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Olson N, Griggs J, Balhara KS, Kann K, April MD, Olson AS. Evaluation of a Hands-On Wrist Fracture Simulator for Fracture Management Training in Emergency Medicine Residents. Cureus 2022; 14:e27030. [PMID: 35989857 PMCID: PMC9388193 DOI: 10.7759/cureus.27030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
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Lu YT, Haase SC, Chung TT, Chung KC, Sears ED. The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions. J Hand Surg Am 2019; 44:1013-1020.e2. [PMID: 31677910 PMCID: PMC7429450 DOI: 10.1016/j.jhsa.2019.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 07/09/2019] [Accepted: 09/25/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with 3 common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon. METHODS We analyzed a single academic tertiary care center administrative database of encounters from 2006 to 2015 to identify adult patients who were referred to a hand surgeon for 3 conditions (carpal tunnel syndrome [CTS], soft tissue masses [STM], and joint pain [JP]). We recorded patient characteristics, use and timing of diagnostic tests, and wait time for the initial hand surgeon evaluation. RESULTS Among patients who received advanced diagnostic tests before the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared with JP (10.6% ) and STM patients (5.8%). The CTS patients had the highest rates of repeat testing (19.5%) compared with patients with JP (1.4%) and STM (0%). Across all 3 conditions, patients who received pre-referral advanced testing waited an additional 19 to 94 days to see a surgeon, compared with patients who received only post-referral testing or no testing. CONCLUSIONS Use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions. CLINICAL RELEVANCE Hand surgeons should have a role in identifying patients who do or do not benefit from advanced testing before referral to ensure that tests ordered before consultation are useful to both patients and treating surgeons.
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Affiliation(s)
- Yu-Ting Lu
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine
| | - Steven C. Haase
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine
| | - Ting-Ting Chung
- Center for Big Data Analytics and Statistics and Division of Rheumatology, Allergy and Immunology, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kevin C. Chung
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine,Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Erika D. Sears
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine,Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI,Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury. J Am Board Fam Med 2018; 31:795-804. [PMID: 30201676 PMCID: PMC6341471 DOI: 10.3122/jabfm.2018.05.170423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRI's application in soft-tissue wrist injury. METHODS We conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI). RESULTS Among 140 MRI scans, 39 (28%) impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians (P = .001). More Impact MRIs were found when an MRI was ordered for patients younger than 36 years (P = .01), within 6 weeks of symptom onset (P = .03), to question a specific anatomic injury (P = .0001), or by a board-certified hand surgeon (P = .001). Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs. CONCLUSIONS MRIs for soft-tissue wrist injuries may more likely change management when the patient is younger, ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery/trauma, older than 36 years likely due to confounding chronic wrist changes, symptomatic for more than 6 weeks, and without clear differential diagnoses for the symptoms.
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Appropriateness of the Use of Magnetic Resonance Imaging in the Diagnosis and Treatment of Wrist Soft Tissue Injury. Plast Reconstr Surg 2017; 141:410-419. [PMID: 29036028 DOI: 10.1097/prs.0000000000004023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND When diagnosing wrist soft tissue injury, the authors hypothesize that magnetic resonance imaging is used injudiciously and is associated with unnecessary cost. METHODS A retrospective review was conducted of patients aged 20 to 60 years who underwent magnetic resonance imaging for possible wrist soft tissue injury at a tertiary care center between 2009 and 2014. Treatment recommendation was classified as nonoperative, operative, or equivocal. If the magnetic resonance imaging-directed treatment recommendation differed from the pre-imaging recommendation, it was noted that the imaging influenced patient care (impact study). The cost estimate of an impact study was calculated by dividing the total studies performed by the number of studies that impacted the treatment recommendation and multiplying this value by the institutional wrist magnetic resonance imaging cost ($2246 in 2016). RESULTS One hundred forty patients were included. Magnetic resonance imaging affected treatment recommendation in 28 percent of patients. Independent predictors of impact on treatment recommendation were "question specific injury" (OR, 9.46; 95 percent CI, 3.18 to 28.16; p < 0.001) and "question scapholunate injury" (OR, 2.88; 95 percent CI, 1.21 to 6.88; p = 0.02). The only independent predictor of surgery was ordering physician (hand surgeon) (OR, 3.69; 95 percent CI, 1.34 to 10.13; p = 0.01). The cost of an impact study ordered by a non-hand surgeon versus a hand surgeon was $13,359 versus $6491, respectively. CONCLUSIONS The provider must carefully consider the pretest probability of ordering a study that will affect treatment recommendation. Injudicious screening with magnetic resonance imaging ($15,565) incurred a cost nearly seven times the cost of the one imaging scan ($2246) before impacting one treatment recommendation. In the current era of cost containment and bundled payment, diagnostic test probability must be appreciated to guide physician ordering practices.
