Insurance Status Predicts Hand Therapy Adherence following Flexor Tendon Repair: A Retrospective Cohort Study

BACKGROUND

Many patients are not adherent to hand therapy rehabilitation following surgical repair of traumatic flexor tendon injuries, which can negatively affect surgical outcomes and long-term hand function. The authors aimed to identify the factors that predict patient nonadherence to hand therapy following flexor tendon repair surgery.

METHODS

This retrospective cohort study included 154 patients who underwent surgical repair of flexor tendon injuries at a level I trauma center between January of 2015 and January of 2020. A manual chart review was performed to collect demographic data, insurance status, injury characteristics, and details of the postoperative course, including health care use.

RESULTS

Factors significantly associated with occupational therapy no-shows included Medicaid insurance (OR, 8.35; 95% CI, 2.91 to 24.0; P < 0.001), self-identified Black race (OR, 7.28; 95% CI, 1.78 to 29.7; P = 0.006), and current cigarette smoker status (OR, 2.69; 95% CI, 1.18 to 6.15; P = 0.019). Patients without insurance attended 73.8% of their occupational therapy visits, and patients with Medicaid attended 72.0% of their visits, rates significantly lower than the rate of those with private insurance (90.7%; P = 0.026 and P = 0.001, respectively). Patients with Medicaid were eight times more likely to seek emergency department care postoperatively than patients with private insurance ( P = 0.002).

CONCLUSIONS

Significant disparities in hand therapy adherence following flexor tendon repair surgery exist between patients with different insurance statuses, races, and tobacco use. Understanding these disparities can help providers identify at-risk patients to improve hand therapy use and postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Outcomes in Ballistic Injuries to the Hand: Fractures and Nerve/Tendon Damage as Predictors of Poor Outcomes

BACKGROUND

Gunshot injuries can be devasting, regardless of their location. However, ballistic injuries involving the upper extremity have not been thoroughly investigated. The goal of this study is to evaluate the injury patterns and outcomes of patients who sustained gunshot injuries to the hand.

METHODS

A retrospective chart review of patients with gunshot injuries to the upper extremity at a single, level 1 trauma center between January 2016 and December 2017 was performed. Patient demographics and mechanisms of injuries were reviewed. The injury patterns, location, tendon/nerve involvement, and bony involvement were analyzed. Surgical interventions and long-term outcomes were reviewed. Outcomes were compared using the presence of fractures and nerve/tendon injuries as independent variables.

RESULTS

In all, 32 patients met our inclusion criteria. Of these, 15 patients had gunshots to the hand, 10 patients to the fingers, and 7 patients involving both the finger and hand. In patients with isolated hand injuries, 60% had fractures and 53% had nerve/tendon injuries. The presence of fractures was associated with a 7.9-fold increase in tendon and nerve injuries (P = .032). Patients who sustained tendon/nerve injuries had significantly higher rates of permanent disability (P = .01). The presence of a fracture leads to a higher likelihood of long-term complications, although not statistically significant (P = .13).

CONCLUSION

Ballistic injuries to the hand are frequently associated with fractures and neurovascular and tendon injuries. The presence of fractures is associated with a higher incidence of nerve and tendon injuries. Involvement of these structures is linked to an increased risk of long-term disability.

The Modified Five-Item Frailty Index to Predict Hand and Wrist Surgical Repair Postoperative Outcomes: An ACS-NSQIP Analysis of 11 369 Patients

BACKGROUND

Hand and wrist injuries can cause painful, everyday obstacles for patients. Carefully indexing preoperative patient health conditions may better inform surgical care, leading to improved postoperative outcomes. The purpose of the present study is to evaluate if the Modified Five-Item Frailty Index (mFI-5) can accurately predict postoperative complications for hand and wrist surgical repair.

METHODS

A retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program database was conducted to investigate patients who underwent hand and wrist surgical repair from January 2013 to December 2019. Patient demographics, comorbidities, surgical logistics, and 30-day readmission due to postoperative complications were extracted. Surgical risk proxies including the mFI-5, age, body mass index (BMI), smoking status within 1 year, the Modified Charlson Comorbidity Index (mCCI), comorbidities, and American Society of Anaesthesiologists Physical Status Classification (ASA class) were calculated.

RESULTS

A total of 11 369 patients were included. Thirty-day readmission for total postoperative complications (n = 258) was significantly associated with all surgical risk proxies. However, age, mFI-5 > 2, mCCI > 2, comorbidities > 1, and ASA class 2/3 had the highest statistical significance (P = <.001). Thirty-day readmission rates for surgical site infections (n = 118) had the highest statistical significance with age, BMI, mFI-5 > 2, and ASA class 2/3 (P = <.001). A Clavien-Dindo score > 1 (n = 224) had the highest statistical significance with age, mCCI > 2, comorbidity of 1, and an ASA class 3 (P = <.001).

CONCLUSIONS

The mFI-5 may have value in predicting 30-day readmission due to postoperative complications after surgical repair of hand and wrist injuries.

[Long-term results of plantar skin grafts versus skin grafts of hairy areas for covering loss of skin substances on the palmar surface of the fingers, palm of the hand and sole of the foot in patients with black skin. Prospective cohort study of 123 total skin grafts]

CONTEXT

Despite the use of total skin grafting in the treatment of loss of skin substances on the palmar surface of the fingers, the palm of the hand and the sole of the foot, the data published in the literature on long-term results in black-skinned patients are non-existent.

METHODS

The present study, filling this gap, used data from a prospective cohort of 123 total skin grafts performed on 93 black African patients who benefited from plantar skin grafts versus skin grafts from hairy areas to cover loss of skin substances. of the palmar surface of the fingers, the palm of the hand and the sole of the foot. This study covers a period of 163 months.

RESULTS

Sixty-four grafts of hairy areas were carried out in 52 patients, 29 of whom were male and 23 female, for a M/F sex ratio of 1.3; and 59 plantar skin grafts in 41 patients including 21 males and 20 females, M/F sex ratio of 1. The digital palmar surface was the most recipient of the plantar graft, i.e. 35.5% of cases. After a post-operative follow-up of at least 12 months, patients or their entourage judged the functional and aesthetic results of plantar skin grafts to be better and acceptable, unlike the results of hairy area grafts. The texture and color are even better if the total skin graft is taken from an identical histological area.

CONCLUSION

In view of these results, we recommend a plantar skin graft for black-skinned patients to cover losses of skin substances on the palmar surface of the fingers, the palm of the hand and the sole of the foot, if indicated.

