal abnormalities were detected in 97% (n = 62) of symptomatic wrists and 91% (n = 58) of asymptomatic wrists, with an average of three abnormal findings per wrist. Signal abnormalities of the articular disc and extensor carpi ulnaris tendon were present in 64% and 45% percent of wrists and they were bilateral in 85% and 72% of patients, respectively. MRI findings were considered incidental to the symptoms in 95% (n = 61) of patients. In 55% (n = 35) of the cohort, symptoms were attributed to idiopathic or senescent pathophysiology and in 41% (n = 26) symptoms were considered nonspecific (no pathophysiological explanation). A trip and fall injury mechanism was the only variable associated with the presence of an abnormal MRI signal in the symptomatic wrist alone. CONCLUSIONS:Occupational injury claimants with unilateral wrist symptoms tend to have symmetric MRI signal changes that do not correspond with symptoms, suggesting that new symptoms from idiopathic or degenerative conditions are far more common than traumatic pathophysiology. TYPE OF STUDY/LEVEL OF EVIDENCE:Diagnostic IV.

OBJECTIVE:This study explored patient experiences with non-traumatic painful upper-extremity conditions (NPUCs) and co-occurring risky substance use and assessed perspectives on the acceptability and usability of Web-TIRELESS, an integrated web-based mind-body intervention addressing both conditions concurrently. METHODS:Nineteen adults with NPUCs and risky substance use completed individual semi-structured interviews. Data were analyzed using a hybrid deductive-inductive thematic analysis approach. RESULTS:Four themes emerged: (1) Challenges managing pain: Patients reported functional deterioration, emotional distress, and frustration with limited symptom relief, often associated with maladaptive coping strategies, including substance use. (2) Motivations for substance use and change: Alcohol, cannabis, and tobacco were commonly used to manage pain, stress, or sleep difficulties. Participants had limited awareness of the reciprocal relationship between pain and substance use and expressed low motivation to change. (3) Intervention preferences: Web-TIRELESS was viewed positively for its flexibility, privacy, and accessibility. Participants preferred credible, evidence-based, and practical pain-coping content. (4) Barriers and facilitators: Barriers included skepticism about efficacy, low motivation, and technological accessibility. Facilitators included live-human support, streamlined content, and accountability reminders. CONCLUSION:Patients prefer flexible, accessible, and evidence-based psychosocial interventions addressing pain and substance use simultaneously. Upon integrating patient suggestions, Web-TIRELESS may effectively bridge gaps in integrated orthopedic care.

PURPOSE:Online health queries are often addressed by large language models (LLMs) embedded in search engines. It is possible that LLMs, like human clinicians, might be misdirected by vague symptom descriptions or inaccurate self-diagnoses. We examined patient and scenario factors associated with an LLM's ability to identify intended upper-extremity musculoskeletal diagnoses and its tendency to deviate from patient self-diagnoses in structured clinical vignettes. METHODS:ChatGPT (GPT-5) evaluated 180 randomized hypothetical clinical vignettes depicting five common upper-extremity conditions: de Quervain tendinopathy, rotator cuff tendinopathy, lateral epicondylitis, trigger digit, and trapeziometacarpal arthritis. Each vignette included randomized patient characteristics, characteristic or vague symptom descriptions, and a patient self-diagnosis (categorized as correct, a plausible alternative, or a common misconception diagnosis). The LLM was prompted to select the single most likely diagnosis. Multivariable logistic regression identified independent predictors of diagnostic accuracy and deviation. RESULTS:The LLM correctly identified the intended diagnosis in 165 of 180 scenarios (92%). Accuracy was unaffected by the patient's self-diagnosis, was higher for characteristic than vague symptom, and was lower for de Quervain tendinopathy relative to other conditions. The model deviated from the patient's proposed diagnosis in 117 scenarios (65%), of which 104 deviations (89%) appropriately aligned with the intended diagnosis. The LLM was more likely to disregard patient-provided diagnoses that did not match the intended diagnosis, regardless of whether they represented plausible alternatives or common misconceptions. CONCLUSIONS:In this experimental setting, an LLM identified simulated upper extremity conditions regardless of patient self-diagnosis, suggesting limited susceptibility to the anchoring, confirmation, and acquiescence biases known to affect human diagnostic reasoning. LLMs may therefore support debiasing and patient guidance by helping address unhealthy misconceptions and aligning tests and treatment choices with patient values. TYPE OF STUDY/LEVEL OF EVIDENCE:V (Experimental Vignette Diagnostic Accuracy Study).