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Grantham WJ, To P, Watson JT, Brywczynski J, Lee DH. Retrospective Review of Air Transportation Use for Upper Extremity Amputations at a Level-1 Trauma Center. J Hand Microsurg 2016; 8:86-90. [PMID: 27625536 DOI: 10.1055/s-0036-1583299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 03/17/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Air transportation to tertiary care centers of patients with upper extremity amputations has been utilized in hopes of reducing the time to potential replantation; however, this mode of transportation is expensive and not all patients will undergo replantation. The purpose of this study is to review the appropriateness and cost of air transportation in upper extremity amputations. MATERIALS AND METHODS Consecutive patients transported by aircraft with upper extremity amputations in a 7-year period at a level-1 trauma center were retrospectively reviewed. The distance traveled was recorded, along with the times of the injury, referral, transportation duration, arrival, and start of the operation. The results of the transfer were defined as replantation or revision amputation. RESULTS Overall, 47 patients were identified with 43 patients going to the operating room, but only 14 patients (30%) undergoing replantation. Patients arrived at the tertiary hand surgery center with a mean time of 182.3 minutes following the injury, which includes 105.2 minutes of transportation time. The average distance traveled was 105.4 miles (range, 22-353 miles). The time before surgery of those who underwent replantation was 154.6 minutes. The average cost of transportation was $20,482. DISCUSSION Air transportation for isolated upper extremity amputations is costly and is not usually the determining factor for replantation. The type of injury and patients' expectations often dictate the outcome, and these may be better determined at the time of referral with use of telecommunication photos, discussion with a hand surgeon, and patient counseling. LEVEL OF EVIDENCE III.
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Affiliation(s)
- W Jeffrey Grantham
- Vanderbilt University Medical Center, Vanderbilt Orthopaedic Institute, Nashville, Tennessee, United States
| | - Philip To
- OrthoArizona, Scottsdale, Arizona, United States
| | - Jeffry T Watson
- Colorado Springs Orthopaedic Group, Colorado Springs, Colorado, United States
| | - Jeremy Brywczynski
- Vanderbilt Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Donald H Lee
- Vanderbilt University Medical Center, Vanderbilt Orthopaedic Institute, Nashville, Tennessee, United States
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Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type. J Hand Surg Am 2016; 41:516-525.e3. [PMID: 26880497 DOI: 10.1016/j.jhsa.2016.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/31/2015] [Accepted: 01/01/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients. METHODS Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation. RESULTS In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients. CONCLUSIONS Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/decision III.
