The Evolution of Hand Injuries at a State's Only Level I Trauma Center: A Look From the 1980s Through the Global Pandemic

BACKGROUND

The purpose of this study is to evaluate any changes to hand trauma in the past three decades and through the COVID-19 pandemic. We hypothesized that improved consumer safety regulations, changes in access to care, and the impact of a global pandemic, among other variables, have significantly influenced the mechanisms and treatment of hand injuries between the 1980s, 2010s (pre-COVID-19), and 2020s (post-COVID-19).

METHODS

A retrospective single-center review was performed at the only level I trauma center in Mississippi, identifying all hand trauma consultations between 2012-2019 and 2020-2021, compared to aggregated data from 1989.

RESULTS

Car accidents, gunshots, saw injuries, door injuries, and falls increased in 2012-2019 and 2020-2021 compared to 1989, whereas knife injuries, glass injuries, industrial injuries, and burns decreased. Crush injuries, de-gloving injuries, and lacerations with irregular edges were increased in recent cohorts, corresponding with increased amputations and tissue loss. Skin and subcutaneous injuries decreased in modern cohorts, corresponding with a decreased ability for primary skin repair and the need for more flaps. Additionally, while hospitalizations have increased, patients have improved follow-up.

CONCLUSIONS

The nature of hand trauma has changed significantly over the past three decades. Increased numbers of cars and greater access to firearms might have led to increased rates of high-energy trauma, whereas burn and industrial injuries have decreased, potentially secondary to improved safety efforts. Despite increased overall hand trauma, time to treatment and follow-up have improved. Through this study, we can be more cognizant of the evolution of hand trauma in the modern era. This can allow improved access to care and further refine management to optimize functionality for hand injuries.

A Retrospective Analysis of Dynamic Compression Plating Versus Intramedullary Nailing for the Management of Shaft of Humerus Fractures in an Urban Trauma Care Center

Introduction There is constant debate regarding the best surgical technique for the fixation of shaft humerus fractures. Intramedullary nailing and dynamic compression plating are the most popular surgical options. Materials and methods In our study, we retrospectively analyze the results of 27 patients with shaft humerus fractures managed with intramedullary nailing (10) and dynamic compression plating (17) at our institute from September 2021 to October 2022. Preoperative clinical assessment sheets, postoperative follow-up sheets, operative notes, anesthesia sheets, and preoperative and follow-up radiographs were analyzed. Reamed antegrade nailing was done in all cases, while dynamic compression plating was done through a posterior approach. Results The operative time of the nailing group was 82.1 ± 7.61 mins, which was significantly lesser (P value <0.05) than that of the plating group, which was 119.59 ± 10.16 mins. The intraoperative blood loss of the patients who were managed with nailing was 71 ± 7.38 mL, which was significantly lesser (P value <0.05) than that of the plating group, which was 130.59 ± 11.44 mL. The patients in both groups had a statistically nonsignificant difference in terms of functional results, which were assessed using Rodriguez-Merchan criteria. Complications were similar in both groups with infection (17.65%), and postoperative radial nerve palsy (11.76%) was more common among the patients undergoing plating, and shoulder impingement(20%) was common among those undergoing nailing. Conclusion This study concluded that both surgical options are similar in the case of functional results. The selection of the surgical method should be as per the surgeon's surgical familiarity and personalized to individual patients.

Discovering the Forgotten Trauma Behind Chronic Shoulder Pain: The Critical Role of a Thorough Medical Interview

We report a rare case of a patient experiencing pain and dysfunction attributable to bone fragments from a trauma sustained over two decades prior. A 43-year-old Japanese woman presented with persistent left shoulder pain. Initial radiographs revealed glenohumeral joint osteoarthritis, an unusual finding for her age. Her medical history included a previously overlooked traumatic dislocation of the left acromioclavicular joint over 20 years ago. Computed tomography scans later uncovered bone fragments below the coracoid process without signs of scapular or tuberosity fractures. The fragments were arthroscopically removed, resulting in significant pain relief. The patient's Shoulder Pain and Disability Index score improved from 60 to 9 at the six-month postoperative follow-up. This case underscores the importance of considering historical trauma in patients presenting with atypical shoulder pain and highlights the potential diagnostic value of revisiting a patient's medical history when unusual lesions are discovered.