[Clinical effects of early rehabilitation treatment after repair surgery of skin and soft tissue defects accompanied by extensor tendon injury on the back of hand]

Objective: To explore the clinical effects of early rehabilitation treatment after repair surgery of skin and soft tissue defects accompanied by extensor tendon injury on the back of hand. Methods: This study was a retrospective non-randomized controlled study. From February 2015 to February 2023, 24 patients (15 males and 9 females, aged 12-55 years) with skin and soft tissue defects accompanied by extensor tendon injury on the back of hand, who met the inclusion criteria and were repaired with flap transplantation and tendon grafting or tendon anastomosis, were admitted to the First Affiliated Hospital of Air Force Medical University. According to different intervention time for postoperative rehabilitation treatment of patients, the patients were divided into conventional rehabilitation group and early rehabilitation group, with 12 cases in each group. Patients in early rehabilitation group received rehabilitation treatment immediately after surgery under the rehabilitation guidance of specialized rehabilitation physicians based on the characteristics of different postoperative periods. Patients in conventional rehabilitation group began rehabilitation treatment from the third week after surgery, and their rehabilitation treatment was the same as that of patients in early rehabilitation group from the second week after surgery. The patients in 2 groups were treated in the hospital until the sixth week after surgery. The occurrence of flap vascular crisis and tendon rupture were observed within 6 weeks after surgery. After 6 weeks of surgery, the manual muscle test was used to measure the pinching force between the index finger and thumb, lateral pinching force, three-point pinching force, and grip force of the affected hand; the total action motion method was used to evaluate the finger joint range of motion of the affected hand, and the excellent and good ratio was calculated; the Carroll upper extremity function test was used to score and rate the function of the affected hand. Results: Within 6 weeks after surgery, only 1 patient in conventional rehabilitation group suffered from venous crisis, and the flap survived after the second surgical exploration and anastomosis of blood vessels; there was no occurrence of tendon rupture in patients of 2 groups. After 6 weeks of surgery, there were no statistically significant differences in pinching force between the index finger and thumb, lateral pinching force, three-point pinching force, or grip force of the affected hand between the two groups of patients (P>0.05); the excellent and good ratio of the finger joint range of motion of the affected hand of patients in early rehabilitation group was 11/12, which was higher than 7/12 in conventional rehabilitation group, but there was no statistically significant difference (P>0.05); the affected hand function score of patients in early rehabilitation group was 90±6, which was significantly higher than 83±8 in conventional rehabilitation group (t=2.41, P<0.05); the function rating of the affected hand of patients in early rehabilitation group was obviously better than that in conventional rehabilitation group (Z=2.04, P<0.05). Conclusions: Early rehabilitation treatment for patients with skin and soft tissue defects accompanied by extensor tendon injury on the back of hand after repair surgery can improve hand function, but it would not increase surgery related complications, which is worthy of clinical promotion and application.

Clinical application of a free flap supplied by the osteocutaneous branch of the anterior interosseous artery

OBJECTIVES

To explore the clinical application and efficacy of transplantation of free composite flaps supplied by radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery for reconstructing bone and skin defects in the hand.

MATERIAL AND METHODS

Anatomically, the radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery has constant collateral anastomoses which can provide a large dorsoradial flap from the dorsum of the forearm. This flap was used for reconstruction in five cases of cutaneous and phalangeal defects.

RESULTS

Reconstruction was successful in all five cases, with consolidated phalanx and good cosmetic results. All donor sites could be closed directly.

CONCLUSION

Reconstruction with dorsoradial forearm flaps is a reliable procedure which causes minimal trauma. Thus, it is an ideal approach for repairing cutaneous and phalangeal defects.

Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know

This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.

Trends in the Management of Fifth Metacarpal Neck Fractures

PURPOSE

To describe management trends of fifth metacarpal neck (5MCN) fractures within a large health care system. We aimed to define patient and surgeon factors associated with nonsurgical versus surgical treatment, as well as to identify factors associated with receiving care only in the emergency department (ED).

METHODS

We identified all 5MCN fractures within our system for the years 2012-2020 and recorded baseline demographics for cases. Injury, treatment, and fracture characteristics were all recorded. For fractures treated nonsurgically, we determined the type of immobilization used (if any) and recorded whether patients were seen only in the ED or received subsequent outpatient follow-up. Demographic comparisons were made between groups, and adjusted logistic regression models were generated to predict the odds of having a surgical 5MCN fracture or being seen in the ED only.

RESULTS

There were 611 5MCN fractures over an 8-year period, of which 10% were treated surgically. During the first half of the study period, 8% of isolated cases were treated surgically compared with 7% of cases in the second half. Soft dressings were increasingly used. There were no nonsurgically managed cases that underwent subsequent surgical procedures for symptomatic nonunion or malunion. Twenty-one percent of patients were seen only in the ED. Fracture angulation, associated injuries, insurance status, and treatment by a hand surgeon were all significantly associated with an increased likelihood of surgery.

CONCLUSIONS

Of the 611 5MCN fractures identified, 90% were treated nonsurgically. Patient and surgeon factors were associated with increased odds of surgery. Of patients who sought care for 5MCN injuries, >20% received no follow-up care outside of the ED. These data can be used to assess future changes in management trends and suggest that nonunion and symptomatic malunions are uncommon occurrences.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Youngest hand injury during cesarean delivery: A case report

An emergency cesarean surgery resulted in extensor tendon lacerations in a 27-week-old preterm fetus. This injury is unique because fetal hand lacerations rarely occur, and to the best of our knowledge, this is the youngest case of hand injury during cesarean delivery reported in the literature. This case report sets the framework for a more in-depth investigation of the incidence and treatment options for fetal lacerations, with an emphasis on the less common but clinically important hand lacerations that can occur during cesarean section. LEVEL OF EVIDENCE: Therapeutic IV.

Antibiotic treatment of hand wounds in children: Contribution of a decision tree

BACKGROUND

The need for prophylactic antibiotic treatment of hand wounds in children requiring emergency surgical exploration is still controversial. Our starting hypothesis was that the absence of prophylactic antibiotic treatment in this setting (as specified by a decision tree) does not increase the likelihood of surgical site infection.

METHODS

A decision tree for antibiotic prescription was developed by a working group in compliance with the guidelines issued by the French High Authority for Health, as part of a clinical pathway. One injection of intravenous antibiotics was prescribed for bite injuries, open joint injuries, injuries left untreated for more than 24 h, and suspected contaminated wounds. All children admitted for surgical treatment of a hand wound between July 2018 and March 2023 were included. Demographic data, antibiotic prescription and onset of postoperative surgical site infection were recorded.

RESULTS

The 238 children included had a mean age of 8 ± 4.8 years; 102 received antibiotics and 136 did not. Eleven children (4.6%) had superficial surgical site infection requiring no revision surgery or antibiotic therapy. 206 children (86.5%) were treated following the decision tree. Ten had superficial surgical site infection: 3 received antibiotics (3.7% of the 80 who were treated) and 7 did not (5.5% of the 126 not treated) (p = 0.74). Thirty-two patients (13.5%) were off-protocol, only 1 of whom received antibiotics for superficial surgical site infection.

DISCUSSION

Applying the decision tree standardized the prescription of antibiotics in hand wounds, was not associated with a significantly greater rate of surgical site infection, and avoided exposure to antibiotics for 61.1% of the children, thus limiting potential adverse events.

LEVEL OF EVIDENCE

III.

[Severe and complex traumatic hand]

SEVERE AND COMPLEX TRAUMATIC HAND . Serious and complex traumatic injuries of the hand are multiple tissue injuries (skin, vascular, bone and nerves), requiring urgent surgical management. They are responsible for significant functional and aesthetic sequelae. Their incidence is clearly decreasing thanks to information, prevention and security measures. The absolute emergencies are injections under pressure, amputations-devascularizations, and serious mutilations. The objective of the management is to make a functional and aesthetic hand: restoration of the opposition of the thumb with a key-pinch, a sufficient length thumb, and restoration of the sensitivity of the reconstructed hand. This calls for numerous surgical and microsurgical techniques and must be undertaken by trained teams in specialized centers.