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Abstract
BACKGROUND Orthopedic and plastic surgery residents receive unique training yet often compete for similar hand surgery fellowships. This study compared didactic hand surgery training during orthopedic and plastic surgery residency. METHODS The Plastic Surgery In-Service Training Exam and Orthopaedic In-Training Examination were analyzed for hand content for the years 2009 to 2013. Topics were categorized with the content outline for the Surgery of the Hand Examination. Differences were elucidated by means of Fisher's exact test. RESULTS Relative to the Orthopaedic In-Training Examination, the Plastic Surgery In-Service Training Exam had greater hand representation (20.3 percent versus 8.1 percent; p < 0.001) with more annual hand questions (40 ± 3 versus 24 ± 2; p < 0.001). The Plastic Surgery Exam questions had more words, were less often level I-recall type, and were less often image-based. The questions focused more on finger and hand/palm anatomy, whereas the Orthopaedic examination was more wrist-focused. The Plastic Surgery Exam emphasized wound management and muscle/tendon injuries, but underemphasized fractures/dislocations. References differed, but Journal of Hand Surgery (American Volume) and Green's Operative Hand Surgery were common on both examinations. The Plastic Surgery Exam had a greater publication lag for journal references (10.7 ± 0.5 years versus 9.0 ± 0.6; p = 0.035). CONCLUSIONS Differences in didactic hand surgery training are elucidated for plastic surgery and orthopedic residents. Deficiencies in the Plastic Surgery In-Service Training Exam hand curriculum relative to the Orthopaedic In-Training Examination may underprepare plastic surgeons for the Surgery of the Hand Examination. These data may assist future modifications to hand surgery training in the United States.
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McEvenue G, FitzPatrick F, von Schroeder HP. An Educational Intervention to Improve Splinting of Common Hand Injuries. J Emerg Med 2015; 50:228-34. [PMID: 26472606 DOI: 10.1016/j.jemermed.2015.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 07/09/2015] [Accepted: 08/13/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hand trauma is a top presenting complaint to hospital emergency departments (EDs) and can become costly if not treated effectively. The cornerstone for initial management of the traumatized hand is application of a splint. Improving splinting practice could potentially produce tangible benefits in terms of quality of care and costs to society. OBJECTIVES We sought to determine the following: 1) whether the present standard of ED splinting was appropriate and 2) whether a strategically planned educational intervention could improve the existing care. METHODS We used a pre- and postprospective educational intervention study design. In the preintervention phase, patients referred to our hand clinic were assessed for injury and splint type. Splinting appropriateness was evaluated according to a predetermined hand surgeons' expert consensus. Next, an educational intervention was targeted at all ED staff at our institution. Postintervention, all patients were again evaluated for splint appropriateness. A follow-up evaluation was performed at 1 year to see the long-term effects of the intervention. RESULTS The most common mechanism of injury of referred patients was falling (35%), and the most frequent injury was metacarpal fracture (40%). Splint appropriateness increased significantly postintervention from 49% to 69% (p = 0.048). At follow-up after 1 year, splinting appropriateness was 70% (p = 0.041). CONCLUSION Appropriate hand splinting practice is essential for hand trauma management. Our results show that an educational intervention can successfully improve splinting practice. This quality of care initiative was low-cost and demonstrated persistence at 1 year of follow-up.
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Affiliation(s)
- Giancarlo McEvenue
- University of Toronto Hand Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Fiona FitzPatrick
- University of Toronto Hand Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Herbert P von Schroeder
- University of Toronto Hand Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Sears ED, Chung KC. Future education and practice initiatives in hand surgery: improving fulfillment of patient needs. Hand Clin 2014; 30:377-86, vii-viii. [PMID: 25066857 DOI: 10.1016/j.hcl.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the current health care environment, there are several areas in the delivery of health care to patients having hand surgery that need improvement to adequately fulfill patient needs, including difficulty in maintaining adequate emergency call coverage for patients having hand surgery, decreasing trends in hand surgeons willing to perform microsurgery and replantation, and deficiencies in musculoskeletal education of non-hand surgery providers. Both educational reforms and reforms in the practice environment are needed to improve the ability of hand surgeons to fulfill patient needs in the future.
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Affiliation(s)
- Erika D Sears
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA.