Musculoskeletal injuries severe enough to warrant hospitalization commonly co-occur with alcohol misuse and posttraumatic stress disorder (PTSD) symptoms, complicating recovery (return of comfort and capability). Nearly half of trauma patients have detectable alcohol at injury, and over one in five exhibit symptoms of PTSD during recovery. These co-occurring conditions are associated with greater levels of pain intensity and incapability, limited participation in exercises, and adverse events and hospital readmissions. Routine screening and brief interventions such as Screening, Brief Intervention, and Referral to Treatment for alcohol misuse and standardized self-report screening tools such as the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) have established clinical utility; however, implementation within orthopaedic practice remains inconsistent because of resource limitations, clinician uncertainty, and fragmented care coordination. Integrated, technology-enhanced interventions incorporate psychoeducation, coping-skills training, motivational interviewing, and personalized feedback to concurrently address alcohol misuse, PTSD symptoms, and pain. Digital health platforms-including telehealth and mobile applications-may help overcome barriers to implementing integrated interventions in orthopaedic trauma settings, thereby supporting widespread use and long-term sustainability. Adopting multidisciplinary care pathways tailored to individual risk profiles may facilitate implementation of these interventions, enhancing clinical efficiency, patient adherence, and orthopaedic recovery outcomes.

PURPOSE:In a survey- and scenario-based experiment, we addressed the factors associated with surgeon recommendations for specific distal radius fracture treatment options, including patient financial insecurity and insurance coverage. METHODS:One hundred sixty-two surgeons were with presented seven sets of radiographs of dorsally displaced fractures, accompanied by a scenario with randomized elements regarding the patient and circumstances of the injury. Surgeons then rated the likelihood they would offer reduction and cast immobilization, percutaneous Kirschner wire fixation, and volar plate fixation. Patient factors were randomized in each scenario, including age, sex, specific distal radius fracture radiographs, financial status "I (never/sometimes) have enough money to buy food," family support "I (have/don't have) a close circle of friends or family," and insurance status. We constructed multilevel mixed-effects linear regression models to measure the sources of variation in the likelihood to recommend each of the three treatment options. RESULTS:Offers of cast immobilization and percutaneous Kirschner wire fixation were more likely when patients were sometimes worried about having enough money, and for one specific fracture. Recommendations for cast immobilization were also associated with limited insurance and older age. The likelihood of offering volar plate fixation was higher when a patient had a close circle of friends and lower in the presence of financial concerns. CONCLUSIONS:Surgeon recommendations vary according to patient financial insecurity and insurance coverage. CLINICAL RELEVANCE:Patient financial concerns might become a more routine topic of inquiry, particularly in the United States, where out of pocket costs can be notable and are increasing.

Background: There is growing evidence that social determinants of health (SDOH) are associated with disparities in access to care and hand and upper extremity health. Quality measures represent an opportunity to evaluate disparities in access and outcomes that can inform improvement interventions. We performed a systematic review of evidence regarding health disparities within hand surgery and aimed to develop suitable quality measures that are clinically important, feasible, usable, and scientifically acceptable. Methods: We performed a systematic review including common hand surgery terms to identify health disparities in hand surgery related to SDOH. Candidate quality measures were constructed based upon evidence from the systematic review. A consortium of 11 US-based hand and upper extremity surgeons completed a modified RAND/UCLA Delphi Appropriateness process to evaluate the importance, feasibility, usability, and scientific acceptability of the candidate quality measures. Panelists rated each measure on a scale of 1 ( definitely not important/feasible/usable/scientifically acceptable ) to 9 ( definitely important/feasible/usable/scientifically acceptable ) in 2 voting rounds separated by a face-to-face discussion. Agreement among panelists and validity were assessed using predetermined criteria. Results: Fourteen candidate quality measures addressing health disparities were identified based on evidence from the systematic review, including time to surgery and emergency department use after hand surgery based on insurance type, clinical outcomes based on social deprivation, among others. All 14 measures were accepted. Conclusions: Fourteen candidate quality measures were identified and accepted based upon consensus to address health disparities in hand surgery, although future investigation will be needed to evaluate their effectiveness.