Metacarpal and Phalangeal Nonunions

The majority of phalangeal and metacarpal fractures will proceed to union when appropriately treated. However, when a nonunion does occur, it can lead to significant functional impairment for patients and societal costs. Operative intervention is typically required in these cases, but the technique can vary depending on each individual patient scenario. This article provides an overview of nonunions of the metacarpals and phalanges in the hand, including incidence, risk factors, current treatment options, and postoperative care.

[Surgical indications for hand wounds]

SURGICAL INDICATIONS FOR HAND WOUNDS. Hand injuries are common, with potentially severe consequences. When a patient is seen in the emergency department, a lesion assessment must be carried out to distinguish between extreme emergencies such as amputation or devascularization, which require immediate treatment in a specialized centre. If there is no immediate indication of seriousness, a clinical examination, possibly combined with meticulous exploration, helps to identify the lesions. The presence of tendon, nerve or vascular damage requires surgical management in the operating theatre. Any wound that cannot be reliably explored should be managed in the operating room by a hand surgeon.

[Hand accident prevention]

HAND ACCIDENT PREVENTION. Advances in surgical techniques and a better organization with SOS mains structures have improved the management of hand injuries. However, there are still too many accidents, which can lead to functional and aesthetic after-effects, as well as their socio-professional consequences. The prevention of hand injuries is therefore mandatory. It is organized with three levels: primary prevention, that aims to prevent the occurrence of the accident itself; secondary prevention, to guide and provide the best emergency care for the patient; and tertiary prevention, to avoid deprofessionalization and provide support for any physical and psychological after-effects.

Local flaps of the hand

Hand injuries are common, and due to the complex functions of the hand, soft tissue defects present a surgical challenge in reconstruction. Hand defects exposing deeper structures warrant reconstruction with local flaps, but in Denmark, reconstruction surgery of the hand is routinely managed within the orthopaedic specialty alone with no plastic surgical involvement. This review aims at describing the most common local flaps of the hand and forearm and encourage to stronger collaboration between hand- and plastic surgeons in Denmark.

Hand Fractures-Management and the Complications That Inevitably Occur: Metacarpal Fractures

Metacarpal fractures are among the most common hand fractures. To properly manage these injuries, surgeons must understand the anatomy, biomechanics, clinical assessment, surgical and nonsurgical treatment options, and potential complications. Metacarpal head fractures often require surgical treatment to restore the joint surface by using a variety of techniques. Metacarpal neck fractures are usually stable injuries that do not require surgical intervention, but surgeons must know when surgical intervention is indicated. Fractures of the metacarpal shaft can be treated surgically and nonsurgically and may be associated with large bone defects or soft-tissue injuries that require careful consideration. Finally, fractures involving the carpometacarpal joints must be promptly managed to avoid long-term complications, potentially requiring salvage procedures.

Mangled Thumb Injury Reconstruction with the Use of Definitive External Fixation and the Masquelet Technique: A Case Report

CASE

A 23-year-old right-hand dominant man presented with a high-velocity gunshot wound injury to the right thumb with severe soft-tissue damage, vascular injury, and large osseous defect of the right thumb metacarpal. The patient was successfully treated with metacarpophalangeal joint arthrodesis and metacarpal reconstruction using definitive external fixation, an intramedullary Kirschner wire, and use of the Masquelet bone grafting technique.

CONCLUSION

The authors' treatment approach for a mangled thumb injury with definitive external fixation and utilization of the Masquelet technique resulted in restoration of a large osseous defect, avoidance of infection, and limited loss of mobility.

Epidemiology of adult hand injuries presenting to a tertiary hand surgery unit: a review of 4216 cases

This study investigates the pattern of hand injuries presenting to a UK regional tertiary centre. All referrals to our Hand Surgery Unit in 2019 were reviewed. Subgroup analyses of sex, deprivation, occupational injuries and assault cases were carried out. Over the study period, 4216 cases were referred. Most were male (70%), with a median age of 36 years and from a deprived area (75.2%). Soft tissue injury was documented in 53.6% and bone injury (fracture/dislocation) in 52.4%. Surgical management was required in 2214 (52.5%) cases. Work-related injuries accounted for 16.7% of cases and were more likely to require surgery. Assault-related injuries accounted for 8% of cases, with a male preponderance. Our findings can help facilitate service provision and guide regional and national prevention policies.Level of evidence: III.

Retro-Antegrade Technique in the Management of Severely Angulated Fourth and Fifth Metacarpal Neck Fractures: A Case Series

Background: This study introduces a novel method for the management of closed metacarpal neck fractures. Kirschner wires (K-wire) are introduced in a retrograde and the wires withdrawn through skin proximally at the base of the metacarpal. The fracture is reduced using traction and the reduction is maintained by antegrade advancement of the K-wires. The aim of this study is to report the outcomes of this technique. Methods: A total of 36 patients with severely angulated closed metacarpal neck fractures underwent reduction and fixation using this novel method from January 2017 to December 2020 in centres in Ireland and Saudi Arabia. We performed a retrospective review of these patients' clinical data examining their outcomes. Results: Six months postoperatively, all fractures demonstrated bony union and correction of angulation. All patients exhibited excellent range of motion (ROM) with no significant impairment of hand function. Conclusions: The method detailed here is a simple, minimally invasive and reliable technique that has not previously been described. It is suitable for use in the management of closed metacarpal neck fractures of the fourth and fifth metacarpal, with dorsal angulation greater than 60°. Level of Evidence: Level IV (Therapeutic).

The Hand and Wrist: AntImicrobials and Infection (HAWAII) trial

BACKGROUND

Hand trauma, comprising injuries to both the hand and wrist, affects over five million people per year in the NHS, resulting in 250 000 operations each year. Surgical site infection (SSI) following hand trauma surgery leads to significant morbidity. Triclosan-coated sutures may reduce SSI in major abdominal surgery but have never been tested in hand trauma. Feasibility needs to be ascertained before a definitive trial can be delivered in hand trauma.

METHODS

A multicentre feasibility RCT of antimicrobial sutures versus standard sutures involving adults undergoing surgery for hand trauma to evaluate feasibility for a definitive trial. Secondary objectives were incidence of SSI in both groups, hand function measured with patient-reported outcome measures, health-related quality of life and change in employment. Randomization was performed on a 1:1 basis, stratified by age of the patient and whether the injury was open or closed, using a secure, centralized, online randomization service. Participants were blinded to allocation.

RESULTS

116 participants were recruited and randomized (60 intervention, 56 control). Of 227 screened, most were eligible (89.5 per cent), and most who were approached agreed to be included in the study (84.7 per cent). Retention was low: 57.5 per cent at 30 days, 52 per cent at 90 days and 45.1 per cent at 6 months. Incidence of SSI was >20 per cent in both groups. Hand function deteriorated after injury but recovered to near pre-injury levels during the study period.

CONCLUSIONS

Risk of SSI after hand trauma is high. A definitive RCT of antimicrobial sutures in hand trauma surgery is feasible, if retention is improved.

TRIAL REGISTRATION

ISRCTN10771059.