Widening Access: Sterile Tourniquets for Surgery to the Distal Humerus

Purpose of the study The use of tourniquets during surgery of the distal humerus can improve visibility and reduce surgical time. However, the available operating field can be limited due to the size and placement of the tourniquet. This proof-of-concept study aimed to determine if sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus. Methods Volunteers (n = 5) were positioned to simulate access to the distal humerus. The distance from the posterior corner of the acromion to the tip of the olecranon was measured. Participants were draped according to the standard protocol for the use of a non-sterile or sterile tourniquet for distal humerus and humeral shaft fractures. Two non-sterile pneumatic tourniquets (standard and narrow) and two sterile tourniquets (pneumatic and elastic exsanguination) were tested. The surgical field was measured from the sterile drape or tourniquet proximally to the tip of the olecranon. A one-way repeated measures ANOVA was conducted to examine the effect of each tourniquet on the surgical field. Results The sterile elastic exsanguination tourniquet had the largest available field with a mean of 24.4 cm (71% of arm available for incision after application), followed by the sterile pneumatic tourniquet of 20.0 cm (58%), narrow non-sterile pneumatic of 19.2 cm (55%), and standard non-sterile pneumatic of 17.0 cm (49%). Repeated measures ANOVA determined that mean surgical field length is statistically significant between tourniquet devices (F (1.729, 6.914) = 21.783, p = .001). The surgical field length was statistically significantly increased from a non-sterile standard tourniquet to a sterile elastic tourniquet (7.4 (95% CI, 2.9-11.9) cm, p = .008) but not the other two tourniquet devices tested. Conclusion The use of certain types of sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus, specifically the sterile elastic exsanguination tourniquet providing a statistically significant mean gain of 7.4 cm from the non-sterile tourniquets. These findings suggest that the use of sterile tourniquets should be considered more frequently in surgery of the distal humerus, and a sterile exsanguinating tourniquet could be considered for midshaft humeral fractures, facilitating safer exposure of the radial nerve and reduced blood loss.

An Analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) in Non-operative Posterolateral Elbow Dislocations

INTRODUCTION

The purpose of our study is to analyze the outcomes of traumatic posterolateral elbow dislocations using patient-reported outcomes measurement information system (PROMIS). We hypothesized that physical function (PF) and upper extremity (UE) scores in PROMIS will significantly improve over six months of follow-up and correlate with a positive change in the patient-acceptable symptom state (PASS).

METHODS

This is a seven-year retrospective study of 165 consecutive adult patients with traumatic posterolateral elbow dislocations. Demographic information, PROMIS PF, PROMIS UE, PROMIS pain interference (PI), PROMIS depression, and PASS were recorded over six months of follow-up.

RESULTS

At the time of injury, mean PROMIS scores were PF 41.24 (SD 11.16), UE 34.27 (SD 11.87), PI 60.44 (SD 8.07), and depression 49.82 (SD 10.42). At six months, the mean PROMIS scores were PF 39.71 (SD 9.71), UE 33.95 (SD 9.09), PI 57.35 (SD 8.59), and depression 51.43 (SD 10.62). The overall six-month changes in PROMIS scores were PF -1.53, UE -0.32, PI -3.09, and depression +1.61. At the 6-month follow-up, 41.7% responded positively on the PASS, which correlated only with PROMIS PI.

CONCLUSIONS

Among patients who improved from negative to positive response on PASS, the PROMIS PF, UE, and depression scores did not significantly improve. Only PROMIS PI correlated with PASS at the six-month follow-up; PROMIS PI significantly improved among simple posterolateral elbow dislocation patients at both short-term and long-term follow-up points. PROMIS PF, UE, and depression did not significantly differ between time of injury and short-term and long-term follow-up points.

A Unique Presentation of the Glenoid, Coracoid, and Proximal Humerus Fractures

Fractures of the proximal humerus are common injuries with a bimodal age distribution. They usually present in younger patients after high-energy trauma and in elderly patients after lower-energy trauma. Fractures of the proximal humerus are rarely associated with concomitant fractures of the glenoid, and this is a complex injury pattern that indicates the presence of significant instability. Such injuries are usually treated surgically. Even more rarely, patients may present with proximal humerus fractures and fractures of the coracoid process. A male patient presented to our emergency department (ED) after a fall off the loading platform of his heavy goods vehicle (HGV), resulting in a right shoulder injury. During his initial assessment in ED, a computerised tomography (CT) scan demonstrated the presence of a comminuted proximal humerus fracture, a comminuted anterior glenoid wall fracture, and a coracoid process displaced fracture. Surgical fixation of all three fractures was undertaken in the same sitting. This is the first case described in the literature with a combination of the above injuries and serves as a reminder that as trauma complexity and incidence continue to increase, we should maintain a high index of diagnostic suspicion when dealing with such patients. Furthermore, we present our treatment approach for this case and the rationale behind it.