OBJECTIVES:To determine whether self-reported financial stress is associated with levels of capability during recovery from musculoskeletal injury. METHODS:Design: Cross-sectional survey SETTING: Multiple metropolitan musculoskeletal outpatient specialty offices PATIENT SELECTION CRITERIA: Adult outpatients seeking specialty care within 6 months of a musculoskeletal injury (fracture, tendon rupture, sprain, or dislocation). OUTCOME MEASURES AND COMPARISONS:Capability was measured using the PROMIS Physical Function Computer Adaptive Test. Financial stress was measured using the FACIT-COST Version 2 questionnaire. Explanatory variables included levels of distress and unhelpful thoughts regarding sensations, social health, and sociodemographic characteristics. Associations with capability were examined using bivariate analyses and multivariable linear regression. RESULTS:Among 131 participants (56% men, mean age 42 ± 17 years), and an average of 8 ± 6 weeks had elapsed since injury. In multivariable analysis, higher capability was associated with longer time since injury (regression coefficient [RC] = 0.51, p < 0.01) and uninsured status (relative to Medicare coverage; RC = 13, p < 0.01). Lower capability was observed among unemployed participants (RC = -4.6, p = 0.033) and those with lower extremity injuries (RC = -4.5, p < 0.01). Financial stress demonstrated a modest inverse association with capability (RC = -0.20, p = 0.014). Measures of distress and unhelpful thinking were not independently associated with capability. CONCLUSIONS:LEVEL OF EVIDENCE: Level IIIb, Cross Sectional Observational study.

Risky alcohol use and post-traumatic stress disorder (PTSD) commonly co-occur with musculoskeletal injury–related pain, forming a recovery-delaying cycle. Web/app-based digital Personalized Feedback Interventions (dPFIs) show promise as a first-step adjunct for addressing this comorbidity. We conducted an exploratory cross-sectional survey of 138 musculoskeletal clinicians assessing (1) screening/referral practices for risky alcohol use and PTSD, and (2) interest in a dPFI for alcohol/PTSD treatment engagement, integrated with pain-coping skills. Clinicians indicated that risky alcohol use and PTSD impose multiple recovery challenges. Screening was largely interview-driven (alcohol: 40.4

This cross-sectional study of individuals seeking outpatient musculoskeletal specialty care investigated whether lower general interpersonal trust, measured using the validated Interpersonal Trust Scale (ITS), is associated with worse patient experience as measured with the Trust and Experience with Clinician Scale (TRECS-7). A total of 294 adult patients completed TRECS-7, ITS, as well as measures of levels of unhelpful thoughts and distress regarding sensations, social health, and personal health agency. There was no correlation between ITS and TRECS scores. K-means cluster analysis identified four statistical subgroups of patient psychosocial factors. Higher mean TRECS-7 scores were observed in clusters characterized by high personal health agency and favorable psychosocial health, while lower mean clinician-specific trust scores were seen in clusters with low agency and problematic psychosocial health-independent of levels of general interpersonal trust. In the context of musculoskeletal specialty care, difficulty establishing trust with a patient may therefore signal relatively low personal health agency, highlighting a potential target for health and care strategies aimed at enhancing experience. Level of evidence:III (Observational, Cross-sectional Study).

Aims:Almost half of distal radius fractures (DRFs) lose threshold alignment (i.e. instability) after closed reduction and immobilization. This study aimed to investigate surgeons' ability to estimate secondary displacement by addressing three questions: 1) What is the diagnostic accuracy of surgeons to estimate instability of DRFs on pre- and post-reduction radiographs?; 2) What is the diagnostic accuracy of surgeons to estimate instability of DRFs on post-reduction CT imaging?; and 3) What patient factors are associated with estimating instability? Methods:We performed a scenario-based, randomized experiment with two distinct online surveys. In Part I, 116 members of the Science of Variation Group assessed radiographs of 20 initially displaced DRFs (11 'stable', nine 'unstable'), and estimated the loss of threshold alignment after closed reduction. Half viewed pre- and post-reduction radiographs, while half viewed only post-reduction radiographs. In Part II, 115 participants assessed 15 DRFs cases (six 'stable', nine 'unstable') to estimate loss of alignment. Half of the participants evaluated pre- and post-reduction radiographs, and half also received post-reduction CT imaging. Results:In Part I, diagnostic accuracy for estimating loss of threshold alignment on pre- and post-reduction radiographs was 54% (95% CI 51% to 57%), similar to 55% (95% CI 46% to 62%) when only viewing post-reduction radiographs (p = 0.063). In Part II, the accuracy was 70% (95% CI 64% to 77%) with both radiographs and CT, compared with 67% (95% CI 61 to 67) with radiographs alone (p = 0.240). Patient factors associated with estimating instability were female sex and higher age. Conclusion:Surgeons' ability to detect DRF instability on both pre- and post-reduction radiographs, as well as post-reduction CT-scans, was limited, reflecting a restricted value of probability estimates for clinical decision-making. Given suboptimal estimations of alignment loss, it seems prudent to monitor adequately reduced fractures during initial immobilization. Future studies should focus on aids that can overcome this limited accuracy.