Surgical site infection following surgery for hand trauma: a systematic review and meta-analysis

Surgical site infection is the most common healthcare-associated infection. Surgical site infection after surgery for hand trauma is associated with increased antibiotic prescribing, re-operation, hospital readmission and delayed rehabilitation, and in severe cases may lead to amputation. As the risk of surgical site infection after surgery for hand trauma remains unclear, we performed a systematic review and meta-analysis of all primary studies of hand trauma surgery, including randomized controlled trials, cohort studies, case-control studies and case series. A total of 8836 abstracts were screened, and 201 full studies with 315,618 patients included. The meta-analysis showed a 10% risk of surgical site infection in randomized control trials, with an overall risk of 5% when all studies were included. These summary statistics can be used clinically for informed consent and shared decision making, and for power calculations for future clinical trials of antimicrobial interventions in hand trauma.

Principles of management of hand fractures

The optimal management of hand fractures requires a multidisciplinary approach. Initial assessment should include a thorough medical history and clinical examination, followed by appropriate radiological imaging. These are crucial in determining the appropriate management. Following joint stabilisation to allow fractures to unite, early mobilisation is needed to maximise the functional restoration of the hand. In this review, the principles of operative and non-operative management of these injuries are discussed.

The free Thenar flap for thumb pulp reconstruction: A case report

The thumb is acknowledged to contribute significantly to hand function, accounting for up to 40% of its overall capability. Consequently, injuries affecting the thumb can have a profound impact on the quality of life experienced by patients. When it comes to the surgical reconstruction of thumb injuries, the primary objective is to promptly provide coverage of the affected area with glabrous skin, thus preserving both the length and functionality of the thumb. Managing injuries specifically involving the thumb pulp can be particularly challenging due to the digit's size and vital role. Acquiring an adequate amount of glabrous soft tissue poses a difficulty in such cases. Various reconstructive approaches, encompassing a range of options on the reconstructive ladder, have been documented for thumb pulp injuries. The most popular options include pedicled flaps and free flaps obtained from both the hands and feet. However, a consensus regarding the optimal method for reconstructing the thumb pulp has yet to be reached. We present a case of total thumb pulp reconstruction for a 40 × 30 mm defect using the free thenar flap in a 65-year-old carpenter who sustained a work-related injury. This flap was designed and raised on the superficial branch of the radial artery with a single subcutaneous vein and a branch of the palmar cutaneous nerve, the flap measured 43 × 32 mm. It was inset transversely with an end-to-end arterial anastomosis to the ulnar digital artery, venous anastomosis to the dorsal digital vein and nerve coaptation to the ulnar digital nerve. The postoperative course was uneventful, and the patient was discharged the following day without any complications. Eight months after surgery, the patient was extremely satisfied with the results of the procedure in terms of both function and appearance. The patient had experienced an improvement in function, sensation, and aesthetics. The patient had a QuickDASH disability/symptom score of 15.91 and a QuickDASH work module score of 18.75; the range of motion in the treated thumb was almost the same as the opposite thumb. The patient successfully resumed work three weeks following the procedure, initially with modified duties, and fully regained their work capacity within six weeks. As the patient's primary concern was their ability to return to work, the utilization of a free thenar flap offered several distinct advantages. These included minimal post-operative complications, facilitated by a single operative site, allowing for reconstruction under regional anesthesia. Moreover, the procedure was conducted in a single stage, enabling the patient to be discharged on the same day without the need for further procedures. Furthermore, similar to several other reconstructive options for the thumb, the utilization of a free thenar flap offered the advantage of providing high-quality, like-for-like glabrous tissue.

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort

BACKGROUND

Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis.

METHODS

A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis.

RESULTS

From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar.

CONCLUSIONS

Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

Surgical Interventions for Chronic Ulnar Collateral Ligament Injuries of the Thumb: A Systematic Review

Background: There is no consensus for the appropriate surgical management of symptomatic chronic ulnar collateral ligament (UCL) injuries of the thumb. The aim of this study is to systematically review the treatment of chronic thumb metacarpophalangeal (MCP) joint UCL injuries to determine the optimal approach to treatment. Methods: A systematic review of PubMed, Medline, Embase and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-Analysis (PRISMA) guidelines. Results: Data from 11 studies using various surgical techniques in 245 thumbs were heterogenous and meta-analysis of results not possible. These data were qualitatively assessed. Direct repair, reconstruction with free tendon grafts and arthrodesis all demonstrated favourable outcomes with patient-reported outcome measures (PROMs). Conclusions: Direct repair can be safely performed more than 2 months following injury. Arthrodesis may be considered in heavy manual labourers or those with osteoarthrosis. Tendon grafting is safe, yet the optimal type and configuration are yet to be determined for reconstructive methods. Level of Evidence: Level III (Therapeutic).

An Updated Surgical Approach of Using Flap and Cutaneous Nerve in the Lateral Arm to Reconstruct Complex Injuries of the Forearm and Hand: A Case Series Study

BACKGROUND

Complex injuries involving the nerves and other soft tissues in the forearm and hand lead to functional and aesthetic defects. In such situations, multiple types of nerve autografts and flap donor sites are available. However, multiple donor sites cause donor morbidity in different locations and may lead to awkward operational positions. Therefore, based on the anatomical characterization, we aimed to modify the utilization of the lateral arm donor site for reconstruction, which restricts donor morbidity in the affected upper extremity.

METHODS

We report a case series (N = 6) using a lateral arm flap (LAF) to reconstruct complex soft tissue defects in the forearm, palm, and finger. The posterior antebrachial cutaneous nerve (PACN) is the primary option for nerve bridging, whereas the LAF can carry the lower lateral brachial cutaneous nerve (LBCN) as a sensory flap. Once the PACN was insufficient, the LBCN was harvested simultaneously. All the cases included in this study were performed between January 2012 and August 2021. Demographic information, flap and nerve characteristics, complications, and hand function were analyzed.

RESULTS

The LAF plus PACN or plus LBCN as nerve autograft, both successfully repaired 6 complex injuries: 2 cases in the forearm side, 1 in the hand palm, and 3 in the finger defects. Posterior antebrachial cutaneous nerve was the most used (8-15 cm), and LBCN plus PACN was used to bridge nerve defects when necessary (in total, 20 and 21 cm). The average follow-up time was 19.7 months. The disabilities of the arm, shoulder and hand score ranged between 6 and 12, and the mean 2-point discrimination values ranged between 6 and 12. The Semmes-Weinstein monofilament test result was under 5.46. In addition, 2 patients underwent a secondary debulking surgery. The average length of hospital stay was 10.4 days. Hematoma occurred in 2 cases, and all patients reported numbness in the donor nerve innervated areas.

CONCLUSIONS

This surgical refinement can reconstruct complex injuries in the forearm and hand. In addition, this approach restricts donor morbidity in the affected limb, comforts the operational position, and is achieved under brachial plexus anesthesia.

The Superficial Circumflex Iliac Artery Perforator Flap for Devastating Hand Injuries in Obese Patients

INTRODUCTION

Blast injuries to the hand, such as those from fireworks, are debilitating and life altering. Often, because of the nature of the injury, there is a need for soft tissue and skin coverage. However, in the increasingly obese American population, free flaps often are too bulky for functional hand coverage. In this study, we present a series of 7 patients who underwent the superficial circumflex iliac artery perforator (SCIP) flap for upper extremity reconstruction with improvement in cosmesis, including a primarily repaired donor site, as well as an overwhelmingly high return to work with minimal revision surgery necessary.

METHODS

All patients who underwent a SCIP for hand injuries from a blast were included. Flaps were harvested based on previously described methods. A single attending surgeon performed all surgeries. All patients were followed for at least 6 months. Preoperative and postoperative characteristics were described.