[Digital artery pseudoaneurysm. Case report and systematic review of the literature]

INTRODUCTION

aneurysms are focal and permanent dilations of an artery; in pseudoaneurysms, the normal layers of the blood vessel are replaced by fibrous tissue. Due to their low incidence, as well as the diagnostic and therapeutic challenge they represent; our objective is to present the clinical case of a pseudoaneurysm of a digital artery of the hand and to carry out a systematic review of this pathology.

MATERIAL AND METHODS

literature search in Medline, using the terms "digital artery" and "aneurysm." Studies of vascular dilation pathology affecting the hand and fingers were incorporated. Studies with pathology of proximal involvement of the hand were excluded.

CASE PRESENTATION

a 79-year-old female patient who, after a sharp force trauma to the fifth finger of the left hand, develops a rapidly growing necrotic tumor. She had ultrasound and angiography that suggested hematoma. Surgical management was decided, during which it was observed that the tumor involved ulnar collateral digital artery of the fifth finger. The lesion and the arterial segment involved were resected. Post-surgical course without complications. The histopathological diagnosis of pseudoaneurysm of the lesion was confirmed.

DISCUSSION

traumatic etiology is the most frequent cause of digital aneurysms. Risk factors for pseudoaneurysms include sharp force trauma and alterations of the coagulation pathways, as in the case presented.

CONCLUSION

the pseudoaneurysm of a digital artery is a rare pathology with great variability of therapeutic management. Surgical resection of the lesion with vascular flow reconstruction is the recommended treatment.

Multidisciplinary Management of Complex Regional Pain Syndrome (CRPS) Type 1 in the Hand and Wrist: A Case Report

Complex regional pain syndrome (CRPS) is a rare disorder that presents as a highly variable combination of intense regional pain, autonomic and vasomotor disturbances that are uncharacteristic of the inciting trauma or event. We report a 36-year-old male construction worker who presented to the orthopedic department status post crush injury to his hand, with acutely increasing right-hand pain, swelling, skin/hair changes, and dysfunction. Presentation changed over a course of 2-8 weeks, with CRPS becoming the eventual working diagnosis. Initial diagnoses were not made by occupational med, nor the urgent care, and definitive diagnosis was achieved in the orthopedic hand office via a thorough history and physical exam as well as imaging modalities including X-ray, CT, and MRI. A multidisciplinary approach involving aggressive hand therapy, anti-inflammatory agents, high-dose prednisone, Gabapentin, and over-the-counter vitamins and supplements was used in the treatment of this patient. This patient had a unique progression of his condition with respect to his carpus, demonstrating acute reduction of bone density on plain film. Stiffness ensued. This patient's condition was almost "missed" by the masking of the ulnar ossicle variant (os triangulare), and anatomical snuffbox pain on exam, in the face of initially "normal" X-rays. It is important for providers to recognize the clinical signs of complex regional pain syndrome, especially in the acute phase of crush injury, swelling, skin and hair changes, and stiffness, and to treat patients' symptoms with a variety of treatment options due to the marked variability of this condition. The patient has made a favorable recovery with some residual functional deficits, however, the patient stated that his quality of life has been restored despite his current stiffness.

Open Reduction Internal Fixation of Distal Radius Fractures: Retrospective Cohort Analysis of the Geriatric Population Using the NSQIP Database