Introduction Seeking emergency care regarding musculoskeletal sensations is far more prevalent than limb or life-threatening pathophysiology. We studied the ability of an LLM to distinguish between urgent and nonurgent upper extremity symptoms and provide an accurate diagnosis. Methods Five LLMs (ChatGPT-4, ChatGPT-4o, Co-Pilot, Gemini, and PerplexityChat) were presented with descriptions of seven urgent and seven nonurgent symptom scenarios written below a sixth grade reading level. LLM responses were identified as appropriate if immediate urgent medical attention was recommended after an initial and ongoing inquiry (“What additional information do you need to diagnose my condition?”). Diagnoses provided were identified as correct, partially correct, or incorrect. The analysis was repeated 24 months later with the current LLM versions and results were compared. Results LLMs discerned nonurgent conditions with 97% positive predictive value (PPV) and an 89% negative predictive value (NPV) on initial query, which improved to 96% and 97% respectively after ongoing inquiry. Compartment syndrome was misidentified as nonurgent in 80% of scenarios on initial inquiry, although four of five LLMs corrected on continued inquiry. Diagnosis was correct or partially correct for 115 of 150 (82%) on initial inquiry. An updated analysis 24 months later demonstrated marked improvement in LLM ability to identify emergencies with 100% PPV and 95% NPV on initial query and 98% NPV after ongoing inquiry. Conclusion The finding that LLMs can distinguish urgent from nonurgent upper extremity conditions suggests that artificial intelligence tools could help reduce unnecessary use of high-cost emergency services, allowing those resources to be reserved for patients who require timely care.

Background: Diaphyseal clavicle fractures are common in athletes. While surgery can reduce the risk of nonunion and expedite return to sport, it carries risks and may lead to hardware removal. How patient and surgeon characteristics influence treatment decisions in athletes with displaced midshaft clavicle fractures has not been clearly defined. Methods: Participants from the Science of Variation Group were invited to review randomized radiographs of displaced midshaft clavicle fractures paired with different patient scenarios that included age, sports level, dominant arm, type of sport, timing within the season, presence of an upcoming significant sporting event occurring within the next three months, and five distinct sets of radiographs. Surgeons rated their likelihood of offering surgery (scale: 0-100). Multivariable analysis identified factors associated with the likelihood of offering surgery. Data are presented as regression coefficients (RCs) with corresponding 95% confidence intervals (CIs). Statistical significance was set at P < .05. Analyses were conducted in STATA version 13. Results: A total of 94 surgeons reviewed 470 different clinical scenarios. Surgeons were primarily based in the United States (43%) and Europe (32%); 90% were male and 82% were involved in teaching trainees. The predominant specialty was orthopedic trauma surgery (40%), followed by hand/wrist surgery (28%) and shoulder/elbow surgery (14%). Compared with weekend athletes, surgeons were significantly more likely to offer surgery to professional athletes (RC = 14; CI = 7.8-20; P < .001), corresponding to a mean increase of 14 points on the 0-100 scale. The presence of an important upcoming sporting event was also associated with a higher likelihood of offering surgery (RC = 9.5; CI = 4.5-15; P < .001), corresponding to a mean increase of 9.5 points on the 0-100 scale. Male surgeons were more likely to offer surgery than female surgeons (RC = 16; CI = 4.1-26; P = .004), corresponding to 16 points higher on the 0-100 scale. This observed association should be interpreted with caution, given the limited number of female respondents. Conclusions: Surgical decision-making for displaced midshaft clavicle fractures in athletes is influenced not only by anatomical considerations but also by contextual factors directly related to functional recovery. Overall, the findings suggest that surgeons weigh functional demands and timing heavily when making these decisions, underscoring the importance of shared decision-making tailored to the individual athlete.