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Background: Prior studies have suggested that misconceptions (i.e., unhelpful thoughts or cognitive errors resulting from cognitive bias) and distress (symptoms of anxiety or depression) are key factors associated with variation in health, as quantified with use of patient-reported outcome measures. The primary purpose of the present study was to identify mental-health phenotypes (i.e., combinations of various types of misconceptions and distress) that might help direct care and to test for differences in magnitude of activity tolerance, pain intensity, and self-efficacy in response to pain between phenotypes. We also studied demographic factors and diagnostic categories associated with mental-health phenotypes.Methods: In a cross-sectional study, 137 patients seeking upper-extremity musculoskeletal specialty care completed a survey including demographics, mental-health questionnaires, and measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy. We used cluster analysis to identify groups of patients with similar phenotypes. We used analysis of variance testing to assess differences in activity tolerance, pain intensity, and pain self-efficacy among phenotypes. Results:The cluster analysis yielded 4 unique mental-health phenotypes, which fit the theoretical conceptualizations of "low misconception and low distress," "notable misconception," "notable depression and notable misconception," and "notable anxiety, depression, and misconception." Patients with low bias and low distress had significantly greater activity tolerance and greater pain self-efficacy than the other phenotypes, as well as a significantly lower pain intensity than phenotypes with notable distress.Conclusions: Cluster analysis of mental-health questionnaire data can identify mental-health phenotypes that are associated with greater activity tolerance and pain intensity. This approach might help clinicians to strategize and prioritize approaches that correct unhelpful thoughts and ameliorate symptoms of distress among patients seeking musculoskeletal specialty care. Such strategies have the potential to achieve more comprehensive, whole-person care, more selective operative treatment, and improved outcomes.Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. Extensive research regarding musculoskeletal illness has established that variations in the intensity of pain and magnitude of activity intolerance cannot be explained through a purely biomedical paradigm. In other words, there is limited correspondence between objective pathology and the state of being unwell (i.e., illness). Prior studies indicate that this variation in illness may be the result of psychological factors, such as common misconceptions about symptoms (i.e., cognitive biases) and the symptoms of anxiety or depression (i.e., distress) 1-7 .These cognitive biases are common and arise from the normal functioning of the human mind. The Nobel Prize-winning research of Kahneman ...

Background: The Tampa Scale for Kinesiophobia (TSK) is used to quantify fear of painful movement. A shorter form with only 4 questions (TSK-4) can be used by physicians to look for fear of movement independent of catastrophic thinking with less responder and survey burden. We assessed the difference explained in amount of variation in the Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity (PROMIS PF UE) between the TSK and TSK-4. Additionally, we looked for other factors that were associated with the PROMIS PF UE, and we assessed reliability and validity of the TSK and TSK-4 by looking at mean scaled scores, internal consistency, floor and ceiling effects, interquestionnaire correlations, and collinearity with the Pain Catastrophizing Scale short form (PCS-4), PROMIS Depression, and PROMIS Pain Interference (PROMIS PI). Methods: One hundred forty eight new and follow-up patients were seen at 5 orthopedic clinics in a large urban area and given the TSK, PROMIS PF UE, PROMIS Depression, PROMIS PI, and PCS-4 questionnaires. Results: Both long and short measures of greater fear of painful movement were independently associated with less physical function (PROMIS PF UE). The longer version accounted for more of the variation in physical function than the short version (TSK, semipartial R2 = 0.12, adjusted R2 full model 0.25; TSK-4, semipartial R2 = 0.03, adjusted R2 full model = 0.16, respectively). The shorter measure had slight floor and ceiling effects. There was high internal consistency for both the TSK and TSK-4. Conclusions: A short measure of fear of painful movement may be an adequate screen in the care of patients with upper extremity problems. Using this short form can help decrease questionnaire burden while accounting for kinesiophobia along with catastrophic thinking. Level of Evidence: Prognostic, level II

The coronoid process has been shown to play a critical role in ulnohumeral stability. Coronoid process fractures can occur in isolation or as part of a complex injury pattern. The most common complex pattern, known as the "terrible triad," includes a radial head fracture and elbow dislocation along with the coronoid fracture. Failure to address these fractures and ligamentous injuries can result in recurrent instability and progression to painful arthrosis. Both medial and lateral approaches to the coronoid have been popularized in recent literature, but there is no universally accepted approach. Common fixation techniques include suture lasso, suture anchors, lag screws, and plating all of which have various drawbacks. We describe a direct anterior approach to address coronoid process fractures made in addition to a lateral approach to address radial head and lateral collateral ligament injuries. Coronoid fractures addressed through the anterior approach were stabilized with anterior to posterior screw fixation combined with buttress plating, which allowed anatomic reduction and stable internal fixation at short-term follow-up.