RESULTS

A total of 7 patients were included in this study. Ages ranged from 16 to 58 years and body mass index from 19 to 48 kg/m 2 . More than half of the patients had a body mass index greater than 30 kg/m 2 . All donor sites were primarily closed. Five patients returned to their preinjury work. Three patients had neurotized flaps with return of protective sensation. Three patients required revision surgery; all 3 had liposuction, and 1 had additional flap advancement surgery.

CONCLUSION

The SCIP flap is a versatile flap that can be used in hand reconstruction in blast injuries with good functional outcome and improved cosmesis compared with other perforator flaps for the upper extremity.

WALANT for hand wound exploration in isolated conditions: Feasibility study

INTRODUCTION

Military doctors usually deal with hand wound management. Their practice sometimes takes them far from any specialized surgical center. The WALANT could be a powerful tool for doctors operating in nuclear submarines or as part of special forces. This is a comparative, prospective and multicenter study. The hypothesis was that the management of hand wounds by military doctors specifically trained in WALANT and in the surgical exploration of hand wounds allowed a diagnosis as effective as in the FESUM center.

PATIENTS AND METHODS

Military doctors, usually operating in isolated conditions, were trained at WALANT. Then, this method was used for the exploration of hand wounds in the emergency room, in a center outside FESUM. At the end, two different questionnaires were completed respectively by the patient and the operator. They aimed to assess various criteria such as the overall satisfaction of the patient and the operator, the level of pain felt or the ability of the operator to establish a precise lesion assessment. The results were compared with those obtained under the same conditions by hand surgeons in the FESUM centre.

RESULTS

No significant difference was found between the two centers in terms of diagnostic capacity, satisfaction, comfort and perceived pain intensity.

DISCUSSION

Under cover of prior training, the WALANT is effective for the exploration of hand wounds by submariner doctors and members of the special forces. Its use makes it possible to establish a precise injury report and this in material and human conditions approaching as closely as possible those of the armed forces on mission. The comfort of the patient remains preserved.

CONCLUSION

The WALANT represents an effective tool for the exploration and lesion assessment of hand wounds outside the FESUM centre. Since emergency conditions are similar to those encountered in operational conditions, its use is also possible in situations specific to military doctors: nuclear submarines, special forces on mission.

LEVEL OF EVIDENCE

III; comparative study, retrospective, multicentre.

A New Source of Mutilating Hand Injuries: The Side-by-Side Utility Terrain Vehicle

BACKGROUND

Rates of mutilating hand injuries are increasing from accidents caused by all-terrain vehicles (ATVs) and the recently popularized side-by-side utility terrain vehicles (UTVs). Increasing surgeon familiarity with upper extremity (UE) injury patterns, severity, and outcomes following ATV and UTV accidents may improve patient care and advocacy.

METHODS

Retrospective comparisons of UE injury patterns, severity, hospital and intensive care unit (ICU) admission lengths, and number of operations were made between ATVs and UTVs. Findings were analyzed with Fisher exact tests, multivariate analysis of variance, analyses of variance with post hoc analyses, and multiple linear regressions.

RESULTS

A total of 154 cases were identified for inclusion (ATV, n = 87; UTV, n = 67). Patient ages ranged from 4 to 89 years. The UTV group contained significantly more hand and finger injuries, and more of the fractures were open ( P = 0.005, P < 0.001, and P < 0.001, respectively). Riders of UTVs had nearly three times as many mutilating hand injuries and a nearly ninefold increase in amputations compared with ATV riders ( P < 0.001 and P < 0.001, respectively). On average, the UTV group spent 2.5 additional days in the hospital, 0.91 additional days in an ICU, and had 1.3 additional operations ( P = 0.001, P = 0.007, and P < 0.001, respectively). Vehicle type was the only variable significantly correlated with days in the hospital, ICU, and number of UE operations ( P = 0.002, P = 0.008, and P < 0.001, respectively).

CONCLUSIONS

Hand surgeons are in a unique position to serve as forerunners for increasing public awareness of off-road vehicle risks and promoting rider safety. Collaborating with manufacturers and emergency care providers and directing teaching initiatives may improve patient outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Role of Preoperative Nerve Conduction Studies for Penetrating Hand Injuries Involving the Median Palmar Cutaneous Nerve

Penetrating lacerations to the hand are a common cause of nerve injury and can lead to debilitating pain and numbness in the distribution of the nerve affected. Owing to an overlap in the cutaneous innervation from different sensory nerves, clinically identifying the injured nerve can be difficult. We present a novel case of isolated injury to the palmar cutaneous nerve from a penetrating knife injury which was detected using 'comparison waveform' nerve conduction studies. Using this technique, we can isolate injuries to the palmar cutaneous branch of the median nerve (PCBmdn) from the median nerve, dorsal radial sensory nerve, and lateral antebrachial cutaneous nerve. In addition, sensory nerve testing identified conduction block as the mechanism of injury, which resolved after surgery at 8 weeks postoperatively. Preoperative nerve conduction study can discern the level of nerve injury to PCBmdn only, thus eliminating the need for median and radial nerve exploration at the forearm, unnecessary incisions, pain, and scarring. The objective of this case report is to illustrate the value of preoperative comparison waveform nerve conduction study, particularly the PCBmdn, in patients presenting with neurologic deficits who have sustained penetrating lacerations to the hand.

Heterotopic Digital Replantation in Mutilating Hand Injuries: An Algorithmic Approach Based on 53 Cases and Literature Review

BACKGROUND

 Reconstruction of the mutilated hand is one of the most difficult challenges for hand microsurgeons. When multiple digits are amputated, orthotopic digital replantation of the available remnants may not adequately restore the hand function. In such cases, heterotopic digital replantation may provide a more functional reconstruction.

METHODS

 Between 1997 and 2018, 53 patients with mutilating hand injuries were treated with heterotopic digital replantation at our institution. A retrospective chart review was conducted to determine the details of the injury, indications for heterotopic digital replantation, and functional outcomes.

RESULTS

 In total, 173 digits were amputated from 53 patients (one patient suffered from bilateral hand injuries, so totally 54 hands). Sixty-eight digits underwent heterotopic digital replantation, 30 digits had orthotopic digital replantation, and 75 stumps were terminalized. The survival rate of digits treated by heterotopic digital replantation and orthotopic digital replantation was 83.8% (57/68) and 86.7% (26/30), respectively (p = 1). Tripod grip was achieved in 83.3% (45/54) of patients following replantation and optional secondary reconstructive surgeries.

CONCLUSION

 Heterotopic digital replantation is a practical and reliable method for achieving optimal hand function following mutilating hand injuries. The basic principles are to restore a functional thumb in the first instance, followed by at least two adjacent fingers against which the thumb can oppose. This method is particularly indicated when orthotopic digital replantation of the available amputated parts would yield a suboptimal result.

Metacarpal fractures

Metacarpal fractures are common and can be functionally disabling. The majority are managed non-operatively. When surgical intervention is indicated, various methods of fixation are available with the utility of each being based on injury pattern, patient function and surgeon preference. Early mobilization, especially in case of open reduction and internal fixation, is a critical component of treatment to prevent stiffness and restore function. When possible, a fixation construct that can withstand the applied forces of early postoperative motion is chosen. We provide an updated description for diagnosis, treatment options and operative fixation for metacarpal fractures.