Background: Distal radius fractures (DRFs) are the most common upper extremity fractures with more than 600 000 cases per year in the United States and account for up to 18% of fractures in the geriatric population. The purpose of our study was to identify the influence of age on 30-day postoperative outcomes while adjusting for patient demographics and comorbidities. Methods: The National Surgery Quality Improvement Program database was queried for patients having undergone open reduction internal fixation (ORIF) of DRFs. Current Procedural Terminology codes 25607, 25608, and 25609 between the years 2007 and 2016 were collected and analyzed. Patients were divided into 2 groups: group 1, 18 to 64 years; and group 2, 65 years and older. Patient demographics; preoperative, perioperative, and postoperative variables; and complications were recorded and analyzed. Results: In all, 5894 patients were identified; group 1 consisted of 4056 patients aged <64 years, and group 2 consisted of 1838 patients aged 65 years and older. The total complication rate was 2.7% for all patients, 2.2% for group 1, and 3.4% for group 2. The most common complications included surgical site infection for group 1 and urinary tract infection for group 2. Univariate analysis demonstrated association between age ≥65 years and complication (hazard ratio, 1.55; 95% confidence interval, 1.12-2.14; P = .009). However, after controlling for statistically significant factors, age was not an independent predictor of complications (P = .685). Admission status, American Society of Anesthesiologists classification, operative time, renal failure, and bleeding disorders were independent predictors of 30-day complications across all patients. Conclusion: Our data suggest that patients aged 65 years and older without high-risk comorbidities should be offered ORIF of DRFs as their complication risk remains low.

Comparison of Treatment Options of Three- and Four-Part Humerus Proximal Fractures in Patients Over 50 Years of Age

Introduction

Our aim was to evaluate different treatment methods including conservative treatment (CT), locking-plate osteosynthesis (OS) and hemiarthroplasty (HA) in three- and four-part humeral fractures in patients older than 50 years.

Methods

Forty-seven patients that have at least one year of follow-up were divided into three groups: 18 patients treated with OS, 14 patients treated conservatively and 15 patients treated with HA. For further evaluation, constant shoulder score, disabilities of the arm, shoulder and hand score (DASH), American Shoulder and Elbow Society (ASES) score had been used. Shoulder range of motion was also assessed.

Results

OS and CT groups had better scores than HA group. In OS group, average Constant score was 71.6 ± 16.2, DASH score was 12.1 (5.2-24.2) and ASES score was 77.5 (50.8-96.6). In CT group, average Constant score was 69.6 ± 19.2, DASH score was 16.4 (12.5-36.7) and ASES score was 76.6 (45.4-87.9). DASH scores (p = 0.032), Constant scores (p = 0.001), forward elevation (p < 0.001), abduction (p < 0.001), internal (p = 0.022) and external rotation (p = 0.048) were significantly improved in OS and CT groups than HA group.

Conclusions

HA should not be considered a priority in surgical planning in Neer three-part and four-part proximal humerus fractures. CT is superior for patients with additional morbidity and advanced age. But in patients who are younger and can tolerate the surgical procedure, the priority should be OS.

Failure of Major Upper Extremity Replantation Due to COVID-19-Related Arterial Thrombosis

Coronavirus disease of 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in Wuhan, was declared a pandemic by the World Health Organization. COVID-19 has many different clinical manifestations. One of them is arterial hypercoagulopathy. Although its mechanism is not fully explained, acute thrombosis and thromboembolism can be seen in patients. In this study, we present a case who was amputated due to the development of arterial thrombosis on the 10th day following infection with coronavirus, despite successful replantation after traumatic above-elbow amputation. After replantation on the seventh day, it was learned that the patient’s husband was positive for COVID-19 and had come to visit the patient. For this reason, we performed reverse transcription polymerase chain reaction (RT-PCR) to confirm the patient’s COVID-19 status. We found that the patient, who was asymptomatic, was positive by RT-PCR for COVID-19. On the 10th day after the operation, it was observed that the blood circulation of the replanted extremity was impaired, although it had been perfect until that day. Emergency embolectomy and vascular reanastomosis were planned for the patient. Although we generally observe thrombosis at an end-to-end anastomosis site, massive axillary arterial thrombosis was detected at the proximal end of the vascular anastomosis. Upon development of tachycardia, hypotension, and metabolic acidosis after embolectomy and vascular reanastomosis, the decision was made to amputate the replanted limb to reduce the risk of life-threatening complications. To our knowledge, this is the first such COVID-19-related complication on upper extremity replantation in the literature.