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA
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Scher DL, Ferreira JV, Cote M, Abdelgawad A, Wolf JM. The need for musculoskeletal education in primary care residencies. Orthopedics 2014; 37:511-3. [PMID: 25102493 DOI: 10.3928/01477447-20140728-03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Abstract
OBJECTIVES Emergency medicine (EM) physicians are frequently responsible for evaluating and treating patients with urgent or emergent musculoskeletal conditions, so it is critical that they achieve a basic level of proficiency in musculoskeletal medicine. However, inadequacies in musculoskeletal education have previously been documented among medical students, residents, and attending physicians in a number of specialties. The goal of this study was to assess the proficiency with musculoskeletal medicine among EM physicians in particular. METHODS A validated musculoskeletal medicine competency examination was administered to the EM residents and faculty at a university-affiliated level 1 trauma center. Demographic data and satisfaction with musculoskeletal education were also surveyed. RESULTS Twenty-three EM residents and 21 attending physicians completed the survey. Thirty-five percent of residents and 43% of attending physicians failed to demonstrate proficiency on the examination. Pass rates were not significantly different among junior residents, senior residents, or attending physicians. Twenty-three percent of respondents indicated that they were dissatisfied with their musculoskeletal education. CONCLUSIONS Significant deficiencies in musculoskeletal education exist among EM physicians in training and attending staff. Given the frequency with which these physicians evaluate and treat acute musculoskeletal conditions, additional resources should be committed to their training.
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Stoker GE, Kim HJ, Riew KD. Differentiating c8-t1 radiculopathy from ulnar neuropathy: a survey of 24 spine surgeons. Global Spine J 2014; 4:1-6. [PMID: 24494175 PMCID: PMC3908974 DOI: 10.1055/s-0033-1354254] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/09/2013] [Indexed: 11/30/2022] Open
Abstract
Study Design Questionnaire. Objective To evaluate the ability of spine surgeons to distinguish C8-T1 radiculopathies from ulnar neuropathy. Methods Twenty-four self-rated "experienced" cervical spine surgeons completed a questionnaire with the following items. (1) If the ulnar nerve is cut at the elbow, which of the following would be numb: ulnar forearm, small and ring fingers; only the ulnar forearm; only the small and ring fingers; or none of the above? (2) Which of the following muscles are weak with C8-T1 radiculopathies but intact with ulnar neuropathy at the elbow: flexor digiti minimi brevis, flexor pollicis brevis, abductor digiti minimi, abductor pollicis brevis, adductor pollicis, opponens digiti minimi, opponens pollicis, medial lumbricals, lateral lumbricals, dorsal interossei, palmar interossei? Results Fifteen of 24 surgeons (63%) correctly answered the first question-that severing the ulnar nerve results in numbness of the fifth and fourth fingers. None correctly identified all four nonulnar, C8-T1-innervated options in the second question without naming additional muscles. Conclusion The ulnar nerve provides sensation to the fourth and fifth fingers and medial border of the hand. The medial antebrachial cutaneous nerve provides sensation to the medial forearm. The ulnar nerve innervates all intrinsic hand muscles, except the abductor and flexor pollicis brevis, opponens pollicis, and lateral two lumbricals, which are innervated by C8 and T1 via the median nerve. By examining these five muscles, one can clinically differentiate cubital tunnel syndrome from C8-T1 radiculopathies. Although all participants considered themselves to be experienced cervical spine surgeons, this study reveals inadequate knowledge regarding the clinical manifestations of C8-T1 radiculopathies and cubital tunnel syndrome.
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Affiliation(s)
- Geoffrey E. Stoker
- Department of Orthopaedic Surgery, Cervical Spine Service, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Cervical Spine Service, Washington University School of Medicine, St. Louis, Missouri, United States
| | - K. Daniel Riew
- Department of Orthopaedic Surgery, Cervical Spine Service, Washington University School of Medicine, St. Louis, Missouri, United States,Address for correspondence Dr. K. Daniel Riew, MD 660 South Euclid AvenueCampus Box 8233, St. Louis, MO 63110United States
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