Impact of surgical first excision delay on function for heat-press hand injury by the Quick-DASH questionnaire: Series over 20 years

BACKGROUND

Heat-press hand burn leads to complex and severe lesions, with potentiation of thermal burn by the crushing mechanism. Management remains poorly codified, and the surgical strategies found in the literature remain contradictory. The objective of our study is to report our experience and define the first burn excision delay through functional evaluation with a Quick-DASH questionnaire.

METHODS

We carried out a retrospective study of 20 burned hands by heat-press managed in our burn unit between 2002 and 2021. Following data were collected, at least one year after the accident: Quick-DASH score, which was our primary endpoint, injury assessment according to the Tajima's classification, overall surgical management, and impact on their professional activity. A descriptive statistical analysis of these data was performed followed by a univariate analysis to assess the correlation between delay to first surgical excision and the long-term functional result (Quick-DASH score and time before return to work).

RESULTS

Burns were Tajima grade 1 (supra-fascial dermal burn) in 35 % of cases, grade 2 (exposure of subfascial structures) in 45 % and grade 3 (bone or joint exposure) in 20 %. There were no cases of bone fractures. We received 18 out of 20 questionnaires with no significant differences between those who send back or not. The median QuickDash score was 7.15 [IQR 0-52.25]. The first surgical excision was performed with a median of 8 days after the accident [min: 0; max: 20]. The median time before return to work was 24 weeks [IQR 17-42.25]. Only 11 patients (55 %) were able to go on the initial employment. Spearman test found a strong trend for a negative correlation between the time to the first excision and the QuickDash score (ρ = -0.46; r2 = 0.087; p = 0.053).

CONCLUSION

According to observations made in our unit and in agreement with Tajima, who first described heat-press injury, the first surgical excision should be performed approximately one week after the accident. Subsequent excisions may be performed to reassess the lesions and complete the debridement, with reconstruction to follow. Multidisciplinary management is still necessary, including early and intensive physiotherapy, psychological support, and assessment by an occupational physician.

RSTN COVID Hand: Hand trauma in the United Kingdom and Europe during the COVID-19 pandemic

The COVID-19 pandemic rapidly impacted the delivery of hand surgery services throughout the UK and Europe; from triage to treatment. Our aim was to assess the impact on management of common hand trauma injuries to inform future service delivery and research. The Reconstructive Surgery Trials Network led a service evaluation during the first wave of COVID-19 in 2020. Data was collected on hand injury management during the COVID-19 pandemic and was compared to the management clinicians would have delivered prior. Across 35 hand surgery units, 2540 patients with hand trauma were included. There was an increase of between 3% and 7% in non-operative management of injuries, apart from flexor tendon injuries where management remained unchanged. Cases triaged by a consultant doubled, with a 22% increase in the see-and-treat model. There was a move to operating in low-resource settings; a 13% increase in the use of minor operating theatres and 10% in clinic rooms. Use of WALANT, absorbable sutures, and remote follow-up also increased by 16%, 24%, and between 11% and 25%, respectively. The reported 30-day complication rate was 3.2%, with a surgical site infection rate of 1.8%. The pandemic led to rapid change in many aspects of hand trauma care. It was the impetus for increased out-of-theatre operating, use of local anaesthetic, and more non-operative management of injuries, without an increase in complication rate. Further research needs to assess the clinical and cost-effectiveness of these changes to ensure that COVID-19 is a catalyst for a modern, evidence-based, and environmentally sustainable delivery of hand trauma services.

Prospective Comparison of the Early Outcomes of Headless Compression Screw and Percutaneous K-Wire Fixation in Metacarpal Fractures

PURPOSE

The study aimed to assess early clinical outcomes achieved by headless compression screws (HCS) in fixation of metacarpal fractures, and to compare them with outcomes of percutaneous K-wire fixation. The hypothesis was that HCS would show better arc of motion and superior early clinical outcomes.

METHODS

This was a randomized study of nonthumb metacarpal neck and shaft fractures. To compare the 2 surgical techniques, 23 patients treated for metacarpal neck and shaft fractures were divided into 2 groups: 11 treated with K-wire fixation and the other 12 with HCS fixation. We followed the patients for 12 weeks. The primary objective was to compare metacarpophalangeal arc of motion, and the secondary aim was to determine clinical union, radiographic union, and recovery time before returning to employment in the 2 groups.

RESULTS

At each follow-up visit, patients in the group treated with HCS had better metacarpophalangeal arc of motion than those treated with K-wire fixation. The HCS group showed a shorter time interval to return to work (at 3 weeks) and no complications, while the K-wire group had 1 pin track infection, which was treated with oral antibiotics and pin removal.

CONCLUSIONS

Compared with K-wire fixation, limited-open HCS fixation for metacarpal neck and shaft fractures was superior in terms of the early postoperative metacarpophalangeal arc of motion and return to work.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Study on the prevention and nursing intervention of infection after flap transfer for hand trauma

To analyze the factors associated with infection after flap transfer for hand trauma and use them to develop nursing strategies and observe the effects of their application. Eighty-two patients admitted to our hospital for flap transfer for hand trauma from January 2020 to May 2020 were selected for the retrospective analysis. Logistic regression analysis was performed to analyze the factors associated with postoperative infections to develop care strategies. Another 88 patients admitted for flap transfer for hand trauma from September 2020 to June 2021 were retrospectively analyzed and divided into the observation (n = 44) and control groups (n = 44) according nursing strategies that they received. The operative time, intraoperative bleeding, incision healing time, first postoperative time to get out of bed on their own and hospital stay were compared between the 2 groups. The patients postoperative adverse effects and flap survival rates were also counted. visual analogue score, total active motion, manual muscle test, Barthel index, self-rating anxiety scale, self-rating depression scale scores were used to assess patients pain, hand function recovery and psychology before and after treatment. Logistic regression analysis manifested that postoperative bed rest time, affected limb immobilization, and pain were independent factors affecting postoperative infection after flap transfer (P < .05). After using targeted care strategies, the observation group had dramatically shorter operative time, intraoperative bleeding, incision healing time, time to first postoperative bed release on their own, and hospital stay, less postoperative pain and adverse effects, and higher flap survival rate than the control group (P < .05). Total active motion, manual muscle test, and Barthel index were higher in the observation group than in the control group after treatment, while self-rating anxiety scale and self-rating depression scale scores were lower than in the control group (P < .05). Finally, total satisfaction was higher in the observation group than in the control group (P < .05). Postoperative bedtime, fixation of the affected limb, and pain are independent factors affecting postoperative infection after flap transfer for hand trauma. Implementing infection prevention care strategies based on these factors can effectively improve the safety of flap transfer, reduce the possibility of infection, and shorten the recovery period of patients, which has high clinical application value.

Dupuytren contracture after acute traumatic hand injury in an adolescent: A case report

Dupuytren's disease is a fibroproliferative disease that affects the palmar hand, causing progressive, permanent, and symptomatic flexion contracture of the digits. It is a disorder of polygenetic and multifactorial origin, usually affecting middle-aged males. Dupuytren's disease developing as a result of hand trauma in younger ages is rarely reported. In this case, we present a 14-year-old male patient with Dupuytren's disease following acute traumatic injury. We performed the fasciectomy and Z-plasty with full thickness skin graft. He recovered completely additional injection of triamcinolone for one year.