Radial Recurrent Artery: Autologous Patch Graft for Acute Brachial Artery Laceration

Brachial artery injury is the most common vascular disruption in upper extremity penetrating trauma, usually treated by primary repair or saphenous vein interposition graft. We report the case of a young male who presented after assault with stab wound to the right antecubital fossa, an asymmetric vascular exam, and unknown depth contaminated wound that warranted operative exploration. We performed open exploration through a triangular flap extension of his oblique linear laceration for both exposure and flexor surface scar contracture prophylaxis. Exploration revealed brachial artery laceration with loss of approximately 30% of vessel circumference proximal to the radial and ulnar artery bifurcation. A near-complete transection of the recurrent radial artery was also present, leading to the decision to sacrifice this vessel for use as an autologous patch graft of the injured brachial artery. Distal vascular flow was re-established, and the vessel was slightly ectatic with no evidence of stenosis. Patient suffered no complications and was discharged at post-operative day four after perioperative heparin drip on anti-platelet therapy. Autologous patch grafting in the acute setting is a less-often considered surgical option that is effective for arterial bifurcation reconstruction, which may be employed through the sacrifice of injured and redundant local branch vessels. Patch grafts are commonly utilized in planned vascular surgery, such as carotid endarterectomy, but this is the first report of autologous patch graft to an acute brachial artery injury. By combining knowledge of the lateral arm flap with the plastic surgery principles of "like replaces like", this technique avoids the stenosis associated with primary repair, the multiple anastomoses necessary for interposition grafting, the need for a secondary donor site, and provides a theoretical blood-flow advantage.

Validating the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests for upper extremity fracture care

BACKGROUND

Computerized adaptive testing (CAT) for patient-reported outcomes (PROs) is a developing area within orthopedic surgery. Our objective was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) CATs for upper extremity fracture care. We sought to correlate PROMIS with legacy PROs and to investigate floor and ceiling effects.

METHODS

Patients who underwent open reduction and internal fixation of upper extremity trauma were prospectively enrolled. Legacy PROs included the visual analog scale for pain, the Disabilities of the Arm, Shoulder and Hand questionnaire, the University of California-Los Angeles Shoulder Rating Scale, the Mayo Elbow Performance Score, and the 36-Item Short Form Health Survey. PROMIS CATs included Physical Function (PROMIS PF), PROMIS Pain Interference (PROMIS Pain), and PROMIS Upper Extremity (PROMIS UE). Correlations between the PROs were calculated as were the absolute and relative floor and ceiling effect.

RESULTS

The study prospectively enrolled 174 patients with upper extremity trauma. There was moderate to high correlation between PROMIS UE CAT and legacy upper extremity-specific PROs (ρ = 0.42-0.79), and high correlation between the PROMIS PF CAT and the 36-Item Short Form Health Survey Physical Component Summary (ρ = 0.71, P < .001). The visual analog scale for pain, University of California-Los Angeles Shoulder Rating Scale, Constant Score, and Mayo Elbow Score demonstrated a significant absolute ceiling effect (20.5%-23.7%), whereas the PROMIS PF, PROMIS UE, and PROMIS Pain CATs demonstrated no absolute ceiling effect.

CONCLUSION

PROMIS PF, Pain, and UE correlate well with legacy PROs in a upper extremity trauma population, with less absolute floor or ceiling effects. This study provides preliminary evidence for the utility of PROMIS CATs in upper extremity trauma patients.

Principles of nerve repair in complex wounds of the upper extremity

Peripheral nerve injuries are common in the setting of complex upper extremity trauma. Early identification of nerve injuries and intervention is critical for maximizing return of function. In this review, the principles of nerve injury, patient evaluation, and surgical management are discussed. An evidence-based approach to nerve reconstruction is reviewed, including the benefits and limitations of direct repair and nerve gap reconstruction with the use of autografts, processed nerve allografts, and conduits. Further, the principles and indications of commonly used nerve transfers in proximal nerve injuries are also addressed.

Ballistic trauma: lessons learned from iraq and afghanistan

Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.

Scapula fractures

Over the past decade, there has been an increased interest in understanding the operative indications and techniques in treating scapular fractures and tracking their outcomes. Multiple studies have documented poor functional outcomes following nonoperative management of displaced scapular fractures. There is a groundswell of recognition that severe deformity from scapular malunion is associated with functional consequences for patients. This has led to a growing recognition that scapular fractures should be held to the same standards as other bodily fractures with regard to fracture fixation principles, including anatomic articular reduction, proper alignment, and stable internal fixation. Through research, there has been an improved understanding of scapular fracture patterns and the relevant surgical approaches and exposures used for fracture fixation. As with many bones, however, there still remains the absence of a compelling study that defines thresholds for surgical indication based on degrees of deformity and amounts of displacement.