Current Outcomes and Treatments of Complex Phalangeal and Metacarpal Fractures

Phalangeal and metacarpal fractures that require operative treatment have documented complications in around 50% of patients. The most common of these complications are stiffness and malunion. These can be highly challenging problems for the hand surgeon. In this article, we discuss complications after phalangeal and metacarpal fractures and treatment strategies for these complications.

[Analysis of three minimally invasive methods in the treatment of the fifth metacarpal neck fracture]

OBJECTIVE

To explore the effective method of applying Chinese medicine manipulative repositioning Kirschner wire fixation for minimally invasive treatment of fractures of the neck of the fifth metacarpal.

METHODS

From January 2018 to November 2021, 90 patients with closed fractures of the neck of the fifth metacarpal bone were treated minimally invasively with closed repositioning Kirschner wires, all fractures AO type was type A. All patients were divided into three groups according to the mode of internal fixation involving 30 cases in the crossed Kirschner's wire group, 30 cases in the transverse Kirschner's wire group, 30 patients in the intramedullary Kirschner's wire group. By comparison, gender, age, disease duration, and preoperative neck-stem angle were not significant. The postoperative fifth metacarpal neck-stem angles, postoperative fifth metacarpophalangeal joint flexion mobility and fifth metacarpophalangeal joint extension hyperextension angles were compared among three groups. The overall clinical efficacy was evaluated according to the patient outcomes of surgery-hand/arm(POS-Hand/Arm) scoring system.

RESULTS

All patients had 12-month follow-up and achieved bony union without malunion. There was no significant difference in the 5th metacarpal neck-stem angle, the fifth metacarpophalangeal joint flexion angle and the fifth metacarpophalangeal joint extension hyperextension angles among three groups at 12 months after surgery(P>0.05). There was no significant difference in physical activity and symptom scores in POS-Hand/Arm scores at 12 months after surgery(P>0.05), psychological status and aesthetic score among three groups(P<0.05) and between cross and transverse Kirschner wire groups(P>0.05). The three POS-Hand/Arm total scores were statistically different(P<0.05), between the crossed and transverse(P>0.05), and the intramedullary group had the highest POS-Hand/Arm scores.

CONCLUSION

All three techniques of Kristener's wire fixation could achieve minimally invasive treatment, and patients have need for cosmetic and early activity, and the author recommend minimally invasive intramedullary fixation with manipulative repositioned Kristen wires as the preferred procedure.

A Single Institution's Recent Experience With Pediatric Hand Burns

Children are at risk for sustaining hand burns due to their innate curiosity, slow withdrawal reflexes, and thin palmar epidermis. We sought to summarize our recent experience managing pediatric hand burns, focusing on injuries that required surgical management. This was a retrospective review of children with burn-injured hands managed at a quaternary referral children's hospital between 2016 and 2020. Demographics and mechanisms of injury were collected for all patients. Initial management of all wounds included pain control, deflation of blisters, and mechanical debridement. Wounds were then dressed, and a plaster-backed soft cast was applied for positioning if the swelling was controlled. Wounds were reassessed in 4-7 days, at which time a nonadherent dressing with antifungal ointment or a bismuth dressing was applied to partial-thickness wounds, vs an active silver dressing for deep partial-thickness burns. For patients who underwent split-thickness or full-thickness skin grafting, additional wound care, operative, and short-term outcomes data were collected. A total of 3715 children were seen for burn injuries during the study period, of which 2100 (56.5%) were seen for hand burns. In total, 123 (5.8%) required a skin graft an average of 11.7 days from the date of their burn injury. Surgical complications were minimal with 5 (4.1%) incomplete graft takes, though none required reoperation, and 1 (0.8%) experiencing a postoperative wound infection. Pediatric hand burns are common. A multidisciplinary treatment approach, including standardized wound care and adept therapeutic interventions, will lead to spontaneous healing in approximately 95% of patients.

Cost Comparison of Kirschner Wire Versus Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures

BACKGROUND

Intramedullary screw fixation is a relatively new technique for fixation of metacarpal and phalangeal fractures. The objective of this study was to compare health care-associated costs and outcomes for intramedullary screw versus Kirschner wire (K-wire) fixation of hand fractures.

METHODS

A retrospective review of patients undergoing intramedullary screw fixation of hand fractures at a single center during 2016-2019 inclusive was conducted. Health care-associated costs were compared with age-matched and fracture pattern-matched controls who underwent K-wire fixation.

RESULTS

Fifty patients met the study inclusion criteria, incorporating 62 fractures (29 K-wire, 33 intramedullary screw fixation). The median age was 34.6 years (18.0-90.1 years). There was no significant difference in primary operative costs (£1130.4 ± £162.7 for K-wire vs £1087.0 ± £104.2 for intramedullary screw), outpatient follow-up costs (£958.7 ± £149.4 for K-wire vs £782.4 ± £143.8 for intramedullary screw), or total health care-associated costs (£2089.1 ± £209.0 for K-wire vs £1869.4 ± £195.3 for intramedullary screw). However, follow-up costs were significantly lower for the uncomplicated intramedullary screw cohort (£847.1 ± £109.1 for K-wire vs £657.5 ± £130.8 for intramedullary screw, P = .05). Subgroup analysis also revealed that overall costs were significantly higher for buried K-wire techniques. Complication rates, time to return to active work, and Disabilities of the Arm, Shoulder, and Hand scores were similar.

CONCLUSIONS

This study identified significantly lower outpatient follow-up costs for uncomplicated intramedullary screw fixation of hand fractures compared with K-wires, along with a trend toward lower overall health care-associated costs. In addition, buried K-wire techniques were also found to carry a significantly higher financial burden. Higher powered prospective studies are required to determine indirect costs.

Management of Complex Forearm Injuries: Our Strategy of Reconstruction and Clinical Results

ABSTRACT

The management of complex forearm injuries is challenging, not only because of the anatomical complexity of the region but also because of the dramatic functional consequences of these injuries. Preservation of the upper limb and restoration of hand function are the focus of the surgical management of these injuries. Decision making will consider several parameters such as the type of injury, the patient, the moment of reconstruction, the debridement, and the options available for reconstruction.A multidisciplinary approach joining plastic surgeons and orthopedic surgeons in a team effort is essential to achieve the best outcomes. On the basis of their experience, the authors conclude that the keystone in complex forearm injuries management is represented by a careful assessment of the lesions, an aggressive and early debridement, the prevention of complications such as infection and compartment syndrome, and an "as early as possible" reconstruction.

[Effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with wrist electric burn]

Objective: To explore the effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with severe wrist electric burn. Methods: A retrospective observational study was conducted. From January 2017 to December 2020, 4 patients with wrist high-voltage electric burn admitted to the Department of Burns of the First People's Hospital of Zhengzhou and 4 patients with wrist high-voltage electric burn admitted to the Department of Hand Surgery of Beijing Jishuitan Hospital met the inclusion criteria, including 6 males and 2 females, aged 12 to 52 years. They were all classified as type Ⅱ wrist high-voltage electric burns with median nerve defect. In the first stage, the wounds were repaired with free anterolateral thigh femoral myocutaneous flap. In the second stage, the free gracilis muscle flap combined with sural nerve transplantation was used to reconstruct the digital flexion and sensory function of the affected hand in 3 to 6 months after wound healing. The cut lengths of muscle flap and nerve were 32 to 38 and 28 to 36 cm, respectively. The muscle flap donor area and nerve donor area were both closed and sutured. The survival condition of gracilis muscle flap and sural nerve, the wound healing time of recipient area on forearm, the healing time of suture in muscle flap donor area and nerve donor area were observed and recorded after operation, and the recovery of donor and recipient areas was followed up. In 2 years after operation, the muscle strength of thumb and digital flexion and finger sensory function after the hand function reconstruction were evaluated with the evaluation criteria of the hand tendon and nerve repair in the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association. Results: All the gracilis muscle flap and sural nerve survived successfully after operation. The wound healing time of recipient area on forearm was 10 to 14 days after operation, and the healing time of suture in muscle flap donor area and nerve donor area was 12 to 15 days after operation. The donor and recipient areas recovered well. In the follow-up of 2 years after operation, the muscle strength of thumb and digital flexion was evaluated as follows: 4 cases of grade 5, 3 cases of grade 4, and 1 case of grade 2; the finger sensory function was evaluated as follows: 4 cases of grade S3+, 2 cases of grade S3, and 2 cases of grade S2. Conclusions: For patients with hand dysfunction caused by severe wrist electric burn, free gracilis muscle flap combined with sural nerve transplantation can be used to reconstruct the digital flexion and sensory function of the affected hand. It is a good repair method, which does not cause great damage to thigh muscle flap donor area or calf nerve donor area.

Hand Trauma Virtual Clinics Prove Effective During the COVID-19 Pandemic

BACKGROUND

Due to the devastating and far-reaching impact of the novel COVID-19 pandemic, hospital resources have been redirected to protect patients and health care staff, thereby vastly reducing the capacity for outpatient follow-up within a busy Plastic Surgery and Hand Trauma center. Through the use of telephone and video technology, virtual clinics were rapidly introduced to reduce hospital footfall.

METHODS

This retrospective cohort study analyzed patient experiences in virtual and traditional face-to-face clinics through the month of April 2020, from the second week of the government-imposed lockdown. A 5-point Visit-Specific Satisfaction Questionnaire was used to subsequently collect patients' feedback regarding their appointments.

RESULTS

A total of 107 hand injury-related follow-up appointments were recorded during the 4-week period. Sixty (56.0%) appointments were performed as a virtual consultation, and 47 (43.9%) face-to-face consultations were carried out on site. It was possible to discharge 43.3% from the virtual clinic group and 57.4% from the face-to-face group. We identified no significant difference in patient satisfaction (P = .368, Mann-Whitney U test) between the 2 cohorts.

CONCLUSION

Virtual clinics appear to be safe and effective for the follow-up of patients with traumatic hand injuries during the COVID-19 pandemic. This approach may prove beneficial in terms of workforce organization, reducing waiting times, and providing an alternative for patients unable to attend physical appointments.

The Impact of COVID-19 on Hand Trauma

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has had a dramatic impact on individual and societal behaviors, as well as on health care systems. It confers a unique opportunity to examine the relationship among disease, policies, and patterns of activity, as well as their impacts on surgical unit functionality. This study aims to compare the distribution and patterns of injury at a tertiary hand surgery trauma center before and during the COVID-19 pandemic.

METHODS

A retrospective analysis of all patients presenting to the Royal North Shore Hospital hand surgery service in the 5-week period from March 16 to April 21 in 2019 and 2020 was undertaken, forming 2 cohorts for comparison. Demographic, injury, and operative data were collected and compared descriptively using comparative statistics.

RESULTS

There were 114 primary operative presentations during the 5-week period in 2020, representing a 27.4% decrease from the 157 presentations during the equivalent period in 2019. There was an increase in the proportion of emergency presentations from 73.9% in 2019 to 85.1% in 2020 (P = .03), with a corresponding decrease in elective presentations during 2020. The incidence of sporting injuries and motor vehicle accidents decreased in 2020, whereas falls and accidents involving knives and tools remained relatively constant. Operating times decreased in 2020, whereas the length of hospital stay remained constant.

CONCLUSIONS

The COVID-19 pandemic and consequent restrictions of activity have had substantial impacts on the patterns of hand trauma and its management. These insights have implications for staff and resource management during times of social disruption in the future.

The impact of COVID-19 on hand surgery: A French retrospective comparative study in COVID-19 and non-COVID-19 hand trauma centers

INTRODUCTION

In 2020, the pandemic divided France into two zones: COVID-19 and non-COVID-19. The main objective of our study was to compare the variability of surgical and emergency consultation activity amongst two hand trauma centers, between the pandemic period and outside the pandemic period. The secondary objective was to identify at-risk patients in order to develop preventative strategies in hand trauma.

METHODS

This bi-centric retrospective study considered the epidemiology of admissions to trauma centers during the first French lockdown. The data were compared to the same period in 2019 (control group). Two thousand and fifty-five patients underwent consultations for hand or wrist trauma.

RESULTS

The first French lockdown was associated with a 35% decrease in hand and wrist injuries in the COVID-19 zone versus 24% in the non-COVID-19 zone, compared to the same period in 2019 (p<0.0001, 95% CI: 6.5-15.6). Comparing 2019 and 2020, the incidence of wounds significantly increased in the COVID-19 zone (58% vs. 78%, p<0.0001) and significantly decreased in the non-COVID-19 zone (55% vs. 50%, p<0.0001). Complex wounds (16% vs. 35%, p<0.0001 and 15% vs. 17%, p<0.0001) and open fractures (8% vs. 14%, p=0.019 and 4.5% vs. 5.3%, p<0.0001) significantly increased in both zones during the pandemic. The rate of male, non-manual workers injured in domestic accidents (76% vs. 36%, p<0.0001) was significantly increased in all areas.

CONCLUSION

Hand and wrist trauma was less frequent but more severe during the pandemic compared to the same period in 2019. By encouraging the public to be aware of the risks and the means to avoid trauma, such as better information and compliance with safety instructions, we could minimize these risks. This data can be useful in planning preventative strategies for future lockdowns.

LEVEL OF EVIDENCE

III; case-control study.

Nerves in Continuity Following Hand Trauma: A Descriptive Report

BACKGROUND

Understanding the clinical presentation of nontransected nerve injuries in acute hand trauma/wrist trauma will help in early intervention, which is vital for maximizing return of function in patients. This retrospective study evaluated patients who experienced traumatic hand injuries with nerve in continuity within the zone of injury.

METHODS

This was a single-center retrospective chart review of 20 patients with hand or wrist trauma resulting in damage to bone, tendon, or soft tissues within Zones II to V. Patients were 18 to 70 years of age and had documented visualization of at least one nerve within the zone of injury at the time of surgery but no documented full or partial nerve transection. The cohort was characterized using descriptive statistics including mechanism of injury, extent of strength and sensation deficits, and outcomes. Resolution of symptoms was defined as full, partial, or none.

RESULTS

Of the 20 patients included in the study, 15 patients (75%) showed symptoms of impaired nerve function either prior to surgery or at the first post-surgical follow-up visit. Without direct nerve treatment, only 23% (3/13) of patients experienced full recovery based on qualitative sensory assessment. However, patients reporting pain after surgery (57%; 8/14) showed full recovery from pain despite no direct nerve treatment.

CONCLUSIONS

In our retrospective cohort of patients with hand/wrist trauma that presented with an intact nerve in continuity, we found that a majority showed symptoms of nerve injury. Further, these patients showed slow recovery over time with a minority achieving partial or full recovery or improvement in pain.